A 
SYSTEM OF MEDICINE 
MANY WRITERS 
EDITED BY 
THOMAS CLIFFOBD AJ.LBUTT 
M.A., M.D., LL.D., F.R.C.P., F.R.S., F.L.S., F.S.A. 
REGIUS PROFESSOR OF PHYSIC IN THE UNIVERSITY OF CAMBRIDGE, ETC., ETC. 
VOLUME I 
Neto 
MACMILLAN AND CO. 
LONDON: MACMILLAN & CO., Ltd. 
1896 
AU rights reserved Copyright, 1896, 
MACMILLAN AND CO. 
Nortonoh ^rcaa 
J. S. Cushing & Co. - Berwick & Smith 
Norwood Mass. U.S.A. TO 
SIR J. RUSSELL REYNOLDS, BART., M.D., F.R.S. 
PRESIDENT OF THE ROYAL COLLEGE OF PHYSICIANS 
THIS WORK IS DEDICATED 
IN MEMORY OF THIRTY YEARS OF FRIENDSHIP 
BY THE EDITOR PREFACE 
The latterday Editor of a System of Medicine is met on the thresh- 
old by a vast increase of the matter with which he has to deal. 
In the Introduction some fuller reference is made to this increase; 
at present it is sufficient to point out that to aetiology alone the 
whole chapter of bacteriology has been added. Contributors speak 
of the difficulty of keeping the matter within anything like the 
limits assigned to them; for what is true of aetiology is true more 
or less for every section of every chapter. 
When nothing more than opinions were needed as support for 
opinions teaching was easily made dogmatic and compact. In 
modern Medicine, however, every statement must not only be sub- 
mitted to verification, but submitted again and again. The methods 
of verification must also be punctually given, and all statements as 
accurately reported as if for cross-examining counsel. We cannot 
be any longer content to state that "the soldier said" such and 
such a thing, but we must give our testimony at first hand, or from 
carefully accredited and recent sources. 
Again, pathology has not only become intolerant of second hand 
evidence, but is irresistibly leading us to the study of origins - 
to the study of processes in a disinterested way as an aspect of 
natural history. It is impressed upon us in the field of Medicine, 
as in all other fields of knowledge, that to pursue knowledge with a 
consciously utilitarian end before us is to fail even in our immediate 
ends. It is as true now as it was two thousand years ago that Wisdom 
must be sought with a single heart devoted to her love and service; VIII 
SYSTEM OF MEDICINE 
and that even the relief of humanity cannot stand always first in 
our sight.1 The ultimate use of thought, no doubt, is to guide our 
conduct; but biology must be studied as an end in itself before we 
can hope to apply biology successfully in the conduct of living 
processes. 
On the other hand, were an Editor to rule out of his treatises 
all formulated thought on things not measured or comprehended 
he would err in the opposite direction. To speak or act as 
if things seen imperfectly or confusedly do not exist were worse 
than pedantry; all that lore which has the approximate truth of a 
large number of observations - of a number large enough to reduce 
the margin of error, if not to expel it, - would be rejected, 
and with it much useful art. Many a bridge was built before 
engineers learnt to calculate stress; and although traditional 
medical lore may prescribe for evils wastefully, yet in a more or 
less cumbrous or roundabout fashion it often attains or approaches 
the desired purpose. In a strange land a tedious, painful and 
circuitous route is better than no route at all. It has been 
our endeavour to preserve these traditional practices and these hazy 
views, where we cannot replace them by more definite measure- 
ments, lest we pull up wheat with tares, and, waiting for more light 
deprive sufferers meanwhile of some kind of aid however rude.2 
The acquired tact and patient study of individual physicians, as I 
have indicated under the head of Prognosis in the Introduction, 
must pilot them through these uncharted waters. 
It has been my duty to consider in what way the large mass of 
new matter may be accepted without an enormous expansion of the 
limits of this work. Contributors have done their best to be con- 
cise, and have not in any instance resented editorial co-operation 
to this end. Footnotes as a rule have been excluded, and references 
in the text have been replaced by very select " bibliographies." 
Perhaps all " overlapping " parts ought to have been ruthlessly 
1 " That knowledge may not be as a curtesan, for pleasure and vanity only, or as a 
bondwoman, to acquire and gain to her master's use; but as a spouse, for generation, 
fruit, and comfort."-Adv. of L., lib. i. 
2 No better examples could be given to illustrate this argument than the revival of 
counter-irritation and of bleeding on reasonable grounds and discriminating methods. PREFACE 
IX 
excised, but I have often held my hand; and this for several 
reasons. Continual cross-references tease the reader; the same matter 
may take on different meanings with changes in its context, and 
various writers may put the same substance in very different lights. 
For example, the repetitions involved in Sir Joseph Fayrer's review 
of "Fevers" from the stand-point of an Indian physician have been 
accepted; and I am bold to think that my readers will thank me, 
even at the cost of some additional pages, for presenting to them 
the uncurtailed opinions of this distinguished member of our 
profession, particularly those of them who practise in this vast 
possession of the Empire. To have given cross-references to the 
respective specific fevers at every division of so important a chapter 
would neither have been fair to the writer nor tolerable by the 
reader. 
Historical matter has been for the most part omitted: this 
relieved the System of some burden, and at little loss to the 
reader. During nearly two millenniums of time and over broad 
domains of the world the story of Medicine has been but a melan- 
choly study. \ To the curious scholar the " pseud-ideas " of 
sophists, the dreams of mystics, the quaint conceits of monkish 
craft, the devices of magicians, the grotesque or brutal records of 
folk-lore may be entertaining, or even instructive; far be it from 
us to find any human things alien. Primus sapientice gradus est 
falsa intelligere. Here may be some felicity of observation; there 
some shrewdness of opinion: ' yet after all we read the history 
of medicine rather for the honour of a certain few of our ancestors 
than for our own instruction. I To enter into this subject fully 
would occupy much of the very pages which I am trying to 
economise; but I may briefly say that the only period of the past 
history of our profession which can interest the medical student 
directly is the Medicine of Ancient Greece, which came to life 
again on contact with our own. Greek medicine of the fifth 
century b.c. seems to be almost of yesterday; English medicine 
of the twelfth century of our era seems more alien to our thought 
than the Galenical treatises of the Arabs, and almost as grotesque 
as the demonology of the Chaldeans. No modern book of Chemistry X 
SYSTEM OF MEDICINE 
deals with the stories of Alchemy, nor of Astronomy with those of 
Astrology. 
The great profession of the Law may feel a just pride in the 
growth of its reasonable and gradual dominion; Medicine, after the 
decay of the school of Hippocrates, and in countries which knew 
not that master, became the tool of priests, slaves, charlatans, or 
literary men. To trace the living waters of the healing art and 
the auxiliary sciences in their secret channels under the foundations 
of the Temple, of the Gymnasium, of the Museum, or of the 
Marketplace, until they burst forth once more in the time of 
Wesalius, of Harvey, of Morgagni, of Haller, of Hunter, of Bichat, 
of Bernard, of Laennec, is not a pursuit for these pages. 
The Prolegomena which open this volume, and others which 
will appear occasionally hereafter, are in part to enlarge the concep- 
tions of the student, to lead him to see the domains of Medicine 
from points of advantage: in part, by means of these broader 
surveys of General Pathology, of Statistics, or of Dietetics and 
Therapeutics, to avoid some repetitions, otherwise necessarily fre- 
quent, in the several articles of the work. 
The pleasant duty remains of thanking my contributors for 
the kindliness, good faith, and intelligent support which they have 
manifested throughout this undertaking, which, although now pub- 
lished in small part, is in a fair way of completion. If all be as 
well as the promise of it the future volumes will be published 
without long delay. The first volume of such a co-operative work is 
the most arduous: the time allotted to the several contributors is 
shorter than to those whose treatises come in later. Moreover, the 
heavy sickness of the two past winters played havoc with my staff. 
Some of these, prostrated with one plague or another, have striven 
hard on their imperfect convalescence to perform their task. Others, 
such as the late Dr. Sturges, Dr. Beaven Rake, and Prof. Walley, 
had finished their work, but not for us. My cordial thanks are due 
to Dr. Cheadle, to Dr. Phineas Abraham, and to Dr. M'Fadyean, for 
generously taking up the labours of those who had passed away. Pro- 
fessor Burdon-Sanderson took up the chapter on Fever at very short 
notice, and wrote it under severe pressure of time and other engage- PREFACE 
XI 
ments. Dr. Rolleston lias given me invaluable aid throughout in 
the reading of proofs, in advising me continually, in forwarding my 
arrangements with contributors in London, and in many other ways. 
Finally, I have to thank those kind and able friends who have 
not only given me the advantage of their articles on special subjects, 
but have spent much time and pains, which they could ill spare, in 
the arrangement of certain sections of the System or in proof 
reading. Invaluable help of this kind has been ungrudgingly given 
to me by Dr. Ferrier (Cerebral Diseases), Dr. Manson (Tropical 
Diseases), Dr. Payne (Skin Diseases), Dr. Savage (Mental Diseases), 
and Dr. Felix Semon (Laryngeal Diseases). Dr. Venn and Mr. 
Thomas Marshall, of Leeds, have given me valuable help in the 
revision of the Introduction, for the contents of which, however, I 
am wholly responsible. 
T. C. A. CONTENTS 
PAGE 
Introduction ......... xix 
DIVISION I.-PROLEGOMENA 
Medical Statistics. Dr. Billings ...... 3 
Anthropology and Medicine. Dr. Beddoe . . . . .21 
On Temperament. Dr. Rivers .. . . . . . .36 
On the Laws of Inheritance in Disease. Mr. Hutchinson . . 39 
Medical Geography of Great Britain. Mr. Haviland . . .46 
Inflammation. Dr. Adami . . . . . . .54 
/The Doctrine of Fever. Dr. Burdon-Sanderson .... 139 
The General Pathology of Nutrition. Dr. Mott .... 161 
,General Pathology of New' Growths. Mr. Sliattock and Mr. Ballance . 201 
Principles of Drug Therapeutics. Dr. Leech .... 217 
Climate in the Treatment of Disease. Dr. Hermann Weber and Dr. 
Michael G. Foster ........ 247 
Artificial Aerotherapeutics. Dr. Theodore Williams . . . 300 
Balneology and Hydrotherapeutics. Dr. Hermann Weber and Dr. Parkes 
Weber ......... 318 
The Medical Applications of Electricity. Dr. Lewis Jones . . 349 
Massage: Technique, Physiology, and Therapeutic Indications. Dr. 
Kearsley Mitchell . . . . . . . .373 
The General Principles of Dietetics in Disease ; or, the Feeding of 
the Sick. Sir Dyce Duckworth ...... 385 
The Diet and Therapeutics of Children. Dr. Eustace Smith . . 412 
Nursing. Miss Amy Hughes ....... 423 
The Hygiene of Youth. Dr. Dukes ...... 457 
Life Assurance. Dr. Symes Thompson ..... 476 XIV 
SYSTEM OF MEDICINE 
DIVISION IL-FEVERS 
Part I. 
PAGE 
Insolation or Sunstroke. Sir Joseph Fayrer .... 491 
Part II. - The Infections 
The General Pathology of Infection. Dr. Kanthack . . . 504 
Septicemia and Pyemia. Mr. Watson Cheyne .... 586 
Erysipelas. Mr. Watson Cheyne ...... 613 
Infective Endocarditis. Dr. Dreschfeld ..... 626 
Puerperal Septic Disease. Dr. Playfair ..... 635 
Furuncle ; Carbuncles. Dr. Melsome ..... 651 
Epidemic Pneumonia. Dr. Whitelegge ...... 655 
Epidemic Cerebro-Spinal Meningitis. Dr. Ormerod . . . 659 
Influenza. Dr. Goodhart ....... 679 
Diphtheria. Dr. Gee, Dr. Thorne Thorne, Dr. Kanthack, and Dr. Herringham. 701 
Tetanus. Sir George M. Humphry and Dr. Sims Woodhead . .758 
Enteric Fever. Dr. Dreschfeld ...... 791 
Cholera Asiatica. Dr. MacLeod, Mr. Ernest Hart, Dr. S. C. Smith, Dr. 
Kanthack, and Mr. J. W. W. Stephens ..... 864 
Plague. Dr. J. F. Payne ....... 917 
Relapsing Fever, or Famine Fever. Dr. Rabagliati and Dr. Wesbrook . 940 
Index .......... 961 ILLUSTRATIONS 
FIG. PAGE 
1. Spleen Pulp of Monkey . . . . . . .82 
2. Two Giant Cells from a Rodent . . . . . .83 
3. Phagocytes from Spleen and Eye of White Rat . . . .84 
4. Anthrax of Pigeon . . . . . . . .84 
5. Cortical Pyramidal Cell ....... 182 
6. Microphotograph of Pyramidal Cell from a Case of General Paralysis of 
the Insane ......... 183 
7. Microphotograph of Pyramidal Cell undergoing Atrophic Degeneration . 183 
8. Atrophic Liver Cells from Cyanotic Atrophy of Liver . . . 185 
9. Microphotograph of Heart, showing early Fatty Degeneration . . 190 
10. ,, ,, ,, a few Fibres more highly magnified . 190 
11. Microphotograph of Liver from a Case of Pernicious Anaemia . . 191 
12. ,, ,, showing a few Cells more highly magnified . 191 
13. Cloudy Swelling of Liver Cells treated with Acetic Acid . . 192 
14. „ „ ,, . . 192 
15. Oertel's Steam Nebuliser ....... 305 
16. Waldenburg's Apparatus for condensing and rarefying Air . . 307 
17. Fraenkel's Apparatus for condensing and rarefying Air . . . 308 
18. The Pneumatic Cabinet ....... 309 
19. Compressed Air Bath . . . . . . . .311 
20. Tracing showing Depth of Respiration in Compressed Air . . 313 
21-25. Sphygmographic Tracings showing Pulse-rate .... 314 
26. Motor Points of the Head and Neck ..... 357 
27. Motor Points of Extensor Aspect of Upper Limb . 358 
28. Motor Points of Flexor Aspect of Upper Limb .... 359 XVI 
SYSTEM OF MEDICINE 
FIG. PAGE 
29. Motor Points of Front of Thigh ...... 300 
30. Motor Points of Posterior Aspect of Lower Limb . . . 361 
31. Motor Points of Leg and Foot ...... 362 
32. Feeding-Cup ......... 387 
33. Apparatus for Nasal Feeding ...... 387 
CHARTS 
1. Death-rates in New York, etc. ...... 6 
2-8. Variations in Temperature of Puerperal Fever . . . 642-648 
9. Enteric Fever ........ To face 791 
10. Temperature of an Acute Case of Plague, with Temperature in 
Rectum after Death ....... 930 
11. Temperature of a less rapid Case of Plague .... 931 
12. Temperature and Pulse in Relapsing Fever .... 946 
13. „ „ „ .... 947 
PLATE 
Hsematoidin, Melanin, and Carbon Pigmentation . . . To face 197 LIST OF AUTHORS 
Adami, George John, M.D., Professor of Pathology, M'Gill University of Montreal. 
Ballance, Charles Alfred, M.S., F.R.C.S., Surgeon to the National Hospital for the 
Paralysed and Epileptic; Assistant Surgeon to St. Thomas's Hospital, and to the 
Hospital for Sick Children, Great Ormond Street. 
Beddoe, John, M.D., LL.D., F.R.C.P., F.R.S., Late Physician to the Royal Infirmary, 
Bristol; Ex-President of the Anthropological Institute. 
Billings, John S., M.D., LL.D., D.C.L. Oxon., F.C.P. Phil., Surgeon U.S. Army; Libra- 
rian to the Surgeon-General's Library, and Professor of Hygiene in the University 
of Pennsylvania. 
Burdon-Sanderson, John, M.D., D.C.L., D.Sc., LL.D., F.R.S., Regius Professor of Medicine 
in the University of Oxford, Fellow of Magdalen College. 
Cheyne, William Watson, M.B., C.M., F.R.C.S., F.R.S., Surgeon to King's College 
Hospital, and Professor of Surgery at King's College. 
Dreschfeld, Julius, M.D., B.Sc., F.R.C.P., Physician to the Manchester Royal Infirmary, 
and Professor of Medicine in the Owens College, Victoria University. 
Duckworth, Sir Dyce, M.D., LL.D., F.R.C.P., Physician to and Lecturer on Medicine at 
St. Bartholomew's Hospital. 
Dukes, Clement, M.D., M.R.C.P., Physician to Rugby School, and Senior Physician to 
Rugby Hospital. 
Fayrer, Sir Joseph, Surgeon-General, K.C.S.I., LL.D., M.D., F.R.S., F.R.C.P., Late 
President Medical Board, India Office. 
Foster, Michael George, M.A., M.D., L.R.C.P., M.R.C.S., San Remo. 
Gee, Samuel Jones, M.D., F.R.C.P., Physician to St. Bartholomew's Hospital. 
Goodhart, James Frederick, M.D., C.M., F.R.C.P., Physician to Guy's Hospital, and 
Consulting Physician to the Evelina Hospital. 
Hart, Ernest, D.C.L., M.R.C.S., Editor of the British Medical Journal. 
Haviland, Alfred, M.R.C.S., Late Lecturer on the Geography of Disease at St. Thomas's 
Hospital. 
Herringham, Wilmot Parker, M.D., F.R.C.P., Assistant Physician St. Bartholomew's 
Hospital, Physician Paddington Green Children's Hospital. 
Hughes, Miss Amy, Superintendent of Nurses, Bolton Union Workhouse; Late Superin- 
tendent Central Training Home, Queen Victoria Jubilee Institute for Nurses for the 
Sick Poor. 
Humphry, Sir George Murray, M.D., F.R.C.S., D.Sc., LL.D., F.R.S., Honorary Fellow 
of Downing College, and Fellow of King's College, Cambridge; Professor of Surgery 
in the University; Consulting Surgeon to Addenbrooke's Hospital. 
Hutchinson, Jonathan, M.D., LL.D., F.R.C.S., F.R.S., Consulting Surgeon to the London 
Hospital, Senior Surgeon to the Hospital for Diseases of the Skin, Late President 
of the Royal College of Surgeons. XVIII 
SYSTEM OF MEDICINE 
Jones, Henry Lewis, M.D., F.R.C.P., M.R.C.S., Medical Officer in charge of the Electrical 
Department of St. Bartholomew's Hospital. 
Kantback, A. A., M.D., M.R.C.P., F.R.C.S., Lecturer on Pathology and Pathologist at 
St. Bartholomew's Hospital. 
Leech, Daniel John, M.D., F.R.C.P., Senior Physician to the Manchester Infirmary, and 
Professor of Materia Medica and Therapeutics in the Victoria University. 
MacLeod, Kenneth, Brigade Surgeon Lieutenant-Colonel, M.D., LL.D., F.R.C.S.E., Late 
Professor of Surgery in the Medical College of Calcutta. 
Melsome, William Stanley, M.D., Fellow of Queen's College, Cambridge, and Senior 
Demonstrator of Anatomy in the University. 
Mitchell, John Kearsley, M.D., F.C.P. Phil., Physician to St. Agnes's Hospital, Assistant 
Physician to the Orthopaedic Hospital and Infirmary for Nervous Diseases, Lecturer 
on General Symptomatology, University of Pennsylvania. 
Mott, Francis Walker, M.D., F.R.C.P., M.R.C.S., Assistant Physician to Charing Cross 
Hospital, and Pathologist to the Asylums Board of the London County Council. 
Ormerod, Joseph Arderne, M.D., F.R.C.P., Assistant Physician to St. Bartholomew's 
Hospital, and Physician to the National Hospital for the Paralysed and Epileptic. 
Payne, Joseph Frank, M.D., F.R.C.P., Late Fellow of Magdalen College, Oxford ; 
Physician and Lecturer on Medicine at St. Thomas's Hospital. 
Playfair, William Smoult, M.D., LL.D. F.R.C.P., Professor of Obstetric Medicine at 
King's College, and Physician to Women and Children at King's College Hospital. 
Rabagliati, Andrea Carlo Francisco, M.D., F.R.C.S.E., Late Senior Surgeon to the 
Bradford Infirmary and to the Bradford Fever Hospital. 
Rivers, William, H.R., M.D., M.R.C.P., Lecturer on Moral Science in the University 
of Cambridge. 
Shattock, Samuel G., F.R.C.S., Joint Lecturer on Pathology; Curator of the Pathological 
Museum, St. Thomas's Medical School. 
Smith, Eustace, M.D., F.R.C.P., F.R.C.S., Physician to the East London Hospital for 
Children, and to the City of London Hospital for Diseases of the Chest. 
Smith, Solomon Charles, M.D., M.R.C.P., M.R.C.S., Consulting Surgeon Halifax Infirmary, 
Physician Westminster General Dispensary. 
Stephens, J. W. W., M.B., B.C., The Treasurer's Student in Pathology at St. Bar- 
tholomew's Hospital. 
Thompson, Edmund Symes, M.D., F.R.C.P., Consulting Physician to the Consumption 
Hospital, Brompton; and Gresham Professor of Medicine. 
Thorne, R. Thorne, C.B., M.B., F.Rf.C.P., F.R.S., Medical Officer to the Local Government 
Board, and Lecturer on Public Health at St. Bartholomew's Hospital. 
Weber, Hermann, M.D., F.R.C.P., Consulting Physician to the German Hospital, London, 
and to the Royal Hospital for Diseases of the Chest, Ventnor. 
Weber, Frederick Parkes, M.D., M.R.C.P., M.R.C.S., Physician to the German Hospital, 
London. 
Wesbrook, Frank Fairchild, M.D., Professor of Bacteriology in the University of 
Minneapolis, U.S.A. 
Whitelegge, Benjamin Arthur, M.D., B.Sc., M.R.C.P., M.R.C.S., County Medical Officer 
for the West Riding of York. 
Williams, Charles Theodore, M.D., F.R.C.P., Consulting Physician to the Consumption 
Hospital, Brompton. 
Woodhead, German Sims, M.D., C.M., F.R.C.P.E., F.R.S.E., Director of the Research 
Laboratories of the Conjoint Board of the Royal Colleges of Physicians and 
Surgeons. INTRODUCTION 
Medicine as a System. -The title which has been chosen for this work 
is one which may be necessary for present purposes, but one which on 
logical grounds cannot be defended: a System of Medicine cannot now 
be written, either by one man or by many, and this state of things is 
by no means to be regretted. Of a body of empirical knowledge a 
system may be made, and in such a system place may be found for new 
accretions or elaborations; before the days of Bacon, for example, and 
even after the publication of the Novum Organon, it was the ambition 
of learned men to attain to encyclopaedic knowledge, to spread them- 
selves over the whole realm of it, and laboriously to gather all its prod- 
ucts into a Corpus or System: this was their end. To construct such 
an " Orbis Doctrinse " seemed to them to be a mere matter of time, 
ability and capacity; and to its attainment many noble lives were 
devoted. It seems probable that even Bacon himself had little idea of 
the remote consequences of his own method: it seems probable that he 
believed the new Organon to be a key to the discovery of natural 
knowledge which at no distant time would reveal that realm to us as a 
band of scouts, armed with other weapons, might reveal to us, let us say, 
the parts of Central Africa. A system of natural knowledge would 
thus have completed the encyclopsedia - the " Institutio in circulo " - 
already fairly sufficient for the student of discovered subjects such as 
theology and philosophy. That his method, as afterwards interpreted 
and extended by Newton and later thinkers, had an application correla- 
tive in depth and extent with the perceptible universe, and that, this 
depth and extent being infinite in all dimensions, its analysis must be 
inexhaustible, Bacon perhaps never apprehended.1 The complexity and 
the infinity of nature were not and could not be realised in the infancy 
of the investigation of it. As later generations learned that natural 
knowledge cannot be held in categories, but must be conceived as a classi- 
1 Glanvil (Vanity of Dogmatising) says: "And 'tis the observation of the noble 
St. Alban, that philosophy is built upon a few vulgar experiments." The noble St. Alban 
thought more wisely than this, but not altogether out of this fashion. In saying this I do 
not forget the well-known 127th Aph. of N. O., lib. i. My view is founded upon Bacon's 
own way of going about to apply his method, which indeed he drew almost entirely from 
Aristotle. XX 
SYSTEM OF MEDICINE 
fication by kinds1 whose similarities and dissimilarities are inexhausti- 
ble, it became obvious that a system uniform in its proportions and parts 
is impossible; or that, so far as possible, such a system would indicate 
not progress, but arrest of development - in a word, a stereotype. 
In times when knowledge is almost stationary, as was approximately 
the case, for instance, in the Arabian schools, a System of Medicine may 
be thus made; its parts will be classified by means of resemblances 
only as deep as the foundations of contemporary knowledge: thus, for 
example, a specious group or class of pulmonary diseases may be made. 
At no time, however, is knowledge quite stationary; and, even at its 
most stable moments, some deeper resemblances, truer explanations that 
is, are hit upon by this man or the other, and the fixity of the system 
and of its categories is disturbed. On the revelation of profounder 
resemblances objects hitherto set near each other are detached, and 
objects far apart in the system are approximated. Thus, in respect of 
the pulmonary diseases, kinds of pulmonary phthisis or of pneumonia 
may be carried away to the class of Infectious Diseases, and so forth; 
every new explanation bringing about a change of the order. 
Moreover, in seeking and verifying explanations, we find that pio- 
neers in natural researches do not rule themselves as an army in the 
field, pressing forward on a uniform plan and upon all faces of the enemy 
at once; but attacks are made upon certain quarters, and individuals or 
companies penetrate particular parts regardless of the advance of others. 
At one time morbid anatomy, at another bacteriology, at another phar- 
macology, or several quarters of each of these respectively, are the 
chief subjects of inquiry; progress in one direction thus passes out of 
immediate relation to progress in another. Individual tastes, again, 
occasional facilities, and the advances of ancillary sciences or arts, 
modify the rates of progress in the several sections of each department 
of natural knowledge. It is then characteristic of natural knowledge, 
if not strictly pertinent to it, that its progress should be largely unsys- 
tematic ; although from time to time generalisations are made, such as 
the classification by genetic affinities, which break up older systems, 
and bring some method into large groups of things which before had 
appeared to be unrelated. Thus no doubt, as generations of men pass, 
the subjects of knowledge are more and more co-ordinated; but, if prog- 
ress continue, we shall observe still that new and irregular adits are 
driven into the unknown before the older winnings are completely 
surveyed and' classified. 
The reader will, therefore, be disappointed if, on opening the follow- 
ing pages, he expects to find a System of Medicine formally so called: 
1 The logician may remind me that to put matter in natural groups and to classify it 
are the same thing; and that as " natural groups " do not exist, such a classification, like 
any other, is but a convenient device for a particular purpose, a way of looking at things 
from a certain point of view. In the biological sciences, however, classification, since it 
has become an expression of affinities, - that is, since the publication of the Origin of 
Species, - has taken a larger meaning, and is a conceptional summary of permanent and 
universal convenience. INTRODUCTION 
XXI 
he will rather find our knowledge set forth on the whole as immediate 
convenience and the exigencies of contemporary learning may dictate. 
The arrangement which may seem good to one editor may be displeas- 
ing to another: in biological subjects all editors desire to place their 
matter in groups as natural as possible - to classify its parts by the tie 
of kind, so that the classification may become explanatory of the matter; 
on the other hand, orders of convenience are no less imperative, and a 
treatise of Medicine must be based upon a compromise. If herein the 
formal mind occasionally feel pain, I trust it will be remembered, as I 
have said, that irregular expansions which burst the limits of a " System " 
are signs of life and progress. 
Some endeavour I have made to recompose my matter in accordance 
with the latest advances of science; yet when faced on one side by a 
large block of ignorance, or diverted on another by some dictate of con- 
venience, I have not hesitated to regard rather the habit and convenience 
of the ordinary reader than the doctrines of the systematic thinker: I 
have endeavoured to make provisions for the former and for the latter 
necessities, yet, systematising where I can, and "distributing our igno- 
rance " as equally as I can, I have had to present much of the matter in 
the unconnected way in which it was discovered. 
Science and Practice. -No thoughtful man versed in the methods of 
natural inquiry can fail to be reminded at every moment of the ultimate 
and universal dependence of every one group of phenomena upon every 
other. Too often we regard causation as a pedigree drawn up on the 
plan of primogeniture in the male line - as a series of linear sequences, 
each result owning a parent, and so on until a primal cause is reached. 
I need not say that such a conception, and the use of such metaphors as 
" the chain of causation," are so narrow as to be false. So incalculable 
are the properties of things, so contingent is each event upon every other, 
that anything like a final presentment of causation is impossible, nay, 
inconceivable by our limited faculties; and our propositions are but pro- 
visional formulee which, if permitted to harden into aphorisms, become 
fetters of thought. Our formula;, then, should be in a state of continual 
flux: fresh exceptions are continually turning up, and fresh qualifications 
are incessantly made. On the other hand, without provisional formulae 
we cannot act, and in action lie the purpose and end of medical studies. 
The " merely scientific " physician is apt to be blind to useful manoeuvres 
which rest rather upon the accidental than upon the more permanent 
qualities of things: indeed, the practical man often sees more of the 
surface of things than does the analytical man, and thus keeps more 
sense of proportion, more of the sense called " common." So it comes 
about that in practice personal tact and character are as important to 
the operations of a physician as scientific equipment. He has to deal 
with men of limited vision, full of accidental qualities, and subject to 
accidental disturbances; and the tact which deals with these confused 
and conflicting attributes is born rather of a wide survey of the outsides 
of things, and of transitory conventions, than of a penetrating insight SYSTEM OF MEDICINE 
XXII 
into causation. Excessive concentration, if it fit a man for analytical 
study, may unfit him for the world. Moreover, the purely scientific 
physician tends to undervalue opinion, as the man of the world to over- 
value it. Now, prevalent opinions, though not formal truth, generally 
contain truth, and this the practical physician does not fail to perceive; 
nor does he forget that the observations of any one person, however pro- 
found, being the observations of an individual of brief life and limited 
faculties, need some tempering by traditional lore - by the embodied 
opinions of a vast number of observers over a long period of time; 
opinions which, individually inaccurate as they may be, yet make collec- 
tively an approximation to truth of no small value to the man, be he 
statesman or physician, who has usually " to act on a choice of second 
best courses" [yide paragraphs on Prognosis]. 
Methods. - We are met at the outset of our study by the questions 
- What is health; and what is disease 2 The man who lives to the age 
of a hundred years, and who during that time suffers no pain, and is 
continually able to make use of the powers proper to his age, would by 
universal testimony be regarded as an example of health: yet even the 
life of such an one would not always be at its best; and health, like 
.every other such name, is to be used in a relative sense. Into the life 
of the healthiest man disorder must frequently enter. Absolute health 
is an ideal conception, as the line of the mathematician, the ether of the 
physicist, and the atom of the chemist; it is a positive conception of a 
perfect balance of the moving equilibrium which we call systemic life: 
disease is a negative conception, and signifies something less than this 
. perfect balance. 
In other times, nay, even in our own, there has been a disposition to 
regard disease as something imported into the system, as a possession of 
it by a malign agent which may be expelled by some sorcery or virtuous 
herb; in this sense health and disease are not different attitudes of one 
thing, but a binary combination. Insensibly this personification of dis- 
ease falls by a sort of refinement into the " principle " of the vitalists, 
as in the phrase of a distinguished physician who describes a patient as 
" saturated with insanity " ; or it becomes the peccant humour of a less 
unscientific pathology; or, again, it may be identified with a microbe or 
a virus. Yet to speak thus is to confound disease with the causes of 
disease, and to use figurative language to our confusion-the "perilous 
stuff " from which the bosom must be cleansed is no more a disease 
than a blackthorn staff is a broken head. The blackthorn may be the 
cause of a green wound ; by this gate other bacilli, less gross in kind, 
may enter the body, and cause the oscillations in its system which 
we call fever; the consequent dislocations and disturbances in the 
body are properly called diseases. A cancer is no more a disease than 
the hyssop on the wall: a cause of disease it may be, but the disease 
is in the damaged tissues, which are irritated, invaded, or choked by 
the growth. 
Again, whether the causes be prevented inside the body or outside it, INTRODUCTION 
XXIII 
are matters of no essential difference. To kill Laveran's microbe1 within 
the body by eating quinine is not to cure an ague, but to prevent the 
cause of a future ague: the ague itself is a perturbation of the systemic 
balance which will usually yield to the vis medicatrix naturae; that is 
to say, to the tendency of all stable equilibriums to maintain them- 
selves-the vis medicatrix naturae being an aspect of inertia. 
If we keep clearly before us this distinction between the causes of 
disease and disease itself, we shall use our remedies more intelligently; 
we shall see how dominant is the sphere of preventive medicine, and 
that curative medicine is often but the ancillary mouse which liberates 
the body for its own work of recovery. 
To know disease, then, we must first know the latitudes of health; 
we must study the balance of forces in their normal play before we can 
comprehend and neutralise the disturbances to which this balance is sub- 
ject. The corporeal system of man is one of vast multiplication and differ- 
entiation of members; in him, therefore, comprehension of the system is 
most difficult. As we descend the scale of life, and study simpler sys- 
tems and simpler functions, description becomes easier; and physiol- 
ogists, building up our knowledge of the normal by the comparative 
method, take pathologists with them, who, in their turn, working upwards 
from the lowest forms of life, or the embryos of the higher or the embryonic 
tissues of the higher, are revealing to us day by day the secret ways of 
the earliest and simplest deviations from the normal - that is to say, 
the elements of disease [yide arts, on " Inflammation," " Fever," and 
"Pathology of Infection" in this volume]. Again, as the building up 
of an organism is not by permanent accretion like the building of a house, 
but by an incessant repair of decay, the student of the normal, that is the 
physiologist, is constantly in the presence of pathological features. As 
the healthy, so the normal is but a relative term; that which is normal 
in one series may be abnormal in another, and thus the physiologist and 
the pathologist are intimately one: physiology as well as pathology is 
concerned with decay. The comparative method necessarily embraces 
the work of both, pathology being one aspect of physiology; to speak 
metaphorically, it is the reverse view of physiology, the study of accel- 
erated or irregular rates of decay. Disease is a matter of time relations. 
What, then, is the nosologist ? The nosologist bears the relation to 
the pathologist that the naturalist or morphologist does to the physi- 
ologist ; as the pathologist classifies the morbid variations of plants and 
animals, so the nosologist describes the natural history of diseases: the 
nosologist, as such, has no concern with curative means; he has his views 
of the balance of forces, but has no concern in the promotion of them. 
Cure is an art; it is the application of these sciences, and is the concern 
of the physician: a physician is an engineer who cannot construct, but 
is skilled in conservation and repair. 
Classification. - The nosologist or clinician, describing and comparing 
1 The use of the word " microbe " is not to be limited to bacteria. A general term for 
minute living things is required, and " micro-organism " is too cumbrous. XXIV 
SYSTEM OF MEDICINE 
organisms which have deviated from the normal balance of function, finds 
that, infinite as are the gradations between health and disease and be- 
tween one mode of perturbation and another, yet these perturbations tend 
to resolve themselves in certain ways, to fall into certain morphological 
groups which present some low degrees of constancy. By these recurrent 
characters he is enabled to classify them; and this he tries to do after 
the method of a naturalist, that is, on an explanatory arrangement based 
upon degrees of genetic affinity. As the naturalist cannot, however, go 
far without the anatomist, so the nosologist, soon finding that a study 
of superficial features leads to classifications which, however convenient 
for the time, are but provisional, has to classify by likenesses of a 
deeper and a deeper kind; and as he does so he becomes a pathologist. 
As the naturalist without the help of the comparative anatomist might 
classify, let us say, the swift with the swallow, so the nosologist with- 
out the comparative pathologist might, as he has done, classify leprosy 
with psoriasis, tubercular with typhoid enteritis, sarcoma with car- 
cinoma, and so forth. 
Here, however, we are led to the reflexion that to regard and name 
diseases as species, or even as varieties, in a biological sense, is an error 
of the same kind as to regard them as entities. A disease is a particular 
state of an individual; and, although certain families show persistent 
bents to certain kinds of morbid variation, yet the constancy of this 
fashion bears a very small proportion to that of the characters of a 
variety in a biological sense. Moreover, although careless clinical 
teachers will continue to speak of the " development " of this or that 
disease, yet disease is no new advance, but a retreat, a stage of decline 
failing in relative stability, a state which must end either in a recovery 
of the normal balance or in dissolution. All attempts to describe 
diseases in terms equivalent to the genera, species, or natural varieties 
of plants or animals are then erroneous; they lead to mistakes both of 
theory and of practice, and to ignorance of the underlying unity in the 
various forms of disease. A sick plant or animal is but itself in another 
state, a state more transient and less useful. 
On the other hand, amid the instabilities and the frequent and rapid 
changes of natural perturbation, nosologists in early times - times earlier 
than our records - observed, nevertheless, that symptoms do not occur 
haphazard, or congregate pell-mell, but that they tend to arrange them- 
selves in recurrent groups of some likeness, so that a medical mor- 
phology is possible. We should anticipate perhaps that, inasmuch as 
in animals of the same kind the several systems of the body are ap- 
proximately alike, so their disorders, like autumn leaves, would appear 
with fairly uniform features within the kind. We do find, accordingly, 
in man that diseases, or symptom groups, present broad features of 
resemblance, diversified in subordinate detail as individuals are diverse. 
No two men are alike at all points, and no two cases of disease are 
identical; but comparative nosologists tell us that, so far as observation 
has gone, each kind of plant and each kind of animal seems on the whole INTRODUCTION 
XXV 
to have certain sets of morbid characters more or less peculiar to 
itself. 
That symptoms do not occur in disorderly jumbles, but tend to form 
groups of certain degrees of constancy varying with various organisms, 
may receive some explanation not only by the set of the lines of least 
resistance in the several anatomical systems of which the higher organ- 
isms consist, but also by a study of certain other facts in biology lying 
as deep as diseases or anatomical systems. 
Biologists1 tell us that there may often or generally be " discon- 
tinuity" between the arrangements, or related compounds, mechanically 
stable under various conditions. Either of two arrangements may be 
relatively stable, but nothing between them; so that the transition 
between them can only take place by a swift passage. If this be a true 
view of biological variations it may have truth likewise in respect of 
disease. The most stable attitude of the bodily functions is no doubt 
the position we call " health "; but there are, we may suppose, several 
other positions in which component functions have degrees of stability, 
and these may be the sundry kinds of disease. It may well be, again, 
that interferences reinforce or neutralise each other along certain lines, 
so that, wheresoever the disturbance, the set of functional balance, after 
a brief oscillation, would tend to resolve itself in a particular direction; 
thence, after a time of moderate steadiness it may recover the more 
perfect balance of health or fall into dissolution. 
These opinions seem likely to illuminate some nosological riddles. 
We have heard a little too much of the proverb, Natura nihil facit per 
saltum, and have been led to forget that, however gradual transitions 
may be, intermediate phases between positions of relative stability may 
be so rapid as to be elusive ; or again, that retrocession may take place 
to a certain point, whence a new position is reached. 
In this light such a saw as "We are, all of us, more or less insane " 
takes on a new untruth, and we see how it comes that, in respect of 
mental and other disease, there is not in practice the difficulty which 
laymen assume of definitely recognising perversions from the normal. 
Theoretically, of course, "borderland phases" must occur, but they 
may not be persistent or frequent enough to embarrass us, and a new 
position of relative equilibrium may be reached so quickly that inter- 
mediate positions, like the flap of the wing of the albatross, are unper- 
ceived. Even thought runs, no doubt, in certain grooves. It is not to 
be supposed that our senses have continual cognisance of every property 
of things, or exhaust every possible combination of them. We are, as 
artists, consciously or unconsciously ever selecting. Moreover, in our 
development our thoughts have probably followed certain lines of 
balance, cohesion, cleavage, or what not, consisting either in the physical 
basis of life or in the conditions of the medium. Thus every old fancy 
may be said to have some quality of science in it. But whether the 
1 Mr. Galton and Mr. Bateson (Materials for the Study of Variation, Macmillan & Co., 
London, 1894) have dealt with this subject before me, but with other aspects of it. XXVI 
SYSTEM OF MEDICINE 
inclination to particular attitudes be inherent in the structure of living 
molecules, or arise in the same way as the differentiation of the several 
anatomical systems, or be impressed upon the organism by the preva- 
lences of certain combinations of parts in the medium, or be again but 
an aspect of inertia, is not important to my argument, nor are these, 
indeed, soluble questions at present. 
These considerations indicate the factors which make classification 
and diagnosis possible; perturbations tend to fall into groups which 
can be arranged in classes by likenesses and separated by unlikenesses. 
In the earlier stages of pathological knowledge, stages we have scarcely 
left behind, classification of symptom groups could only be made by 
reference to superficial and obvious features; for instance, scarlatina 
was confounded with measles, typhus fever with typhoid; all eruptions 
on the skin were classed together, - small-pox and impetigo, psoriasis 
and leprosy, and so forth. Even yet we put together certain syphilides 
and certain tubercular eruptions, and these again with other skin 
affections, and so on; and convenience, as I have said, may often con- 
tinue for a while an arrangement which began in ignorance. 
As our insight, however, becomes more penetrating, we detect re- 
semblances more and more profound, and very commonly profound 
resemblances between diseases so unlike on the surface that we may 
hesitate at first which signs to follow. In the biological sciences, how- 
ever, classification consists in the discovery of the profounder resem- 
blances which have a wider bearing and indicate the remoter genetic 
origins. Clinical diagnosis, however, is not investigation - a distinction 
some practitioners forget; diagnosis depends not upon all facts, but 
upon crucial facts. Indeed we may go farther and say that accumula- 
tion of facts is not science ; science is our conception of the facts : the 
act of judgment, perhaps of imagination, by which we connect the 
unknown with the known.1 As pathology advances we detect still 
deeper affinities, still more permanent qualities in disease, and we form 
more natural classifications - classifications, that is, which depend less 
and less upon those superficial characters which are more likely to be 
products of accidents ; diagnosis is the art of placing any given morbid 
group in the class to which at bottom it is most akin. 
An explanatory classification of disease must rest, then, upon such 
an analysis of all life, whether animal or vegetable, as may enable us 
to trace the more intimate processes of disease, beginning with those 
of widest generality and moving onwards to the more complex. Fever, 
for example, is a symptom group of wide generality, and may be found 
in its degree no doubt in all warm-blooded animals, possibly in 
all animals which possess a nervous system; biologists have, indeed, 
inquired whether even in plants, or parts of plants, oscillations of 
1 "We cannot describe a fact without implying more than the fact" (J. S. Mill, 8. of 
L., vol. ii. p. 189, ed. 1872). Whewell repeatedly enforced the same truth, saying that 
comparison precedes induction, and that every record of an observation implies a com- 
parison {Phil. Ind. Sci.f INTROD UCTION 
XXVII 
temperature inco-ordinate with that of the surrounding medium may be 
detected during rapid changes of the tissues. A local disengagement of 
heat is a factor of inflammation rather than of fever, which latter term 
is more properly applied to the irregular propagation of heat waves in a 
system integrated by blood-vessels and nerves. There is a point where 
differentiation of fever from inflammation has not begun-where destruc- 
tive changes for lack of integrating machinery cannot maintain their 
balance by diffusing their vibrations; when component parts fight as 
individual members or clans, and not yet as a national regiment. In- 
flammation, then, is even a more general term than fever. 
Proceeding farther we find that fever forms part of a large group of 
maladies within which sub-groups are made according to more and more 
special differences. Broussais, deplorable as was his teaching on its' 
therapeutical side, destroyed the idea of Fevers as several morbid enti- 
ties: an immense service to nosology. We now know that cow-pox and 
small-pox, widely different as they superficially appear, must be classed 
together, because the processes in the cow and in men follow like initial 
causes; although, owing to differences in the media, they reach the sur- 
face in widely different forms. Within the memory of living physicians 
Mr. Hutchinson and others have impressed upon us that syphilis, widely' 
eccentric in its superficial aspects, profoundly resembles such febrile 
diseases as scarlet fever and its kin, and is to be classified with these. 
The various phases of tuberculosis have still more recently been fitted 
into a serial order [yide art. " Tuberculosis and the malady as a 
whole carried into the same class of syphilis, small-pox, scarlet fever, 
leprosy, and so forth, - a class presenting the widest differences in the 
superficial features of its members. Tuberculosis and syphilis are now 
indeed recognised as the most exemplary instances of a nosological 
series " of which we have cognisance. 
When we turn to consider the forms in which diseases present them- 
selves to the eye, we shall find that, even within the limits of the most 
definite kinds such as small-pox, no two cases are identical; anil in kinds 
of more aberrant habit, such as syphilis, the unlikeness of cases is so 
marked that many of the various phases of this protean malady have 
been fitted into the series within the last few years. We must not 
suppose, indeed, that our observation of this series is even yet complete. 
For not only may corresponding members of two or more series of morbid 
phases differ in degree, but one or more members of the series may be 
absent - scarlatina may occur without rash, whooping-cough without 
whoop, angina pectoris without pain, migraine without headache, and 
so forth. Only by a study of genetic affinities can we dispose such 
cases in proper serial order; and some symptom groups, no doubt, are yet 
undistinguished, or if distinguished, are not yet placed in a series. The 
obscure series which we call gout may yet receive many more affections 
within its limits - attributions perhaps as unexpected as was that of 
" pathologists' warts," when this deformity appeared in the series we call 
tuberculosis. Many skin diseases have yet to find their places in series of XXVIII 
SYSTEM OF MEDICINE 
affinity, places which will be found for them when their causation, im- 
mediate and remote, is better comprehended. A description cannot, of 
course, be complete until our knowledge of morbid processes is complete, 
indeed, classification by genesis, being the expression of the order of our 
thoughts, is but the form of such knowledge, and it is by the study of 
aberrant processes that we may often detect the more intimate kinships. 
When morbid affections are all plotted out in serial order the number 
of such series may turn out not to be large, and the fashions of disease 
may indicate the several lines of cleavage or paths of least resistance in 
each organism or class of organisms. 
If I may convert Whewell's fine figure to my present purpose, I will 
compare the field of disease to a large woodland country in which woods 
are seen of various sizes and kinds occupying hills or valleys in several 
masses; in places the confines are definite, in other directions smaller 
tufts of trees and scattered trees so diversify the intermediate tracts 
that we cannot precisely say where one wood ends and another begins. 
So again in respect of the kind of trees: on the limestone uplands we 
may see beech, fir on sandy knolls, elm and oak in the loam or clay of 
the lowlands, yet even of these kinds it may be hard to mark the limits, 
so gradually may clay pass into sand, or sandy clay blend with the lime 
into marl. So likewise with the various distribution of the waters we 
find other changes in the character of the vegetation, whether of the 
trees, of the shrubs, or of the herbs, which again confound the superficial 
observer by apparent caprice. Yet to one who has penetrated to the 
underlying facts of causation that which seemed confusion falls into 
order. 
Once more; as these underlying and antecedent conditions of land 
and water do not fall apart or together by haphazard, but are likewise 
obedient in their turn to yet profounder series of antecedent changes, 
so oak, elm, beech, pine, and the rest are not flung together pell-mell, 
but grow in divers groups, which are repeated again and again wher- 
ever the underlying conditions repeat themselves, though never perhaps 
with identical repetitions: so the groups of symptoms which we call 
disease, if never identically repeated, because their antecedents may 
never be identically repeated, yet tend,-as I have said, to manifest them- 
selves in sets or in recurrent series of approximate resemblance. Now 
the forester, if ignorant of causation, yet learns to note the recurrence of 
these patterns, and the discovery is valuable to him for many practical 
reasons. By his practised eye the various contents of a group of trees 
would be thus recognised at once from previous experience, and he would 
be disposed to set up types in his mind, types of the natural associa- 
tions of trees and plants with which he is already familiar. He might 
give names to these recurrent groups, as we name our symptom groups, 
and would speak approvingly or disapprovingly of individual groups as 
his convenience was favoured by the sum and qualities of the several 
kinds of trees which enter into them. Aberrant and defective groups 
would offend his practical mind, and he would gladly have all conform- INTRODUCTION 
XXIX 
able to his main patterns, that descriptions and recognitions might for 
practical purposes be more easy. 
Thus nosologists have been disposed to set up ' ' Types, ' ' and to look for 
the repetition of these types for purposes of recognition and practical uses. 
If by the word "type" we mean no more than a prevalent and 
recurrent group, a common order of symptoms, we may thus refer 
diseases to types. But we run into two dangers by so doing: we tend 
to undervalue diversities and the teachings of diversity, fixing our eyes 
on the nuggets and forgetting to test the "tailings"; moreover we 
keep up the error connoted in the word " type," which comes down to 
us from the Platonist schools of philosophy. Diseases are not cast 
in a mould; nor would any one now affirm that behind phenomenal 
groups there exists a transcendental type towards which any par- 
ticular embodiment is an approximation; although biologists of 
the school of Owen used language very like it not long ago, and 
the language of some of us, even if we do not talk of the "archi-" 
or "schematic mollusc," implies the same thing still. We use the 
words " type " and " typical " too often, and bring with them something 
more than the notion of a mean-some sense of approximation to or 
falling away from a standard or conceptual model. Teachers who would" 
deny that they apply the term " scarlet fever " to a type in the sense of 
an ideal standard, yet themselves use and allow their disciples to use 
the word " type " in such a sense. On every page of a student's 
note-book we see the phrases " a typical case " or a " non-typical "; by the 
former some students seem to indicate a complete case, one, that is, which 
presents every symptom ever seen in the disease, others a case presenting 
a mean of them, and better called an ordinary case; others such a case 
as their teacher or their book sets forth; and lurking in the minds of 
most of them is the notion that there are real standards, or architypes, 
to which disease ought to conform, a notion which tends to blind them 
to the continuity of nature and the modes of causation. Description 
by " type " lends itself, then, rather to the epic of disease as presented 
in those "systematic" lectures on medicine which are mischievous to 
beginners, and except in the hands of teachers of fresh and original 
gifts, do on the whole more harm than good, preferring academic 
reasoning and pictorial description to the place of immediate observation 
and measurement at the bedside or in the laboratory.1 
Of the confusion which this term brings into our thought the dis- 
cussion on " change of type in disease " is an example. Physicians try 
to conceive some standard to which a disease approximates, so that a 
change of type means generally a change of the features of this figment 
in the mind of the speaker. Thus there are as many types of disease 
as there are varieties of individual imagination. A change of type in a 
scientific sense is a " pseud-idea " - one which eludes analysis and defini- 
tion. If we thoroughly realise that diseases are but so many attitudes 
1 Vide excellent remarks on systematic lectures on medicine by Sir J. Russell Reynolds 
in his Address to the British Medical Association in London in 1895. XXX 
SYSTEM OF MEDICINE 
of men we realise the correlative of this that there can no more be a 
standard pattern of disease than a standard pattern of man. That the 
functions even of a peculiar sort of man - Englishmen or Frenchmen, 
let us say - preserve a constant centre of gravity is highly improbable, 
as improbable as that circumstances should be permanently uniform, or 
that differential evolution should bring about no changes in the relative 
values of component organs inter se.1 Man, even the most secluded and 
protected of mankind, has advanced or retrograded, and at various rates 
of acceleration; it has never been alleged, even of an Andaman islander, 
that he has stood still. I conceive that in the minds of the able and 
accomplished physicians who somewhat polemically declare that" disease 
has not changed its type " there survives still - if unconsciously to them- 
selves - a belief that disease is an entity which so dominates mankind 
and its circumstances as to impress a large measure of uniformity upon 
the phenomena of their interaction. Otherwise it seems to me they 
would hesitate to assert that every perturbation preserves a constant 
mean rate, and every deflected molecule a constant mean distance from 
a centre of gravity which never shifts. 
Yet, if we teach ourselves to regard diseases as oscillations of actual 
men and women, to assume a constancy of these attitudes is to assume 
a constancy of the kinds and generations of men, and a constancy of 
the circumstances under which they live. If the whole argument be 
not a dispute with windmills, at any rate it will not do in the same 
breath to denounce the mischief of " modern civilisation." 
What ought physicians to mean, then, when they speak of types; 
and what shall we lack if this term be denied to us ? 
Now, in any disease, the more closely a particular symptom is con- 
cerned with the functions of the organ affected, the more frequent will 
be its occurrence. In other words, if a large number of cases in which 
a certain organ is affected were arranged in order of the intensity with 
which the direct functions of the organism are affected, it would be found 
that in the more intense cases certain symptoms were universal or very 
frequent, and that as the intensity of the infection fell off, so also did the 
frequency of the occurrence of the symptom noted. 
The organisms of individuals are variable in themselves, and are 
subject to disturbances which are not identical in each instance; but a 
large number of observed cases of any disease may be grouped about a 
certain " morbid mean," and any particular case of disease will naturally 
be compared with the "morbid mean." Any symptom may vary in 
excess of or defect from this morbid mean, and thus the morbid mean 
forms a convenient standard for expressing to our minds the set or bent 
of the phenomena. 
By a typical case, then, we ought to signify (for we use the word 
very inconsistently) a case in which the symptoms do not differ largely 
from those occurring in the " morbid mean." As parallel instances, we 
1 Vide art. on " Typhus," in which Dr. Moore tells us that this symptom group 
varies with intellectual cultivation. This is certainly my experience also. INTRODUCTION 
XXXI 
may take the variation of the stature of the men of a nation about a 
mean, or the distribution of bullet marks on a target. 
Not only this question but many others also might be explained if by 
plotting out measurable symptoms in curves we could get the mean 
intensity of each and the amount of its variability; and could determine 
whether the measures are symmetrically arranged about this mean. To 
form such a curve the measurements would be set out along the abscissa, 
and the numbers of instances as ordinates. This is, however, too difficult 
an undertaking to discuss here, even were I capable of its discussion.1 
We have also to bear in mind that the treatment of statistics is somewhat 
dangerous, unless carried out by one who has some acquaintance with the 
theory of errors; the curves might be constructed accurately, but they 
might be made and used on wrong principles. 
Again, a like traditional habit of thought may be seen in respect 
of causation itself. Students are taught on the highest authority 
to divide causes into the categories of " pre-disposing " " and exciting " - 
the " causce prevenientes" and the "causes efficientes" of the schoolmen. 
This habit is mischievous in two ways: to divide causes into stronger 
and weaker kinds keeps up that obstinate habit of men to seek in the 
word " cause " something more than an indication of invariable ante- 
cedence, something of a community of nature between cause and effect; and 
to associate with the word " cause " some notion of a casting act, of effort, 
or genesis: moreover, being a confusion of thought it breeds confusion. 
Need I say that by the causation of a thing we mean those events of 
the infinite past which preceded it - events which have no degree of 
rank or affinity, either within themselves or in respect of the thing 
under observation, and whose invariable precedence is a mere matter of 
routine experience, and not of generation, enforcement, or even of col- 
ligation. Some of the antecedent events are nearer, others are more 
remote; some vast sections of the system we take for granted, others 
which immediately concern us we quote; but there is no difference of 
quality - indeed, the same event may be called a " predisposing cause " 
at one moment and an "exciting cause " at another: a certain coccus 
on one day harmlessly traverses the lung, on the next a chill and the 
coccus together precede a pneumonia; which of the two is the exciting 
cause ? Whichsoever comes first, some one may say; but what if they 
arrive at the same moment ? The distinction is of course absurd. We 
sometimes even hear of a " plurality of causes," or that one of two or 
three " causes " might have produced a particular result. This is loose 
thinking; a certain general result - such as fever - might have been 
caused in this way or in that, but a ''case," with all its individual 
characters, could have had but one set of antecedent phenomena and no 
other. Why this is we know not; that so it is, experience hitherto has 
taught us; and upon this experience we make our forecasts. 
11 may refer the inquiring reader to a paper by Prof. Karl Pearson in the Proc. Royal 
Soc., January 24,1895, entitled " Mathematical Contributions to the Theory of Evolution ; " 
although this paper is not written with a view to medical applications, yet the principles 
set forth in it underlie all applications of the method. SYSTEM OF MEDICINE 
XXXII 
Another otiose distinction is made in the formal separation of signs 
and symptoms - signs being matters rather of direct, symptoms of 
inferential notation. The adjective " physical " makes matters worse, 
and yet I have heard many a student worried by such distinctions, and 
have even seen questions on the distinctions in an examination paper! 
A cough or a pale cheek is of course as much a 11 physical sign " as a 
mitral murmur; everything that befalls a patient is a " symptom," and 
his symptoms are the signs of his malady. Strictly speaking, health is a 
symptom group as well as disease, and this we must remember although 
common usage restricts the word to morbid incidents. 
From what has gone before it becomes evident that all efforts to 
define diseases fully are in vain. The love of definition conies from the 
Socratic School,1 and definition is absolutely necessary to settle a use of 
words, or of certain abstract conceptions, such as line, point, molecule, and 
the like, which are used as counters in reasoning; these words and concep- 
tions are arbitrarily adopted, and their use must be made precise by the 
logician. But to define a disease is to build the wall round the cuckoo: 
natural processes' will not be thus impounded; they are infinite 
and elusive. To define is to pretend to sum up knowledge, or at any 
rate to enumerate likenesses and unlikenesses which are inexhaustible; 
we are no more in a position to define diseases than to define dogs and 
cats. The use of "definitions," like the use of "types," leads the 
student to form conceptions which interfere with his appreciation of the 
infinite variety and gradation of natural processes; like the use of 
"types," it leads to contemplation of Krankheitsbegriffen rather than 
of Krankheitszustdnde - of entia rather than of fientia. The aspects 
of disease are not to be likened to a picture gallery in which every set of 
impressions is contained within its own frame. The " definitions " of 
systematic writers on disease are of course no more than brief descriptions, 
and as such are no doubt useful as mere indications of subject matter. 
To sum up: disease is a state of a living organism, a balance of 
function more unstable than that which we call health; its causes may 
be imported, or the system may " rock " from some implicit defect, but 
the disease itself is a perturbation which contains no elements essentially 
different from those of health, but elements presented in a different 
and less useful order. Diseases, therefore, have no analogy with the 
genera and species of the biologist. They may be arranged for con- 
venience of reference by any external character, such, for example, as 
locality; but a natural classification of diseases is an arrangement 
of them in order of genetic affinity, and is a description of their 
causation. Diagnosis is the recognition of a disease already classified 
and the reference of it to its place, and thus differs from research 
or discovery. Classification is a measure of our knowledge of the 
pathology of all organisms, and a pathology limited to man, like a 
geocentric astronomy, is, or ought to be, a notion of the past. 
1 8vo 8' civ dyrboocev tis 'SwKpdret Sucalus' rotis 8' eira.K.TiKoi>s X670U, Kai rb 
KaObXov. -Arist. Met. xii. IN TH OD UCTION 
XXXIII 
The causes of diseases cannot be divided into categories; causes are 
merely the antecedent phenomena - the routine found by experience to 
be invariable. Although symptom groups tend to run in sets, yet it 
is with much inconstancy, infinite variety, and manifold transition; so 
that although a disease may be summarily indicated by some prominent 
features, yet to define it is a bootless quest; a definition cannot be 
regarded as a schedule. 
Are then symptom groups so fluid that we can have no nomen- 
clature? In so far as organisms are differentiated into systems, and 
their functions into departments, their perturbations will have some corre- 
sponding orders, and appear in groups which more or less repeat each 
other; in other words, the more complex the organism the more differ- 
entiated its symptom groups. For instance, a blow upon the head of a 
man is followed by a group of changes different from that which follows 
a blow upon his spine or abdomen; indeed, if the violence of the blow be 
given, the main characters' of the resulting group in each case may be 
foretold with some approach to accuracy. As we descend from man to 
lower animals, these results will have a more general character and their 
groups be less definite. 
Again, symptom groups can be arranged in an order beginning with 
the most general and ending with the most special. Fever, for example, 
is a group of wide generality, and is found at any rate in all warm 
blooded animals; probably heat-regulation or tissue stability is inherent 
in and conditioned by the very existence of a nervous system. The 
extraordinary manifestation of electric control in certain fishes also 
indicates to us that even cold blooded vertebrates have in electric 
regulation an analogous faculty. So far as I am aware, however, no 
experiments have been made upon local and general fluctuations of 
temperature in cold blooded animals subjected to catabolising agents, 
though tissue changes which occur under such influences are described 
by Professor Adami in his article on Inflammation in this volume. If 
fever be a member of the class of most general symptom groups, the 
elaborate automatic actions of certain human epileptics might be taken 
as instances of highly special groups of disordered functions, and 
between these extremes we may distinguish multitudes of groups of 
various stages of complexity, not by any means, as I have said, sharply 
defined one from the other, insensibly rather melting at their limits 
one into another, yet having uniformity enough on the whole to admit of 
naming in sets. " Well-marked cases " are probably those in which a like 
perturbation is felt especially by one organ, or by one set of organs; a 
uniform irritant falling precisely upon the same spot in the body must 
produce a group of events only not invariable in so far as the organism 
may be inconstant. Differences of conditions, however, which to our 
eyes are apparently very small, or even elusive, may and often do 
impress so great a change upon the features of definite perturbations in 
definite spots as to blind us to the underlying similarity of causation. XXXIV 
SYSTEM OF MEDICINE 
Not only, for example, may a morbific agent set up in one kind of mam- 
malian animal a group of symptoms bearing little superficial resemblance 
to the group set up by the same agent in another kind; but, as the 
instance of the tsetze fly, among many others, shows us, the resulting 
syndroma may have widely different characters in the several varieties 
even of the same species - nay, in individuals of the same variety 
reared under different conditions. The so-called protective inoculations 
may be cases of the same order, though the relations of artificial to 
natural immunity are not yet made clear; the former seems hitherto to 
be of a more temporary kind than the latter. 
Symptom groups, then, differ no doubt with the intimate form of 
grosser or finer parts in the various organisms, and every symptom in- 
dicates molecular disarray somewhere, could we but detect it; chemical 
and microscopical discovery, therefore, as they reveal more of such dif- 
ferences, will explain more of the variations of disease - for illustration's 
sake I may refer to the investigations of Metschnikoff, Kanthack, Hardy, 
and others on the blood corpuscles - yet we have seen already that 
variations in morbid phenomena bear no direct relation to the lines 
of obvious anatomical structure, and may vary enormously with pecu- 
liarities of organisation, chemical or other, which are so latent as 
hitherto to have escaped our analysis. If, indeed, we may properly 
appeal to protective inoculations in this place, the modified qualities 
of the contrasted animals, however recondite, may not be very profound 
or permanent. 
When speaking of classification, I indicated these difficulties and 
the labour of detecting underlying similarities between groups of phe- 
nomena apparently disparate, and I will not enlarge again upon the 
same difficulties in respect of naming. We cannot name a series until 
we have laid down the main lines of it, and as meanwhile we must make 
provisional classes, so we must make provisional names. Descriptive 
names cannot be given until we have relatively complete pathological 
explanations; but by pathological explanations I mean no more than the 
formulation of series; or, in other words, the discovery of the causation 
- of the " antecedent routine," as Prof. Karl Pearson would say.1 
Those nosologists are not unreasonable who now cry out for names 
which shall indicate pathological characters, but they anticipate our 
powers. Until we have set forth the routine of events such names are 
impossible, or only possible partially and in so far as we have made 
out some fragments of the "routine." To compare ethnology with 
pathology, let us suppose that an ethnologist of the linguistic school 
had fifty years ago discovered the Basques and called them Mongolian. 
Later ethnologists, putting language in a much lower place as a test of 
race, would supplant this name by another - say by the present name, 
" Basque." No sooner is the former name uprooted, and the new name 
affixed, than comes the craniologist to tell us that this people is of 
mixed race, and that distinctive names for at least two stems are 
1 Grammar of Science. London, 1892. INTRODUCTION 
XXXV 
required, and so forth. Now, names are not easy to attach, and 
when attached are still harder to get rid of; moreover, in the sup- 
posed instance, the name " Mongolian " would, during its existence, not 
only be defective as an index of quality, but positively mischievous as 
teaching some positive error - the name " Basque," on the other hand, 
which conveys no ethnological meaning, being in this respect a better 
one. 
Thus it is in the nomenclature of disease; to give pathological 
names prematurely may be to teach error immediately and persistently. 
By the illustrations I have used above, I have indicated that pathology 
has yet formulated but few series or even large segments of series of 
ordinary morbid phenomena. Events and startling features of the 
greatest import to us and to our patients come before us daily, and 
many times a day, and cannot be linked on to any other groups with 
which we are familiar. 
Before permitting ourselves, then, to fix names significant of current 
hypotheses upon symptom groups not even half understood, may it not 
be well, until our knowledge is enlarged, to wait and be content with 
some name that is but a label ? Nay, it is undesirable even in our 
merely provisional and descriptive names to connote too much; in so 
doing we may combine parts of different series the concurrence of which 
is accidental. Take, for example, the disease often called exophthalmic 
goitre ; this name, given descriptively, is bad because as a descriptive 
name it postulates two events, either of which may be absent from the 
group, while it omits the cardiac events which are at least of equal im- 
portance. Had a pathological name been given matters would have been 
worse still, seeing that at least three mutually exclusive hypotheses are on 
foot. Is it not really more scientific after all to be satisfied for a time 
with such a name as " Graves' disease," which sufficiently indicates the 
inconstant group of events we have in view, and commits us neither to 
a fixed order in the group nor to any premature classification ? Every 
physician, again, in his tractable moments will admit the usefulness of 
such a name as " Bright's disease " which, until the pathology of kidney 
disease is better understood, saves us from tossing on the conflicting 
currents of interstitial, of glomerular, or of tubular nephritis. Dr. 
Dickinson, in an article in this work, has deliberately preferred the 
name Lardaceous Disease as one which in the present state of our 
knowledge commits us to no " notiones temere a rebus abstractse." 
But, it is argued, these names may confer an immortality on the 
wrong man! Well, oblivion blindly scattereth her poppies: yet after 
all, is this often so? These names may occasionally violate the strict 
order of priority in discovery, as do the names of capes and islands ; but 
the man who attaches his name to a discovery usually deserves it. If 
the New World had been called after Columbus, neither Sebastian 
Cabot nor Amerigo Vespucci would have had reason to complain. 
Neptune had often been observed before it was " discovered "; and a 
recent writer happily said concerning Fraunhofer's lines, " Wollaston XXXVI 
SYSTEM OF MEDICINE 
saw them, but did not discover them." There were Brights before 
Bright, no doubt; but the great Guy's physician worked out that which 
previous observers had not genius or energy enough to reveal to mankind. 
And, after all, these names are, as I have said, but provisional 
tickets, and by no means always dedicatory - as measles, shingles, 
epilepsy, and the like. Such a label as " Graves' disease," when it has 
served its temporary purpose, will give way to a pathological name 
when the series is discovered in which this malady has its place, and its 
position in that series is plotted out. Are nosologists so ignorant, then, 
that as yet we can have no scientific nomenclature ? Can none of our 
names be an intellectual instrument ? By no means; but we must be 
content to give such instrumental names to the simpler diseases, and 
thence cautiously to the more complex, remembering that to name 
scientifically a disease of complex causation is to suppose that pathol- 
ogy has advanced far beyond its present stage. 
Meanwhile, beside the ticket names, we have some, such as chorea, 
which, although given in ignorance of the nature of the malady, are 
fairly well descriptive; paralysis agitans is another good name of the 
kind; anatomical names also, such as bulbar palsy, disseminated scle- 
rosis, and the like, are largely displacing those descriptive of symptoms 
- displacing, I say, and not superseding, because symptoms will prob- 
ably hereafter be grouped under general and special heads from a 
clinical point of view, such as modified movements, modified sensations, 
modified reflexes, modified secretions, and so forth. But with all this 
we should fall short of any indication of general pathological characters 
- for instance, mischief in one anatomical seat, say in a joint, may be 
primarily of traumatic, chemical or microbic causation, and yet at cer- 
tain stages produce similar modifications of motion and sensation. 
Identical or closely similar results may be reached from distant, and 
even widely different starting-points; and we come back to the conclu- 
sion that in respect of most diseases we are ignorant of the series to 
which they belong. We can give a clinically descriptive name to " gen- 
eral paralysis "; or we can pathologically call it " chronic encephalitis," 
but we have not learned to what series - syphilitic or other - it be- 
longs ; and until we know this we cannot finally name it. 
A name is not complete, therefore, unless it indicate the tissue ele- 
ments primarily engaged, and the series of which the affection forms a 
part. But the subject is far too extensive and various, and our knowl- 
edge too small to make it profitable to pursue the matter further in this 
place; indeed it cannot be fully discussed without a survey of that 
field of comparative nosology - of the symptoms and the causes of 
them in all organised beings - the exploration of which is scarcely yet 
begun, unless it be in respect of certain diseases of animals and plants 
which interfere with our industries. Pathology itself remains in 
much the same merely "anthropocentric" and descriptive stage as 
was anatomy fifty years ago; but its morphological stage is already 
initiated. INTRODUCTION 
XXXVII 
Of our Terminology I have little to say - technical terms are more 
fluid than names, and are undergoing continual modification as our knowl- 
edge increases. As Dr. Kanthack incidentally discusses some weak 
points in our terminology in his article on the General Pathology of In- 
fection, I will not speak so fully as I had intended on this subject. 
The improvement of our terminology is much impeded by the loose 
clinical slang which too many teachers allow their pupils not only to use 
at the bedside, but to enter in their case-books also. Colloquial vulgar- 
isms, effete terms of logic, relics of humoralism and pseudo-scientific 
phrases, make up a large part of the language of the wards, and so long 
as our teachers countenance, and even themselves use such slovenly 
language, so long will students be content with it. It is but fair to add 
that Medicine is not a subject in which terminology and nomenclature 
find their best exemplification: the matters of our inquiry, not having 
relatively fixed specific characters, do not lend themselves as yet to the 
construction of an appropriate terminology. If, for instance, we seek 
to affix a constant termination, such as " itis," to signify all kinds of in- 
flammation, we are met by the inconstancy of the meaning of the term 
" inflammation," and by its possible confusion with the encroachments 
of competing tissues and with acute degenerations. We cannot yet say 
when fibrosis is " inflammatory " in origin, or when, on the other hand, 
it may be relatively atrophic, for we are also uncertain in our use of the 
terms atrophy or hypertrophy. Still there is no reason why in the near 
future these terms should not be better defined. I am not without hope 
that the work of Professor Adami and Dr. Mott in this volume may go 
far to help us on our way. 
To illustrate at length the looseness of our terms, and the errors 
which arise from the equivocal use of any of them, were an undertaking 
far beyond the space at my disposal. The student finds his notorious 
security in terms,1 because he has not learned that one term does not 
always carry one and the same meaning. As Mr. Grote has said, 
no part of the Platonic writings is more useful than those Dialogues in 
which the disputant is forced to feel how imperfectly he understands 
the phrases in common use. But it was reserved for Aristotle to 
recognise "equivocal terms" as a class, ajid to assign to them a par- 
ticular name. Until we are at one in our use of terms we cannot 
formulate propositions as true or false; we cannot, that is, combine our 
terms as subject and predicate. As was said of another matter, medi- 
cal discourse and medical literature are " pervaded by assumptions " : I 
would therefore earnestly appeal to all bedside teachers to compel their 
pupils to look every term well over as it comes to them ; to scrutinise 
it obversely, reversely and edgewise before using it as currency. As 
things are, candidates for degrees use arguments based upon equivocal 
terms, shelter themselves under phrases which save them the trouble of 
1 Need I quote from Faust the well-known lines ? - 
" Denn eben wo Begriffe fehlen . 
Da stellt ein Wort zu rechten Zeit sich ein." XXXVIII 
SYSTEM OF MEDICINE 
thought; and are disposed to feel as injured as Thrasymachus if these 
current phrases are challenged. 
I have spoken of the causation of disease; I have shown that diag- 
nosis is the practical aspect of classification ; I will now conclude with 
a few words on Prognosis. 
A living being is found in a given abnormal state (diagnosis); we 
have then to find how this came about (aetiology) ; and, thirdly, we have 
to foretell the state in which the creature will be at a given future time. 
Such forecasts are already possible when we deal with large numbers. 
If we wish to know the mean duration of life in a young man of twenty 
years of age we have tables at hand which will inform us; if any par- 
ticular young man be associated with a sufficiently large number of 
others like himself, we can deal with him on a definite "curve of 
frequency." 
But when a particular patient comes to a physician he is not satisfied 
to know the mean expectation of a thousand sufferers in his case, but 
he will insist upon knowing the future part of the curve of his own in- 
dividual phases. If he present himself before a physician of large 
experience he will get some such estimate - an estimate fallible, it is 
true, but in many cases having sufficient probability to justify the 
patient in laying out his plans for the future with some confidence. 
Now, how is this attained? Let us go a step farther, and consider 
a sub-class of the young men aged twenty, namely, young Englishmen; 
we may still find statistics for this purpose, and give an estimate of the 
mean duration of life in this sub-class. Suppose that we go a step far- 
ther still, and construct a class still more subordinate, namely, of young 
medical students, or of young medical students in a certain university, 
or of young medical students classed as students, oarsmen, or cricketers, 
and we may still find something like statistics to guide us. But in thus 
subdividing our classes, we shall soon arrive at sub-classes for which 
registered statistics are no longer available - the numbers are too few, 
the cases too special, or they have not been tabulated. Thus we 
approach the prognosis of individual cases, and rely more and more 
upon the quality of the observer. In discussing this matter with Dr. 
Venn, it appeared to us, nevertheless, that the method is still one of sta- 
tistics - one of conscious or unconscious abstraction, based upon numeri- 
cal summary. The accumulated experience, although not formulated, 
is nevertheless an accumulation of records of cases - cases recorded 
imperfectly, it may be, but written upon the memory of a skilled 
observer, and of these the observer more or less automatically strikes a 
mean when called upon to estimate the expectation of a given life, or 
of particular events in the life. The observer may rely more upon his 
note-books, and make a calculation dependent upon their fulness and 
accuracy; or he may rely rather upon an acquired instinct bred of 
accumulated impressions upon his senses, and dependent upon the 
tenacity of his memory and the quickness of his observing faculties: 
still in either case - whether the judgment be more automatic or less INTRODUCTION 
XXXIX 
automatic - it is based, in the last analysis, upon statistics, and the 
result has the more validity as the number of observed cases increases. 
Again, this acquired judgment does not wholly die with the indi- 
vidual.1 The instructed observer formulates certain middle axioms 
which he illustrates at the bedside before his pupils: using these with 
discrimination, his pupils revise, confirm or modify them; and thus 
something like a body of quasi-statistical knowledge is handed down 
from generation to generation. As observation becomes more accurate, 
as the number of observed cases increases, and as classes are better 
and better distinguished, the nearer will the physician be able to 
approach an accurate prognosis - though the time when any suffi- 
cient rule can be applied to individual cases must long be out of our 
sight; and the application of any approximate rules must long be sub- 
ordinate to the instinctive tact of the educated physician himself, who 
alone can apprehend the sum of the peculiarities which must modify 
their application to individual instances. Like the so-called cumulative 
photographic image which results from the blending of many superposed 
faces of the same kind, there grow up before the mind's eye of the edu- 
cated physician, images of this morbid facies, and of that, to which he 
refers individual instances; and he pronounces his opinion of the state 
and probable future phases of individuals as these severally vary this 
way or that from the standards within himself. 
T. CLIFFORD ALLBUTT. 
1 Dr. Venn writes to me on this passage as follows: - "I think this is very important. 
I have often been struck by the way in which an apparently subjective judgment can 
be perpetuated, as an almost objective standard, within some specially trained class of 
persons, who are in frequent communication. In order to avoid frequent interruption of the text, the Editor has only inserted 
the numbers indicative of items in the lists of "References" in cases of emphasis, 
where two or more references to one author are in the list, where an author is quoted 
from a work published under another name, or where an authoritative statement is 
made without mention of the author's name. In ordinary cases an author's name is 
a sufficient indication of the corresponding item in the list. DIVISION I 
PROLEGOMENA 
VOL. I 
B MEDICAL STATISTICS 
In this paper the term "Medical Statistics" includes statistics of dis- 
eases in their relations to etiology, symptomatology and results, as 
derived from comparisons of records of cases of such diseases. It will 
also be necessary to consider some of the results of mortality statistics, 
derived from a comparison of the number of deaths in a given time with 
the number of people among whom such deaths occurred; and of mor- 
bidity statistics, derived in like manner from comparisons of the num- 
ber of cases of disease occurring in a given population in a given time; 
in a broad sense, the term medical statistics no doubt includes both 
mortality and morbidity records. 
The essential difference between the methods of medical statistics 
and those used by the vital statistician is that the former have usually 
no reference to population data. The medical statistician inquires how 
many cases of pneumonia, or of consumption, or of Bright's disease have 
been under observation; what proportion of these have been of certain 
ages, or races, or occupations; and what proportion have recovered or 
died under certain modes of treatment: but, as a rule, he has no data to 
show the number of cases of pneumonia occurring among a given num- 
ber of people who are between forty-five and sixty-five years of age, he 
cannot therefore deal with ratios to population, which are the basis of 
most of the work of the vital statistician, who would inquire as to the 
relative probabilities that an Irish male between forty-five and sixty-five 
will have pneumonia as compared with a German male of the same age 
group; or that a plumber between twenty and forty years old will con- 
tract pulmonary phthisis as compared with a carpenter of the. same age. 
The physician finds from hospital records that in each 1000 cases of 
cancer in males a greater number occur in persons between the ages of 
fifty-five and sixty-five than in any other age group; while the vital 
statistician, from the records of deaths, finds that the mortality from 
cancer steadily increases with advancing years up to the age of ninety, 
and concludes that the reason why there are few cases of cancer in 
people seventy-five years of age and upward is simply because there 
are comparatively few people of that age. In the tabulation of the 4 
SYSTEM OF MEDICINE 
returns of cases of acute rheumatism in the Collective Investigation 
Record it is shown that of the 655 cases recorded 71 were in domestic 
servants, 16 in agricultural labourers, 10 in grocers, etc., and the con- 
clusion is drawn that domestic servants are especially liable to rheuma- 
tism, and that this may be due to their greater use of alcoholic drinks. 
Such a conclusion has no basis in the figures, because we know noth- 
ing of the proportion of domestic servants attended by the physicians 
who made the reports, to the total number of these servants in exist- 
ence, or to the number of servants who had rheumatism. The utility 
of medical statistics has not been so great as was hoped by Louis and 
others. As applied to the study of a disease it is necessary that the dif- 
ferent observers who furnish the records shall be referring to substan- 
tially the same disorder of structure or function - that is, there must be 
a tolerably definite series of symptoms, such as occur in specific diseases 
and acute affections of particular organs. The statistical method is 
most applicable, and has proved most useful in surgical cases. With 
improved methods of diagnosis, the possible utilities of medical statis- 
tics are becoming greater; evidently little could be done with statistics 
of fevers before the differences between typhus, enteric and relapsing 
fevers were known; but, on the other hand, when we have discovered by 
experiment that a given result must follow a given cause, a few repe- 
titions of such experiments give as great a degree of certainty as would 
several thousand. Statistics are useless to prove that chalk will be de- 
composed by sulphuric acid, and they are now of little value in discussing 
whether tuberculosis be caused by a particular form of bacillus; but they 
are the only means yet available for determining the varying degrees of 
immunity against this bacillus possessed by different races. 
The causative influence of a given condition upon the results of a dis- 
ease can only be calculated approximately, because we can never be sure 
that the sum of all other conditions which might influence the result re- 
mains the same in the different cases investigated; but much may be 
done to estimate the effects of the different conditions of the living body 
and of its environment upon disease, provided that we can obtain a suf- 
ficient amount of data to enable us to come within the limits of the law 
of probable error. This matter of the probable or possible error of 
ratios in relation to the magnitude of the figures from which they are 
derived should be kept in mind in the use of medical statistics. The 
most convenient method to estimate it is by what is known as " Pois- 
son's formula," as follows: - 
m , o 2mn .... . „ 
- ± 2\-- = possible variation m proportion of m to q. 
q » qs 
q = total number of events. 
m = number in one group. 
n = number in the other group, so that m + n = q. 
For example, suppose that in 1000 cases of typhoid fever in whites MEDICAL STATISTICS 
5 
100 die, while in 1000 cases of the same disease in negroes 95 die, what 
is the probability of the conclusion that this disease is less fatal in 
negroes than in whites ? 
By the formula - For the whites, q = 1000, m = 100, n = 900, 
and the possible variation in the ratio or 04 is plus or minus 
2 Vioqq^qqq^qqq = '^68, so that the death-rate might be from 04268 
to 0'0732, i.e. from 127 to 73 per 1000. By the formula-For the negroes 
the possible variations in the ratio - is 2 -1^1,950-_ .Q2Q2, 
1000 V 1,000,000,000 ' 
so that it might be either 04212 or 0'0687, i.e. from 121 to 69 per 
1000. 
The figures are therefore too small to answer the question definitely 
as to influence of race. But if of 1,000,000 cases in whites 100,000 
die, and of a similar number in negroes 95,000 die, then the probable 
error for the whites becomes + or - -000424 - or from 100'424 to 
99'576 per million die-and the probable error for the coloured becomes 
+ or - -000414, or from 95'414 to 94-586 per million die. 
Stating these in the usual form of ratios per 1000, it would b6 that 
among the whites the death-rate is between 99-58 and 100-42, and 
among the coloured between 94-59 and 95-41 per 1000, indicating a 
definite and positive difference between the death-rates of the two races. 
A special application of this law of possible error in connection with 
the length of time covered by the data should be borne in mind in com- 
paring medical and vital statistics. The death-rates of a city of 10,000 
inhabitants for ten successive years are much more indicative of the 
relative healthfulness of the place than is the death-rate of a city of 
100,000 inhabitants for a single year, because the death-rate for a single 
year may be greatly influenced by epidemics and by meteorological 
peculiarities. 
The following table and diagram show the relative magnitude of the 
death-rates in New York, Brooklyn, Boston, Philadelphia, and Baltimore 
in each of the sixteen years from 1875 to 1890 inclusive: - 
[Table 6 
Year. 
New York. 
Brooklyn. 
Boston. 
Philadelphia. 
Baltimore. 
1875 
28'8 
26-3 
30-0 
23-5 
24-5 
1876 
26-6 
25-1 
26-3 
24-4 
24-2 
1877 
23-3 
22-3 
22-5 
20-2 
25-4 
1878 
23-5 
21-0 
22-6 
19-4 
21-1 
1879 
24-0 
21-1 
21-1 
18-6 
23-4 
1880 
26-4 
23-3 
23-5 
20-9 
24-2 
1881 
31-3 
24-7 
24-3 
22'5 
25-8 
1882 
30-0 
24-6 
23-7 
22-7 
25-4 
1883 
26-3 
21-8 
25-1 
22-2 
26-0 
1884 
26-5 
21-6 
24-3 
21-6 
22-4 
1885 
26-3 
22-7 
23-8 
22-7 
21-4 
1886 
27-0 
22-5 
22-4 
20-8 
21-3 
1887 
27-5 
23-5 
23-9 
22-1 
20-8 
1888 
27-7 
24-0 
23-7 
20-3 
21-7 
1889 
26-7 
23-7 
23-3 
20-0 
20-5 
1890 
26-4 
24-5 
23-7 
20-7 
23-4 
SYSTEM OF MEDICINE 
Rate 
Years 
1875 
1876 
1877 
1878 
1879 
1880 
1881 
1882 
1883 
1884 
31 
■ 
30 
29 
28 
/ 
27 
X 
/ 
26 
\ 
/ 
25 
i 
/ 
\ 
y*- > 
24 
v 
/ 
* *t 
t y 
23 
■ \ \ 
\ 
- 
/t 
X 
\ 
% 
\ 
22 
\ 
% \ 
t \- 
\ 
\ 
/ 
/ 
/f 
/f 
/t 
/" 
\ 
21 
\ 
\ 
\ r 
\ % 
\ r 
7 
7 
20 
\ 
\ 
X. 
/ 
/ 
19 
'x. 
/ 
/ 
18 
New York __ Boston Brooklyn 
Baltimore Philadelphia MEDICAL STATISTICS 
7 
It will be seen from this table that in all these cities the death-rates 
fell from 1875 to 1878-79, then rose until 1881-82, and then again 
declined. The influence which produced these great variations could 
not have been a local one. 
What is the normal sickness rate of a people ? That is to say, in a 
general population of 100,000, how many are constantly sick to such a 
degree as to require medical attendance, or to be incapacitated from 
pursuing their ordinary avocations ? The only sources to which we can 
look for the answer to this question are the records of the army and 
navy in different countries, of certain benefit societies providing insur- 
ance against sickness, of the police force in certain cities, of employees of 
railroads, and of the last censuses of Ireland, of the Australian colonies, 
and of the United States. 
The following table shows for various armies the number of admis- 
sions to treatment for sickness and injury per 1000 of mean strength in 
a year, the number constantly sick, the average number of sick days to 
each soldier, and the average duration of each case of sickness: - 
Armies. 
Periods. 
In 1000 mean strength. 
Sick Days to 
each Soldier 
of mean 
strength. 
Average 
Duration of 
each case of 
Sickness. 
Admissions. 
Constantly 
sick. 
Belgian army. 
1880-89 
1407 
28-3 
10-3 
7-3 
Prussian army 
1883-89 
830 
30-8 
112 
129 
Italian army . 
1878-91 
853 
34-7 
12-6 
15-7 
Dutch army . 
1884-89 
906 
37-0 
13-5 
14-1 
United States (white) . 
1881-90 
1337 
433 
15-8 
11-0 
Austrian army 
1879-89 
1185 
45-3 
165 
13-4 
British army at home . 
1881-90 
820 
46-0 
16-7 
20-4 
French army . 
1875-84 
2476 
46-8 
17-1 
6-9 
British in India 
1881-90 
1458 
730 
26-6 
182 
Coloured Troops. 
United States (coloured) 
1881-90 
1577 
44-3 
162 
10-0 
British troops (coloured 
in North India) . 
1881-90 
1035 
51-1 
18-6 
180 
British troops (coloured 
in North Africa). 
1881-90 
1736 
76-5 
27-9 
17-0 
From this table it will be seen that of each 1000 soldiers serving in 
temperate climates about 35 are constantly sick, the figures varying from 
28-3 in the Belgian army to 46-8 in the French army. It must be 
remembered, however, that these figures relate only to males of certain 
groups of ages, and of a carefully selected class of population, but of a class 
much more apt to claim exemption from duty on account of sickness 
than would be the males of corresponding ages in the general population. 
Taking the male members of friendly societies from the age of fifteen to 
eighty-five, Mr. Finlayson found that about five years of sickness occurs 
to each man during those seventy years; but the sickness occurring in 8 
SYSTEM OF MEDICINE 
men from forty-two to sixty-six years of age is almost double the sickness 
occurring in men from fifteen to forty-one years of age. From the com- 
mencement of the sixteenth year of age to the close of the sixty-sixth the 
amount of sickness averages about one and a half weeks per man. (See 
Insurance Cyclopaedia, vol. v. p. 83.) 
In the " Hearts of Oak Benefit Society," Mr. Ralph Hardy reports 
(Journal of the Institute of Actuaries, January 1894, p. 86) that from 1884 
to 1891 the total number of members was 940,224, of whom 7853 died, 
and 238,787 were claimants on account of sickness or disability. 
The following table shows for each of certain groups of ages the 
number exposed to risk, the number of weeks of actual sickness or dis- 
ability for which claims were made, and the number of weeks of sickness 
or disability per member in each group : - 
Ages. 
Number exposed 
to Risk. 
Number Weeks 
actual Sickness. 
Number Weeks 
Sickness 
per Member in 
each group. 
19 
2,007 
3,241 
•68 
20-24 
68,637 
69,370 
•75 
25-29 
178,275 
164,740 
•81 
30-34 
235,268 
249,700 
•92 
35-39 
189,502 
261,428 
106 
40-44 
135,164 
239,682 
1-28 
45-49 
75,441 
168,242 
1-65 
50-54 
29,567 
93,373 
2-20 
55-59 
14,054 
67,679 
3-13 
60-64 
7,712 
60,926 
4-74 
65-69 
3,418 
49,278 
7-34 
70-74 
1,001 
20,448 
11-50 
75-79 
169 
3,817 
16-19 • 
80 
9 
181 
5200 
All ages. 
940,224 
1,452,106 
It will be seen from this table that for those under forty years of 
age there was less than one week's sickness in each year, and that after 
this age the amount of sickness nearly doubled every ten years. 
The following table gives the results observed in 311 Italian mutual 
benefit societies as regards the sickness occurring among 254,193 males. 
(Annali di Statistica, Tavole della frequenza e durata deUe Malattie, etc. 
Homa, 1892): - 
[Table MEDICAL STATISTICS 
9 
•Ages. 
Number taken 
sick yearly per 
1000 of N umber 
observed. 
Number of 
cases of Sick- 
ness in a year 
per 1000 of 
Number 
observed. 
Number of 
days' Sickness 
to each 
Member in a 
year. 
Number of 
days' Sickness 
to each sick 
Person in a 
year. 
Average J 
Duration of 
each Sickness 
in days. 
10-15 
191 
235 
3-9 
20-3 
16-5 
15-20 
234 
276 
4-9 
20-9 
17-7 
20-25 
213 
251 
5-0 
23-2 
19-8 
25-30 
229 
266 
5-4 
236 
203 
30-35 
223 
256 
5-1 
23-0 
20-6 
35-40 
240 
278 
6-0 
24-8 
214 
40-45 
232 
273 
6-2 
26-7 
22-7 
45-50 
253 
289 
6-8 
270 
23-7 
50-55 
258 
304 
7-9 
30-7 
26-1 
55-60 
275 
328 
9-2 
33-7 
28-2 
60-65 
299 
361 
112 
37-3 
309 
65-70 
322 
404 
13-4 
39-9 
33-4 
70-75 
344 
397 
14-7 
43-0 
37-2 
75-80 
286 
337 
134 
411 
39-9 
Ave. over 10 
242 
283 
6-6 
27-1 
232 
The following table shows the number of sick and of those suffering 
from accidents, per 1000 of population, in certain states and countries, 
as found in recent censuses : - 
States and Countries. 
Years. 
In 1000 Population. 
Diseases. 
Accidents. 
Maine 
1890 
12-93 
•84 
Connecticut .... 
1890 
15-23 
•97 
Massachusetts .... 
1890 
12-31 
•93 
New Hampshire .... 
1890 
22-09 
2-41 
Rhode Island .... 
1890 
18-36 
1-04 
Vermont ..... 
1890 
28-98 
1-66 
Virginia 
1890 
16-69 
2-06 
Alabama 
1890 
15-08 
1-36 
District of Columbia . 
1890 
17-08 
1-56 
Delaware ..... 
1890 
13-18 
1-45 
Victoria 
1890 
11-36 
1-97 
South Australia .... 
1890 
10-98 
1-46 
New South Wales 
1890 
9-00 
1-34 
Tasmania 
1890 
8-00 
1-29 
New Zealand .... 
1890 
7-81 
1-23 
Queensland .... 
1890 
7-51 
1-21 
Western Australia 
1890 
4-85 
1-03 
Ireland 
1891 
7-12 
• 
•47 SYSTEM OF MEDICINE 
10 
Including women and children, it is probable that for each 1000 of 
population under ordinary circumstances, 400 are taken sick or laid up 
by accidents during the year, and that about thirty are constantly sick, 
the average duration of illness being about four weeks. ♦ 
It is usually estimated that for every case of death in a community 
there are two persons constantly sick - that is to say, there is an aver- 
age of two years' sickness to each death; or with an annual death-rate 
of 18 per 1000, the average number constantly sick is about thirty-six 
per 1000: but this estimate is probably somewhat in excess of the true 
figures under ordinary circumstances, and it should be distinctly under- 
stood that it does not apply to individual diseases, but only to the whole 
mass of diseases and injuries. The proportion of "cases constantly 
sick " to " deaths " is very different for consumption, diabetes and can- 
cer, from that which exists in diphtheria, typhoid fever and tetanus. 
The sickness ratios derivable from the data of those censuses in which 
an attempt has been made to enumerate all the sick living on the day of 
the census are evidently too small; but it is probable that they repre- 
sent very fairly the different proportions of sickness existing in males 
and females of certain groups of ages. According to the census of 1880 
in the United States, the proportion of sick to 1000 of population of 
different ages was as follows: - 
Age. 
Males. 
Females. 
15 to 25 . 
6-9 
6-8 
25 to 35 
8-6 
9-7 
35 to 45 . 
12-2 
11-5 
45 to 55 . 
16-8 
14-4 
55 to 65 
25-5 
20-4 
65 and over 
44-5 
35-3 
In the state of Massachusetts on 1st June 1890 out of a total popu- 
lation of 2,238,943 there were reported 41,512 sick and defective, of 
whom 25,490 were males and 16,022 females, giving a ratio of 23-44 
for males and 23-46 for females per 1000 of population. 
The ratio per 1000 at different age groups was as follows : - 
Ages. 
Males. 
Females. 
15 to 25 . 
9-74 
6-90 
25 to 35 
12-38 
8-84 
35 to 45 
21-80 
1311 
45 to 55 . 
57-14 
21-76 
55 to 65 
71-17 
3419 
65 and over ...... 
96-41 
60-84 MEDICAL STATISTICS 
11 
In each 1000 of the total sick and defective there were as follows : - 
Male. 
Female. 
Total of all diseases . 
623-9 
719-6 
Rheumatism 
175-8 
176-2 
Consumption ...... 
34-5 
51-3 
Cancer and tumours .... 
9-0 
36-9 
Nervous system...... 
37-8 
80-7 
Circulatory system . . _ . 
568 
70-7 
Urinary organs 
48-4 
224 
Bones and joints 
42-1 
64-8 
Total deformed, ex. spine . 
23-4 
18-6 
Total lost arms .... 
30-6 
3-8 
Total lost legs 
31-3 
6-4 
Total lame 
105-6 
84-0 
Accidents and injuries .... 
77-9 
29-3 
Paralysed 
82-2 
101-2 
There are no figures available as to the amount of sickness among 
children, but it is probably much greater among them than in adult life, 
corresponding generally to the greater mortality of the earlier years of 
life. 
It is not probable that anything like complete returns of sickness will 
be obtained in the near future for any large body of the general popula- 
tion. The registration of diseases will be confined to infectious and 
spreading diseases - that is to say, to diseases which are known or 
supposed to be preventable - and the more unusual the disease the more 
likely is the registration to be complete. In England and the United 
States, nearly all cases of Asiatic cholera, small-pox and yellow fever will 
be registered, while the registration will always be defective for such 
diseases as measles, scarlet fever, diphtheria and typhoid fever. The 
only means then at our command for calculating the number of cases of a 
given disease, occurring in a given community during a given time, is by 
taking the number of deaths reported as due to that disease, and multiply- 
ing this by the ratio of deaths to cases, a ratio obtained from hospital 
and other medical records, being what is called the " case mortality." 
This method contains many sources of error. Many forms of disease 
which render life more or less of a burden seldom or never appear in 
the registration records as a cause of death; while even of those diseases 
which are reported as the cause of a considerable proportion of deaths, 
it is usually impossible to establish any definite and certain relation 
between the number of cases of the disease and the number of deaths 
reported even for the acute specific diseases, such as scarlet fever, 
measles, yellow fever, etc. The mortality varies greatly in different 
epidemics, such variations appearing to depend partly upon particular 
conditions of the specific micro-organisms to which such diseases are 
generally attributed, and partly upon particular conditions of the people, SYSTEM OF MEDICINE 
12 
and the environment as to race, density of population, temperature, 
moisture, etc. For example, in 1867 yellow fever entered the United 
States by two distinct routes - one from Vera Cruz, and the qther direct 
from Havana. At that time the United States had troops along the 
southern border of the country, and hence we have a series of returns 
showing both the number of deaths and the cases of sickness from this 
disease in a given population. Now in those places where the disease 
was of Mexican origin, the cases were more fatal than in those where it 
was of Cuban origin; the ratio of deaths being 400 per 1000 cases for 
the first of those groups, and 284 for the second.1 
The statistics of diseases with reference to their etiology, using this 
term in its widest sense, have attracted much attention within the last 
fifty years, but the data have been derived mainly from mortality 
statistics. The immediate, or so-called efficient causes of disease are 
physical or chemical agents, micro-organisms, or sensory impressions 
leading to disordered brain action; but these agencies produce different 
effects in different persons. The same exposure to cold may give rise in 
one man to coryza, in another to pneumonia, in a third to rheumatism, 
in a fourth to diarrhoea, and in fifty others to no apparent disturbance 
whatever. The hsematozbon of malaria, the bacillus of tubercle, or the 
bacillus lanceolatus, produce their specific effects in some people but not 
in others. 
If the axiom that " like causes, under like circumstances, produce 
like effects," be as true for the living human body and all its parts 
as it is for a laboratory experiment in chemistry or physics, it follows 
that the different results as to production of disease brought about by the 
same immediate cause must be due to differences in the circumstances 
- that is, to differences in structure and function of the human beings 
upon which they act. 
These differences may be inherited and innate, or connate without 
being inherited, or acquired after birth; and are indicated by such words 
as temperament, diathesis, idiosyncrasy, immunity, acclimatisation, etc. 
That such differences exist is well known to every physician, and he 
takes them into account in diagnosis, prognosis, and in hygienic and 
therapeutic advice. He knows, for example, that delirium in specific 
fevers has a very different significance in certain families from that 
which it has in others; that malaria and chorea affect the white more 
than the black or yellow races ; but as yet we have little definite scien- 
tific information as to the relative effect and importance of such circum- 
stances upon liability to, or effects of different forms of disease. Such 
information can only be obtained by comparing a large number of cases 
by statistical methods to see if any general laws can be deduced there- 
from, and then studying individual cases or groups of cases which form 
an exception to these laws. 
The influence of age upon mortality is well known, and, through the 
1 War Department, Surgeon-General's Office, Circular No. 1, p. xviii. MEDICAL STATISTICS 
13 
labours of W. Farr and other vital statisticians, it can now be expressed 
in mathematical terms, not for any single individual but for the aver- 
age of a large number of people, by means of life tables. It may be 
summed up in the law of Gompertz, as modified by Makeham, namely, 
that after the age of puberty the vital power of the organism, or the 
sum of its powers to resist death, diminishes by a series consisting of 
the sum of two terms, one of which is a constant quantity, while the 
other increases in geometrical progression. 
It is evident that the same law must apply to a considerable extent 
to sickness, and we have shown above that sickness rates vary with age 
very much as mortality rates do. The dominating influence of age 
upon sickness and mortality is usually not sufficiently appreciated by 
medical men who prepare and publish statistical records of hospitals or 
dispensaries. It is hardly possible to draw useful conclusions as to the 
mortality of most of the diseases of adult life, unless the cases and their 
results are given by age groupings. 
The following table, compiled from the records of eighteen hospitals 
for the last fifteen years, indicated the differences in the fatality of 
certain diseases in patients of different ages: - 
[Table SYSTEM OF MEDICINE 
14 
Ages. 
Pneumonia. 
Typhoid Fever. 
Consumption. 
Diphtheria. 
Cases. 
Deaths. 
Rate per 
100 
cases. 
Cases. 
Deaths. 
Rate per 
100 
cases. 
Cases. 
Deaths. 
Rate per 
100 
cases. 
Cases. 
Deaths. 
Rate per 
100 
cases. 
0-10 
2273 
246 
10-8 
363 
30 
8-2 
43 
20 
46-5 
1251 
725 
57-9 
10-20 
6076 
501 
8-2 
3787 
491 
12-9 
4,278 
1984 
46-3 
148 
33 
22-3 
20-30 
8726 
1342 
15-3 
4801 
818 
17-0 
14,504 
7101 
48-9 
166 
17 
10-2 
30-40 
5644 
1242 
22-0 
1170 
295 
25-2 
11,446 
6351 
55-4 
40-50 
4107 
1242 
30-2 
352 
118 
33-5 
6,282 
3627 
57-7 
50-60 
2811 
1134 
40-3 
133 
54 
40-6 
3,386 
2003 
59-1 
60- 
2548 
1456 
57-1 
32 
21 
65-6 
1,635 
1028 
62-8 
.... 
This table includes 32,185 cases of pneumonia with an average or 
gross death-rate of 22-25 per cent. It shows, however, that the propor- 
tion of deaths steadily increased from 8-2 per cent in the cases between 
ten and twenty years of age, to 57 per cent in the cases sixty years of 
age and upward; hence the giving of gross death-rates only for a few 
dozen, or even a few hundred cases of pneumonia, to show the influence 
of a particular mode of treatment, is almost useless. The same increase 
in the death-rate with increase of age is shown in typhoid fever, the 
gross death-rate for the 10,638 cases reported being 19 per cent of the 
cases, varying from 12-9 to 65-6 per cent in different age groups. In MEDICAL STATISTICS 
15 
consumption also the hospital death-rate increases with advancing age, 
but not to such a marked extent; while in diphtheria it rapidly falls after 
ten years of age. But the hospital death-rate in consumption given 
above is misleading, since the figures are taken from annual reports, and 
the same cases are reported two or three times. The hospital death-rate 
for 116,673 cases of consumption was 443-4 per 1000, which signifies, 
not that the death-rate in this disease is a little over 44 per cent of the 
cases, but that the average duration of the disease is a little over two 
years, the true death-rate being about 90 per cent. 
The fatality of different diseases will, of course, be indicated in the 
special articles treating of them, but the following are the death-rates of 
a few as indicated by hospital records - age not being stated: - 
Disease. 
Cases. 
Deaths. 
Rate per 
1000. 
Pneumonia .... 
36,273 
9438 
260-1 
Typhoid fever 
37,986 
5657 
148-9 
Diphtheria .... 
7,090 
2526 
356-2 
Scarlet fever 
5,757 
737 
128-0 
Acute pleurisy 
20,871 
2229 
106-7 
Acute bronchitis . 
30,408 
913 
30-0 
Acute nephritis 
2,207 
562 
254-6 
The following table shows the case mortality of certain diseases as 
shown by the Norwegian reports for the four years 1888-1891 inclu- 
sive : - 
Diseases. 
Cases 
treated. 
Deaths. 
Deaths in 1000 
Cases treated. 
Meningitis simplex (leptomeningitis 
cerebralis acuta) .... 
1,311 
1,015 
774-2 
Cancer 
7,082 
4,641 
655-3 
Croup 
1,646 
961 
583-8 
Phthisis pulmonalis.... 
26,374 
11,844 
449-1 
Cerebro-spinal meningitis 
170 
58 
341-2 
Puerperal fever .... 
2,034 
621 
305-3 
Bright's disease .... 
7,070 
1,840 
260-3 
Diphtheria ..... 
30,473 
7,010 
230-0 
Pneumonia 
46,085 
6,873 
149-1 
Typhoid fever 
7,467 
755 
101-1 
Scarlet fever 
24,657 
1,547 
62-7 
Dysentery 
1,013 
5.9 
58-2 
Whooping cough .... 
27,914 
1,327 
47-5 
Pleurisy 
11,659 
388 
33-3 
Measles 
36,149 
1,169 
32-3 
Acute diarrhoea and Cholera nostras 
101,491 
3,212 
31-6 
Rheumatic fever .... 
13,654 
250 
18-3 
Acute catarrh and bronchitis . 
227,466 
3,493 
15-3 
Influenza ..... 
93,149 
794 
8-5 
Mumps . 
6,087 
2 
0-3 
Let us now compare the number of deaths from certain diseases with 
the number of population in which they occurred, that is, the death-rates 
of the vital statistician. 16 
SYSTEM OF MEDICINE 
The following table shows the average annual death-rates from each 
of certain causes per 10,000 living population, during a period of about 
ten years in different countries: - 
Countries. 
Periods. 
Death-rates per 10,000 Population. 
Aggre- 
gate. 
Small- 
pox. 
Measles. 
Scarlet 
Fever. 
Diph- 
theria. 
Diph- 
theria 
and 
Croup. 
Whooping 
Cough. 
Enteric 
Fever. 
Pneu- 
monia. 
Consump- 
tion. 
Diarrhoeal 
Diseases. 
Cancer. 
Child- 
birth. 
England and 
Wales . . 
1880-89 
192 
•48 
4-46 
3-77 
1-56 
2-95 
4-56 
2-05 
10-32 
17-49 
7-61 
5-75 
1-52 
Ireland . . 
1880-89 
18V 
•12 
1-95 
2-50 
•69 
2-26 
3-06 
1-65 
5-33 
20-97 
3-29 
3-95 
1-69 
Scotland . . 
1880-89 
192 
•03 
3-65 
3-25 
2-10 
4-25 
6-00 
2-47 
10-40 
20-17 
4-93 
5-70 
1-75 
Belgium . . 
1880-87 
204 
3-23 
5-15 
2-55 
5-55 
6-72 
5-35 
15-09 
2-30 
Sweden . . 
1880-89 
170 
•17 
1-88 
5-17 
5-82 
7-26 
1-80 
2-59 
4-33 
1-17 
Prussia . . 
1880-89 
248 
•16 
4-14 
4-55 
16-32 
5-17 
3-83 
14-04 
30-43 
10-38 
3-59 
2-10 
Austria . . 
1877-86 
307 
6-13 
5-04 
6-15 
16-51 
11-00 
7-22 
38-76 
4-29 
Saxony . . 
1881-89 
278 
2-61 
3-84 
15-31 
2-75 
2-14 
23-84 
7-32 
Norway . . 
1880-89 
167 
•06 
1-06 
3-67 
5-54 
1-76 
1-07 
7-81 
13-89 
4-99 
2-07 
Bavaria . . 
1885-87 
•02 
3-13 
2-66 
11-43 
5-00 
1-70 
27-97 
6-46 
Holland . . 
1885-87 
208 
•11 
3-23 
2-00 
5-00 
3-36 
1-40 
19-30 
22-10 
6 66 
Rhode Island 
1880-89 
179 
•02 
1-02 
4-77 
5-37 
8-10 
1-42 
4-95 
13-57 
23-98 
15-46 
5-20 
1-02 
Connecticut. 
1880-89 
168 
•09 
•92 
2-65 
5-45 
7-94 
1-17 
3-84 
12-65 
20-91 
13-50 
4-26 
•98 
Massachusetts 
1880-89 
193 
•08 
1-12 
2-33 
6-53 
9-22 
1-24 
4-52 
15-65 
28-84 
14-23 
5-42 
•91 
New Jersey . 
1879-88 
187 
•55 
1-08 
4-66 
9-76 
1-46 
4-72 
23-99 
21-28 
3-90 MEDICAL STATISTICS 
17 
Iii dealing with medical statistics we usually have no data as to 
population, and the best rates we can obtain to show the relative prev- 
alence of a given disease in different localities, or in the same locality 
at different times, are rates per 1000 deaths from known causes. 
The following table shows these rates for the countries and periods 
given in the preceding table: - 
Countries. 
Periods. 
Death-rates per 1000 Deaths from all causes. 
Small- 
pox. 
Measles. 
Scarlet 
Fever. 
Diph- 
theria. 
Diph- 
theria 
and 
Croup. 
Whooping 
Cough. 
Enteric 
Fever. 
Pneu- 
monia. 
Con- 
sump- 
tion. 
Diar- 
rhoeal 
Dis- 
eases. 
Cancer. 
Child- 
birth. 
England and 
Wales . . 
1880-89 
2-5 
23-1 
19-6 
8-1 
15-3 
23-6 
10'6 
53-6 
90'9 
39-5 
29-8 
7-8 
Ireland . . 
1880-89 
0-7 
10-7 
13-8 
3-8 
14-6 
16-8 
9-1 
29-4 
115-8 
18-1 
21-8 
9-3 
Scotland . . 
1880-89 
0-2 
18-9 
16-9 
10-9 
21-9 
31-1 
12-8 
54-0 
104-7 
25-6 
29-6 
9-1 
Belgium . . 
1880-87 
15-7 
25-1 
12-4 
27-1 
32-8 
26-1 
73-6 
11-2 
Sweden . . 
1880-89 
1-0 
110 
30-3 
34 1 
42-3 
10-7 
15-2 
25-4 
6-8 
Prussia 
1880-89 
0-6 
16-7 
18-3 
65-7 
20-8 
15-4 
56-5 
122-6 
41-8 
14-4 
8-4 
Austria . . 
1877-86 
19-9 
16-4 
20-0 
53-7 
35-7 
23-4 
126-0 
13-9 
Saxony . . 
1881-90 
9-4 
13-8 
55 0 
9-9 
7-7 
85-7 
26-3 
Norway . . 
1880-89 
0-3 
6'3 
21-8 
33-0 
10-4 
6-4 
46-5 
82-7 
29-7 
12-3 
Rhode Island 
1880-89 
0-1 
5-3 
26-6 
29-9 
45-1 
7-9 
27-6 
75-7 
133-7 
86-2 
29-0 
5-7 
Connecticut . 
1880-89 
0-5 
5-4 
15-8 
32-4 
47-2 
6-9 
22-9 
75-3 
124-5 
80-3 
25-3 
5-8 
Massachusetts 
1880-90 
0-4 
5-7 
12-2 
34-2 
48-3 
6-5 
23-7 
82-1 
151-3 
74-7 
28-4 
4-9 
New Jersey . 
1880-89 
3-0 
5-8 
25-5 
53-4 
7-9 
25-8 
131-3 
116-5 
21-3 
VOL. I 
c 18 
SYSTEM OF MEDICINE 
It is important to remember that a table like this does not give true 
mortality rates, and that the rates given by it for any given disease are 
affected not only by the actual prevalence of that disease, but of other 
causes of death, so that very erroneous conclusions may easily be drawn 
from them ; nevertheless, they are often the only rates available, and if 
the gross death-rates of the different localities are about the same, or if 
it is possible to estimate their difference, some useful conclusion may 
be drawn from a table of this kind. For example, each of these tables 
indicates that typhoid fever caused a little more than twice as great 
a mortality in Massachusetts as it did in England; and that diphtheria 
caused about four times as great a mortality in Massachusetts as in 
England. Where the average annual death-rate is about twenty per 
1000, the number of deaths due to a special disease per 1000 deaths 
from all causes should be about five times the number of deaths from that 
disease per 1000 of population, if the population has the usual propor- 
tions of sex and age ; but this ratio is not applicable in most cases, because 
an epidemic of any particular disease changes the proportion of deaths from 
any other disease per 1000 deaths from all causes, while the number of 
deaths from that other disease may have remained the same per 1000 of 
population; and the proportion of children in a locality will greatly influ- 
ence the death-rate from diphtheria and scarlet fever, just as the proportion 
of old people will influence the death-rates from pneumonia and cancer. 
Next to age in the importance of its influence upon disease is 
heredity. At present almost the only data we have on this subject 
relate to race differences; but there are equal, and probably greater 
differences in families of the same race, recorded only in a vague wray 
in the memories of old family practitioners. 
Professor Allbutt has pointed out that studies of hereditary disease 
have been limited mainly to observations of one particular form of disease 
in a given family, while for scientific purposes what is wanted is a record 
of all the diseases, fatal and non-fatal, which have occurred in a given 
family (Brit. Med. Jour. 1888, 11, 287). A beginning of such records 
has been made in the study of insanity and its relations to chorea, neu- 
ralgia, epilepsy, etc.; but they are never complete; and it would require 
the records of several generations in each of many families to furnish star 
tistical data sufficient to determine the relationships of diseases which are 
supposed to be connected with what are called gout and rheumatism. 
Certain portions of the United States present specially favourable con- 
ditions for the study of race influences upon disease and mortality, because 
different races may be found there under nearly the same conditions as 
to climate, food, occupation, etc., which is not the case if we attempt to 
use data derived from countries inhabited mainly each by a different race. 
The following table shows for New York City the death-rates per 
1000 of the white population during the year ending 31st May 1890, 
with distinction of birthplaces of mothers and of eight groups of ages. 
(The birthplace of the mother is the best means at our command for 
indicating the probable race in this case) : - MEDICAL STATISTICS 
19 
Birthplace of Mother. 
All Ages. 
All Ages. 
Under 15 
years. 
15 to 20 
years. 
20 to 25 
years. 
25 to 35 
years. 
35 to 45 
years. 
45 to 55 
years. 
55 to 65 
years. 
65 years 
and over. 
United States (white) . 
29-16 
46-92 
4-92 
7-00 
9-67 
12-55 
20-66 
34-41 
93-35 
England and Wales 
27-59 
43-28 
5-63 
10-04 
12-96 
19-28 
29-78 
42-70 
127-82 
Ireland 
32-20 
43-26 
7-75 
13-81 
20-72 
30-76 
40-91 
63-32 
133-11 
Scotland 
26-55 
35-32 
4-38 
10-77 
14-34 
20-70 
36-21 
41-84 
108-75 
France .... 
24-08 
42-46 
6-96 
5-27 
10-22 
15-26 
28-05 
44-31 
111-52 
Germany 
22-08 
36-90 
4-30 
7-73 
11-05 
16-94 
22-65 
43-27 
84-52 
Russia and Poland 
21-18 
40-25 
3-27 
4-67 
7-01 
9-93 
20-63 
31-25 
102-80 
Canada 
26-85 
39-53 
5-68 
13-24 
15-89 
28-95 
18-25 
70-55 
95-24 
Scandinavia. 
28-32 
62-56 
7-72 
11-87 
14-44 
19-21 
28-30 
49-42 
85-23 
Hungary 
29-25 
58-73 
7-91 
5-49 
8-14 
11-99 
30-84 
40-23 
102-19 
Bohemia 
36-22 
62-19 
5-69 
13-11 
18-45 
20-30 
23-54 
58-38 
89-74 
Italy .... 
39-96 
84-18 
7-94 
13-50 
11-03 
15-36 
19-90 
38-34 
88-40 
Other foreign countries 
18-06 
32-11 
4-14 
6-39 
7-47 
13-20 
18-96 
36-48 
66-73 20 
SYSTEM OF MEDICINE 
It will be seen from this table that the death-rate of those whose 
mothers were born in Russia and Poland was very low between the ages 
of fifteen and forty-five, and that at other groups of ages it was also 
lower than that of any other race. These people were nearly all Jews, 
and were 80,235 in number. The death-rate of the offspring of Irish 
mothers was high, much higher than that of the Germans, and as there 
were about 400,000 of each of these races, the comparison is a fair one. 
The Jewish population was poor, crowded in tenement houses. The 
interesting point to the medical statistician is, What were the forms 
of disease to which the marked differences in the death-rates of these 
races were due ? To answer this in part, we will take the statistics 
of deaths for the six years ending 31st May 1890 for the Irish, the 
Germans, the Russian and Polish Jews, the American white offspring of 
American mothers, and the coloured in New York City. The average 
annual death-rate from consumption per 100,000 of population was - 
for the Irish, 645-73; for the coloured, 531-35; for the Germans, 
328'80; for the American whites, 205'14; and for the Russian Polish 
Jews, 76'72. The average annual death-rate from pneumonia per 
100,000 of population was - for the Irish, 343'99; for the coloured, 
389'50; for the American whites, 272'87; for the Germans, 214-12; 
and for the Russian and Polish Jews, 170-17. 
It seems probable that members of the J ewish race possess a dis- 
tinctly higher degree of immunity against the bacillus of tuberculosis and 
the micrococcus of pneumonia as compared with the other races above 
mentioned; and that on the other hand the Irish and the American 
negro are specially susceptible to the effects of these micro-organisms. 
Professor Stokvis has pointed out that in all colonial armies in 
warm climates the death-rate from diseases of the respiratory organs is 
more than twice as great among the native troops as it is among the 
Europeans (" On the Comparative Pathology of Human Races," etc., 
Practitioner, Lond. xlvi. 1891, p. 233), while hepatitis is decidedly more 
fatal in the European than in the native. 
In the Dutch East Indian colonies the natives are decidedly more 
liable to beriberi than the Europeans; but the comparative immunity of 
the latter against this disease appears to be decreasing in recent years. 
Even when we have the means of comparing the death-rates of different 
races in the same locality it is usually impossible to say how far the 
differences in these death-rates depend upon inherited peculiarities of 
physical structure, and how far they are due to the poverty, uncleanli- 
ness, and habits as to different kinds of alcoholic drinks which charac- 
terise the great mass of the population of certain races. 
John S. Billings. ANTHROPOLOGY AND MEDICINE 
21 
ANTHROPOLOGY AND MEDICINE 
Our knowledge on this subject is scanty and far from clear; and the 
little we believed ourselves to possess has been disturbed by recent 
changes in pathological theory. Divers diseases formerly supposed to be 
the outcome of constitutional and hereditary proclivity are now believed 
to be the results of infection; and the remoter causes are apt to be 
neglected in the consideration of aetiology. 
That many pathological processes are known to be common to man- 
kind and to other mammalia, or even to animals further removed from 
us, while others are reasonably suspected to be so, makes it d prion 
improbable that any great differences should subsist in the distribution 
of diseases among different races of men. On the other hand, though 
men and women respectively can hardly be said to have any peculiar and 
exclusive diseases (except in so far as this results from the differences 
in their sexual organs), yet we see that their respective liability to some 
at least of these diseases varies. A curious instance of this is afforded 
by cretinism and goitre: goitre being much more common in women than 
in men, while cretinism is pretty evenly distributed - if anything there 
is a preponderance of male cretins. 
The most conspicuous difference in the external aspect of men and of 
races of men is in colour; and here comparative pathology would lead 
one to look for some corresponding differences in susceptibility to disease, 
for the experience of horse-breeders and veterinarians is pretty clearly 
expressed on this point. Thus Youatt says that the dark chestnut, as a 
rule, yields to no other colour in any quality; but that the light chest- 
nut, which appears to be the analogue of the sanguine-blond man, is 
spirited, but irritable and delicate in constitution. Black horses, again, 
number among them some of the very finest of their species ; but many 
of them are heavy and dull in temperament, and there is an idea afloat 
that they are particularly liable to malignant disease. Here we may be 
led to think of the choleric and the melancholic temperaments. Among 
breeds of sheep, the blackfaced have the reputation of being hardier than 
the whitefaced. Certain black pigs, according to Darwin, can eat with 
impunity what would be poisonous to white ones on the same pasture; 
and like differences are seen in black and white rats. On the whole, 
however, the deposition of pigment in the skin and hair of mammals 
would seem to be the result of processes which connote or accompany 
health and vigour rather than the opposite. 
The statistics of morbidity and mortality, which alone could yield 
a sound foundation for generalisations on this subject, are unfortunately 
imperfect, or altogether wanting, in the regions where the material would 
be most valuable - those regions, namely, where nations of different SYSTEM OF MEDICINE 
22 
colours and constitutions of body live side by side under comparable 
conditions. In fact, we have hardly any trustworthy statistics, except 
from the most civilised of the countries, whose populations are com- 
pounded from more or less distinct divisions of the human race [yide 
Dr. Billings' art. on "Med. Statistics"]. 
Much information, more or less trustworthy, as to the distribution of 
disease among different races, may be gleaned from Hirsch, Lombard, 
Boudin, Oesterlen, Bordier, etc.; but even where the facts can be relied 
on, they are generally capable of interpretations that make them of little 
value for our purpose. Thus, when we learn that aneurysm is four times 
more common in San Francisco among foreigners than among native 
Americans, we must remember that a far larger proportion of the 
foreigners are males in the prime of life, and that most of the hard 
bodily labour is performed by foreigners. 
Negroes are said to be exempt, or nearly so, from piles and from vari- 
cose veins, and the cause assigned is the greater strength, in them, of the 
walls of the blood-vessels. Apoplexy, on the other hand (using the word 
in the ordinary sense), appears to have no racial preferences. Thus, in 
New Orleans negroes and whites are said to die of apoplexy in the pro- 
portions respectively of 103 and 91. Within Europe - England, Scot- 
land, Prussia and Italy yield almost exactly the same figures for death by 
apoplexy: in all of them these vary between 10 and 11 per 10,000 
living; Switzerland and Holland yield 8-5 and 7-9, but Ireland only 
5-9. The deaths from brain disease of all kinds, as returned, are singu- 
larly few in the insular parts of Scotland and in the Highlands, where 
the inhabitants are in blood very near akin to the Irish, so that here one 
might have supposed one had lighted on a real case of hereditary exemp- 
tion, or at least favourable hereditary constitution; but the fact that 
Shetland, where the race is Norse, returns fewer deaths from brain 
disease than even the Highlands and the other islands, is sufficient to 
negative the idea that the Gaelic race has any such special immunity. 
The rate of mortality from this class of diseases is certainly lower in 
quiet rural districts than amid the hurry and worry or excesses of towns, 
and this may account for some degree of the apparent immunity; the 
remainder must be attributed to the tendency to set down all cases of 
death in advanced life to simple "old age." In Shetland and the 
Hebrides about 25 per cent of the deaths are thus certified. 
In cancer, again, the enormous differences in mortality reports are 
doubtless largely due to the non-recognition of internal growths. But 
the differences reported to exist in divers registration districts in England 
seem too great to be wholly due to this cause, and the extreme varia- 
tions in both directions are by no means such as would have been 
expected on such a hypothesis. For example, rural districts in general 
seem to suffer quite as much as cities, and ancient cities more than great 
centres of industry, even allowing for the difference of constitution of 
the population in respect of age [yide Mr. Haviland's art. on " Med. 
Geography of Great Britain ANTHROPOLOGY AND MEDICINE 
23 
There is some little ground for considering cancer to be a disease of 
•civilisation, or of civilised communities and races, though here of course 
the question of failure in diagnosis comes in with double force. The 
most formidable death-rates that we have, such as 990 per million 
living in Drontheim and 930 in Lombardy, come from highly-civilised 
communities. Cancer is said to be rife in China, but rare in Egypt, 
the scene of a yet older civilisation. It is thought to be uncommon in 
the negro race generally, whereas we have seen that it is prevalent in 
Norway, among one of the blondest populations in the world. The 
asserted rarity in Iceland may perhaps be remanded for further evi- 
dence ; could it be proved, it would be of great importance, the Nor- 
wegians and Icelanders being of the same race. That the disease is 
strongly hereditary scarcely any one doubts; and I shall presently 
submit some evidence to show that in Britain it is especially common 
among people of dark complexion. 
Gout is another strongly hereditary disease, common in certain 
races and communities, but very rare, perhaps non-existent, in others. 
Roughly speaking, it is a disease of the ruling races and the higher 
classes; of the civilised man, not of the savage; of the white man, 
not of the negro; of cold and temperate rather than of hot climates. 
Probably there exist large communities of men among whom it never 
occurs; but, given some of the requisite exciting causes, habitual but 
not extreme excess in eating and drinking, disproportionate use of the 
brain as compared with the muscles, consumption of certain kinds of 
drinking-water, etc., it could doubtless be produced in any race and 
in almost any climate. Negroes, as I have said, are generally free; 
but Lobengula, the famous king of the Matabele, drank much beer, 
and suffered severely. The reported distribution of the disease is very 
instructive. Thus, in India, it is said, the Hindus scarcely ever suf- 
fer ; the Mussulmans, freer in diet, sometimes. Gout occurs in China, 
where the mandarin class unite most of the requisite factors. In Mad- 
agascar, the comparatively clever and light-complexioned ruling race, 
the Hovas, suffer from it; the subject negroes are not known to be 
attacked. In the United States of America it occurs in the cities, but is 
little known elsewhere; the American farmer is active and temperate. 
The registered death-rate from gout in England is about 25 per 
million living, in Scotland it is 4-3 per million, in Queensland, where 
much more fresh meat is eaten than in England, about 5. The chief 
missing factor is probably beer; but at least we are justified in saying 
that in these cases differences of regimen and climate reduce the mor- 
tality in the same race to about one-fifth. 
Still, it must be acknowledged that the distribution of gout has a 
racial aspect. In France, according to Hirsch, Lorraine, Normandy and 
Lyons are said to be its chief pasture-grounds: others add Burgundy 
and blame the wine. The natives of all these districts have more or 
less of the Germanic element in them. In Spain, the least Iberian of 
Spaniards, the Asturians, are the most gouty. The Belgians, the Dutch, 24 
SYSTEM OF MEDICINE 
the Danes, the Northern Germans, the Upper Austrians, and, in Russia, 
the upper classes of St. Petersburg and the Baltic provinces (Germans 
again) are all said to suffer from it. If there be one thing which 
all these people have in common, it is that fondness for he'avy feeding 
which has been a characteristic of our own most gouty nation from 
time immemorial, and belongs particularly to the true Saxon-English 
type. 
Phthisis has always been a sort of battle-ground for the believers in 
infection, and the believers in hereditary transmission and the suscepti- 
bility of particular types. Until quite recently, though the former 
opinion ruled in Southern Europe, the latter was almost universally held 
in England. And though even now clinical and practical experience 
point in the same direction as formerly, the general and geographi- 
cal history of the disease seem to support the infective theory. The 
effects of local conditions of soil and climate, though undoubtedly very 
powerful, are not always distinct, and may be used in support of either 
theory. 
The local statistics of phthisis are of very great interest, and could 
not, of course, be dealt with satisfactorily within the compass of this 
essay. Some of them seem to point to the applicability to phthisis of 
the li virgin soil " doctrine, which at first sight seems incompatible with 
that of the importance of heredity. 
Among the more important points which may be taken as estab- 
lished are- 
1. The extreme rarity of phthisis at very high elevations. 
2. Its rarity in high latitudes: for example, in Iceland. 
3. That some of Mr. Haviland's conclusions as to local mortality are 
correct - for example, that damp clayey soil coincides with a high 
phthisical death-rate ;1 and that the warm, fertile, ferruginous-red-sand- 
stone tracts of country are most remarkable for low death-rates; " a 
sheltered position and a warm, fertile soil, well drained, being coincident, 
as a rule, throughout England and Wales, with a low mortality from 
phthisis." 
4. That, among bodily characters, tall stature is the most distinctly 
unfavourable. 
The following opinions may be put forward more doubtfully : - 
1. That though local situation, varieties of social habit, occupation, 
and the like, overbear and obscure in Britain anything like racial ten- 
dency, it would appear that the Gaelic and Kymric or Ibero-Keltic stocks 
are, cseteris paribus, rather more subject to phthisis than the Saxon and 
Scandinavian. (The principal objection to this statement is furnished 
by the very unfavourable position of Suffolk, one of the most purely 
Anglian counties.) 
2. That the tropical negro is particularly subject to phthisis, at least 
when removed from his own country. The Melanesians, or Oriental or 
Pacific negroes may be here included; these are the people, incorrectly 
1 Bowditch and Buchanan. ANTHROPOLOGY AND MEDICINE 
25 
called Polynesians, who work in the Australian sugar-fields, and though 
well fed and fairly lodged, die of consumption in very large proportions - 
Phthisical Death-rate in Queensland, 1890 and 1891. 
" Polynesians " per 1000 living . . . 16-76 
Chinese . . . . ' , . 1-17 
Europeans and Colonials . . . . -981 
It is needless to cite statistics of the decimation of the true African 
negro in other climates than his own. In some cases the figures are 
even more appalling than those I have quoted from Queensland; and in 
some of the countries into which negroes have been introduced they 
seem to melt away chiefly from this cause. The most remarkable 
exception to the rule is that furnished by the southern portion of the 
'United States of America. Here, though within the temperate zone, a 
negro peasantry has been firmly established, thrives and multiplies. It 
is even said that the death-rate from phthisis in the Southern States 
generally is lower among the blacks than the whites.2 If it be so it is 
because the former are the peasantry, and a fairly well fed and lodged 
peasantry, with a wholesome amount of bodily labour; whereas the 
whites are generally inhabitants of towns and villages, with inferior 
conditions of life, quoad liability to phthisis. 
The mortality from this disease waxes and wanes in different countries 
in a manner that invites speculation on the causes of change. England 
and Holland used to be thought its special seats. But now for a con- 
siderable time phthisis has appeared to be on the wane in England,3 and 
the death-roll therefrom in the cities of France and Germany and North- 
ern Italy has been growing or becoming more visibly formidable. It has 
also grown in Scotland coincidently with the growth of urban popula- 
tion, and with what has been regarded as improvement in the dwellings 
of the rural population. In North Germany the western provinces yield 
heavier rates than the easternand here too, though some might rely 
upon the racial difference between the true German and the Slav, I 
believe the real difference to consist in a rather more elaborate civilisa- 
tion, which brings with it air tight houses and other fair-seeming but 
really evil conditions. 
Yellow fever is one of the most selective and fastidious of diseases; 
almost as much so as the sweating sickness of the Middle Ages, which on 
its first appearance is said to have sought out the well-to-do and lusty 
Englishman, abroad as well as at home, and let the starveling and the 
foreigner go scatheless. In New Orleans, for example, there is said to 
be a regular scale of exemption, complete in the case of the full-blooded 
1 Blakeney, Vital Statistics of Queensland. 
2 But see article " Statistics." 
3 Partly, no doubt, from a change of name, but not, I think, wholly so. The great in- 
crease of deaths registered under bronchitis and pneumonia has been at other ages than 
those at which phthisis has decreased. 26 
SYSTEM OF MEDICINE 
negro, less in the mulatto or other man of colour, less still in the dark- 
complexioned creole of Spanish or French descent; while even the 
Southern European suffers less than the Englishman, and the Scandi- 
navian fares worst of all. This sounds a little too artificial; but all 
agree that the dark skin connotes a kind of acclimatisation to the 
scourge similar to that which long residence confers. We have here, 
perhaps, the most conspicuous instance of race peculiarity in disease, 
the hereditary anomalies of pigmentation in the negro being clearly 
connected with his exemption from a disease in which that function is 
much implicated. The yellow colour of the fat in the negro, and the 
comparative whiteness of the stools, should be remembered in this 
•connection. 
Scarlatina is much milder and less formidable in Southern than in 
bl orthern Europe. More than one reason suggests itself for this; 
but the greater frequency of enlarged tonsils in the lymphatic tern-' 
perament, which is so common in North-western Europe, supplies one of 
these. 
Small-pox is exceedingly fatal to peoples among whom it is intro- 
duced for the first time. No doubt this is partly owing to terror at the 
appearance of a new and dreadful enemy, and to ignorance of proper 
methods of treatment, etc.; but we can hardly doubt that it is also con- 
nected with the fact that any such organism flourishes best in a virgin 
soil. The frightful amount of destruction of life by small-pox among 
the North American Indians, especially on its first introduction, can 
hardly be accounted for in any other way. Thus the Mandan nation 
was almost destroyed; it has even been stated that in their principal 
village only forty out of 2000 survived the invasion; but it has never 
been asserted, so far as I am aware, that with vaccination and proper care 
the Indians suffer more from small-pox than other races. To show that 
other races suffer almost equally under similar conditions, we may quote 
the earliest epidemic of small-pox in Iceland, when 18,000 out of 52,000 
were said to have perished. Some facts of this sort might lead one to 
suspect that past diseases may exercise some kind of protective power 
against others, even when their relation is much more distant than that 
of vaccinia to variola. Thus we hear of the discovery of a village 
church in Tellemarken (Norway), whose very existence had been for- 
gotten, the entire population of its remote parish having, there is reason 
to believe, been swept off by the black death. In this case, probably, 
the soil was virgin to many other diseases besides this particular pest: 
or is it that a population which has not been sifted through the meshes 
of other zymotics is more vulnerable than another, though apparently 
more healthy ? 
Whether the virgin soil hypothesis be necessary to explain the 
occasional destructiveness of measles may be doubted. Though on its 
introduction to Fiji it killed about a fourth of the population, it is said 
not to have been extraordinarily severe among those Fijians who were 
carefully nursed in European fashion, and protected from their own ANTHROPOLOGY AND MEDICINE 
27 
folly; the mortality has been quite as great in France under bad sani- 
tary conditions. There is no sufficient reason to think that any one 
race is more liable to be severely handled by measles than another, under 
equal conditions. Negroes suffer much more than whites, it is said, in 
the United States; but the difference is only what we find in this country 
between the upper and the lower classes. Tetanus and trismus neona- 
torum are supposed to be particularly fatal among negroes; but here 
again it is probably the habits of the race that are in fault, rather than 
anything in its physical constitution. One can hardly imagine any re- 
semblance in the latter respect between negroes and Icelanders; yet the 
inhabitants of the Westmann Islands, off the coast of Iceland, used to 
lose the greater part of their infants from trismus, until they were 
taught by Schleisner to reform their manner of treating them during 
the first few days of life. Hirsch assigns as a probable cause a peculiar 
sensitiveness of the negro skin; but the suggestion appears to me un- 
warranted and gratuitous. 
Chorea is said to be unknown in China, and we may probably 
assume with safety that it is rare. Whatever its relations with rheu- 
matism, it is certainly a disease of the nervous temperament especially. 
For its physical type see further on. There are several more or less 
obscure diseases to which negroes seem to be exclusively or particularly 
liable. Of these is the sleeping-sickness, described in this work by Dr. 
Manson. The mysterious ainhum, which resembles a limited leprosy, 
is not known to attack other races; but yaws certainly does. 
Of all white races, the Jews are the most likely to reward a careful 
study of special morbid tendencies; but I am not aware that this has 
ever been thoroughly carried out. They are known to have a lower 
death-rate, wherever it has been tested, than the Christian populations 
among whom they live; but this may be due simply to their sober 
habits and carefulness in diet, their avoidance of violent labour, and 
their great care of their children. They are believed to suffer much 
from diabetes, from nervous diseases, and from psoriasis. 
If we now regard the subject from a geographical point of view, 
we shall be able to make use of the gigantic series of anthropologico- 
medical statistics which we owe to Dr. Baxter and to the American civil 
war. Perhaps the clearest and most important fact that comes out of 
them is the inferiority of the blond-complexioned man for recruiting 
purposes. Out of twenty-two principal classes of physical defects, 
twenty of which imply disease of some kind, in only one, chronic rheu- 
matism, did the dark-complexioned recruits yield the larger percentage 
of rejections. As De Candolle says, the very uniformity of the thing 
is somewhat suspicious. He suggests that it may be largely if not 
wholly due to the inclusion of great numbers of Germans, the German 
emigrants being often of inferior physical type. Other possible sources 
of fallacy suggest themselves to me; but it must be allowed that a 
prima facie case was made out against the blonds. The excess of 
blonds was most marked in the rejections for phthisis, and for dis- SYSTEM OF MEDICINE 
28 
eases of the circulatory and urinary systems. Dr. Baxter says there 
was an excess of dark men among the few rejections which took place 
on account of certain acute diseases. To this point we will return 
presently. 
I have made out a list from Baxter's data, showing in relative order 
what appeared to be the weakest points in recruits of several national- 
ities and races: - 
1. White men born in the United States were frequently rejected for dis- 
eases of the digestive and urinary systems, for bad teeth, and for 
phthisis. 
2. American Indians for nothing; they were the soundest of all the nation- 
alities, as well as the tallest and largest in girth. 
3. Negroes - For urinary diseases. Also very healthy; but were probably 
picked men. 
4. British Americans - For nothing specially; generally very healthy. 
5. Mexicans - Diseases of the nervous and cutaneous systems, syphilis, dis- 
eases of the locomotive and generative systems, and local injuries. 
6. South Americans - Syphilis and respiratory disease. 
7. West Indians-Urinary disease. 
8. Englishmen - For bad teeth, and for affections of the digestive organs. 
9. Scotland - Diseases of the circulatory, urinary and digestive systems. 
10. Ireland - Diseases of the circulatory system, of the skin, and of the diges- 
tive system; syphilis. 
11. Wales - Phthisis, and diseases of the urinary and locomotive systems. 
12. France - Diseases of the skin and the nervous system; bad teeth. 
13. Holland - Phthisis ; diseases of the skin, eye and ear, and of the respira- 
tory and locomotive systems; and local injuries. 
14. Germany - Phthisis; diseases of the circulatory and locomotive systems, 
of the ear, and of the digestive system. 
15. Sweden - No morbid peculiarity ; very healthy. 
16. Norway - Diseases of the ear and of the locomotive system. 
17. Denmark - Diseases of the eye. 
18. Switzerland - Diseases of the urinary system; defects of the teeth, of the 
ear, and of the digestive system. 
19. Portugal - Hernia; diseases of the digestive and generative systems. 
20. Italy - Diseases of the skin and of the generative system ; syphilis. 
21. Russia - Diseases of the eye, of the nervous, circulatory and generative 
systems. 
22. Hungary - Diseases of the digestive and nervous systems, of the ear, of 
the generative and respiratory systems ; hernia and phthisis. 
23. Poland - Diseases of the eye, and of the circulatory and respiratory sys- 
tems ; phthisis, and local injuries. 
24. Spain - Diseases of the respiratory organs; syphilis, hernia; diseases of 
the generative and digestive systems, and of the eye.1 
This list, like the results of most voluminous collections of statistics, 
is after all a little disappointing. It is not easy to draw any important 
1 The numbers examined were small in the cases of the Indians, Mexicans, South 
Americans, Spaniards, Portuguese, Russians, Hungarians, and Poles. ANTHROPOLOGY AND MEDICINE 
29 
general conclusions from it except perhaps this, that the native and 
naturalised races of North America stand better than the recently 
imported. Thus the red-skins, the aborigines, stand best; and nearly 
as well stand the West Indians, the coloured men of the States, and the 
British Americans - mostly, I suppose, French Canadians, - a hardy, 
unsophisticated peasantry, largely crossed with Indian blood. 
Respiratory disease is found rife among Spaniards and South Ameri- 
cans, but not, as might have been expected, among Mexicans, West 
Indians or Portuguese. The numbers were perhaps insufficient, except 
in the case of the West Indians. 
Dr. Baxter makes a remark on a certain relation, signs of which 
appear in some of his tables, though not in my abstract of them. It is a 
sort of general resemblance in the nosology of the British races, among 
whom, I think, he means to include the American whites, as compared 
with the other races observed. He found the proportion of rejections 
to increase with age and with height. To some small extent the latter 
fact was due to the former one, but the increase of phthisis with a 
stature beyond 65 inches was far too great to be accounted for in that 
way. The same may be affirmed of cardiac disease and varix, both of 
which appear to increase rapidly with increase of stature. Hernia, 
however, contrary to the opinion of Boudin, does so very little, or not at 
all. General debility, as a cause of exemption from service, decidedly 
lessens with increase of stature. 
In all these there is a distinct, though not very great excess of men 
of light complexion. There are, however, a number of morbid conditions 
entailing rejections, the majority of the sufferers wherefrom are set down 
as dark, though none of these are of great importance numerically. 
Most notable are dropsy, cancerous and other tumours, cataract, certain 
defects or affections of the nervous system - as imbecility, neuralgia, 
chorea - chronic alcoholism, chronic pleurisy, and certain affections of 
the portal system, as liver disease, haemorrhoids and prolapsus. It may 
be noted that most of these are precisely the vices of the " melancholic 
temperament." 
Next in value, for our purposes, to the great American statistics are 
those of the French recruiting service; not so much for their intrinsic 
importance as for the light thrown upon them by Boudin and Broca, and 
by the investigations of Topinard into the distribution of complexions, 
and by those of Collignon into that of head-form in that country. More- 
over, great as is the assimilative power of the French nation, its principal 
anthropological types - the Kymric, the Keltic, the Mediterranean, the 
Norman, etc. - still remain tolerably distinct. 
French anthropologists generally take the view that the Norman 
and the Kymric types are but varieties of one, - the tall, blond, long- 
headed North European type; and that this, so far at least as it appears 
in France, is characterised not only by these three qualities, but also by 
tendency to chest disease, to dental caries, to varices, and to some other 
affections, from all of which the short, thick-set, dark, round-headed Kelt 30 
SYSTEM OF MEDICINE 
of the central provinces is comparatively free. The southern and south- 
western portions of the country are occupied partly by the last-mentioned 
race, but partly by short, dark, long-headed people, often classed together 
for convenience as the Mediterranean or Iberian race; but probably 
capable of analysis into more than one type or stock, not to speak of 
various admixtures added during the historic period. We should there- 
fore have in the French recruiting statistics an opportunity almost 
unequalled of testing the comparative morbidity of different types of 
man, and the nature of hereditary morbid tendencies, could we rely on 
the carefulness of the medical examination of recruits. Unfortunately, 
however, there is intrinsic evidence that, during the period for which 
we have published statistics, this used to be by no means sufficiently 
careful and systematic. 
For example, it was the practice usually to measure the conscripts, 
and reject those under size, before investigating the other possible dis- 
qualifications. Of course this plan, otherwise unobjectionable, had, from 
the medico-statistical point of view, the disadvantage that the infirmities 
of the undersized men were not disclosed or tabulated, and that those 
departments which yielded a large proportion of small men did not 
exhibit in the reports their actual proportion of myopia, chest disease, 
and so forth, but only the proportions occurring in the taller men. But 
sometimes this order seems to have been reversed, with the effect of 
assigning to the department or commune under examination too high a 
stature, but its full proportion of infirmities. These things must be 
borne in mind in the examination of the table which I have constructed 
in order to exhibit the relative morbidities of several groups of depart- 
ments, selected on anthropological grounds. The column headed, " Do., 
probable, corrected," is the result of an attempt to neutralise the errors 
resulting from these defects of method. Though conjectural, I have no 
doubt it comes much nearer to the truth than the official statement. 
Boudin's book was published when France had eighty-six departments; 
she subsequently gained three, and then again lost other three, so that 
the number is once more eighty-six. In forming my table I have always 
taken the several departments in what may be called the order of excel- 
lence; thus, under the column of " Dolichokephaly " No. 1 would be the 
department with most long-headed men; under that of " Mortality " No. 
1 would be the department with the lowest death-rate, No. 86 that with 
the highest; under that of "Myopia" No. 1 would be the department 
with the fewest short-sighted youths, and so forth. In making my 
groups I have thrown together the ordinal figures belonging to several 
departments, and set down the average in the table. Thus, in the case 
of the ten departments yielding the tallest men (or rather the fewest 
undersized men), I set down 5. But the order in which they produce 
tall men is slightly different from that in which they are free from 
dwarfs, so that the average position of these same ten, in that column, 
comes out as low as 12. 
Bertillon's order of mortality also requires explanation. Instead of ANTHROPOLOGY AND MEDICINE 
31 
assessing the mortality simply on the aggregate population of all agesr 
Bertillon calculated the death-rate for each of twelve age-periods on the 
population living at such ages respectively, and averaged the several 
orders thus obtained in order to get the proper rank of the department. 
The result is sometimes a startling change in its position. Thus the 
Seine-et-Marne stands fifty-fifth on the ordinary plan, with a death-rate of 
23-5. This low position is really owing to the great number of children 
sent out from Paris to be nursed in this neighbouring department, who 
sustain a frightful mortality. The ultimate rank of the Seine-et-Marne, 
on Bertillon's plan, would be the twenty-third; the average of its several 
ranks, which I have chosen for use in my table, being 29. The Seine-et- 
Oise similarly leaps from the sixty-fifth to the fortieth place, with an 
average rank of 41. Indre, where the infant mortality is low, falls from 
tenth to fiftieth, with average 49, and Creuse from sixth to fifty-first,, 
with 50. 
The table (p. 32) is full of instruction, and yields, on examination, some 
valuable and unexpected results, of a nature not directly germane to our 
inquiries. Thus, the very pregnant fact comes out that high mortality 
and military inefficiency - or unsound health from the recruiting-officer's 
point of view-stand in no direct relation to each other: in truth the 
relation is very frequently inverse. Thus, of all my fifteen categories 
the Breton departments stand worst in regard to mortality, but best 
by far in point of soundness; while the ten thinly-peopled low-country 
departments have the worst rate of exemption for unsoundness, but,, 
with one exception, the lowest rate of mortality. 
The most promising lines of investigation for us, however, are those 
afforded by pulmonary disease (including especially phthisis), by mental 
derangement, by myopia, and by defects of the teeth. 
Of these the first, as we have learned already, has some relation to 
tall stature, and this law is borne out by our table, wherein the depart- 
ments of highest stature take the forty-eighth rank, but those of lowest 
stature the thirty-fourth. There appears no evidence that colour, per se, 
has anything to do with the matter; the comparatively blond Lor- 
rainers, for example, standing very well in this as in most other respects, 
and the dark Provencals very badly. The great towns stand ill, of 
course; but when we find that the ten departments where the northern 
dolichokephalic race is most in evidence, and the five of Normandy, and 
the five which I have selected as best exhibiting the combination of tall 
stature, long head, and blond complexion,1 agree in yielding a high 
average of phthisical recruits, little doubt remains on my mind that we 
have to do with an affair of race or heredity. This is in some degree 
confirmed by the Belgian statistics, which exhibit the Flemings and Bra- 
banqons as yielding more tall recruits and more cases of phthisis than 
the Walloons.2 Here, as in other parts of our subject, cause and effect 
1 Viz., Pas de Calais, Somme, Aisne, Oise, and Calvados, the last only a Norman de- 
partment. I excluded Nord and Seine Inferieure as having a strongly urban character. 
2 See Vanderkindere's and Houze's papers on Belgian Anthropology. 32 
SYSTEM OF MEDICINE 
Number. 
Order for high 
Statures. 
Do. low, do. exemp- 
tions. 
Dolichokephaly. 
Blondness. 
Mortality. 
Do. (Bertillon). 
Do., 0 to 5 years. 
Exemptions for 
Mental Alienation. 
Exemptions for 
Infirmities. 
Do., probable, 
corrected. 
Phthisis and 
Respiratory Diseases. 
Weak Constitution. 
Scrofula. 
Hernia. 
Myopia. 
Epilepsy. 
Mutism. 
Defective Teeth. 
1 
10 Departments of 
highest stature 
12 
5 
49 
22 
33 
32 
40 
49 
41 
48 
44 
29 
0 
36 
38 
35 
41 
57 
2 
10 Lowest stature. 
76 
81 
35 
60 
49 
57 
38 
42 
52 
34 
59 
40 
- 
40 
27 
32 
50 
31 
3 
10 Most blond 
23 
23 
28 
5 
51 
42-5 
38 
40 
37 
46 
42 
40 
+ 
33 
34 
43 
50 
53 
4 
10 Darkest . 
56 
46 
33 
81 
50 
45 
51 
35 
35 
49 
35 
31 
- 
42 
50 
62 
55 
45 
5 
10 Dolicho north'n 
18 
19 
12-6 
17 
57 
42 
54 
57 
51 
54 
47 
42 
0 
49 
48 
48 
42 
71 
6 
10 Do., southern or 
western . 
64 
60 
9 
62 
48 
53 
49 
42 
46 
43 
51 
22 
60 
54 
43 
45 
42 
7 
10 Brachykephaly 
38 
35 
81 
52 
40 
43 
38 
41 
40 
33 
47 
56 
0 
41 
45 
43 
59 
32 
8 
9 Auvergnat race 
60 
71 
72 
63 
60 
55 
52 
30 
39 
27 
43 
66 
- 
20 
32 
44 
58 
15 
9 
5 Normans . 
28 
26 
20 
6 
43 
35 
35 
62 
59 
54 
55 
40 
+ 
45 
50 
32 
43 
73 
10 
4 Bretons . 
74 
71 
41 
28 
69 
65 
41 
6 
21 
22 
17 
27 
- 
3 
6 
41 
41 
9 
11 
5 Remo - Lothrin- 
gians 
22 
14 
61 
16 
26 
25 
35 
39 
30 
24 
41 
46 
+ 
43 
46 
43 
48 
48 
12 
6 Urban 
34 
28 
25 
42 
61 
59 
55 + 
49 
45 
62 
45 
49 
+ + 
51 
62 
46 
29 
54 
13 
5 Tall, dolicho- 
blond combined 
12 
13 
15 
15 
45 
33 
54- 
55 
47 
55 
50 
40 
+ 
37 
36 
46 
39 
73 
14 
10 Mountaineers . 
51 
48 
58 
56 
53 
50 
47 
42 
43 
41 
32 
48 
- 
38 
49 
41 
50 
36 
15 
10 Thinly - peopled 
low-country . 
45 
46 
34 
44 
29 
35 
44 
62 
60 
51 
54 
48 
- 
52 
43 
38 
37 
50 
The materials for this table are derived from Boudin (Geographic Medicale, 1857), from Broca, from Topinard (Anthropologic Generate, 
1885 and Revue d 'Anthropologic, 1889), and Collignon (L' Anthropologic, 1890); and from Bertillon pore's Demographic de la France, 1875. 
The number of departments being eighty-six, the normal or mean position is 43'5. 
The urban mortality, especially that from 0 to 5 years, is understated, and that of No. 13 perhaps slightly overstated, by reason of the num- 
ber of town-born and especially Paris-born infants who die in the country. 
In the column " Mental Alienation," 0 represents about the average of France, .+ an excess, ++ a large excess,.- a deficiency, -- a large 
deficiency of insane persons, as compared with the average. Bordier, quoting Chervier, gives a list of departments in which mental alienation 
is common, and in which no Norman, aud no strongly urban district appears. 
Table illustrative of the Distribution of Disease in France chiefly from Recruiting Statistics. ANTHROPOLOGY AND MEDICINE 
33 
are almost inextricably confounded; and, in order to understand the 
problems, the local history and conditions must be studied. Thus in 
France - 
Of 10 brachykephalic departments, only 1 has more than the average 
density of population. 
Of 10 Northern dolichokephalic departments 10 have more. 
Of 5 Norman ,, 5 ,, 
Of 4 Breton ,, 4 ,, 
Of 10 Most blond ,, 9 ,, 
Of 10 Darkest ,, 3 ,, 
Of 10 Southern dolichokephalic ,, 2 ,, 
We in England, with our almost unchequered experience of higher 
phthisical death-rates in cities than in rural districts, would be inclined 
to say at once, " Here, in the greater density of population, is the one 
and sufficient reason for the greater amount of phthisis in the recruits 
from Flanders and Picardy and Normandy I " This would be too hasty 
a conclusion. In France, as my table shows, the hard-wrought, ill-fed 
peasantry of the plains suffer much from phthisis and scrofula. The 
peasantry of Limburg, the most Germanic province of Belgium, and 
perhaps the most rural except Luxemburg, stand about the worst in 
this respect. On the other hand Bretagne, the least phthisical part of 
France, has, as we have seen, a dense population. 
The fact is the tall, long-headed blond population is where it is 
by reason of its physical and moral qualities; its striving, ambitious, 
masterful character, which enabled it to occupy the best and most fertile 
parts of France, leaving the hills and heaths to the dark, short-headed 
Kelts. 
Mental alienation has not the same distribution as phthisis and 
pulmonary disease, which seem to affect the dark southern or Mediter- 
ranean race as much as the fair northern one; sparing only the sturdy, 
dark, broad-headed people of the centre, and the anomalous Bretons. 
The number of the insane seems to be large throughout the blond area,1 
where it is probably a race-character; and also, of course, in the districts 
of the great cities. 
It has been affirmed that myopia is structurally connected with 
dolichokephaly, the deep orbit and the long-axed eyeball going naturally 
with the long head. A certain amount of evidence has been adduced in 
support of this idea; and the tall blond race has been saddled, in the 
minds of some anthropologists, with yet another hereditary defect. The 
evidence of my table is not conclusive either for or against this view 
but it certainly does something to render it unlikely. Of the five de- 
partments selected as representative of the type, one only, the Aisne, had 
an excess of myopes; and of the ten most blond departments only two, 
11 draw this inference from Boudin's figures, vol. ii. 235-7; but they are perhaps 
hardly sufficiently detailed, though very striking. 
VOL. I 
D SYSTEM OF MEDICINE 
34 
viz., Eure and Seine Inferieure. In fact, myopia distinctly belongs to 
the dark-eyed inhabitants of the south of France, and to those of the 
cities, with the strange exceptions of Lyons and the urban district of 
the Nord: Brachykephals have their full share of it. 
The subject of defective teeth would, of course, furnish material for a 
goodly volume. So far as my materials testify, good teeth in France go 
with short average stature, dark complexions, and, less distinctly, with 
broad heads. Bad teeth concur with tall stature, and almost as clearly 
with long heads and blond complexion. Or, to put it in another way,, 
teeth are good in the mountains as a rule, bad in the plains, and 
especially bad, as Boudin himself remarked, around the mouths of all 
the great rivers. They are good among the Auvergnats (or central 
Kelts), and especially so among the Bretons; also in the Catalans of 
Rousillon, etc.; bad among the northern blond long-heads (including 
the Normans), and among the Gascons; moderately good among the 
Ligurians. In all these cases the boundaries are pretty clearly drawn, 
so as almost irresistibly to suggest that either the hereditary constitution 
of the several races or kindred, or something in the local (may I say 
tribal) habits and customs must have to do with the phenomena. For 
example, the Loire Inferieure was formerly politically a part of Bretagne, 
but its people were not Bretons in blood and customs. Accordingly the 
Bretons have a very high mortality and very good teeth; the Nantese, or 
Lower Loire folk, have a low mortality and very bad teeth. On the 
other hand the neighbouring department of Mayenne was not Breton 
politically, but its people are said to resemble the Bretons in character.. 
Accordingly they have a rather high mortality and excellent teeth ! 
This connection between good teeth and a high death-rate is strange,, 
but unquestionable. Of the ten departments which furnish the fewest 
exemptions for defective teeth, every one has an excessive mortality,, 
and in most cases, and on the average, a very excessive one. They 
are all in two masses, viz., 1. Auvergne and Lyonnais ; 2. Bretagne 
with Mayenne. If we seek for dietetic causes of caries, we shall find 
that the great wine-producing districts, Gironde, Dordogne, Marne, Cote 
d'Or, as well as the cider-drinking Normandy, are among the worst on 
the list. But, after all, there is plenty of sour wine in Auvergne and 
of cider in Bretagne. 
On the whole, then, I am disposed to subscribe to the belief of the 
French anthropologists, that we have here another example of a heredi- 
tary and constitutional defect. But it is one which cannot be dated 
back indefinitely; it must have been developed on French soil. Even 
now the Scandinavians, the purer-blooded cousins of the northern French, 
are generally " euodont; " and it is certain that when the Saxons invaded 
England, and the Franks and Normans Gaul, they were still so. If Harold 
of Denmark, the conqueror of the Cotentin, had not been a singular 
exception, he would hardly have been nicknamed Blue-tooth. 
In the British Isles we have no such groundwork of statistics to- 
work upon as those on which I have been building from America and ANTHROPOLOGY AND MEDICINE 
35 
France, and I have little more than personal observation whereto to 
trust. This, however, is sufficient to enable me to assert that phthisis 
is not here, as some have supposed, especially prevalent among 
blonds.1 The proportions of the several colours of hair and eyes in the 
sufferers are not very different from those which obtain in the general 
population. If anything, there is even an excess of black and very dark 
hair. Some statistics given me by Dr. Edward Liddon of Taunton, 
from the Brompton Consumption Hospital, are confirmatory of my 
own. I think, however (on this point statistics are unavailable), that 
hereditary phthisis in the upper ranks often presents itself in a frail 
blond type with very light hair; and I am sure that a tine transparent 
skin is a sign of vulnerability. In fact, the typical victim of phthisis 
is, in my opinion, a tall person with blue eyes, a transparent complex- 
ion, and dark hair. Such persons are also more liable to haemorrhages• 
it would seem that in them other structures partake of the delicate 
organisation of the skin. 
I have already said, apropos of the supposed absence of chorea from 
the Chinese, that, whatever its connection with rheumatism, it is a 
disease specially belonging to the nervous temperament. Fatal and 
severe cases almost always present the signs of that temperament. 
There is usually something remarkable about the development of pig- 
ment; the hair is often coal black, but sometimes extremely light, 
flaxen, or pale red. Epileptics, cataleptics, ecstatics, thought-readers, 
clairvoyants are very frequently of one or other of these strongly- 
contrasted colour-types. Mania seems to occur rather more often in 
the xanthous type, with chestnut, red or fair hair; but with regard to 
melancholia the observation of the ancients was undoubtedly correct: 
it belongs especially to the type which they called melancholic, whose 
outward signs are tall stature, olive complexion, and straight dark hair. 
More than one theory has been advanced as to the physical con- 
stitution which furnishes the best seed-bed for cancer. For example, it 
has been said to be very common in persons with orange-hazel eyes, or 
with eyes in which the colour is much mixed or broken, in which the 
general effect on a distant view is green. My own observations have 
not confirmed this notion. Cancer, in my opiniop, is most common in 
people who have a fairly healthy constitution in other respects. The 
prevailing complexion, among the subjects of cancer in this country, is 
dark. Out of sixty-seven such, English and Scotch, I found eight with 
black or brown-black hair, and thirty-two with dark brown; thirty-four 
had light, ten neutral, and twenty-three dark eyes. These figures vary 
from those of the surrounding non-cancerous population very decidedly 
in the direction of darkness. Dr. Roger Williams, who has also investi- 
gated this subject and on a somewhat larger scale, has kindly shown 
me his figures, which bear out my own conclusion. It will be remem- 
bered that Dr. Baxter's American statistics also agree with our own 
on this point. Of course it does not necessarily follow that cancer is 
1 See analysis of upwards of 1000 cases in Races of Britain, pp. 222, 223. 36 
SYSTEM OF MEDICINE 
at all more prevalent among generally swarthy than among generally 
blond nations; nor am I aware of any evidence in favour of such a 
belief. On the contrary, there is some reason for supposing it to be 
a disease whose development is favoured by civilisation, comfort and 
intellectual progress; and these are on the whole most prevalent in 
the races whom Huxley calls Xanthochroi, although it is the swarthy 
individuals among them who suffer most. 
John Beddoe. 
REFERENCES 
1. Oesterlen. Handbuch der medicinischen Statistik. Tubingen, 1875. - 2. Lom- 
bard. Climatologie medicale. Paris, 1877. - 3. Bertillon. Demographic Figures 
de la France, etc. Paris, 1874.-4. Boudin. Geographie medicale. Paris, 1857.- 
5. Lagneau. Anthropologic de la France. Paris, 1879. -6. Bordier. Geographic 
medicale. Paris, 1884. - 7. Baxter. Medical Statistics of the Provost-Marshal's 
Bureau. Washington, 1875. - 8. Hirsch. Handbook of Historical and Geographical 
Pathology. Translated by C. Creighton, M.D. London, 1883. - 9. Haviland. Geo- 
graphical Distribution of Disease, etc. London, 1875. 
J. B. 
ON TEMPERAMENT 
Temperament is usually understood to denote a certain combination of 
physical and mental characteristics. Its practical importance is of two 
kinds; as a guide to the disposition to certain kinds of disease, and 
as a guide to the disposition to certain lines of conduct: the subject 
of temperament has been treated accordingly by two classes of writers, 
medical and philosophical. The two have treated the subject in differ- 
ent ways: the physician has considered chiefly, and often exclusively, 
the physical aspect of temperament; the psychologist, on the other hand, 
has regarded temperament as a type of mental character with tendencies 
to certain forms of emotion, and has neglected the physical side. The 
doctrine of temperament was originally founded on a physiological 
basis, and physical conceptions of temperament prevailed till the end 
of the last century. • Kant then took up the subject, and although he 
made use of terms derived from the character of the blood, his treat- 
ment was exclusively psychological. Since the time of Kant the sub- 
ject of temperament has been treated more fully by psychologists than 
by physicians, and the popular use of the term shows that the word has 
now come to mean a certain type of mind rather than a certain type 
of physical organisation. The comparative neglect of temperament by 
recent writers on medicine is not surprising. Medical practice has 
gradually been more and more influenced by the exact methods of 
modern physiology; thus it is natural that the doctrine of temperament, 
resting on simple observation of more or less vague characters, should 
have fallen into disuse. At the present time, although the subject of 
temperament is specifically mentioned by few, its importance is being ON TEMPERAMENT 
37 
more recognised. The predisposition of certain individuals to certain 
forms of disease, and the different effects which the same dose of the 
same drug may have on different individuals, are well-recognised facts 
which show the importance of what is popularly called " constitution." 
But though the importance of constitution or temperament is acknowl- 
edged, little has yet been done to study the subject on modern methods. 
Whenever it has been studied, as by Stewart in his book, Our Tempera- 
ments, the old classification has been adhered to with far from satisfactory 
results. The importance of temperament is also being more recognised 
in relation to many problems of practical life - to such questions as the 
methods of education and the choice of occupation in life. Yet here 
again little has been done in the scientific study of the subject. The 
doctrine of temperament falls under the head of individual as opposed 
to general psychology, under the head of that branch of psychology 
which deals with the differences which distinguish different minds 
rather than of that which deals with the laws of mind in general. 
Individual psychology has been comparatively neglected not only by 
the older school of psychologists, but also by the recent experimental 
school; and it is but quite recently that a beginning has been made in 
the systematic investigation of the mental characters on which a scien- 
tific doctrine of temperaments should be based. 
In order to establish such a doctrine, it will first be necessary to 
study more closely, and by more exact methods than hitherto, the phys- 
ical differences which distinguish different individuals. Much has been 
done in this way by anthropologists; but their investigations have been 
carried out chiefly from an ethnological stand-point, and it is probable 
that their methods will have to be modified to suit the different end in 
view. A second necessity is the investigation of mental differences by 
exact methods. This has hitherto been the greatest difficulty in the 
way of a scientific doctrine ; but experimental psychology is now suffi- 
ciently advanced not only to show how this may be done, but to have 
taken some steps in this direction. Up to the present time the most 
important work on these lines of investigation has been done by Mr. 
Galton. On the physical side his anthropometrical researches furnish 
the kind of material which is needed to establish the existence of dif- 
ferent groups of physical organisation. He has also made some advance 
on the mental side. His division of individuals according to the nature 
of their mental imagery, which has been further developed by Charcot 
and Binet, is a valuable contribution to individual psychology, and an 
example of the kind of distinction to be made out. At present the most 
important work on the mental side is being done by Professor Kraepelin 
of Heidelberg. He and his school work at the subject from the psychi- 
atrical point of view; and one important division of their work has 
been the investigation of certain fundamental properties of the mind 
which are of great importance in the study of temperament. These 
include the capacity for mental work, the susceptibility to fatigue from 
mental work, the power of recovery from such fatigue, the extent of 38 
SYSTEM OF MEDICINE 
the influence of practice, and the power of concentration of attention. 
They have also investigated the relations of bodily and mental fatigue, 
the depth of sleep, and other questions of psychical or psycho-physical 
capacity. In all these investigations they have found that individual 
differences occur; and it is in such differences as these, so important in 
relation to practical life as well as to insanity, that we may hope to find 
the materials for a new classification. It would be fruitless here to 
attempt to formulate a new system of temperaments. Such an attempt 
should only be made on the basis of experience gained in the investiga- 
tion of physical and mental characters by methods such as those of 
Galton and Kraepelin. 
A few suggestions in this direction may, however, be made. There 
has been singular unanimity among both medical and philosophical 
writers in favour of a fourfold division of temperaments. Both Kant 
and Lotze accepted the old division, while modifying and describing the 
mental characteristics more fully than had been done before. Wundt 
has retained the old types, but defines them on the basis of the strength 
of the emotions, and of the rate at which they change. Thus, in the 
choleric temperament the emotions are strong and change quickly; in 
the melancholic, strong but change slowly; in the sanguine, weak and 
quick; in the phlegmatic, weak and slow. One recent writer goes so 
far as to say that the fourfold division must be approved " by all who 
advocate intelligently any theory upon the subject." In spite of this 
consensus of opinion, it would probably be best to put the older classi- 
fication on one side, and to start afresh from the beginning. 
In one direction, however, it may be well to take advantage of 
previous methods; the old doctrine had a pathological basis, and it is 
probable that pathological investigation may give us the clue to a more 
satisfactory method. It is customary to speak of certain dispositions 
to disease as diatheses, of which the nervous diathesis and the uric acid 
diathesis may be given as examples. The exact investigation of the 
physical and mental characters of these diatheses has yet to be carried 
out, and probably no more useful contribution to the doctrine of tem- 
perament could be made than such an investigation. 
Another line of inquiry which might be useful is the study of the 
different characters of the two sexes, and of various ages. The temper- 
aments of age have been most fully considered by Lotze. He regarded 
the sanguine as the temperament of childhood; the melancholic, or as 
he called it, the sentimental, as the temperament of youth; the choleric 
of manhood, and the phlegmatic of old age. The reaction to disease is 
known to vary with the different epochs of life, and it is probable that 
exact investigation of the characteristics of different ages may enable us 
to define groups of temperament useful both from the pathological and 
sociological points of view. It would be especially interesting to dis- 
cover whether the individual who retains in adult life the mental traits 
which are found to be characteristic of childhood, retains also youthful 
characteristics in his physical organisation. ON THE LA IVS OF INHERITANCE IN DISEASE 
39 
Another possible basis for a classification of temperaments is purely 
psychological. As a working hypothesis at the present time, the cus- 
tomary tripartite division of mind might be accepted, and an endeavour 
be made to find the physical and mental traits which characterise the 
three types of Auguste Comte - the man of thought, the man of feel- 
ing, and the man of action. 
It must be remembered that a satisfactory doctrine of temperaments 
has not only to be useful in defining the nature of the more special 
disposition to react in certain ways to disease, but also, and perhaps 
more essentially, in defining the nature of the disposition to react in 
certain ways to other and more general features of the environment. 
W. H. R. Rivers. 
REFERENCES 
(a) Temperament 
1. Kant. Anthropologie, Werke vii. S. 610.-2. Prichard. Cyclopedia of Practi- 
cal Medicine.-3. Lotze. Microcosmus (Eng. trans.), vol. ii. p. 24.-4. Laycock. 
Med. Times and Gazette, 1862.-5. Henle. Anthropologische Vortriige, Heft i. S. 103. 
- 6. Wundt. Grundziige der phys. Psychologic, 4th Anti. Bd. ii. S. 519. - 7. Ladd. 
Elements of Physiological Psychology, p. 574. - 8. Stewart. Our Temperaments. 
London, 1887. - 9. Siebeck. Geschichte der Psychologie, ii.S. 278. -10. Hutchinson. 
Pedigree of Disease. London, 1884. 
(6) Other References 
1. Galton, F. Inquiries into Human Faculty, London, 1883 ; Natural Inheri- 
tance, p. 71.-2. Kraepelin. Ueber geistige Arbeit, Jena, 1894. Psychologische 
Arbeiten, Bd. i. S. 1,1895. Der psychologische Versuch in der Psychiatric. - 3. Oehrn. 
Psychologische Arbeiten, Bd. i. S. 92. Experimentelle Studien zur Individual-psycho- 
logie. -4. Venn, John. " On the Correlation of Mental and Physical Powers," Monist, 
vol. iv. No. 1, 1893.-5. Charcot. CEuvres, t. iii. p. 188.-6. Binet. Rev. philos. 
t. xxxv. p. 104. 1893. 
AV. H. R. R. 
ON THE LAWS OF INHERITANCE IN DISEASE 
We all of us have had two parents, and with the rarest exceptions four 
■grandparents. Most of us have had eight great grandparents, and 
probably to a large majority no fewer than sixteen persons have stood 
in the relation of great-great-grandparents. Now since tendencies to 
individual peculiarities, involving, it may be, liability to special forms of 
disease, may be transmitted not only from parents and grandparents, but 
from much more remote ancestors also, it is obvious that their investiga- 
tion presents us with a very complicated problem. In many instances 
it is almost hopeless to investigate transmission from individual to in- 
dividual, and we may arrive at safer conclusions by estimating average 
prevalence in races, families, or classes of society. It is in this latter SYSTEM OF MEDICINE 
40 
way only that many questions which present themselves, not only to the 
physician, but to the biologist and to the student of sociology, can be 
satisfactorily looked at. [Fide art. on "Anthropology and Medicine."} 
We must, however, in the beginning endeavour to define approxi- 
mately what we believe to be possible as to hereditary transmission. 
Without venturing to do more than mention the Weissmann logomachy, 
which has recently disturbed the creeds of some biologists, I will take 
permission to avow my belief that with the sperm and germ supplied by 
parents there may pass to the offspring tendencies to the reproduction of 
all that these parents had acquired up to the date of the sexual congress. 
By the term " acquired " is meant all that has been received by modifi- 
cation of vital processes, not what has been imposed or taken away by 
external violence. Not only, however, may offspring derive from parent 
cells peculiarities of cell and tissue structure with the proclivities attach- 
ing to them, but it is also in a high degree probable, that in some in- 
stances parasitic elements or specific poisons may pass directly into the 
tissues of the embryo. Such parasitism may be absolutely latent in the 
parent, and may remain so for indefinite periods in the offspring. 
We have then an inheritance of structural peculiarities and tenden- 
cies which is more or less certain, and in addition to it an inheritance of 
parasitic germs or of poisons, which is uncertain and in a sense accidental. 
Respecting this inheritance of specific poisons it is necessary here to 
premise that what takes place may be contamination in utero rather 
than inheritance in the more strict sense of the word. The two parents 
do not stand in an exactly similar relation to their offspring in this 
matter. The father cannot possibly convey any poison unless it be pres- 
ent in his semen; the mother, on the other hand, is in vital relations with 
the foetus for nine months after conception, and may, at any date during 
that period, convey to it any poison which has meanwhile found its way 
into her blood. Thus variola cannot possibly be conveyed by the father 
to the foetus so as to develop only after the birth of the latter; but the 
mother may communicate it during any period of her pregnancy up to 
the last month. The same is the case with syphilis, and possibly with 
some other specific diseases. 
It may be convenient to speak first of the laws of inheritance of 
these diseases which are caused by specific poisons. Of these the 
principal, and the one respecting which most is known, is syphilis; and 
it may be allowed to stand as an illustration of the rest. The facts in 
our possession make it very probable that when syphilis is derived by a 
child from a parent, it is conveyed by the actual transference of some 
specific material, probably of a particulate and organic nature. The child 
does not inherit any modification of tissues which the parent may have 
undergone, but takes over specific germs which are destined to multiply 
in its blood and produce phenomena of similar character and in similar 
order to those which its parent has previously manifested. This char- 
acter and this order may be greatly modified, but they will be essentially 
the same. Thus, however much the health of a parent may have been ON THE LA ITS OF INHERITANCE IN DISEASE 
41 
damaged by syphilis, he will transmit to his offspring nothing unless 
the specific virus of the disease be present in his semen, and in those 
particular spermatozoa which go to the fertilisation of that particular 
ovum. A man might on this hypothesis beget a syphilitic child one 
week, and a non-infected one the next; nay, it is even possible that of 
twins one may receive the poison and the other escape it. It is needful 
to state this definitely, for although we have as yet no direct proof of 
this proposition, the hypothesis is necessary to any clear comprehension 
of the facts. 
The following are the facts which appear to have been established 
respecting the inheritance of syphilis: - 
That the father may infect his offspring (the mother having never 
suffered in any degree), and that this is by far the most frequent mode 
by which the taint is transmitted. 
That the mother may infect her offspring, and that she may do this 
not only at the time of conception, but at any period during pregnancy, 
up to within the last few weeks. 
That there is much uncertainty whether a child will or will not 
receive the poison of syphilis when born of parents one or both of whom 
are tainted. Thus a child may wholly escape under circumstances 
apparently the most dangerous. 
That the nearer the conception to the date of primary disease, in 
one or both parents, the greater the risk to the child. 
That in the tertiary stage a parent may suffer severely and yet 
have healthy offspring. 
That the severity of the disease in the child is in no relation to that 
shown by the parent - many of the worst instances occurring in children 
of parents who were apparently in good health. Severity in the child 
is therefore probably, as in the adult, a matter of idiosyncrasy in the 
recipient, and not of peculiarity as to source. 
Of twins one may suffer and the other escape. 
Although it is the rule for the first-born after the parental acquisition 
to suffer and for younger ones to escape, yet now and then remarkable 
exceptions to the rule may occur. 
That with rare exceptions, the period during which a parent retains 
the poison of syphilis in a transmissible state is limited. In the father 
it rarely exceeds two years, but as regards the mother nothing trust- 
worthy can be stated. 
Although in the case of syphilis no one has yet succeeded in recog- 
nising the specific germ which is its cause, whilst in tuberculosis this 
is supposed to have been accomplished, yet the fact respecting contagion 
and inheritance remains far more vague and uncertain in the latter than 
in the former malady. When a disease may be obtained by contagion 
unwittingly and very easily - its germs possibly being almost omni- 
present - it becomes very difficult to prove anything as to inheritance. 
Thus there are not wanting those who, relying too exclusively upon 
modern doctrines of bacillary causation, and supporting their creed by 42 
SYSTEM OF MEDICINE 
so-called statistics, are disposed to deny altogether the effect of inheri- 
tance in tuberculosis. In the investigation of this important question, 
we must not restrict ourselves to the narrow platform of tubercular 
disease of the lungs. We must comprise all the various maladies with 
which we now associate the tubercle bacillus, and take in all forms of 
bone, joint, and gland scrofula, with also the various affections of the 
eye and the skin (lupus and its allies) which are in such association. If 
in this way we take cognisance of the whole domain of scrofula and tuber- 
eulosis, it is, I think, impossible for any one acquainted with the facts to 
disbelieve in the power of hereditary transmission, and rest only on the 
theory of contagion from without. The subject is one much too compli- 
cated to be well suited for illustration by statistical calculations; these 
are as likely to mislead as to help us. 
Two factors are admittedly of great importance in reference to the 
development of tubercular affections : we must take cognisance not only 
of the bacillus itself, but also of the state of the tissues upon which it is 
implanted. The possibilities of inheritance are therefore twofold. It 
may be that the bacillus itself may pass bodily or potentially with the 
sperm or germ from parent to child, or it may be that a condition of 
tissues liable to its attacks, but for the time free from its presence, may 
be the result of transmission. If we are permitted to name the tissue- 
eondition, which is prone to favour the development of the tubercle 
bacillus, the name " scrofula " will perhaps be convenient for the present. 
A child may then inherit " scrofula " without the bacillus, or the bacillus 
without "scrofula"; or, what probably is most common, both may be 
present together. Pathological facts leave us in no doubt that the 
tubercle bacillus may find its way into the body of the foetus in utero 
and may there develop. Whether it does so in association with the 
semen, or in union with the maternal germ; or whether it is always 
derived by the ovum from the mother's blood, we are as yet uninformed. 
We may plausibly conjecture that any one of these three modes is an 
easy possibility. The life history of the tubercle bacillus is probably by 
no means wholly known to us. We do not know, for instance, what are 
the conditions or how long the periods under and during which it may 
remain latent in the tissues. Many clinical facts suggest that it may 
in some resting form be present in most persons - waiting until some 
local damage or some degradation of general health gives it opportunity 
for development. The prevailing creed which suspects external conta- 
gion as the cause of all scrofulous and tuberculous attacks is probably a 
much too narrow one. It is clear, however, that as regards the heredity 
of phthisis and scrofula, we can at present do little more than state 
preliminary facts and suggest possibilities. We are by no means yet in 
a position to put forward conclusions. 
If we turn from tuberculosis to leprosy, a malady which is possibly 
a congener, we shall encounter similar sources of uncertainty. Yet, if 
we can get a clear view of the facts, the two will perhaps throw some 
light on each other. Firstly, a bacillus very like that of tubercle attends ON THE LA WS OF INHERITANCE IN DISEASE 
43 
the development of all the most severe forms of leprosy. When leprosy 
ends fatally it is often by the supervention of pulmonary disease not 
distinguishable from phthisis. The facts as regards contagion are much 
the same in the two, and are matters chiefly of conjecture. In both 
maladies it is certain that almost unlimited opportunities for contagion 
may occur without any evidence of its accomplishment. Now, until 
quite recent times, the belief in the hereditary transmission of leprosy 
has been almost universal. The more careful investigations of modern 
observers have, however, thrown much doubt upon this creed. It is 
quite certain that the children of lepers, born out of leper districts - 
in England or the United States for example - never inherit it. The 
occurrence of the disease in the children of lepers in a leprosy district is 
no evidence at all; for obviously they have been exposed to the endemic 
cause whatever that may be. If it be, after all, a food disease, they may 
have partaken of the tainted substance. The recent inquiries of the 
Leprosy Commission in India, which collected facts at the Schools for the 
Children of Lepers, pointed to the conclusion that there is no proof of 
heredity, since these children did not manifest the disease in greater 
proportion than others. The very prolonged periods during which 
leprosy may remain absolutely latent (ten years or more) introduces, 
however, an element of uncertainty into all these investigations. We 
may safely believe that in the case of leprosy the influence of heredity 
is a very small factor, but it would be unwise to deny its possibility. 
If we turn now to the consideration of maladies which are induced, 
not by any specific virus, but by the inheritance of anatomical or 
physiological peculiarities, a few general propositions may be ventured. 
There is probably no peculiarity, whether of structure, of function, 
or both, which can be acquired or augmented during the life of the 
individual which may not be reproduced in his or her offspring; yet 
the transmission of such peculiarities is by no means a matter of cer- 
tainty : one child may suffer and another escape. Of this uncertainty 
double parentage is probably the chief explanation. 
It is quite possible for an individual in whom any given tendency 
derived from a parent may never have disclosed itself to transmit such 
tendency. Thus a disorder or peculiarity present in a grandfather may 
be revealed in his grandchild just as special features in the countenance 
or other resemblances may be transmitted. It is possible, indeed, that a 
peculiarity of structure leading to derangement of function may be trans- 
mitted through many generations, and yet show itself in very few indi- 
viduals in each. Under some law, as yet not well understood, it is possible 
for a peculiarity of structure to show itself suddenly in several children 
of the same parents, there being no proof of its previous occurrence in 
the progenitors. To this group of maladies the term family diseases 
has been given; but it must be clearly understood that it refers to the 
members of one single family and not to descendants in several generations. 
Illustrations of the wide topic upon which we now enter occur on 
every side. The inability to digest the albumen of eggs and of milk SYSTEM OF MEDICINE 
44 
which is often met with as an idiosyncrasy in related individuals in 
several generations must depend upon the constitution of the gastric 
juice, which in its turn is due to some peculiarity in the glandular 
apparatus of the stomach. It may serve as an example of a thousand 
other peculiarities, some more and some less well marked. To the 
whole group we give the name idiosyncrasies; and although we leave 
them for the most part unexplained they are none the less real, and 
dependent no doubt upon actual structural aberrations. Very often a 
sufferer knows that some predecessor - grandparent or great-grand- 
parent- had the same peculiarity. Were habits of family observation 
and record more cultivated, no doubt such evidence would be still more 
frequently forthcoming. 
Psoriasis does not very often affect several brothers and sisters, but 
it frequently seems to be transmitted from parent or grandparent. Thus 
it may persist through many generations, but still affect but very few 
individuals. Its subjects are almost always in good health, and the 
balance of evidence as to its nature would incline us to suspect that it 
depends upon an inherited peculiarity of the structure of the skin. 
The laws of inheritance come to our aid in explanation of many 
of the peculiarities presented by exceptional diseases of the skin; and 
these in turn illustrate the laws of inheritance in a very instructive 
manner. Inherited peculiarities in structure must be invoked to explain 
such phenomena as excessive tendency to freckle; the liability to blister 
in the sun, proneness to chilblains, liability to urticaria and pruritus. 
It is for the most part those who have inherited a skin in which the 
sebaceous glands are large who become the subjects of comedonous acne. 
Amongst the " family diseases " which chiefly show themselves on 
the skin we have the common forms of xeroderma or ichthyosis; and 
the rare malady known as Kaposi's disease, or xeroderma pigmentosum. 
In ichthyosis almost invariably one-half of the family of children suffer 
whilst the others wholly escape. Evidence of it is often but not always 
present at birth. There appears to be no regard to sex. The same 
statements are true of Kaposi's malady, which consists of a most 
excessive tendency to the formation of freckles, which are apt to run 
into ulceration. Its occurrence reveals a congenital imperfection in 
the structure of the skin, which renders it unable to withstand the 
irritation of ordinary sunlight. In this feature it has much in common 
with retinitis pigmentosa, a disease occurring often in several members 
of one family, and due to degenerative changes in the retina apparently 
induced by exposure to light. 
The tendency to bleed on slight cause, which constitutes the 
" haemorrhagic diathesis," affords us another good example of a family 
disease. It is, however, not one of those which is restricted to a single 
generation, being almost always an heirloom, and with the peculiarity 
that it manifests itself almost exclusively in the male sex. It is quite 
possible that our inferences on this latter point may be somewhat exag- 
gerated, for the menstrual relief in women not improbably prevents other ON THE LA WS OF INHERITANCE IN DISEASE 
45 
forms of haemorrhage, and in families in which the males are bleeders 
menstruation in the women is often profuse. The proved relationship 
of haemophilia to inherited gout leads to the consideration of the latter 
malady itself in reference to inheritance. This is a topic which requires 
much patient attention to detail for its clear apprehension. It is not a 
simple matter: we must not restrict our conception of gout to attacks 
of acute podagra, but must include in the term all the conditions which 
lead up to such attacks, or can be proved to be in association with them. 
By general consent the liability to gout is hereditary; indeed it may 
even be doubted whether in its more typical forms it is ever acquired in 
a single generation. That the gouty state may be induced by luxurious 
living and defective exercise is a proposition which no one will deny; 
that it can be so induced with equal facility in all persons is, however, 
well known not to be the case. In some very slight errors in self-man- 
agement will cause it; whilst in others no excess, however long contin- 
ued, seems to be sufficient. The difference as we observe it under the 
existing conditions of society is probably in the main a difference in the 
strength of inheritance, though at the same time it may be true that 
certain differences in race, family, and temperament may in the first 
instance have made themselves felt. Of the middle classes of society 
in England, and amongst other communities where gout has been long 
prevalent, it may be held that all inherit the tendency more or less 
remotely. If we attempt to explain in what that tendency consists, we 
must begin by saying that in the first place it consists in peculiarities 
of appetite and digestion, and next in defects in the excretory organs. 
The man who inherits gout inherits peculiarities of stomach and kidneys, 
and of all organs which are concerned in the assimilation of food and 
the depuration of the blood. We may take this as perhaps the simplest 
expression of the inheritance of gout; but there must follow on it the 
assertion that he inherits also peculiarities of various other kinds. His 
cartilages and ligaments, his nerves, his muscles, his blood-vessels, in 
fact every tissue in his body, has acquired some modification, and with 
it some special proclivity to disease. Congestions, inflammations, nerve 
pains, whatever may have been their exciting causes, will in him assume 
a special character and lead to specialised results. Thus the offspring 
of generations of gouty ancestry may, in virtue of such descent, suffer 
from various maladies which stand in no direct relation with errors in 
diet, defective assimilation, or the accumulation of urates in the blood. 
One of these is the weakening of. blood-vessels, which is the proximate 
cause of hsemophilia, and may also find its expression in epistaxis, 
haemorrhagic purpura, bleeding into the vitreous, and other phenomena. 
In the same way inherited gout may be the parent of iritis in early life, 
and of various forms of joint disease at all periods of life, which are 
wholly unassociated with the deposit of urate of soda in the structures. 
It is an inheritance of tissue proclivity independently of, though usually 
in addition to, peculiarities of assimilation and excretion. Nor must it 
be forgotten that these inherited liabilities may have been inextricably 46 
SYSTEM OF MEDICINE 
mixed with others. Feebleness of circulation, instability of nerve func- 
tion, scrofula, and other causes of disease, may have joined with inheri- 
tance of gout, and the resulting state may thus be a very complicated one. 
It is not necessary to say more than a few words respecting the 
heredity of congenital defects in the growth of external parts. It is 
universally admitted that such defects as coloboma iridis, harelip, 
superfluous digits, webbed digits, and the like may be and commonly 
are hereditary. We also observe respecting them that occasionally they 
occur in many members of the same family ;* whilst there is little or no 
evidence as to their occurrence in former generations. This has been 
especially noted in certain instances of harelip and defects in the iris, 
and it is especially of interest in reference to the explanation of other 
forms of "family disease." 
Another important law which receives occasional illustration in these 
very obvious hereditary defects is that of " transmutation in transmis- 
sion." By this expression is meant that the defect reproduced is not 
always exactly the same as that in the predecessor. Thus one child 
may have a superfluous digit, and another of the same family merely a. 
deformed and overgrown one. What is hereditary is clearly a liability 
to disturbance in the development of a certain portion of protoplasm, 
but falls short of the necessary production of identity of result. This 
law is probably of wide application under conditions in which it is not 
so easy to prove its influence. In the case of various forms of skin 
disease it may be conjectured that a liability to defective formation of 
the skin in general is the antecedent rather than a definite proclivity to 
one single type of malady. Thus an inheritance from a parent who has 
suffered from psoriasis may possibly be transmitted as ichthyosis, or 
some form of chronic eczema or lichen. Many of the known facts as 
regards "family diseases" support the belief that some law of unity 
in variety influences their production. 
Jonathan Hutchinson. 
MEDICAL GEOGRAPHY OF GREAT BRITAIN 
That branch of medicine which has for its subject the Geographical 
Distribution of Disease, may be said to have had a very remote origin 
in the ancient Coan School of Medicine, of which the family of Hip- 
pocrates were the founders. In this school the study first sprang 
into existence as far as we can judge, and then flourished for a time 
under the care of the author of Airs, Places, and Waters, the head 
of the above distinguished family, whose genius, common-sense, and 
vast experience, extending over an unusually long life of active prac- 
tice among the isles of the Greek Archipelago, and the mainland MEDICAL GEOGRAPHY OF GREAT BRITAIN 
47 
of Greece, Thrace, and the Coast of Asia Minor, enabled him to 
accumulate a vast number of clinical facts bearing upon the relation 
between certain classes of disease and certain conditions of soil, water, 
and atmosphere. Within the circumference of his wide experience he 
had almost every variety of land-surface from the Mount Olympus to 
the paludal lakes of the plain, and the swamps alongside the river 
mouth; over those lands he noted the sweep of the atmospheric currents, 
the different lie and aspects of their slopes towards wind and sun. Of 
the winds he studied their moisture, dryness, and temperature, and at- 
tributed the excess or defect of these qualities to their courses over the 
neighbouring lands and seas. The different effects of the various waters 
on mankind - the hard, the soft, the brackish, and paludal - were also 
noted by Hippocrates, and locally the effects of weather and seasons 
were also studied by him, whether in his reports of clinical cases, or of 
epidemics (1). 
In the etiology of disease Hippocrates evidently foresaw the great 
importance of the physical configuration of the land, its aspects and 
soils, and the influence of the two great factors of local climates, the 
sun and the atmosphere,-the latter ever varying in its currents, 
temperature, moisture, and adventitious constituents, whether of 
mechanical, vegetable, or animal origin. The later results of the 
study of medical geography justify these early anticipations of that 
great physician. 
Since the death of Hippocrates (b.c. 480-357) the subject stood still 
until the publication by Dr. Alexander Keith Johnston of his well-known 
Physical Atlas of Natural Phenomena (2), in which maps appeared of the 
geographical distribution of certain diseases. The data were gathered 
principally from the works of our naval, military, and mercantile marine 
medical officers and others, within whose stores of facts there are many 
that might still be profitably studied. 
In 1856 the eMiinent French physician and medical geographer, 
Boudin, published his Geographic Medicale, based principally on the 
statistics of the French army - the first statistics used in the study of 
medical geography. In this work France was divided into departments, 
each so shaded as to indicate death-rates, or the number of conscripts 
rejected on account of certain diseases in proportion to the populations. 
In England the data for constructing maps of disease distribution 
were not published in serviceable form until the late Dr. William Farr 
issued his Decennial Supplement for 1851-1860 to the Registrar- 
General's (Major Graham) 25th Annual Report in the year 1864. Dr. 
Farr published two supplements, including the decennial periods 1851- 
1860 and 1861-1870, giving the number of deaths from twenty-five 
different causes at certain age-periods, among males and females sepa- 
rately, for each of the 630 registration districts during each of these ten 
years; since then the present Registrar-General has confused the sexes 
and rendered his supplement for 1871-1880 useless for this branch of 
study. 48 
SYSTEM OF MEDICINE 
The history of disease distribution is fully dealt with in my recently 
published work (3) ; I will now give the salient facts resulting from my 
own investigations from the year 1868 up to the present time. 
The first firm step in the study of the medical geography of Great 
Britain was made within a short time of the publication by Dr. 
William Farr, C.B., of the supplement already referred to. In this 
important and model report the deaths from twenty-four different causes 
during the ten years 1851-1860, in each of the 630 registration districts 
of England and Wales, were arranged in two tables, one for males and 
one for females respectively. The mean populations of each sex in each 
district were divided into so many (17) age-periods, giving (1) the mean 
number of males and females living during the decennium at each age- 
period; and (2) the number of deaths from each of the twenty-four 
causes during the same time at each of the said age-periods: thus the 
death-rate from each cause at each age-period could be calculated - the 
mean populations at the different ages being given in the same column 
as the actual number of deaths from the different causes. With the 
life and death statistics so arranged the medical geography of England 
and Wales, and the construction of maps showing the geographical 
distribution of each cause of death in the 630 districts, became possible 
for the first time in the annals of medicine; and future investigations 
into the causes of the varieties of the several distributions, as well as of 
the marked inequality of the distribution of each individual cause of 
death, found a solid basis. Such a map once constructed and coloured 
in varying shades, enables the student at once to compare it with other 
maps of the geology, physical geography, hydrography, meteorology, 
etc., of the country under observation; and lastly, with other maps of 
the distribution of other diseases over the same area, and of the 
distribution of the yield of such crops as wheat, a plant whose habits 
and peculiar construction I have shown to be remarkable exponents of 
local climates. • 
In 1875, whilst my first folio edition was going through the press, 
the Registrar-General of Scotland issued his Supplement to the Annual 
Reports for the ten years 1861-1870, which contained a summary of the 
deaths in each of the thirty-three counties during that period from 
heart disease, phthisis, and cancer: he did not, however, take the 
precaution of separating the sexes, or of giving the number of deaths 
and the mean populations at each age-period. It enabled me, how- 
ever, to extend my inquiries and to construct sketch maps, although 
very imperfect ones, of the distribution of the above causes of death in 
that part of Great Britain. 
I will now give an outline of what has been achieved in the medical 
geography of England and Wales. 
Heart Disease. - The first map constructed was that of the geo- 
graphical distribution of heart disease and dropsy during 1851-1860, 
amongst a mean population of 18,996,916, or 9,278,742 males and 
9,718,174 females, distributed over 630 registration districts, amongst MEDICAL GEOGRAPHY OF GREAT BRITAIN 
49 
whom had occurred 236,973 deaths from this cause, of whom 109,527 
were males and 127,446 females. 
As the annual death-rates from this cause were found to differ only 
as 11'8 (males) to 13-1 (females), a careful study of the death-rates of 
the two sexes in each district was made: the difference in the mortality 
attributable to sex was found too small to necessitate two maps, 
especially as the organ affected was common to both. The map, there- 
fore, represented the deaths of both sexes, namely, 236,973, or nearly 
a quarter of a million, and at all ages. The districts having a mortality 
from heart disease above the average of the whole country (12-0 to every 
10,000 living) were coloured in shades of blue, the darkest blue repre- 
senting the highest mortality; and those having death-rates below the 
average were coloured red in different shades, the darkest red represent- 
ing the lowest mortality. 
A map was constructed and coloured in accordance with the above 
scale, which ranged from 4-6 - the lowest rate - to 19-21, the highest 
annual death-rates to every 10,000 males and females living in each 
registration district during the ten years 1851-1860. 
The Map of Heart Disease. - When a map of the 630 districts in 
England and Wales is coloured on such a scale, and each separate 
district coloured with a shade of blue or red according to its death-rate, 
it will be found that instead of the map presenting the appearance of 
a " crazy-patch work," it will be characterised, according to the disease 
chartographed, by groups of red and blue districts, which suggest at 
once to the observer that some unknown general condition gives a 
certain measure of uniformity to the forms and positions of the groups 
he sees before him. 
The observer must now compare the disease-map, and its remarkable 
groups of high and low mortality, with a good map of the physical 
geography of the same country - such as that constructed by the late 
Sir A. C. Ramsay (Stanford) - and carefully note each physical 
feature represented on it with each group of high and low mortality. 
This will prove an easier task than at first it appears to be, for every 
country, even the smallest islands, have their water-partings and 
river-catchment basins, their ridges of high ground, and their valleys 
in the lower, through which the rivers and their tributaries take their 
courses to the ocean or some inland sea. Throughout Great Britain 
these river-catchment basins have been well defined on excellent maps 
which help the student at every step of his investigation. In the case 
of heart disease the first glance at the two maps will disclose the 
following remarkable coincidences: - (1) The east coast of England and 
the west coast of Wales-in fact, those parts of the country most exposed 
to the force of the sear winds - are characterised by almost continuous 
groups of low mortality, red. (2) Wherever on the physical map the 
outlets and courses of the large rivers are seen to have their axes 
corresponding in direction with the prevailing winds - such as the 
south-west and north-east - groups of low mortality are observed on 
VOL. I 
E SYSTEM OF MEDICINE 
50 
the disease-map invariably to extend far into the country, as in the 
cases of the Tyne, the Tees, the Humber, the Norfolk and Suffolk rivers, 
the Thames, the Severn and Avon, the Welsh rivers, the Mersey, the 
Westmorland and Cumberland rivers. On the other hand, (3) wherever 
the trends or axes of the rivers are more or less at such angles to the 
courses of the prevailing winds as to preclude their free access, and force 
them to blow over their valleys instead of sweeping up through them, 
there on the disease-map we see groups of high mortality (blue). In 
the latter instance the river valley systems are imperfectly air-flushed, 
as in Hampshire, Dorsetshire, Devonshire, Herefordshire, and other 
districts where the axes of the rivers are opposed to perfect ventilation 
by the prevailing and other winds. 
The exceptions to the littoral groups of low mortality are found to 
be in those districts characterised on the physical map by high pre- 
cipitous and rock-bound coasts, which protect the land to the leeward, 
and thus offer barriers to air-flushing. Coincident with these conditions 
are groups of districts of high mortality (blue), as in Northumberland, 
the North Riding, Somersetshire, and Devonshire. With these facts 
before us we begin to understand the importance of the characters of the 
foreshores of a country; for in studying the two maps in detail, district 
by district, we are constantly meeting with the coincidences of flat 
foreshores and low mortality, and precipitous foreshores and high 
mortality, which are in harmony with the low mortality of the well- 
flushed valleys and the high mortality of those imperfectly ventilated. 
Since the above results were obtained I have visited all the high- 
est mortality districts, and found that great prevalence of endemic 
rheumatism in one form or other coincided with the heavy death-rates 
from heart disease. I have also mapped out the data for 1861-1870, 
and found that the distribution of high and low mortality groups during 
the second corresponds with those of the first decennium. During the 
ten years 1861-1870 the mean population amounted to 10,417,596 
males and 10,971,649 females, of whom died from heart disease 136,531 
males, and 151,916 females, equal to a total mortality of 288,447, which 
added to the mortality from this cause during the first period, brings the 
total mortality to more than half a million deaths spread over twenty 
years (525,420), and enables us to formulate the proposition: («) That 
throughout England and Wales low mortality from heart disease is found 
in all those districts where the valley-systems are open to the free air- 
flushing by the prevailing and other sea-winds; and on the other hand 
high mortality is found in all those districts with protected valley-systems, 
the river courses of which are at such angles as to preclude free air-flush- 
ing, and to force the winds to blow over instead of up through them. 
Such unventilated valleys are equivalent to the " stuffy hollows " which 
the experience of Hippocrates taught him to denounce, and which, as I 
found by another investigation even in such a fertile county as Devon, 
were incapable of producing a wheat-yield above twenty-one bushels per 
acre, the average for England and Wales being twenty-nine bushels. MEDICAL GEOGRAPHY OF GREAT BRITAIN 
51 
We now proceed to the medical geography of a totally different cause 
of death - cancer; and as this disease is twice as prevalent among 
females as among males, we shall coniine ourselves to its distribution 
amongst that sex. 
Cancer. - During the ten years 1851-1860, amongst the female popu- 
lation above stated (9,718,714), there occurred throughout England 
and Wales 42,137 deaths at all ages from this cause, - a death-rate 
equal to 4-33 to every 10,000 females living; whereas amongst the male 
population (9,278,742) there occurred only 18,059 deaths at all ages, 
equal to an annual death-rate of 1-94 to every 10,000 living, or less 
than half that for the other sex. The scale represents the usual six 
degrees of mortality, those above the average in shades of blue, and 
those below in shades of red, representing different annual death-rates - 
the lowest between 1-2 to every 10,000 living (darkest red), and the 
highest 6-7 (darkest blue). The scale for deaths among females at and 
above thirty-five years of age ranged for the same period from below 
10 to 18 and upwards. 
A map of the 630 registration districts of England and Wales so 
coloured according to the mortality at all ages, or at and above thirty- 
five years of age, presents certain well-defined groups of high (blue) and 
low (red) mortality as in the case of heart disease, but differs from this 
in certain important features. 
If we place such a map by the side of the one of physical geography, 
we shall find that the highest mortality groups cluster around the lower 
courses of fully-formed rivers that seasonally flood their riparial districts, 
from the Tweed to the Thames on the east coast, and from the Stour to 
the Tamar on the south, whilst along the west coast of England and 
Wales, with the exception of the districts watered by the North Devon 
Taw, the Severn, the Dee, and the Eden, low mortality predominates. 
On the east coast we see the lower courses of the Tweed, the Tyne, 
the Swale, the Derwent, the Humber, the Witham, the Ouse, the 
Yare, the Stour, and the Thames, ail characterised by groups of high 
mortality. We see similar groups surrounding the lesser rivers of 
the south coast; and among the rivers emptying themselves into the 
Bristol Channel we have the notable examples of the Severn and Avon 
marked by groups of high death-rates, and farther north the rivers 
Dee and Eden. So far the map of physical geography will aid us up 
to a certain point as regard the high mortality groups; but when we 
proceed to discuss those of low mortality we find that we must have 
recourse to a geological map of England and Wales, such as Green- 
hough's, although in the final stages of our work we must study each 
district and each parish separately side by side with the maps of the 
Geological Survey. For this purpose the Sanitary County Diagrams, on 
a 4-miles to the inch scale, are very useful, especially as an index map 
of the geology of Great Britain is being published by the Geological 
Survey on the same scale. On comparing the low mortality groups of 
districts with the same areas in the geological and physical maps, we SYSTEM OF MEDICINE 
52 
shall find that they correspond with the most elevated tracts of country 
- tracts where floods are rare or temporary; in fact, the lowest mortality 
groups follow the courses of the water-partings, whilst the highest, as 
we have seen, are to be found in the lowest and most frequently flooded 
valleys. The geological map further informs us that the areas covered 
by the lowest mortality groups correspond with areas of the older 
rocks, such as the Cambrian, Silurian, and Mountain Limestone; 
whereas the highest mortality areas are coincident with the more recent 
formations, especially when they consist of clays, such as the Oxford, 
Lias, Gault, Wealden, London, and the still more recent alluvial. 
We are therefore able to summarise the above facts in this propo- 
sition : that the cancer fields in England and Wales are found in the 
sheltered and low lying vales, traversed by fully formed and seasonally 
flooded rivers, and composed of the more recent argillaceous formations; 
and that the districts having the lowest death-rates from this cause 
occupy the more elevated areas composed of the oldest rocks, amongst 
which the limestone areas are coincident with the very lowest mortality. 
Phthisis among Females.-In studying the distribution of phthisis 
we shall again have recourse to the map of physical geography. We 
have now to deal with populations having in their midst an indefinite 
number of individuals bearing in their lungs the bacillus tuberculosis of 
Koch. In every district there are males and females acting as hosts to 
this parasite; and clinical observation tells us that such individuals are 
at all times liable to fatal disease when exposed to certain persistent 
causes of irritation and subsequent inflammation of the lung tissue in 
the neighbourhood of the parasitic colonies. Amongst these are sudden 
chills from exposure to cold when heated, or to more protracted chills 
from dampness of clothing. But there is another source of irritation 
of the delicate mucous membrane of the lungs ending too frequently in 
inflammation and suppuration of the lung tissue, namely, exposure to 
the force of strong winds from the sea. We all know the almost 
instantaneous effects of exposure to such winds even among the health- 
iest and strongest, as evidenced by watering of the eyes and running at 
the nose, signs of temporary catarrh, which too frequently extends 
to the lungs, and there, in the consumptive, arouses the fatal activity 
of the hitherto dormant tubercle bacillus. 
Now of the 9,718,174 females who lived during the ten years 1851- 
1860 more than a quarter of a million died from phthisis pulmonalis 
(269,618), - the scale of six degrees ranging from 17-20, the loicest 
(darkest red), to 37-40, the highest (darkest blue). 
Remembering what the heart disease map taught as to the effect 
of the prevailing sea-winds blowing up through and air-flushing the 
valleys lying in this direction, we shall have no difficulty in recognising 
the areas most exposed to the force of the sea-winds; and on the 
contrary, those other areas that are so shut in by barriers to their 
free access as to form unventilated hollows, in which those with 
damaged lungs find protection from their force and other qualities of MEDICAL GEOGRAPHY OF GREAT BRITAIN 
53 
the sea gales which render them injurious to lungs which are either 
morbidly sensitive or already invaded by the bacillus of Koch. Thus 
along the coast of the eastern counties, and far inland from the low 
foreshores, we observe a large and important group of high mortality 
districts. This area in the heart disease map is characterised by an 
equally large group of low death-rates. Again, along the coast of 
Wales, up to its central ridge or back-bone, is another large group of 
very high mortality which corresponds to the large group of low 
mortality from heart disease. Again, along with the low-lying north- 
western foreshore and far inland - an area well exposed to the sea- 
winds, especially to those from the north-west - and that which on the 
heart disease map showed a low mortality, is, however, in this phthisis 
map coloured in the darker shades of blue, indicating a very high 
mortality from the latter cause. On the other hand, the low mortality 
groups of phthisis are to be found on the leeward side of the Welsh back- 
bone where the air is purest, but robbed of its force, which had been broken 
on the windward side of the mountains where the highest mortality pre- 
vailed. Again, if we study the low mortality groups along the north-east 
coast of Yorkshire and Northumberland, we shall find that these areas 
are protected by the precipitous cliffs of the coast lines from the full force 
of the sea-winds. If we now take the protected Thames valley, where 
so much rheumatism, heart disease, and cancer prevail, we shall find 
another large group of low mortality from phthisis, notwithstanding the 
dampness of the climate arising from clays and floods. 
If we now compare the phthisis and cancer maps, we shall become 
aware of the strong contrast that one bears to the other. As a rule 
where high mortality groups (blue) are found in the one, low mortality 
groups (red) are seen in the other, and vice versa; this arises from the 
fact that cancer prevails in the deep, low-lying, well-protected river- 
valleys, where the force of the sea-winds is mitigated. If we now 
examine the low mortality groups of cancer we shall find them on the 
high, dry Paleeozoic and much exposed formations, where phthisis pre- 
vails. 
The propositions as regards the distribution of heart disease, cancer, 
and phthisis, laid down for England and Wales are equally applicable 
to those causes of death in North Britain. 
The benefits to be derived from this study, which is far too vast to 
be adequately handled within the space of this article, are of a two- 
fold character. To the medical practitioner the maps are guides in his 
consulting room, which enable him to avoid recommending places unfit 
for the relief of the several diseases under discussion. With such maps 
before him he would hardly recommend a member of a cancerous family 
to reside in a low-lying, oft-flooded argillaceous district; or of a 
phthisical family to take up his abode where he would be exposed to 
the full force of strong sea-winds; or a rheumatic person with threatened 
heart affection to continue living in the stuffy, unventilated hollows 
first described by Hippocrates. SYSTEM OF MEDICINE 
54 
Secondly, the maps will direct the bacteriologist to the localities 
where the several diseases prevail, and to the soils that seem to favour 
or to repress the vitality and distribution of pathogenic parasites. 
We have yet to discover the microbe that determines the rheumatism 
which ends in heart disease, and seems to be scattered by air-flushing 
winds, and accumulated in the supra-soil atmosphere of pent-up valleys. 
Alfred Haviland. 
REFERENCES 
1. (Euvres completes d'Hippocrate, ed. Littre, vol. ii. 
2. Dr. Alexander Keith Johnston. - Map 35, " Geographical Distribution of Health 
and Disease." W. & A. K. Johnston, Edinburgh. 
3. Alfred Haviland. - The Geographical Distribution of Disease in Great Britain, 
2nd edition. Sonnenschein and Co. London, 8vo. 
4. Alfred Haviland. - Climate, Weather, and Disease. Churchill, 1855. 
A. H. 
INFLAMMATION 1 
Part I.-A General Survey of the Process of Inflammation 
Chapter 1. Introduction. - Chapter 2. The Comparative Pathology of Inflamma- 
tion.- Chapters. The Main Forms of the Process of Acute Inflammation in the 
Higher Animals. 
Chapter 1. On the Part played by the Leucocytes. - Chapter 2. On the Inflamma- 
tory Exudation.-Chapters. On the Part played by the Blood-Vessels.-Chap- 
ter 4. On the Passage of Corpuscles out of the Vessels. - Chapter 5. On the Part 
played by the Nervous System. - Chapter 6. On the Part played by the Cells of 
the Tissue. - Chapter 7. On Fibrous Hyperplasia and its Relationship to Inflam- 
mation. 
Part II. - The Factors in the Inflammatory Process 
Part III 
Chapter 1. On Classification. - Chapter 2. On Systemic Changes accompanying 
Local Injury and Inflammation. - Chapter 3. Conclusion. - Bibliography. 
PART I. - A General Survey of the Process of Inflammation 
Chapter 1. - Introduction 
Definition of Inflammation. - It is usual to begin the description of 
a morbid process by defining that process. In the case of inflamma- 
1 The following article is an attempt to bring into order the very numerous recent 
researches upon the inflammatory process, and to show whither they appear to tend ; it 
pretends in no wise to be a complete treatise upon the development of our knowledge of 
the subject. Space alone has forbidden that I should trace the full history. I would 
therefore strongly urge that as a corrective other works be consulted in which the earlier 
theories are treated at length; more especially would I recommend (as throwing light 
upon the progress of our knowledge) Professor Burdon-Sauderson's article upon Inflam- 
mation in Holmes's System of Surgery. INFL AM MA TION 
55 
tion, however, we have to deal with a process so complex, so modified by 
modifications of the many factors involved, and so variable in its manifes- 
tations according to the variety of its causes and the region of incidence, 
that the attempt to define it has proved a pitfail to pathologist after 
pathologist; moreover, to advance a definition of the process at the begin- 
ning of this article in terms differing to any considerable extent from 
those employed by previous writers, would demand a criticism of the many 
previous attempts; and in order that the definition put forward be duly 
supported, would necessitate an essay covering the whole field about to 
be traversed. I shall then leave definition to the end, until I have 
marshalled my facts, and have brought into line all that appears to me 
necessary for a correct understanding of the process. The definition 
must be the summing up of the subject, not the introduction thereto. 
Use of the Name.-Yet, in the meantime, inasmuch as divergent 
views are held of the limitations of the use of the name inflammation, 
a few words of introduction are advisable. 
Two courses are before us: either to employ the name strictly in 
accordance with the primitive definition, and thus only to include as 
cases of inflammation those states in which there are present redness, 
swelling, heat and pain, rigidly excluding all cases in which these cardinal 
symptoms are not present; or, on the other hand, departing from 
tradition, to include as inflammations all those morbid processes which 
seem to have a cause and progress inseparable from and merging 
into the cause and progress of the state characterised by the classical 
symptoms. The first course is impossible; it is as though one were to 
declare that red phosphorus is not phosphorus because in externals 
generally it does not agree with the definition of the yellow form made 
years before the allotropic modification was discovered. We are now 
well agreed that of the classical symptoms, one, two or three may be 
unrecognisable, and in fact absent; and yet the condition of inflamma- 
tion be undoubtedly present.1 
The second is the only possible course, that, namely, which associates 
all those states which under suitable conditions may result in the pro- 
duction of the four classical symptoms, and moreover originate from a 
common cause. Holding this view, it will in the meantime be well for 
me, in order to afford a starting-point for the description and discus- 
sion of the subject, to select from the many definitions one which is 
based not on symptomatology, but upon aetiology, and indicates a common 
origin for all cases of inflammation. I would select that which in this 
country has received the most cordial support, the definition given by 
Professor Burdon-Sanderson in his well-known article in Holmes's System 
of Surgery: " The process of inflammation is the succession of changes 
1 A course allied to this has found favour of late years among sundry surgical patholo- 
gists, who would limit the use of the term to those cases and those only in which the classi- 
cal symptoms, or the majority thereof, are present and associated with suppuration,- they 
urge with Hiiter that inflammation only occurs when pyogenic micro-organisms are present, 
and state that when a wound heals aseptically it heals without inflammation. This modi- 
fied course is equally impossible; pyogenesis must not be confounded with inflammation. SYSTEM OF MEDICINE 
56 
which occurs in a living tissue when it is injured, provided that the injury 
is not of such a degree as at once to destroy its structure and vitality." 
This definition includes too much. The haemorrhage that occurs in 
the liver when it is injured, and the changes that there occur in the 
extravasated red corpuscles, are scarcely to be classed among inflam- 
matory phenomena; the atrophic changes which occur in the retina, when 
through injury it becomes detached, are due mainly to malposition 
and disuse rather than to the primary trauma. But, as Dr. Burdon 
Sanderson has pointed out, the definition has this great advantage, 
that stating the cause, it clearly recognises inflammation as a process 
and not as a state. The external manifestations of this process under 
favourable conditions-where the region injured is a loose and vascular 
tissue, and where the injury is sufficiently severe or extensive - are red- 
ness, swelling, and heat with pain: redness from the congestion of the 
vessels; swelling from the exudation of fluid and corpuscles from the 
congested vessels; heat from the increased amount of blood in the region, 
and pain from the pressure upon and irritation of the terminations of the 
nerves in the region. To these four symptoms may be added a fifth, 
disturbance of function brought about by this departure from the 
normal condition of the region. Under unfavourable conditions - where 
the region injured is dense or less vascular, or where the injury is less 
severe - one or all of these symptoms may seem wanting; nevertheless 
a minute examination of the tissues will show the same succession of 
changes as in the former case. 
Chapter 2. - The Comparative Pathology of Inflammation 
Accepting, then, this working definition, in order to arrive at a due 
comprehension of the succession of changes which we take to constitute 
the inflammatory process, it will be well with Metschnikoff1 to institute 
a series of observations upon the reaction to injury exhibited throughout 
the animal kingdom from the lowest forms upwards to man. By this 
means we shall be enabled to determine what factors in the inflammatory 
process are from their constancy of primary importance; what are com- 
mon and essential, and what are superadded in the higher animals. 
The Response to Injury among the Protozoa. - Beginning our study 
with the lowest and simplest forms of life - forms so lowly that 
they have been regarded both as animals and as plants - we find even 
here phenomena accompanying the reaction to injury which throw light 
upon the inflammatory process as seen in the higher animals. Taking as 
an example the amoeba, we find, in the first place, that the nucleus plays an 
1 The succeeding paragraphs are of necessity very largely ah epitome of sundry por- 
tions of M. Metschnikoff's most pregnant work upon the comparative pathology of inflam- 
mation. By comparing them with the work in question, it will, however, be seen that 
they depart from it in several points; more especially in dwelling upon the extracellular 
activity of the wandering cells, and in bringing more prominently forward the response 
to injury on the part of the fixed cells. INFLAMMA TION 
57 
important part in this reaction. If, as Metschnikoff has shown, one of 
the larger amoebee be cut in two, the region of injury becomes rapidly 
indistinguishable - the protoplasm of each moiety closes up, leaving no 
mark or scar: but of the two parts that which retains the nucleus grows 
and proliferates; the other disintegrates in a longer or shorter time. Or 
injury may induce changes in the protoplasm of the entire amoeba: thus, 
Miss Greenwood points out that, without necessarily bringing about 
death, the interrupted current or an aqueous solution of thymol leads to 
a process of exudation or extrusion of clear hyaline spheres, or of spheres 
holding crystals and granules, from the surface of the organism - a pro- 
cess resembling that occasionally seen in the cells of an inflammatory 
area in higher animals. Nor is this all; apart from changes in the 
structure of these unicellular animals, differences may be seen in the 
behaviour of amoebae towards foreign bodies. It would seem, according 
to Le Dantec, that amoebae ingest non-irritating foreign substances in- 
differently, provided they be sufficiently small. Around each particle so 
ingested a vacuole is formed, and the fluid in this becomes increasingly 
acid, and at the same time digestive. Krukenberg, Reinke and Miss 
Greenwood have conclusively proved these and similar food vacuoles in 
the amoeba and other Protozoa to contain a pepsine or digestive ferment, 
which, as Le Dantec has shown by very delicate tests, exerts its action 
in an acid medium (the general protoplasm of the cell body being alka- 
line); this digestive process leads to the solution of food stuffs, pre- 
paring them to be taken up by the protoplasm of the organism. If the 
foreign substances be incapable of digestion they are sooner or later ex- 
truded. It is by this formation of digestive vacuoles that the amoeba acts 
upon and destroys bacteria, diatoms, and other microbes ingested by it. 
There are, however, microbic forms around which it would seem that no 
proper vacuolation is developed, or if developed, the acid digestive fluid 
is neutralised by substances discharged from the parasites; where this 
is the case, instead of destruction there is continuance of vitality and 
actual multiplication of the invading or parasitic form, leading to the 
eventual death of the amoeba. Metschnikoff has observed this chain of 
events in one of the amoebae which ingests and becomes the host of a 
minute rounded form, the Microsphaera. Phenomena of like nature 
may be observed among the ciliate and flagellate infusoria. While 
these phenomena may primarily be regarded as the method employed 
by the Protozoa for the assimilation of food stuffs, they also are clearly 
the means whereby the Protozoa defend themselves against living 
organisms which have gained entrance into them, and thus form the 
reaction to possible injury; for when in certain cases the means of 
defence are overcome, the parasitic organisms gain the upper hand and 
lead to death. 
There is yet another reaction to injurious influences exhibited by 
the Protozoa into which it is necessary that I should enter at some 
length. This is exhibited by the amceba, but can be and has been most 
fully investigated in the myxomycetes - multicellular forms which 58 
SYSTEM OF MEDICINE 
can with equal propriety be classed as animals or plants, although 
usually they are included among the latter. These organisms form 
large plasmodia (masses of protoplasm, that is), in which, under ordi- 
nary conditions, the nuclei are the only indication of the individual 
cells which by their fusion have formed the masses. They are to be 
met with in leaf mould, and on the surface of moist decaying wood over 
which they creep with an amoeboid movement; and inasmuch as they 
may attain great size - some species attaining twelve inches or more 
in length - they form admirable material for biological study. 
Ten years ago Stahl, investigating one of these myxomycetes (the 
AZthalium septicum, an organism found in tan pits), showed that if placed 
upon a moistened surface close to a drop of infusion of oak bark, the 
plasmodium moved actively towards and into the infusion; if placed 
similarly near to a solution of glucose (0-5 per cent) it moved with equal 
rapidity away, and so also in the case of solutions of various salts. These 
observations of Stahl were (if we except Engelmann's observations in 
1881 upon the tendency of sundry bacteria to remove from regions poor 
in oxygen to those where oxygen is present in abundance) the first of a 
series of observations upon the attraction and repulsion of plants and 
portions of plants by chemical substances. To this property Pfeffer, who 
has made the fullest series of studies upon it, has given the name of 
chemiotaxis, in place of Stahl's narrower " trophotropism "; and one 
speaks of a positive or a negative chemiotaxis according to the attrac- 
tion or repulsion exerted. If, as Metschnikoff has pointed out, the 
advancing edge of one of these plasmodia (of Physarum) be injured by 
cauterisation, the region of injury dies ; the protoplasmic currents, 
which had been advancing, reverse themselves abruptly, and within an 
hour the plasmodium has moved away, leaving the debris of the 
destroyed region behind. These experiments are so simple, and the 
results obtained seem so natural, that it may be asked whether it be 
worth while to attach a name to this property of living matter. Yet the 
name is in itself an aid to bearing these properties in mind; and, as will 
be pointed out later, the recognition of them is of material help in solving 
certain of the difficulties that present themselves in the study of inflam- 
mation in the higher animals. Among these myxomycetes another fact 
can be made out. Stahl observed that the plasmodium of Fuligo, which 
at first moves away from a two per cent solution of common salt, will 
after a time (more especially if it has suffered from lack of water) adapt 
itself to the solution, advancing its pseudopodia or protoplasmic processes 
into it. With other myxomycetes the same adaptation has been observed. 
That is to say, by use or adaptation a negative may be transformed into 
a positive chemiotaxis. To this change I shall have occasion to revert. 
The Response to Injury among the Metazoa. - Passing from the 
Protozoa to the Metazoa, we reach immediately (or almost immedi- 
ately) a series of beings in which the division of labour among 
the cells has led to the development of three cell layers - an outer 
ectoderm, an inner endoderm, and an intermediate layer of mesoderm. INFLAMMA TION 
59 
Even in the very lowest forms among the Metazoa it is noticeable 
that of these three layers there is one, the mesoderm, whose cells 
have the especial function of reacting when any irritant or injurious 
stimulation is applied to the organism. Taking what are perhaps the 
simplest forms in which to observe the relationship and properties of 
these layers, Metschnikoff has studied these results of injury in the larval 
forms of astropecten and other echinoderms. At one well-recognisable 
stage these larvae resemble little more than the gastrula stage of the 
embryologist; the endoderm or hypoblast appears as a cul-de-sac - an 
invagination of the ectoderm or epiblast - while the mesoderm is repre- 
sented by amoeboid cells, budded off from the endoderm, lying or float- 
ing in the semiliquid substance filling the general body cavity. The 
ectoderm is so delicate that any sharp substance can readily penetrate 
into the body cavity; and, when this happens, it is noticeable that the 
wandering mesodermal cells make their way to the foreign body, attach 
themselves to it, and fuse into plasmodial masses, thus forming a 
wall, as it were, around the invading substance, and cutting it off from 
the general body system. Here, then, in an organism possessing neither 
nervous nor vascular system, the reaction to injury, where that injury 
has not been sufficiently intense to cause destruction of the outer layer 
of cells, is simply and solely confined to the wandering cells of the 
body; there is no effusion of fluid; there is not necessarily phagocytosis 
on the part of these cells; any digestive and destructive action on their 
part - any attempt in this way to remove the foreign body - must then 
be by excretion, by extracellular action. At the same time, this fusion 
of the cells and formation of a plasmodium around foreign substances of 
greater diameter than the individual mesodermal cells may be looked 
upon as a mechanism whereby the equivalent of intracellular digestion 
is gained. But, as among these low forms cases occur in which, without 
the formation of plasmodia, the cells perform their destructive action 
upon bodies of larger size than themselves we do not lack examples of 
what must be considered as excretory destructive powers on their part. 
That these cells in the echinoderms are also capable of destroying minute 
foreign bodies by intracellular action, that is, by phagocytosis, has been 
demonstrated in the larger transparent larval form known as Bipinnaria 
Asterigera; on introducing bacteria under its ectoderm the mesodermal 
cells are seen to approach, and by their long pseudopodia to adhere to 
and ingest the still living motile bacteria, which are rapidly digested. 
Besides this reaction to injury on the part of the mesodermal cells, 
a further response is exhibited to a remarkable degree among the 
lower Metazoa - I refer to the great power of regeneration of lost parts, 
of cell proliferation leading to the reproduction of destroyed regions. 
This power is best seen in the classical example of the Hydra, which 
may be cut into many pieces, each one of which is capable of 
growing, so that in a relatively short time it becomes a fully formed 
individual. It is interesting to note in relation to the frequent ten- 
dency towards hyperplasia and excess growth following upon injury in 60 
SYSTEM OF MEDICINE 
the higher animals, that among low forms, such as Hydra and Ceri- 
anthus, the same tendency is yet more strongly marked. Thus, as 
Loeb points out, if an incision be made in the stem of a Hydra, a 
whole new oral pole, provided with tentacles, will branch out from the 
region of cell destruction. In the actinian Cerianthus the process is 
not quite so extensive; yet from the lower lip of the lateral incision a 
set of tentacles develops in all respects similar to those around the 
mouth. 
Ascending to the Worms, we find that the protective agency devolves 
upon mesodermal cells suspended in the perivisceral fluid, and again 
forming the peritoneal endothelium. We arrive, that is to say, at a 
state in which a lymphatic system may be said to be present; for the 
spaces in which the free corpuscles lie are strictly homologous to the 
lymph-containing spaces of the vertebrate organism, and these corpuscles 
may be regarded as lymph corpuscles; the peritoneal endothelium cor- 
responds with the mesodermal peritoneal endothelium of vertebrata. 
Among the annelids the process of reaction to injury may be well 
followed in the earth worm by studying the sequence of changes that 
occur around the gregarines which infest the male genital organs. 
While these parasites are active by their movements they prevent the 
adhesion of the wandering cells; but so soon as they pass into the 
resting stage antecedent to spore formation, the cells form a thick mass 
around them. The parasite on its part forms a thick cyst wall; never- 
theless, it may not unfrequently be observed that, despite this protection, 
the parasite changes its appearance under the action of the surround- 
ing plasmodium, and in fact is killed. While this is happening no change 
could be detected by Metschnikoff in the neighbouring blood-vessels; 
these appear to remain completely inactive: no exudation is noticeable 
nor any recognisable change in volume. 
While among the Worms a well-developed and closed vascular 
system is not unfrequently present, in other animal forms, which in 
most respects present a much more complex and advanced develop- 
ment, namely, in the Arthropods and Tunicates, this is not the case. 
In these the blood pours from the tubular heart sooner or later into the 
lacunae of the general body cavity; and whether veins be absent (as 
is most usual), or present (as in the Cephalopods), the blood is sucked 
back from the body cavity into the heart. This incomplete circulation, 
interesting as it is in connection with the development of the vertebrate 
circulation, is interesting also from the fact that its incompleteness 
in these large and wide-spread classes of animals prevents reaction to 
injury from being associated with vascular changes. The blood in these 
animals, circulating through the ramifications of the body cavity, is 
evidently a mesodermal fluid, if it may be so termed. Its corpuscles 
are clearly mesodermal; and without going into full details as to the 
properties of these corpuscles, it may be said that they represent an 
interesting series of stages in the subdivision of labour. For example, 
as Mr. Hardy has shown us in a low form of crustacean like Daphnia (the INFL AM MA TION 
61 
water flea), but one form of cell is present, whereas in the highly- 
developed Astacus (the Cray fish), there are three distinct forms of 
leucocytes (no red corpuscles being present), each of which appears 
to have distinct functions. The one form in Daphnia has the property 
of taking up fat globules and food particles from the alimentary 
tract, foreign particles, such as granules of carmine or Indian ink, and 
the spores of parasites (Monospora, Metschnikoff); it is granulated, con- 
taining minute spherules which stain with basic aniline dyes (basophile 
granules), and under certain circumstances it may be seen to explode 
with lightning-like rapidity. In the higher Astacus there are in the 
circulating heemal fluid two varieties of cells: one is extraordinarily 
explosive; when removed from the body cavity it gives off fine blebs 
or vesicles of its substance with such rapidity that, unless the greatest 
care be taken, nothing is seen of the cell save its nucleus; this form is 
phagocytic: the other form is far more stable, and is loaded with large 
spherules which have a great affinity for acid dyes - they are eosino- 
philous - may be actively extruded, and undergo decomposition; these 
cells never act as phagocytes. The third form, with basophile granules, 
is rarely found in the blood, and then only as the result of special 
stimuli; but it is present in considerable numbers in the peculiar tissue 
which forms a sheath around certain of the arteries - Haeckel's " Zell- 
gewebe; " this form is phagocytic, and can be seen to contain globules 
of ingested fat. 
As Metschnikoff demonstrated, in his most remarkable study upon 
a disease of Daphnia caused by the entry of the spores of a yeastlike 
organism (the Monospora) into its body cavity, its one form of leuco- 
cyte can be seen to react swiftly towards the spores; the cells ap- 
proach them, form a plasmodium around and eventually digest and 
destroy them. If, on the other hand, in consequence of their great 
numbers or the relative paucity of the leucocytes, certain of the spores 
be not attacked and develop uninterruptedly into mature torulee, the 
leucocytes show no tendency to approach them - in fact, their neigh- 
bourhood leads to the explosion of the leucocytes - and the torulae, 
multiplying, lead to the death of the organism. Often, again, brown 
eschars may be recognised upon the transparent carapace of a Daphnia, 
due to injuries by other individuals; beneath these scars are to be found 
masses of leucocytes which remain in the region of injury until the cells 
of the tissue have proliferated, and there is complete union and repair. 
In addition, then, to the immediate reparative and protective re- 
action of the leucocytes, there is exhibited among the higher invertebrata 
a later reaction in the shape of proliferation of the fixed cells. This 
proliferation, while not so extensive as among the lower invertebrates, 
can nevertheless be very great; and cells of all forms, whether of hypo-, 
meso- or epiblastic origin, and tissues so highly developed as the muscular 
and nervous, may participate in it. In illustration of the ample power 
of tissue reproduction after injury possessed by these animals, I need but 
mention the trite examples of the reproduction of the hinder segments 62 
SYSTEM OF MEDICINE 
of divided worms, and in crustaceans the restoration of injured and cast 
off claws and appendages. 
Many more instances might be given to show that the reaction to 
injury remains essentially a reaction on the part of the wandering and 
fixed mesoblastic cells of the organism, followed in sundry cases by 
proliferation of the fixed epi-, meso- and hypoblastic cells, and by repair 
where these have been destroyed. Although these arthropods, molluscs 
and tunicates have a vascular system, yet, inasmuch as this is open, its 
changes, if they occur, could scarcely modify the inflammatory process. 
The Response to Injury among the Vertebrata. - If now we pass to 
the vertebrates, the picture presented is far more complex: not only do 
these present a highly-developed nervous system, but, moreover, the 
blood is enclosed in a complete vascular system. We shall now consider 
at length the results of an injury of an organ in one of these higher 
animals. 
Chapters. - The Main Forms of the Process of Acute Inflam- 
mation in the Higher Animals 
The Experimental Production of Inflammation in Non-Vascular Areas. 
- Let us begin with the succession of changes that occurs in the sim- 
plest case, namely, in a non-vascular area, in one of the lowest vertebrate 
forms - for instance, in the embryonic axolotl ten to fifteen days old; 
let us curarise it, and apply a minute crystal of silver nitrate to the 
side of its flattened transparent tail fin, washing away the remains of 
the crystal with salt solution; or again, we may pass into the tail a 
small needle filled with finely-powdered carmine. By either procedure 
a certain number of cells is destroyed. The neighbourhood of the 
injury now becomes swollen (it may be by imbibition of water through 
the wound), and the surrounding cells tumefied, vacuolated and less 
refractile. This is the first stage-that of injury and modification of the 
surrounding tissue. In a little time a few wandering cells (leucocytes) 
approach the injured region; by the next day these are present in 
fair numbers, and can be seen to have taken up the particles of carmine 
or debris of the destroyed tissue. This is the second stage - that of 
immigration of leucocytes. There are no vessels in the transparent 
fin of these young axolotls, no dilation of those nearest to the fin, 
and no diapedesis. All the leucocytes that pass to the part are pre- 
existing wandering cells of the connective tissue, - a fact of some little 
importance in connection with the origin of certain of the pus cells in the 
suppurative process of higher animals. The third stage is that of repair, 
of proliferation of the injured epithelium, return of the fixed cells of 
the tissue to their previous state, and emigration of the wandering cells. 
A very similar progress of events occurs if the experiment be repeated 
upon the tail fin of the young newt. The same rapid alteration in the 
large branched connective tissue cells (which become vacuolated as their INFLAMMA TION 
63 
long processes are drawn in and shortened), and the same immigration 
of motile cells from the surrounding connective tissue are to be seen; 
but here we now find the earliest evidence of vascular participation, for, 
according to Metschnikoff, complete arrest of the circulation may occur 
in the nearest vascular loop. By the next day the parts have returned 
to the normal condition. 
If from these cases we pass to mild inflammatory disturbances 
affecting the non-vascular regions of animals far higher in the scale, we 
again discover a like process of events. For this purpose the cornea 
affords an excellent opportunity; in health it is absolutely non-vascular; 
it is perfectly transparent, and is so thin that it can readily be examined 
microscopically. 
The cornea of mammalia, and indeed of vertebrates in general, is 
formed of fibres wThich run in layers parallel to the surface. These 
fibres, while roughly arranged side by side and parallel to one another 
in any given layer, are placed at an angle to the fibres of the layers 
above and below. Although free from blood-vessels the cornea is 
far from being devoid of channels along which lymph freely passes. 
Between the several layers there exist spaces in which lie the flattened 
connective tissue cells of the organ; and, by means of numerous tine 
channels, these spaces around the cells are connected with similar 
spaces lying anteriorly, posteriorly and laterally. Through this rich 
anastomosis of channels there is a free flow of lymph. These channels 
are really continuations of the body cavity of the animal; they repre- 
sent, and in fact play the same part as the single body cavity of such a 
simple form as the larva of Astropecten, while the cells lying in the 
spaces are mesoblastic cells which have become fixed. 
Few studies are better calculated to impress the investigator with a 
sense of the depth of the well at the bottom of which truth lies, than a 
research into the abundant literature dealing with observations upon the 
stages of the inflammatory process as it occurs in the cornea, and with 
the deductions therefrom. One after another the adherents to succes- 
sive forms of inflammatory belief have found in experiments upon this 
simple tissue ample support for their particular creeds. 
Selecting from among the many observations those which have stood 
the test of time, I will begin with the simplest, and pass on to those 
dealing with an increasing intensity of the inflammatory process. 
If, as Senftleben first pointed out, the centre of the cornea of a 
rabbit be washed with a strong solution of zinc chloride, then, in favour- 
able cases, although the epithelial covering be gravely injured, there may 
be no actual rupture of the outer layers of the tissue. Such a cornea 
removed twenty-four hours later may show no sign of migration of 
leucocytes - no sign, again, of congestion of the vessels at the peri- 
phery. The only indications of injury and reaction may be the destruc- 
tion of the corneal corpuscles immediately beneath the cauterised area, 
and the appearance of a zone surrounding this in which the corneal 
corpuscles appear enlarged, distinct and tumefied. The process may 64 
SYSTEM OF MEDICINE 
continue and advance insensibly to repair without the intervention of 
leucocytes; the hypertrophying cells of the " granular " zone eventually 
undergoing karyokinesis, and thus by multiplication replacing the cor- 
puscles destroyed. 
Here, then, necrosis and new growth of the fixed cells of the tissue 
are the only recognisable factors in the process of repair of injury. It 
must be confessed that the conditions permitting this simplest form of 
reaction are of rare occurrence; it is worthy of attention that they can 
exist. 
By a slight modification of the preceding conditions another factor 
may be brought into play. If, after cauterisation in the manner above 
described, a break be made into the cauterised surface; or if again, 
without cauterisation, a little of the corneal tissue be removed, then in 
a few hours a small whitish opacity is to be noticed within the corneal 
tissue in the immediate neighbourhood of the break in the continuity, and 
upon examination this opacity is found to be due to a massing of small 
round cells. As there is at this moment no sign of proliferation of the 
connective tissue cells of the cornea, these newly-collected cells can only 
be leucocytes; and further examination of their properties proves them 
to be such: there is, however, no evidence of dilation of the peripheral 
vessels, no indication of diapedesis through their walls. The leucocytes, 
therefore, can only have entered into the wound from the cornea itself 
and from the conjunctiva and the lachrymal fluid bathing it. In this 
experiment the inflammatory process is represented by destruction of 
tissue and immigration of leucocytes, followed by repair; neither the 
vascular nor the nervous system play any part in it. We are forced to 
the conclusion that the leucocytes have massed themselves in the 
injured area purely on their own initiative; and that there must be an 
attraction, a chemiotaxis or chemiotropism, leading them actively to 
approach the region of cell destruction. 
The observations made upon these two simple cases help us materi- 
ally to understand the series of events which occur in more intense 
inflammation of the cornea, such as that produced by injuring the surface 
and causing the entrance into the injured region of a small quantity 
of a pure culture of the Pyococcus aureus. This may be accomplished 
by injecting the culture into the centre of the healthy cornea by means 
of the needle of a Pravaz syringe (Jacobs). The micrococci so intro- 
duced grow rapidly, the growth so extending along the lymph spaces 
that a branched mass of the microbes is produced, having the spot of 
inoculation as centre. Around the growth as it extends may be seen 
a sharply-marked area in which the corneal corpuscles show evidences 
of degeneration; the nuclei stain faintly, and the corpuscles, speaking 
generally, have a shrunken appearance. Here, again, the first effect of 
a microbic, as of a simple chemical injury, is to bring about degeneration 
of the fixed cells of the tissue. Within eighteen hours the zone of pro- 
liferating cocci and cell degeneration is well marked; and now the 
second stage begins to be clearly manifest, namely, the determination INFLAM MA TION 
65 
of leucocytes to the seat of injury. Within twenty-four hours there 
is a dense packing of these corpuscles around the central degenerated 
area, and great numbers of leucocytes may be seen converging along the 
lymph spaces from the periphery of the cornea. This is the second stage 
of the process, the first stage of reaction to the injury inflicted by the 
invading micro-organisms. If, as by Cohnheim1 in his original experi- 
ments upon the injury to the cornea, more careful examination be made 
into the stages of the determination of leucocytes, it can be seen that this 
determination is closely related to changes set up in the vessels at the 
periphery of the cornea; they become more prominent, the region has a 
congested appearance, the smaller as well as the larger vessels are 
dilated, and there is abundant evidence that the leucocytes are passing 
out from the contained blood into the surrounding lymph spaces. In- 
deed the accumulation of leucocytes shows itself: first at the periphery of 
the cornea near the vessels, and gradually approaches the region of 
injury. Into the mechanism of this cliapedesis, and into a fuller descrip- 
tion of the changes that take place in the blood-current in these distended 
vessels, I shall enter later when discussing the changes in highly vascular 
regions. Suffice it to say here that no distinction can be made out between 
the behaviour of the leucocytes in the previous experiment, when they 
entered the wounded area from the external surface, and in this where 
the majority find their entrance from the blood; as in the previous case 
the part played was evidently active, so must it be here also. We cannot 
arrive at any other conclusion than that some attractive force leads to 
their determination towards the inflammatory focus. As we can easily 
show, by repeating the experiment, many of these leucocytes take up and 
contain numerous cocci, while other cocci remain free in the tissue 
spaces. Many of the leucocytes degenerate and present a broken down 
appearance; and, as at the same time an increasing area of the corneal 
tissue becomes disintegrated, an ulcer appears. According to the viru- 
lence of the culture and the reaction on the part of the organism, the 
process may now extend, a larger and larger portion of the corneal 
tissue becoming affected; or, on the other hand, there may be an arrest 
of the progress, the massing of the leucocytes preventing, as a barrier, 
the further extension of the micrococci into the lymph spaces;2 while 
at the same time there is an advance of newly-formed capillary vessels 
into the previously non-vascular tissue. It is to be noticed that the 
blood-vessels at the periphery of the cornea are prominent and dilated, 
and from them fine new vessels *with very delicate walls pass towards 
the injured region. At the same time many of the corneal corpuscles, 
outside the area of destruction, can by appropriate staining be seen 
undergoing mitosis and proliferating. Thus the active repair of the 
tissue is initiated. 
1 There can be no question that Cohnheim in his experiments induced not a simple 
keratitis but one which in the absence of aseptic precautions rapidly became septic and 
suppurative. 
2 Into the details of this action I shall enter more fully later. 
VOL. I 
F 66 
SYSTEM OF MEDICINE 
The Experimental Production of Inflammation in Vascular Areas. - 
From this study of inflammation, as it occurs in a region devoid of 
blood-vessels, let us now pass on to the more complicated process of 
inflammation in vascular areas; and, as in the previous case we considered 
an ascending or advancing series of reactive changes, so here let us begin 
with the slightest injury associated with the mildest reaction, and pass 
onwards to states in which the inflammatory manifestations are more 
and more pronounced. 
If an incision be made with a perfectly aseptic instrument into the 
skin, also rendered aseptic, and be so made as to divide the dermis 
and tissues immediately below, without at the same time injuring any 
large vessel, it is the common experience of modern surgeons that 
repair takes place with the minimal amount of change recognisable as 
inflammatory. Repair takes place indeed so rapidly that, if the 
divided structures have come or have been brought into immediate 
contact, there may be firm adhesion at the end of twenty-four hours. 
This is primary union, or union by first intention, which, rare in the 
old days, commonly occurs in this era of aseptic surgery. The full 
sequence of events in these cases cannot, it is true, be well determined 
by continuous microscopic examination; but if the rabbit or dog be 
employed, and tissues, wounded in the manner described, be removed 
and examined at successive short intervals, we see that the changes 
which occur are mainly, nay almost entirely, related to the pre-existing 
cells of the part. The section divides a certain number of capillaries; 
but in the very act of division the divided walls are apparently brought 
together; and, partly by this means, partly by contraction, the lumina of 
these minute vessels become occluded, and the hsemorrhage into the 
wound is altogether inconsiderable. Within an hour after the operation 
it is evident to the naked eye of a careful examiner that the immediate 
neighbourhood of the wound is slightly reddened and tumefied, but 
only very slightly; and, associated with this, there is a feeble exudation 
between the apposed surfaces. But the exudation is not great, and 
even within this first hour after the infliction of the wound there may be 
development of fibrin and coagulation of the exudate, leading to the 
formation of a provisional cementing together of the opposed surfaces. 
In this exudation, and in the tissues in the immediate neighbourhood, 
the leucocytes that have undergone diapedesis may be few and far 
between, and may scarcely attract attention. The reaction, then, on the 
part of the vessels and of the leucocytes is of the slightest. Study of 
sections shows that the main role is played by the pre-existing cells of 
the part; of these a certain number (not so many as might d priori be 
expected) are destroyed immediately, and show all the signs of disinte- 
gration ; a number relatively large have been injured only, their nuclei 
remaining intact, though their processes or some portions of the cell 
bodies have been cut through. It is difficult to determine these 
injuries in the small cells of the cutaneous tissues; they are better seen 
in the peritoneum when slight inflammatory changes have there been INFLAMMA TION 
67 
induced. This, however, can be made out that the cells in the immedi- 
ate neighbourhood of the wound became enlarged, and, without showing 
signs of division, prolong themselves (that is to say, send out prolonga- 
tions) into the region of the provisional fibrinous cicatrix. In this way, 
before the end of the second day, there may be a more or less complete 
replacement of the primary unorganised cementing substance by organ- 
ised growing tissue, - formed, in the first place, by the interlacing of 
processes from the neighbouring cells; in the second, and later, by a 
multiplication of these cells, together with a development of new 
capillaries, few in number, which branch off from the slightly-congested 
vessels in the neighbourhood. Thus in this case the process of repair 
is characteristically associated with hypertrophy and the new growth 
of the fixed cells of the tissue; while vascular changes, exudation and 
leucocytosis, are relatively little marked. I have, however, never come 
across a case in which they have been entirely absent, save when the 
section has been truly extra-vascular - that is to say, when it has not 
penetrated into the vascular region of the skin, and has affected only 
the epidermis and outermost layers of the dermis. In such cases the 
response to injury may show itself purely as a proliferation of the 
epithelial cells. 
As I have said, observations of the above nature labour under the 
disadvantage that they must of necessity be discontinuous. I bring 
them in at this point, inasmuch as they represent the mildest condition 
of the inflammatory reaction. I have not personally observed this 
series of changes in tissues which permit of continued study under 
aseptic conditions; neither am I acquainted with any observations 
wholly fulfilling these conditions - made, that is to say, upon trans- 
parent vascular tissues subjected to the mildest aseptic injury and 
examined continuously under the microscope. 
The response to injury in the cases just mentioned was of the 
slightest. Let me now pass on to cases in which it becomes more pro- 
nounced; and in order to continue the comparative study of inflam- 
mation I would first describe the series of events in a highly vascular 
and transparent region in a low vertebrate animal, namely, in the 
tadpole's tail. If this be injured, either by the application of a caustic 
or by the introduction of a foreign inert body into its substance, a 
definite advance upon what was recognisable in the case of the axolotl, 
for example, is to be made out. Here the tail is very vascular, the 
wandering cells of the connective tissue are very few in number, while 
the blood is fairly rich in leucocytes which are small relatively to the 
size of the vessels. The results of injury are a congestion of the 
vessels, noticeable within fifteen minutes, and a well-marked determi- 
nation of leucocytes to the injured region. These cells, in the main, 
pass out from the vessels; the few leucocytes pre-existing in the tissue 
appear to play a very small part. Compared with the axolotl experiment 
this observation is of considerable interest. Instead of a slight reaction 
slowly developing there is a rapid reaction; instead of a slight accumula- 68 
SYSTEM OF MEDICINE 
tion of leucocytes there is a most pronounced accumulation. If there be 
any meaning in the determination of leucocytes to the region of injury, 
then evidently the active participation of the vessels of that region in 
the reactive process is fraught with benefit - it is a further important 
factor developed with the development and advance of the organism. 
The fuller details of this vascular interference in the inflammatory 
process have been followed by many observers, among whom first and 
foremost was Cohnheim; and to this end the frog has supplied the most 
convenient means in regions at once vascular and fairly transparent, 
such as the web of the hind feet, the tongue, and the mesentery. Other 
observers passing higher in the scale of vertebrates have employed the 
mesentery of the cat, dog, and other mammalia. Suffice it to say that, 
with slight modifications due to local conditions in the tissue examined 
rather than to the animal selected, the process has been found to 
present the same features throughout the whole of the adult vertebrata, 
from the reptilia upwards. For general examination, perhaps, the best 
and simplest method of observing the succession of changes that follow 
injury of a vascular area is to be found in what I believe to be Coats' 
modification of Cohnheim's original experiment upon the frog's web 
(Coats' Pathology, 1889, p. 119). In order to reproduce as nearly as 
possible the conditions of an ordinary wound, instead of employing a 
caustic or chemical irritant, a small portion of the cutaneous surface is 
nipped off - the section being just deep enough to pass through the 
cutaneous layers without causing haemorrhage. For the experiment to 
proceed satisfactorily, it is necessary that the frog be curarised after 
having been pithed. The web of a small frog is so thin that the 
changes occurring in and around the vessels of the part can readily be 
followed even with a high power of the microscope. • 
The first change noticeable in the immediate neighbourhood of the in- 
jured membrane is a dilation of the vessels, first of the arteries and then of 
the veins; and in this first phase there is a very evident acceleration of 
the blood flow. At this early period the capillaries show little evidence 
of dilation, but in the course of an hour expansion is readily distinguish- 
able, and sundry capillary channels, previously invisible, become occupied 
by blood and show themselves. This first stage lasts for an hour, or in 
some cases perhaps two, and is followed by a phase of slowing of the 
blood current. While previously a well-marked axial stream of cor- 
puscles had been evident, with a peripheral zone of plasma devoid of 
corpuscles, the former now broadens out, the latter becomes less and 
less, and as it narrows an increasing number of the clearer rounded 
heemal leucocytes are to be seen in it travelling at a slower rate than 
the more axial stream, and every now and then stopping beside the 
walls of the vessels, and after a short stoppage passing on again. The 
leucocytes conduct themselves as if they have become " sticky."1 
As the current becomes yet slower all distinction between axial and 
1 Even so low down in the scale as Daphnia this same peculiarity is noticeable: there in 
health, as Hardy has pointed out, the leucocytes move freely; but, if the slightest injury be INFLAM MA TION 
69 
peripheral streams is lost; the corpuscles, closely packed together, fill the 
whole lumen; the leucocytes in increasing number approach the vessel 
walls; they adhere more firmly, and so long as a current is recognisable 
the action of the stream leads them to assume a pear-shaped appearance, 
the rounded ends pointing in the direction of the current. 
As the stream slows gradually the corpuscles may move at last in a 
series of jerks synchronous with the heart beats; or frequently in the 
veins and capillaries the mass of blood may be seen moving slowly first 
in one direction, then in the other. Frequently one or other of these 
stages is followed by complete stagnation or stasis of the blood in the 
vessels of the injured area - I say frequently, for at other times little 
or no absolute arrest is seen in the vessels. Accompanying this stage, 
although observers employing other and chemical methods of inflicting 
injury have in general omitted to call attention to the fact, there is 
already a considerable oozing or exudation of clear fluid from the wound; 
there is, that is to say, an outpouring of lymph, and that apparently from 
the distended vessels. Now, with the slowing of the stream the 
leucocytes, accumulated next to the walls of the small veins and within 
the capillaries, pass from the interior to the exterior of these vessels; 
and, if the process be studied carefully with a higher power, it can 
be seen that this mode of passage is of an active, or apparently active 
nature.1 A series of leucocytes can be distinguished some of which are 
rounded or flattened in immediate contact with the wall of the vein; 
others possess a prolongation passing into the wall; in others, again (or 
in the former if they be watched in the fresh specimen), the prolongation 
enlarges on the outer side of the small vessel while the portion of the 
leucocyte within the vessel becomes smaller. The final phase of this act 
of diapedesis is that the whole leucocyte passes through, and is found in 
the lymph spaces around the vessel wall. This process of diapedesis 
may be so general that in the course of five or six hours all the small 
veins of the region show a crowd of leucocytes situated along their outer 
surface. With these a greater or less number of red corpuscles may 
also make their escape. 
Although the capillaries, from the very smallness of their diameters, 
do not show the so-called " margination " of leucocytes, nevertheless this 
same process of diapedesis may occur at various points along their course, 
so that outside the capillaries also a fair number of the same small highly- 
refractile cells endowed with amoeboid movements can be observed. 
In this modification of Cohnheim's experiment a further stage is to be 
recognised. While at first the fluid exuded was clear and relatively free 
from cells and cell debris, now, as the inflammatory process continues, an 
increasing number of leucocytes is contained in the exudation. The 
inflicted upon the carapace, the leucocytes, previously unadhesive, soon show the tendency 
to adhere to the walls of the body cavity beneath the region of injury and elsewhere. 
1 The process can be fully made out if at this stage the wounded region be removed, 
fixed immediately in weak osmic acid, and prepared for examination by the higher 
powers of the microscope. 70 
SYSTEM OF Al ED I CINE 
leucocytes do not remain in the immediate neighbourhood of the vessels, 
but many of them pass on to the injured surface; still it would seem by 
active amoeboid movement. Thus at the end of six hours this surface 
may be covered by a serum or fluid in which are great numbers of these 
leucocytes. Here then we have the first step towards the formation of 
a scab or provisional protective covering to the wound. 
Further observations cannot well be carried out in the pithed and 
curarised frog; but if an unpithed, non-curarised animal be taken, and 
the observations upon the earlier stage be neglected, it can be made out 
that if irritant matter do not find entry into the wound the process may 
be arrested at this point; the leucocytes upon the surface may break 
down, and with their breaking down and the formation of fibrin a soft 
scab be formed: the stasis of the blood in the distended vessels may be 
followed by a re-establishment of the current and slow return of the 
vessels to their former calibre, while beneath the thin, soft scab the 
epithelial cells rapidly proliferate. Within twenty-four hours there may 
be abundant evidence of this new growth of the epithelium tending 
to encroach upon and cover the wound. At the same time the region 
becomes less and less populated with leucocytes, so that - not to enter 
fully at this point into the reparative process - within sixty hours the 
region may show little sign of the injury and consequent inflammation. 
On the other hand, if irritants of a microbic nature enter the wound 
the process may extend, as in inflammation of the cornea. More especially 
if the water in which the frog is kept become foul, there is a tendency 
in the inflammatory processes to spread; and in the cells of the central 
area, both fixed and migrated, to break down, leading to the formation of 
a spreading ulcer. The steps of this sequence of affairs it is difficult to 
follow by continuous microscopic examination, partly on account of the 
increased opacity of the region, partly because the process extends over 
days rather than hours. Here, therefore, I merely mention this possible 
extension of the change with its main naked-eye appearances. 
It is not possible by continuous observation to make out the steps of 
this more extensive inflammation characterised by excessive emigration 
of leucocytes and destruction of these together with the fixed cells of the 
tissue - the pyogenetic inflammation. Several observers, however, have 
followed its successive stages by means of examination of affected tissues 
at successive intervals after the infliction of injury. 
The Experimental Production of Suppurative Inflammation. - While, 
as shown by Councilman, Grawitz and de Barry, Straus, Leber and 
others, a suppurative inflammation may under certain conditions be 
brought about experimentally by the action of chemical irritants, such 
as mercury and turpentine; yet under ordinary pathogenic conditions 
suppuration is induced by the growth of micro-organisms within the 
tissues. Hence it is better to study the conditions as induced by the 
inoculation of pus-producing microbes into one or other tissue. A very 
full series of observations upon the development of abscesses through the 
agency of the Staphylococcus pyogenes aureus has been made by Hohn- IN FLA MM A TION 
71 
feldt. He employed rabbits, and inoculated small quantities of pure 
cultures of the microbe subcutaneously. 
Four hours after inoculation the vessels of the region were found 
densely filled with corpuscles, and in them a commencing margination of 
the white corpuscles was discernible. Leucocytes were present within 
the tissue in numbers greater than normal; although, compared with later 
stages, they were infrequent. They were of two kinds - the mono- 
nuclear in the majority, the polynuclear (or more truly the form with 
polymerous nucleus) in lesser numbers; both forms were congregated 
mainly around the line of entrance of the injecting needle. Many of 
the connective tissue cells were so swollen as to be rounded rather than 
flattened. The injected cocci, lying in the lymph spaces, were scattered 
through the tissue; in part free, in part already ingested by cells, not 
only by the leucocytes, but also by connective tissue cells: the number 
within leucocytes was not inconsiderable. 
Preparations made at the end of ten hours showed the same conditions, 
but more distinctly. There was ample evidence of migration of the 
leucocytes, margination in the congested vessels, various stages of passage 
through the vascular walls, and large collections of the cells in the peri- 
vascular lymph spaces; from these they spread into the spaces between 
the bundles of connective tissue fibrils. The cocci lay in the lymph 
spaces and were increased in number, and the massing of leucocytes cor- 
responded in position to the accumulation of microbes. In these regions 
the leucocytes were mainly polymerous ot multinuclear, but in the boun- 
dary zone away from the cocci the uninuclear form predominated. 
At the end of twenty hours there was further accentuation of these 
conditions. As yet an abscess proper had not formed, but enormous 
numbers of leucocytes were present, and also of micrococci; the fibrillae 
of connective tissue were widely separated by the collections of leuco- 
cytes, and these cells clustered round and hid the connective tissue cells. 
With the completion of forty-eight hours a well-defined abscess had 
formed, separated sharply from the surrounding healthy tissue. The 
centre of the abscess was seen to consist of densely-packed leucocytes 
mingled with large growths of cocci. These leucocytes were almost 
entirely " multinuclear; " and in this central area the nuclei of some 
showed fragmentation. Neither leucocytes nor connective tissue cells 
showed the slightest indication of mitosis. In the central area all traces 
of the previous capillaries had disappeared; in the peripheral zone they 
were easily recognisable, being fully injected and showing a marginal 
disposition of their leucocytes, many of which could be seen (in osmic 
acid preparations) fixed in the process of diapedesis. 
The majority of the cocci lay in these leucocytes. Even where the 
colonies of the microbes were thickest there the majority were intra- 
cellular. Passing towards the periphery the number of cocci became 
smaller and smaller. At the periphery they could be seen not only to 
be intracellular, but also free in the lymph spaces; and Hohnfeldt, with 
other observers, saw them definitely grouped within the endothelial cells 72 
SYSTEM OF MEDICINE 
of the peripheral vessels. Thus it may be noted that at this stage the 
proliferating microbes extended into the healthy tissues outside the 
abscess. 
In the centre of the abscess the original tissue had wholly disappeared; 
nearer the periphery light streaks and bundles of the disintegrating 
fibrillae could be recognised between the leucocytes. 
Not till about the tenth day did new growth of tissue begin to show 
itself. During the preceding six days there had been more breaking 
down of the polynuclear leucocytes, characterised by fragmentation of the 
nuclei and by fatty degeneration of the cell substance. But by the tenth 
day the periphery had begun to assume the appearance of granulation 
tissue ; it contained numerous capillaries and new-formed connective tis- 
sue with characteristic epithelioid cells or fibroblasts possessing large oval 
pale staining nuclei. In these cells, as in the connective tissue cells of 
the surrounding healthy tissue, could the numerous steps of indirect cell 
division be made out. In this granulation tissue cocci were absent and 
leucocytes were infrequent. In the soft, cheesy central area masses of 
cocci were still present. Whether these were living or dead Hohnfeldt 
did not determine; he inferred (what has since been proved by several 
observers to be an unsafe inference) that inasmuch as they stained well 
with aniline dyes they were alive. 
Thus, to sum up Hohnfeldt's observations, the processes occurring in 
a suppurative inflammation that ends in healing are the following: - 
1. Congestion of the region of invasion, with margination of the 
leucocytes. 
2. Collection, in the region, of uninuclear leucocytes; then diapedesis 
of leucocytes with polymerous nuclei: multiplication of the cocci. 
3. Ingestion of large numbers of the microbes by the polymerous 
leucocytes and other cells, including the endothelial cells of the vessel 
walls. 
4. Increasing immigration of leucocytes until the tissue becomes 
densely packed. This is accompanied by a yet greater proliferation of 
the microbes, which extend (i.e. are carried by lymph streams or by cells) 
into the region outside the developing abscess. 
5. Destruction of the tissue of the affected part. 
6. Degeneration of the leucocytes within the sharply-defined abscess. 
7. Eventual proliferation of the connective tissue at the periphery of 
the abscess; formation of fibroblasts in the highly vascular surrounding 
zone; cicatrisation and encapsulation of the debris of the leucocytes 
and micrococci. 
There are not a few points in connection with these observations of 
Hohnfeldt that deserve discussion; very possibly he has misinterpreted 
certain of the appearances seen by him. On the whole, however, he 
draws a full and accurate picture of the successive stages of suppurative 
inflammation, and I may defer discussion to a later review of the action 
of the leucocytes and of the formation of fibrous tissue respectively. 
However, before leaving this general description of the series of INFLAMMA TION 
anatomical changes induced by injury, there is another phase of the 
inflammatory process set up by pathogenic micro-organisms Which must 
not be passed over - I refer to those cases in which, instead of ending 
in repair, there is extension and generalised disease. The stages pre- 
ceding extension vary with the nature of the microbe; thus, in some 
cases, the reaction to the invasion of the microbe is mainly leucocytic 
(as with inoculations of the micrococci of suppuration), in others it is 
mainly exudative or serous, the congestion of the vessels being followed 
by abundant exudation of serum into the tissues. This is the case in 
inoculation of animals - such as rabbits, guinea-pigs and fowls - with 
cultures of micro-organisms which are peculiarly virulent in their be- 
haviour towards these animals. Such a serous or exudative inflamma- 
tion is, for instance, well seen if the vibrio Metschnikovi be inoculated 
into the pectoral muscles of a fowl. Within twelve hours, it may be, 
the seat of inoculation becomes greatly swollen, and on section is found 
reddened and congested; while from it drains an abundance of relatively 
clear, faintly-reddish serum containing but a few leucocytes. 
In such a case as this the micro-organisms appear to pass with ease 
from the centre of infection into the surrounding tissues, and thence 
into the lymphatics and general circulation, whence they may be 
obtained within twenty-four hours. Where there has been a well- 
marked abscess formation in the region of invasion there, as already 
indicated, it is true that the microbes may be found outside the abscess 
at a fairly early period; but, in the main, proliferation is limited to the 
abscess, and the blood remains free and sterile. Under certain condi- 
tions of great virulence of the pyogenic microbes it is found that as the 
abscess extends it becomes ill-defined - there is no sharp demarcation 
between the collected leucocytes and the surrounding tissue; the 
columns of leucocytes spread indefinitely from the centre, and numerous 
micrococci are intermingled with them. Where this is the case there 
is a marked tendency for the microbes to find their way into the general 
circulation from this irregular peripheral extension along the lymphatic 
spaces, and to set up a condition of septicaemia as in the more serous 
inflammation described above. 
Septicaemia, or the passage of micro-organisms into the blood, with 
all the results of such a passage - the condition which sundry French 
observers have described as inflammation of the blood - is dealt with 
in another article. In septicaemia we pass beyond the local response to 
injury, we deal with a state of general systemic disturbance. Never- 
theless certain phases of the septicaemic condition throw light upon the 
inflammatory process. 
In the first place, it is of interest to note that when the infective 
micro-organisms and their products are within the vessels they fail to 
induce the cardinal symptoms of inflammation. They do not lead to 
exudation of fluid from the blood or to wide-spread diapedesis of leuco- 
cytes. The stimulus, whatever it be, which leads to these phenomena at 
the point of invasion is no longer called into activity when the noxa is 
73 74 
SYSTEM OF MEDICINE 
within the circulatory apparatus. This is the reverse of what might be 
expected if the inflammatory process were primarily due to a modification 
of the endothelium of the vessel walls by the irritant, a modification pas- 
sively permitting the exudation and passage outwards of the leucocytes. 
The statement that infective micro-organisms and their products 
circulating within the blood fail to induce inflammatory changes, would 
seem to need modification when the development of metastatic abscesses 
is taken into account. But a study of the mode of production of these 
abscesses shows that the statement still holds. Such abscesses originate 
round emboli of pyogenic micro-organisms in the capillaries. Sundry 
cocci are arrested in the capillary, proliferate and fill the vessel. It is 
only when a minute vessel is thus occluded that the abscess process 
begins, that is to say, when by this occlusion the vessel has become 
extravascular; and while it is true that, primarily, the arrest of patho- 
genic microbes within the capillaries is often associated with a small 
accumulation of intravascular leucocytes and with degenerative changes 
in the vascular endothelium, the metastatic abscess, as such, forms not 
by accumulation of leucocytes in the occluded vessel, but around it; 
the leucocytes emigrating from surrounding capillaries. 
Inflammatory Fever. - In the second place, through this study of 
advancing inflammation it is of interest to trace the very close relation- 
ship that exists between inflammation and fever. Besides the local 
changes here described, local injury is accompanied by systemic dis- 
turbances. These may be slight or grave. 
Take, for instance, progressive abscess formation, or follow the 
development of a malignant carbuncle in man. At first the reaction 
is purely local, but very soon, long before any of the micro-organisms 
are capable of detection in the blood, there is exaltation of temperature 
and a slight febrile state, the fever becoming more and more evident as 
the local process becomes more and more extensive, until with the 
detection of the microbe in the blood the most severe fever, with con- 
stitutional disturbance, sets in. Local inflammation, then, without any 
other possible explanation than either the nervous irritation to which 
it may give rise, or the passage into the general circulation of the 
soluble products of bacterial growth and tissue destruction, or both, 
may lead to the development of the febrile state. How large a share is 
played by these two possible factors it is difficult to say. That 
bacterial products injected into the circulation lead to the rapid pro- 
duction of the febrile state we have ample evidence ; but whether these 
act directly by inducing increased cellular activity, or indirectly by 
stimulating the cerebral centres, we cannot absolutely say. As yet we 
have little accurate knowledge of the parts played by the nervous 
system in the development of the febrile state. This, however, may 
safely be declared, that the more we study the continued fevers the more 
do we discover that these commence by a local inflammatory disturbance. 
The continued fevers are the continuance, or rather the extension, of a 
primarily localised inflammatory lesion. [Vide art. on "Fever."] INFLAMMA TION 
75 
Summary of the Facts thus far brought forward. 
The main facts gathered thus far concerning the inflammatory pro- 
cess, and the conclusions to be drawn therefrom, may now be placed in 
order before I discuss in detail the various factors in the process. They 
are - 
1. Injury, when it is not so widespread and severe as to lead to the 
death of the individual, is followed by a reaction on the part of the 
organism. 
2. In unicellular organisms the continued vitality of the individual 
after injury, and in multicellular organisms the vitality of the indi- 
vidual cells, are dependent primarily upon the persistence of the 
nucleus; if this be destroyed or removed the rest of the cell is incapa- 
ble of complete restitution and continued growth. 
3. In unicellular organisms the reactive process is twofold, and con- 
sists of (a) destruction or removal of the irritant; destruction being 
brought about by a process of intracellular digestion, removal by extru- 
sion of the irritant: (6) new growth of the organism. 
4. This response to injury on the part of unicellular organisms is 
essentially reparative. 
5. In multicellular organisms, with division of labour among the 
constituent cells of the individual, there is a separation of functions; 
the twofold reaction to local injury is yet more clearly marked; but 
(a) The destruction or removal of the irritant is in the main accom- 
plished by the wandering cells of mesoblastic origin. 
(&) The new growth to replace the tissue destroyed by the irritant 
proceeds in the main from the fixed cells of the tissue. 
6. Ascending the scale of multicellular organisms, a division of 
labour and differentiation of function is discoverable among the wander- 
ing mesoblastic cells. Whereas in the lower forms of the Metazoa one 
type of leucocyte alone is present, in the higher forms two or more 
varieties can be distinguished which possess different properties and 
act differently towards irritants introduced into the system. 
7. According to the nature of the irritant causing the injury, the 
leucocytes are actively attracted in greater or less numbers to the 
region of injury, surround the irritant, and remove or destroy it by 
means very similar to those employed by unicellular organisms. Where 
the irritant is present in the form of discrete particles, there some at 
least of the leucocytes may incorporate the particles, and remove them 
or destroy them by a process of digestion. Others of the leucocytes in 
the higher Metazoa never act thus as phagocytes; nevertheless they are 
equally attracted to the focus of inflammation, and presumably tend to 
counteract the irritant by some other (extracellular) means. 
8. While to the wandering cells appears to be allotted the main 
duty of removing deleterious and irritant matters, certain of the fixed 
cells of the organism, notably the endothelial cells of the vessels, can 
also exert these functions. 76 
SYSTEM OF MEDICINE 
9. Among the very large number of Metazoan forms in which no 
complete vascular system is present, this attraction of the leucocytes to 
the region of injury is at first the sole response to injury. At a later 
period proliferation of the fixed cells occurs in the neighbourhood of 
the injury. 
10. Among the higher Metazoa, in which there is a well-developed 
vascular system, the determination of leucocytes to the region of irrita- 
tion still continues, and is in fact markedly aided by the participation 
of the vessels in the inflammatory process. 
11. The vascular phenomena in inflammation may be regarded as 
serving two main purposes - (a) the pouring out of increased fluid into 
the injured area; (&) the afflux and diapedesis of leucocytes. 
12. Even in the highest Metazoa, possessing fully-developed vascular 
systems, the response to injury in a non-vascular area, such as the 
cornea, may be associated with no change in the surrounding vascular 
areas, but purely with a determination to the injured area of leucocytes 
already free in the surrounding tissues. 
13. The second phase of the inflammatory process, that of tissue 
repair, but very rarely occurs without evidence of previous migration 
of leucocytes and exudation from the congested vessels. 
14. A comparative study leads inevitably to the conclusion that the 
determination of leucocytes to the region of injury is the most constant 
and most characteristic early response to injury recognisable through- 
out the Metazoa, and that it must be regarded as the most important 
factor in the first stage of the inflammatory process. The vascular 
phenomena noticeable in the higher Metazoa must be regarded as a 
second and highly important factor of later development and adjuvant. 
New tissue formation is the prominent characteristic of the later stages 
of the process. 
15. As among the Protozoa, so in the Metazoa, the response to 
injury is consistently an attempt to repair the injury. 
This general survey of the response to injury throughout the animal 
kingdom demonstrates most clearly that the same broad principles, the 
same methods of defence and repair on the part of the organism, are 
called into activity from the lowliest forms to the highest; that, in fact, 
no line can be drawn to separate one set of phenomena as truly inflam- 
matory from another set which, while also a response to injury, are non- 
inflammatory. Although it is true that the term inflammation implies 
a reddening and congestion of the vessels, we find upon closer exam- 
ination that this reddening and congestion is not the fundamental but a 
superadded feature in the process of repair of injury - a feature super- 
added as the organism advances in its place in the animal kingdom. 
Thus if we are to comprehend the process satisfactorily we must pass 
beyond the narrower acceptation of the term. 
Having thus sketched broadly the general phenomena of the inflam- 
matory process, it will be well now to describe in fuller detail the factors 
of this process among the higher vertebrata, and to bring together the INFLAM MA TION 
77 
more important results of the study of the respective functions of the 
wandering cells, the vessels, the fixed cells, and the nervous system 
in inflammation. 
PART II. - The Factors in the Inflammatory Process 
Chapter 1.-The Part played by the Leucocytes 
The Leucocytosis of Inflammation. - As I have already shown, there 
is more than one form of leucocyte in the mammalian organism, 
and the several forms evidently possess different attributes, and act 
differently in the reaction to injury. Inasmuch as these forms have 
been variously classified - so variously, in fact, that it is often far from 
easy to collate the various descriptions, and to discuss the forms distin- 
guished by one observer in the terms of another - it is necessary to 
give the chief classifications of them, and their relations. 
The first to discriminate between the forms of white corpuscles in 
the blood was Wharton Jones so long ago as 1846. He drew a dis- 
tinction between 
A. Granule cells 
, Finely granular. 
Coarsely granular. 
B. "Nucleated" cells - Non-granular. 
His observations, together with those of Rindfleisch in 1861 and 
1863, were confirmed and advanced by Max Schultze, who made out the 
following forms: - 
1. Small round cells with round nucleus and little clear protoplasm. 
2. Larger cells with round nucleus and more clear protoplasm. 
3. Cells with finely granular protoplasm, and one, two, or more nuclei. 
4. Cells with coarse granules in the protoplasm. 
The distinctions drawn were, so far, purely morphological; and very 
little notice was taken of these varieties for a long period until Ehrlich, 
in a notable series of papers extending from 1878 to 1887, drew atten- 
tion to the fact that the wandering cells of the organism react diversely 
towards the different aniline dyes and possess diverse tinctorial affinities 
indicating chemical differences in the nature of certain constituents 
of the cell bodies. The granules of the previous observers were found 
to be variously affected by the dyes employed; they were shown not to 
be fatty, but - as Ehrlich put it - of the nature of a glandular excre- 
tion ;1 and comparing the effects of the two groups of aniline colours 
- that in which the dye is associated with the acid constituent of the 
salt, and that wherein the dye forms the base (the " acid " and " basic " 
1 J. Weiss has studied the micro-chemical reactions of the eosinophilous granules, 
and concludes that they are of albuminoid nature ; as they were found not to be digested 
in gastric juice he would ally them with the nucleins. 78 
SYSTEM OF MEDICINE 
aniline dyes respectively) - he made out the existence of five forms of 
granulation associated with as many varieties of wandering cells. His 
table of cells according to their granulation is as follows: - 
a. Granulation - Eosinophile. - Cells frequently in horse's blood, present con- 
stantly in small numbers in human blood; numerous in medulla of 
bones of rabbits, dogs, guinea-pigs, etc. Stain deeply with acid aniline 
dyes. Granules large and coarse. 
/3. Granulation - Amphophile. - Cells frequent in rabbits and guinea-pigs in 
blood ; present also in medulla of bones. Stain both with acid and basic 
dyes. Granules line. 
y. Granulation - Basophile. - Large cells found in the connective tissue, 
from the frog upwards, "Mastzellen" ; in blood of man only in cer- 
tain cases of Leucaemia. Stain only with basic dyes. Granules 
coarse. 
3. Granulation - Fine Basophile. - The "mononuclear" leucocyte of human 
blood. Granulation fine. Stain with basic dyes. 
e. Granulation - Neutrophile.-The most frequent leucocyte of human 
blood, "polynuclear." Stain only in neutral dyes - not in acid or 
basic. 
While Ehrlich and his pupils, and Rieder, have done much to throw 
light upon the relative numbers of the leucocytes possessing these different 
granulations in different diseases, they have accomplished little in dis- 
covering the origin of the various forms, their functions, or their relation- 
ships. We owe the first satisfactory studies upon the properties of the 
different forms to Metschnikoff, who, at an early period in his long- 
continued and wonderful series of researches upon Phagocytosis, made 
out that the different wandering cells of the body act differently towards 
microbic and other foreign particles introduced into the organisms. Thus 
he was led to draw a distinction between - . 
1. Lymphocytes - immature leucocytes. 
2. Large hyaline cells, mononuclear, phagocytic, il macrophages."1 
3. Smaller neutrophile cells, polynuclear, " microphages." 
4. Eosinophile leucocytes - not phagocytic.2 
Quite recently the admirable researches of Prof. Sherrington, and of 
Dr. Kanthack and Mr. Hardy, have appeared which, starting on the 
groundwork laid down by the older observers, have made a notable 
advance in the determination of the function of the various forms of 
wandering cells in inflammatory and other conditions. The observations 
1 While acknowledging that a certain amount of convenience attends the employ- 
ment of these terms, " macrophage " and " microphage," I cannot but agree with Pro- 
fessor Burdon-Sanderson that they are utterly barbaric. 
2 While this article was passing through the press, M. Mesnil, a pupil of Metschnikoff, 
has stated that eosinophilous cells can occasionally act as phagocytes. The statement is 
contrary to Metschnikoff's previous observations and, I may add, contrary to general 
experience. Until further confirmatory observations have been made, I am not prepared 
to accept the statement. INFLAMMA TION 
of Kanthack and Hardy are especially full, and I shall have occasion to 
refer continually to their results. In the meantime it may be said that 
they materially simplify the classification given by Ehrlich, by dividing 
the leucocytes thus: - 
79 
1. Coarsely granular 
2. Finely granular 
3. Coarsely granular 
4. Finely granular 
5. Hyaline cells. 
6. Lymphocytes. 
Oxyphile cells. Staining with acid dyes. 
Basophile cells. Staining with basic dyes. 
Their coarsely granular oxyphile cells are the eosinophile cells of 
most writers; their finely granular are the neutrophile and amphophile 
of Ehrlich. They prove conclusively that Ehrlich's neutral stain is in 
no sense to be regarded as such, but must be considered as an acid dye. 
It is now possible to collate these various classifications, and in this 
way to begin to study the functions of the various forms with a clear 
appropriation of the terms employed in the following paragraphs. 
Collation of the different Classifications of the Varieties of Leucocytes. 
Kanthack and Hardy. 
Ehrlich. 
Metschnikoff. 
Max Schultze. 
Wharton Jones. 
Lymphocyte. 
Hyaline cell. 
Coarsely granular 
oxyphile. 
Finely granular ( 
oxyphile. 1 
Coarsely granular 
basophile. 
Finely granular 
basophile. 
Lymphocyte. 
Eoslnophile cell. 
Neutrophile ) Dg 
Amphophile 1 
Basophile cell with 
y granulation. 
Mastzellen. 
Basophile cell with 
8 granulation. 
Lymphocyte. 
Macrophagocyte. 
Eosinophile cell. 
Microphagocyte. 
Small round cell I. 
Large round cell II. 
Cells with coarsely 
granular proto- 
plasm. 
Cells with finely 
granular proto- 
plasm. 
Cells with finely 
granular proto- 
plasm. 
1 Non-granular 
f nucleated cells. 
Granule cells, 
coarsely granular. 
Granule cells, finely 
granular. 
? Granule cells, finely 
granular. 
Lymphocyte. - Immature leucocyte ; round nucleus deeply staining ; scanty pro- 
toplasm ; increased in number after food; diminished after starvation; 
indistinguishable from small elements of lymphoid tissue. Not phagocytic; 
variable in number; not amoeboid; may form up to 30 per cent of the 
leucocytes present in human blood. 
Hyaline Cell. - Round or kidney-shaped nucleus of slight staining power; 
abundant protoplasm; hyaline; non-granulated; actively amoeboid and 
phagocytic ; rare in blood (2 per cent) ; abundant in coelomic fluid. 
Nuclei have been seen to undergo mitosis. 
Coarsely Granular Oxyphile. - Large horseshoe-shaped nucleus (in man); rela- 
tively large spherules in protoplasm ; highly refractive; staining deeply with 
acid aniline dyes; abundant in coelomic fluid, in serous cavities, in inter- SYSTEM OF MEDICINE 
80 
stices of areolar tissue (K and H), and in bone marrow (Ehrlich) ; rare in 
blood (2-4 per cent) ; amoeboid ; non-phagocytic. 
Finely Granular Oxyphile. - Smaller than last (in man); nucleus branching or 
polymerous, staining deeply; granules very small and spherical; feeble 
oxyphile reaction (Ehrlich's amphophile reaction in rabbit, neutrophile in 
man, etc.). Abundant in blood (20-70 per cent of all leucocytes) ; absent 
from coelomic fluid; actively amoeboid and phagocytic. The most common 
form of pus cell. 
Coarsely Granular Basophile. - When found free in coelomic fluid, round nucleus 
staining very feebly ; spherules large and numerous, stain with basic dyes 
- somewhat similar cells are found stationary in connective tissue spaces - 
absent from human blood in health ; non-phagocytic. 
Finely Granular Basophile. - Spherical; smallest of the wandering cells ; tri- 
lobed nucleus; clear cell substance containing great numbers of fine baso- 
phile dots. Found in human blood in small numbers (1-5 per cent) ; increased 
after meals. 
From this description of the character of the various forms of leuco- 
cytes (for which I am largely indebted to Kanthack and Hardy) it will 
be seen that certain forms are characteristically present in the circulating 
blood, namely, the finely granular oxyphile and the finely granular baso- 
phile; others in the body fluid, namely, the coarsely granular oxyphile 
and coarsely granular basophile; while the lymphocytes and hyaline cells 
are common to both fluids. It must be added that the eosinophile, or 
coarsely granular oxyphile, are also present in small numbers in the 
healthy human blood: it occurs in larger numbers, however, in diseased 
conditions which do not come within the scope of this article. 
Of the origin and relationship of these diverse cells we still know 
very little. As Gulland has pointed out, the blood of the embryo is 
entirely free from white corpuscles. The exact period at which each 
form makes its first appearance has not yet been studied, although in 
all probability such a study would throw a flood of light upon the origin 
of the different orders of cells. 
The most that we can say with fair certainty is that the lymphocytes, 
while representing the larval form of leucocytes in general, are in the 
main derived from lymphoid tissue; that some of them develop into the 
hyaline cells (for, as Sherrington and others have noted, every gradation 
is observable between these two forms); and that what appears to be an 
immature eosinophile cell can often be detected in the peritoneal fluid, 
as also an immature coarsely granular basophile cell (Kanthack and 
Hardy). Beyond this we have not at present advanced.1 Ehrlich's sug- 
gestion that the eosinophile cells are derived from the bone marrow may 
11 quite understand that sundry observers regard all the various forms of leucocytes 
as modifications one of another. It is true that all embryologically have the same origin; 
so, for example, have the corpuscles of cartilage and bone, yet this does not make carti- 
lage and bone one tissue. Everard, Gulland, Buffer, Demoor and Massart, state that all 
transitions are observable between the various forms; I cannot but think that the methods 
of staining employed by these observers were insufficient for thesq wide conclusions. It 
is interesting to note that these observers, like Kanthack and Hardy, found Ehrlich's 
amphophile and neutrophile cells to stain with eosin, i.e. to be oxyphile. INFLAMMA TION 
81 
be partially true, but not entirely; inasmuch as it is difficult to correlate 
the preponderance of these cells in the body fluid with so special and 
local an origin. Nor can the recent observation of Siawcillo, that 
eosinophile cells are abundant in the ray which possesses neither bone 
nor bone marrow, be regarded as favourable to Ehrlich's hypothesis. 
And again, the observations of Metschnikoff and his pupils render it 
eminently probable that some, at least, of the large hyaline cells are 
derived not from lymphocytes, but from proliferating endothelial cells 
of the lymph and blood-vessels and of serous surfaces. Finally, it is 
noticeable that the cells with multilobate nucleus (the finely granular 
oxyphile), the commonest of the haemal leucocytes, are not to be recog- 
nised in lymphoid tissue: yet, as Sherrington has pointed out, certain 
of their peculiarities, notably the contorted shape of the nucleus, may be 
regarded as acquired, inasmuch as if they be allowed to remain at rest 
in the living state outside the body the nuclei become more spherical. 
Of these varieties of wandering cells not all have, so far, been found 
to bear a part in the inflammatory process : but certain forms appear to 
have distinct functions therein: these are the finely granular oxyphile 
(neutrophile), the coarsely granular oxyphile (eosinophile), and the 
hyaline cells. 
A word should here be said concerning the cells of later development, 
appearing as a result of inflammation - giant-cells, Ranvier's cells, and 
Gluge's corpuscles. Of these the last are evidently leucocytes of the 
hyaline type which have taken up the fatty products of tissue degenera- 
tion; the second - colossal cells breaking down with great ease-are of 
doubtful origin. Giant-cells would seem to be of more than one variety: 
some appear to be due to aberrant cell growth, wherein the nuclei 
undergo division without the protoplasm of the cell body following suit. 
The characteristic giant-cells of tuberculosis and chronic inflammation 
may now be said with fair certainty to be plasmodia, in all respects com- 
parable to the masses of fused cells seen to form in the lower animals 
around foreign bodies, and by Kanthack and Hardy around masses of 
bacteria in the lymph of frogs outside the body. The recent observations 
of Borel and of Duenschmann strongly support this opinion. 
Phagocytosis.-In the case of a very large number of pathogenic micro- 
organisms (so large a number that merely to enumerate them, with the 
names of the observers and of the animals upon which the observations 
have been conducted, makes a list so long that in the bibliographical 
table at the end of this article I give only the more important references, 
and not nearly the complete list), after inoculation into the organism, 
a very considerable proportion are to be discovered, sooner or later, 
within wandering cells which have collected in the region of inocula- 
tion. I have already mentioned more than one case of this nature in 
discussing the comparative pathology of inflammation. Evidently under 
certain conditions one of the functions of certain of the leucocytes is to 
attack and incorporate bacteria. The leucocytes having these properties 
are more especially the finely granular oxyphile (where the injection has 
VOL. I 
G 82 
SYSTEM OF MEDICINE 
been into a neighbourhood richly supplied with vessels), the hyaline cells 
chiefly where the microbes have found an entry into the body cavity. 
It is, for instance, the finely granular oxyphile cell which is found in 
overwhelming numbers in an extending subcutaneous abscess, and these 
are seen to contain great numbers of the micrococci. 
The conditions leading to this phagocytosis have been very fully 
worked out by Metschnikoff. He has amply demonstrated that the 
microbes can be taken up in a living condition. Thus, if the Vibrio 
Metschnikovi (a form closely allied to the cholera spirillum) be inocu- 
lated into the anterior chamber of the eye of an immunised animal, within 
a very few hours phagocytes are discovered filled with the small, slightly 
curved vibriones. If now one such cell be isolated, placed in a drop of 
Fig. 1. - Resolution of acute infectious disease (relapsing fever), spleen pulp of monkey (Macacus 
erythr.), showing (a) microphage, multinuclear, with incepted spirochaetes; (&) solitary, and (c) 
forming dense tangle, (d d) nuclei of splenic tissue (Zeiss, ocular 4 ; x 1515 diam.). - [Metsch- 
nikoff (51). ] 
broth upon a coverslip, made into a hanging drop preparation and exam- 
ined under the microscope, it is seen that the broth causes the death of 
the leucocyte; while with time, and favourable temperature, the microbes 
proliferate rapidly, and completely fill the corpuscle until it disinte- 
grates; whereupon they proceed to multiply in the surrounding fluid. 
This seizing and incorporation of microbes does not then necessarily 
lead to their death. In certain cases of acute disease there may be 
abundant phagocytosis, and the disease progress nevertheless; the 
phagocytes being destroyed by the products of the incorporated organ- 
isms. This is the case in mouse septicaemia, in swine erysipelas, and 
(as has been shown quite recently by Gabritchewski) in diphtheria. As 
M. Roux remarks : " Ils ont fait de leur mieux en englobant les microbes, 
mais ceux-ci se sont adaptes au milieu interieur des cellules, et ils ont 
triomphes." 1 
iRoux.- Trans. Internat. Congress of Hygiene, London, 1891, ii. p. 120. INFLAMMA TION 
83 
In other less acute diseases, such as gonorrhoea; and in chronic 
maladies of a tubercular nature - in tuberculosis, leprosy, and glanders 
- the bacilli may in certain stages be found within the cells and rarely 
free in the lymph spaces, they appear to be almost parasitic, after the 
manner of the microspheera previously referred to as infesting the amoeba. 
Fig. 2. - Two giant-cells, seen under high magnification (x 1515 diam.) from a rodent, the spermophile, 
inoculated with tuberculosis, to show stages in the destruction of the bacilli, a, unaltered 
bacillus; 6, bacillus staining badly, and with greatly thickened capsule ; c, bacillus granular and 
breaking up ; de, "shadows." - [Metschnikoff (51).] 
In these cases it would seem as though the toxic properties of the 
microbes and the antagonising powers of the cells were nearly balanced. 
In tuberculosis, for instance, it is not unusual to find in the giant-cells 
some bacilli which evidently are undergoing degenerative changes, stain- 
ing poorly and irregularly, or but faintly traceable as unstained, translu- 
cent shadows, while elsewhere they are apparently proliferating despite 
their intracellular position.1 
1 It is, however, unsafe to declare in all cases that because a micro-organism con- 
tinues to stain well therefore it was living at the moment the preparation was taken and 84 
SYSTEM OF MEDICINE 
And this equality, or almost equality of the resisting powers of cells 
and microbes, may explain the chronic nature of the diseases above men- 
tioned. Nevertheless, in general, it 
may be stated that there is some rela- 
tionship to be recognised between the 
amount of phagocytosis and the viru- 
lence of the microbe; the more virulent 
the microbes the less the proportion of 
them taken up by the cells; and, as 
Kanthack and Hardy have pointed out, 
the longer the time before the phago- 
cytes come into action. As is the case 
in the unicellular organisms, so in the 
wandering cells of higher animals the 
process of destruction of the included 
microbes can, under suitable condi- 
tions, be seen to be digestive. Sev- 
eral observers have seen the anthrax 
bacillus, in frogs and other animals, 
wholly or in part surrounded by a 
vacuole developed within the leucocyte; and, as an evident result, the 
Fig. 3. - Phagocytes, macrophage and micro- 
phage, to show stages of digestion and 
destruction of bacilli, from spleen and eye 
respectively of white rat with anthrax. In 
1, part of the bacillus is unaffected, but a 
vacuole has formed around the other part, 
which further has now lost the power of 
taking the stain. In 3, various stages are 
seen, the bacilli passing through the granu- 
lar badly staining, to the vacuolated un- 
stained, until finally but faint " shadows " 
are observable (Zeiss -jg, oc. 3). - [Metsch- 
nikotf (51).] 
Fig. 4.-Anthrax of pigeon (an animal but slightly susceptible to the disease) to show stages of 
destruction of bacilli by phagocytes. 1 and 3, macrophages : 1, from exudation from eye of re- 
fractory bird ; 2, from muscle of region of inoculation of bird that succumbed; 3, A, 5, micro- 
phages- all from eye twenty-seven hours after inoculation ; a a, unaltered bacilli; &1 ft2 ?>3, bacilli 
becoming more and more degenerated and indistinct; e c, debris of bacilli (Zeiss A, ocular 3).- 
[Metschnikoff (51).] 
portion so surrounded has been seen to become swollen and fainter when 
stained, until it has undergone a veritable digestion and dissolution. 
As with the lower organisms, so with the wandering cells of 
fixed by heat. Thus in pneumonia after the crisis a fair number of diplococci may be 
found within the leucocytes of the expectorated contents of the alveoli, and these may 
stain perfectly well; yet it may be impossible to gain a single growth of the diplococcus 
from the same material. INFLAM MA TION 
85 
the higher, there is an evident attraction, or chemiotaxis, whereby 
these cells pass towards the microbes and their products; and this 
chemiotaxis would also seem in general to be in the inverse ratio of 
the virulence of the microbes. I say in general, for with chemiotaxis as 
with phagocytosis there appear to be exceptions to any uniform law; and 
cases can be brought forward- of diphtheria, for example - in which the 
leucocytes, instead of being repelled, are attracted in great numbers to 
the region of inoculation of a most virulent bacillus. 
The chemiotactic properties of the wandering cells have been 
especially studied by Pekelharing, Leber, Massart and Bordet, and by 
Gabritchewski. 
Of the results obtained by these observers the most important are 
that leucocytes are variously attracted towards various substances. Thus 
Leber found that the introduction into the system of finely-powdered 
copper and various compounds of mercury caused an abundant collection 
of the wandering cells around the particles, while powdered gold, silver 
and iron exerted no such attraction. Gabritchewski and A. Schmidt 
showed that the products of bacterial growth in general possessed chemio- 
tactic properties yet more powerful than simple chemical compounds. 
While the degree of positive chemiotaxis is found to vary within wide 
limits, the examples brought forward of negative chemiotaxis exerted by 
bacterial products have so far been very few - so few as to support the 
contention of Dr. Kanthack, that it is very doubtful whether any microbes 
by their products actually repel the leucocytes, though they are capable 
of causing the rapid destruction of the attracted leucocytes, and so of 
rendering the area around the microbes relatively free from wandering 
cells. 
A very good study of the action of bacteria of different degrees of 
virulence can be made by repeating an experiment of Metschnikoff. The 
rabbit is an animal susceptible to the growth within its tissues of the 
bacillus of anthrax. As is well known, there are various means whereby 
the virulence of this microbe can be diminished; so that if cultures of 
the " attenuated " bacillus be inoculated into susceptible animals, these, 
instead of causing a fatal disease, induce but a transient local inflam- 
matory disturbance, accompanied by fever, and followed by complete 
recovery. If now a small quantity of a virulent culture of the bacillus 
be inoculated into the one ear of a rabbit, and an equal quantity of an 
attenuated culture into the other, the results are very instructive. 
Within twenty-four hours it can be noticed that an acute inflammation 
has been induced in both ears; in both the vessels round the seat of 
inoculation are greatly congested, but whereas at the seat of inoculation 
of the virulent organism there is a serous inflammation so intense that 
the skin is raised and separated from the subjacent tissues by a clear, 
transparent, reddish fluid which also infiltrates the deeper tissues, in 
the other ear there is not nearly the same amount of swelling and serous 
exudation; the region of inoculation is more opaque and solid. Upon 
more minute examination the serous fluid in the first ear is found to 86 
SYSTEM OF MEDICINE 
contain relatively very few leucocytes; the firmer mass in the second is 
composed of a huge aggregation of leucocytes [vid. art. "Anthrax'']. 
Evidently, therefore, the relative number of leucocytes migrating, 
and the quantity of serum exuded, depend very largely upon the inten- 
sity of the irritant; and by the intensity of the irritant, and the 
behaviour of the leucocytes, the forms of the inflammatory process may 
be classified. 
But to the subject of classification I shall refer later. In the meantime 
it is well to sum up the theory of phagocytosis as upheld by Metsch- 
nikoff and those who see in this phenomenon the all-important factor in 
inflammation and the repair of injury (as also in the production of 
immunity), in order that, having put clearly forward the tenets of those 
upholding the theory, I may the more readily state wherein lies the 
strength and wherein the weakness of the doctrine. 
The theory of phagocytosis as set forth in Metschnikoff's later writings 
may be summed up in the following theses: - 
1. That certain of the leucocytes present in the blood and lymph, 
notably the finer granular oxyphile or neutrophile, and the large 
hyaline, are capable under certain conditions of taking up bacteria which 
have gained entry into the system. 
2. That in addition to these the splenic corpuscles, the cells form- 
ing the endothelium of capillaries, and sundry other fixed cells of meso- 
blastic origin, possess the same property, although they exert it to a less 
extent. 
3. That these phagocytes seize upon and destroy living and active 
microbes under certain conditions. 
4. That the more virulent the microbe the less the tendency for the 
leucocytes above mentioned, and for the other fixed cells, to take up the 
bacteria. The less virulent the microbe the more extensive the phago- 
cytosis. 
5. That in addition to this power on the part of certain cells (the 
phagocytes) to take up and destroy certain bacteria, another factor 
has to be called in to explain why the wandering cells of the body 
migrate towards the focus or foci where the micro-organisms have 
gained an entry into the body. This factor is the " chemiotaxis " 
exerted by the products of bacterial growth, and by some other substances, 
such, for example, as the products of death of tissue and of wandering cells; 
and experimentally also certain chemical irritants as, for example, turpen- 
tine and mercury. In the case of the virulent microbes the leucocytes 
are not attracted to the focus of infection. There is a "negative" 
chemiotaxis, and thus, in the absence of phagocytosis, the proliferation of 
the microbes takes place without hindrance; whereas the less virulent 
microbes and their products attract the leucocytes, they exert a positive 
chemiotaxis, so that there is a migration of leucocytes through the 
capillary and venous walls to the focus of infection, and the leucocytes 
taking up the microbes tend to arrest the infective process. 
6. That the leucocytes may become accustomed and eventually INFL AM MA TION 
87 
attracted to substances from which at first they were repelled, and thus 
a negative may be transformed into a positive chemiotaxis. 
7. That the cells, having once acquired positive chemiotactic pro- 
perties in relation to the products of any specific microbe, retain and 
transmit these properties through a series of cell generations, the length 
of which varies according to the microbe, the extent of the primary 
reaction, and the idiosyncrasies of the individual. 
8. That, consequently, the cure of zymotic or mycotic disease, 
whether localised or general, and immunity also, are mainly brought 
about by the activity of special cells (the phagocytes), and are prima- 
rily dependent upon the attraction existing between these cells and the 
products of bacterial metabolism. 
9. The process of inflammation is essentially the endeavour on the 
part of the organism to promote the migration of leucocytes, and to 
aid the inclusion and destruction of the irritant. "The essential and 
primordial element of a typical inflammation is a reaction of phagocytes 
against the irritant (agent nuisible')." (14) Or, more fully, " inflamma- 
tion is to be regarded, on the whole, as a phagocytic reaction of the 
organism against irritants, - a reaction which at times is accomplished 
by the wandering cells alone, at times with the aid of the vascular 
(fixed) phagocytes, or with that of the nervous system." 
10. That in rare cases bacteria may be affected if not destroyed 
by extracellular action, by substances derived from the leucocytes and 
dissolved in the surrounding lymph. 
In the terms of this theory, then, phagocytosis is the all-important 
factor in the inflammatory process, the vascular, exudative, nervous and 
other phenomena being auxiliary means whereby the phagocytic pro- 
perties of the wandering and fixed mesodermal cells may be brought 
more fully into action: the determination of leucocytes that I have 
described is almost entirely to be attributed to an endeavour on the 
part of these cells to take up and destroy the irritant. 
It is necessary now to ask to what extent this doctrine is to be 
accepted. Certainly phagocytosis is a factor in the inflammatory pro- 
cess- no antagonist of this doctrine nowadays is prepared to deny 
this - but does it occupy the all-important position arrogated to it 
by Metschnikoff? Metschnikoff himself admits that there are certain 
wandering cells - the coarsely granular oxyphiles-which never act as 
phagocytes. When powers so great are found to belong to one set of 
leucocytes, is it likely that another set, which is also especially attracted 
to the inflammatory focus, is absolutely devoid of either bactericidal or 
antitoxic function ? Or, to approach the matter from another stand- 
point, let us take a case supplied recently by Gabritchewski from 
Metschnikoff's laboratory. If a guinea-pig be rendered refractory to 
the bacillus of diphtheria, and if the vulva be cauterised and, infected by 
a virulent culture of this bacillus, there results a necrosis of the surface 
layers. On the free surface of the necrosed region lie the proliferating 
microbes; apposed to the under surface of the necrosed area is a large 88 
SYSTEM OF MEDICINE 
collection of migrated leucocytes. In about three days the necrosed 
tissue sloughs off, and recovery and repair ensue. But in this process 
little phagocytosis is observable. The phagocytosis is evidently not 
commensurate with the extent of the inflammation; and if, as Metschni- 
koff urges, the leucocytes are the all-important factor, their powers of 
defence must here include something beyond the incorporation of the 
micro-organisms. The same additional something would seem to be 
wanted to explain the healing of abscesses. 
A crucial test of the importance of phagocytosis has been devised by 
Baumgarten, and repeated, with like results, by Sanarelli. If microbes 
be placed in an animal which has normally the power of withstanding 
the growth of such microbes; and if, further, they be so placed (in 
bags of filter paper, celloidin, or pith) that the leucocytes cannot attack 
them, although the body fluids can easily bathe them, then, if Metschni- 
koff be right, the microbes ought to flourish unaffected. Baumgarten 
and Sanarelli found that this is not so, that the microbes are destroyed 
despite the absence of phagocytes; but Metschnikoff, repeating these 
experiments, obtained diametrically opposite results. Both Baumgarten 
and Sanarelli are capable observers although it is true that the former 
by the very violence of his attack upon Metschnikoff has materially 
weakened his position. It is, however, difficult to explain away their 
positive results, or to arrive at a conclusion other than that under certain 
conditions the microbes may be destroyed without being ingested. 
The Humoral Theory. - The conception that there is some agency 
besides phagocytosis pure and simple has led bacteriologists, in the 
study of phenomena of inflammation and immunity, to engage in a very 
remarkable series of experiments. Although some of them have failed 
to establish a satisfactory theory of immunity, they have led to results 
of such high importance as the discovery of the serum treatment of 
diphtheria and tetanus. The majority of these researches, indeed, 
bear especially upon the production of immunity, and only secondarily 
upon the inflammatory process. It is unnecessary for me, therefore, to 
describe them in detail; it will suffice if I indicate the direction taken 
by the more important among them. 
First in order of time may be mentioned Nuttall's observations. 
In an attempt to repeat Metschnikoff's researches upon the destruc- 
tion of the anthrax bacillus, this observer noticed that if he placed 
a fine canula containing a fresh culture of attenuated anthrax bacilli in 
the tissue of a rabbit's ear, there resulted in sixteen hours a rich cellular 
exudation; but phagocytosis appeared not to reach its maximum for 
twenty-two hours, and even then half of the bacilli lay free and not taken 
up by cells; and he found, further, that the free bacilli showed involu- 
tion and degeneration to the same extent as did the ingested. This led 
him to study the effect of blood serum, defibrinated blood and lymph upon 
the bacilli, and he discovered that these fluids had a remarkably rapid 
action, destroying great numbers within a very few hours. Moritz, 
Traube, Von Fodor and others, had previously recognised this rapid IN FLAM MA TION 
89 
destruction of micro-organisms in the living blood, but Nuttall's very- 
full research appeared to show conclusively that the bacteria-destroying 
power resided largely in the serum, and that in inflammation the exuded 
fluid rather than the leucocytes brought about, the destruction of the 
microbes. 
These observations were confirmed and extended by Nissen, Behring, 
and Buchner, and a most valuable series of contributions (see article on 
the "General Pathology of Infection") have been made by Hankin, 
Buchner, Vaughan, Tizzoni and Cattani, Behring, and others, upon the 
nature and properties of the substances to be derived from the blood 
serum of animals either naturally immune to certain diseases, or rendered 
immune by one or other procedure. What is more, it has been rec- 
ognised that two orders of substances are recognisable: one capable 
of destroying pathogenetic microbes, the other not destroying them, but 
rendering their products inert. 
It would thus at first sight appear that in these discoveries there is a 
direct contradiction to the theory of phagocytosis. Yet upon further 
study this is found not to be the case. 
As was shown by Nuttall, at the commencement of these studies, the 
blood serum removed from the body acts far more rapidly and energeti- 
cally than do the blood plasma and lymph within the body. The dis- 
parity of action between the two is remarkable. Thus Lubarsch has 
shown that in order to kill a rabbit by anthrax, by injection into the 
circulating blood, at least 16,000 virulent bacilli of the disease must be 
introduced: a smaller number produces only a transient disturbance. 
That is to say, the whole circulating blood can only destroy less than 
16,000 bacilli at a time. On the other hand, one cubic centimeter (15 
minims) of rabbit's blood serum can in a few minutes kill an equal or 
even greater number. 
The Cellulo-Humoral Theory. - If the serum and if the blood plasma 
contain bactericidal substances, these must in all likelihood be developed 
by certain cells, and thus at bottom the humoral theory must be cellular; 
and the very fact of the great increase in the bactericidal properties 
of the blood immediately on its withdrawal from the body, must suggest 
that in the changes which occur in the extravascular blood there is a 
liberation and solution of bactericidal substances. Now the first and 
foremost of these changes is the breaking down of the leucocytes 
as the blood begins to clot. It may therefore be that this breaking 
down of the leucocytes, with liberation of their contents, is capable of 
explaining the increased bactericidal action of defibrinated blood and 
blood serum. 
That the leucocytes contain bactericidal substances was first demon- 
strated by Dr. Hankin, who obtained from the lymphatic glands and 
spleens of animals immune to anthrax (dogs and cats), a proteid of the 
nature of a globulin identical with Dr. Halliburton's cell globulin /3, and 
having a bacteria-killing power similar to that possessed by blood serum. 
In later observations upon the rat he showed that there was a relationship 90 
SYSTEM OF MEDICINE 
between the amount and activity of these " defensive proteids " and the 
power of resistance of the animal to the disease. Thus Hankin showed 
that in animals possessing the power of destroying bacilli, the organs 
containing the largest collections of leucocytes yielded notable quantities 
of a bacteria-destroying substance. 
For the last few years I have steadily urged this view, and observa- 
tion after observation is proving it to be correct. Recently Buchner has 
shown that if sterilised emulsions of the gluten of wheat be injected into 
the pleural cavity of a dog and rabbit, its presence leads to the pouring 
out of an aseptic exudation peculiarly rich in leucocytes, and this exuda- 
tion is more bactericidal than is the blood and serum of the animal. 
Further, Victor C. Vaughan is led to the conclusion that the bactericidal 
action is associated with the leucocytes by his discovery that from 
blood serum a nuclein (or nucleinic acid) can be separated- a body, that 
is, which so far has been found exclusively in connection with nucleated 
cells. This nuclein is either itself bactericidal, or has a bactericidal 
substance in intimate association with it; and Vaughan's observations 
and conclusions have been substantiated by the later and independent 
researches of Kossel upon nucleinic acid. 
Further confirmation of the correctness of these views - that the 
bactericidal action of the blood serum is due to the breaking down of the 
leucocytes-has been supplied from the laboratory of Denys at Louvain. 
Denys and Havel have shown that the blood and exudations of the dog, 
freed from leucocytes either by filtration or by centrifugal action, lose 
their bactericidal action, regaining it when the leucocytes are reintro- 
duced. Van der Velde induced an exudation rich in leucocytes by 
injecting into the pleural cavities of rabbits sterilised cultures of the 
pyococci, and killing the animals at various periods. Centrifugal!sing 
the pleural fluid, he found that the older the exudation, and the richer it 
had been in wandering cells, the more powerful its bactericidal action, - 
this being out of all proportion to the bactericidal action of the blood 
serum removed at the same time and similarly centrifugalised. 
But more convincing proof has been gained by a study of the leuco- 
cytes in action. Even in 1887 Ribbert, in his studies upon the fate 
of spores of various species of aspergillus and mucor inoculated into the 
anterior chamber of the rabbit's eye, had found that two stages of reaction 
were recognisable: at first the spores and developing hyphal filaments 
became surrounded by dense clusters of leucocytes, which remained in 
apposition to, but did not ingest the micro-organisms. Nevertheless 
they appeared to bring about a weakening and lowering of vitality on 
the part of the spores and filaments, so that after a time other cells 
could manifest their phagocytic activity and take them up. Ribbert, it 
is true, attributed the lowering of vitality to the walling in (" Wallbil- 
dung ") by the leucocytes, and consequent lack of nutrition; but the fact 
remains that he demonstrated a preparatory extracellular action upon 
the micro-organisms by the leucocytes. 
Altogether the fullest and most important studies upon this extra- INFLAMMA T10N 
91 
cellular action have been those of Kanthack and Hardy. In their first 
communication to the Royal Society these observers showed (and their 
experiment can be repeated without difficulty) that if a drop of frog's 
lymph be placed upon a coverslip, with the addition of a few anthrax 
bacilli, and this preparation be suspended in a moist chamber, an ex- 
amination extending over four or five hours reveals the following suc- 
cession of changes: - 
1. The coarsely granular oxyphile cells are strongly attracted to the 
bacilli: they move towards them, and apply themselves to their surface; 
their protoplasm, ordinarily sluggish, exhibits quick streaming move- 
ments. Next the eosinophile granules are discharged, and the bacilli 
begin to show signs of degeneration. During this stage the hyaline 
cells, the phagocytes proper, remain quiescent, and are not even at- 
tracted towards the bacilli. 
2. The hyaline cells proliferate and eventually approach the masses 
of oxyphile cells surrounding the bacilli; they fuse with these - forming 
a plasmodium around the chains - and for the next hour or two nothing 
can be clearly made out as to the action of individual cells. 
3. The first stage in the dissolution of the mass is the separation 
and wandering away of the oxyphile cells ; next, the hyaline phagocytes 
containing remnants of the bacilli within vacuoles slowly break apart. 
4. A third set of cells, with basophile granules, is observed to 
approach during this last period; as to their functions Kanthack 
and Hardy are a little doubtful. 
Here, then, we have clear evidence of division of labour among the 
wandering cells of the frog: the coarsely granular oxyphile cells act as 
unicellular glands discharging or excreting their granules, and these 
granules dissolving appear to exert a deleterious action upon the bacilli, 
in consequence of which the hyaline cells are now capable of ingesting 
them. I may add that occasionally the coarsely granular cells may be 
seen to act when not in immediate apposition to the microbes; the num- 
ber of granules in a cell may diminish, and at the same time neighbour- 
ing bacilli manifest signs of partial dissolution.1 
Continuing their research Kanthack and Hardy have demonstrated 
these distinctions in the function of the different forms of leucocytes 
throughout the vertebrata up to man. They have shown that in general 
the hyaline cells act as the phagocytes of the lymphatic and coelomic 
system;-the finely granular oxyphile (neutrophile and amphophile) as 
the phagocytes of the heemal system; while the coarsely granular 
oxyphile (eosinophile) when present possess excretory functions. 
If capillary chambers filled with bacilli or their products, or some 
irritant such as nitrate of silver or turpentine, were placed under the 
skin, or in the peritoneal cavity, and allowed to remain there for periods 
1 Mesnil, in a long and often suggestive work, which appeared while this article was 
in the press, contradicts these observations of Kanthack and Hardy. Apparently he 
never once attempted to repeat their procedure, never once attempted the simple methods 
necessary to confirm their results. His criticism must therefore be relatively valueless. SYSTEM OF MEDICINE 
92 
up to twenty-four hours, they were found to contain a multitude of cells, 
chiefly of the coelomic type. If the irritant were situated in such a 
position as to appeal to the blood-vessels of a vascular membrane rather 
than to the cells of the connective tissue spaces, then the cells were those 
of the haemal system. In both cases in the earliest stages there was 
usually found a preponderance of the coarsely granular oxyphile cells. 
Even in cutaneous blisters induced upon themselves, while the main mass 
of cells present in the serous exudation were the finely granular oxyphile 
of haemal origin, the coarsely granular were always more abundant rela- 
tively to the others than in the blood. The rate of accumulation was 
found to vary according to the irritant. Thus, comparing the action of 
the virulent B. anthracis and the harmless B. ramosus upon rabbits and 
guinea-pigs, it was seen that if cultures of these two forms were placed 
within capillary tubes and introduced into the peritoneal cavity, with the 
former only the coarsely granular oxyphile found its way into the tubes 
(even after seven hours); whereas with the latter enormous numbers of 
the hyaline phagocytes had invaded the chambers within two and a half 
hours. In the former case also the total number of invading cells of all 
kinds was very much less than in the latter case; and there was clear 
evidence of the abundant disintegration and dissolution of many of the 
cells. This destruction of a certain number of cells occurred, whatever 
the nature of the microbe introduced into the system ; and, as these 
observers point out, it must profoundly alter the chemical constitution 
of the plasma, and may therefore play an important part in the struggle 
with the bacilli. They observed phenomena of the same nature as those 
of the frog's lymph, when they placed anthrax bacilli in hanging drops 
of human blister fluid and examined the preparations upon the warm 
stage, noticing here also the rapid diminution of the granules of the 
eosinophile cells. 
Finally, it must be added that Metschnikoff (while misunderstanding 
wholly the drift of these last-mentioned researches) has recently admitted 
that the wandering cells are capable of exerting an extracellular activity 
upon the bacteria. Certain observations of R. Pfeiffer had revealed that, 
under certain conditions, when guinea-pigs have been rendered highly 
refractory to the spirillum of cholera, these microbes when injected into 
the peritoneal cavity are rapidly modified, becoming swollen and spheri- 
cal before any phagocytosis has time to come into play: and this alteration 
was explained by Pfeiffer as due to the fluid secreted by the peritoneal 
cells following upon the inoculation. Without detailing Metschnikoff's 
criticism of the value of these observations, it will suffice to say that, 
carefully repeating them, he discovered that five minutes after such 
injection the leucocytes in the peritoneal fluid - " polynuclear," mononu- 
clear, and eosinophilous - were surrounded by a layer of spirilla, while 
the lymphocytes and red corpuscles were entirely free from any such 
surrounding. Here in the immediate neighbourhood of the wandering 
cells, the short, curved bacillary forms could be seen to have undergone 
the transformation into globules. Metschnikoff further recognised a clear I NFL AM MA TION 
93 
zone, evidently of exuded liquid, between the leucocytes and the spirilla. 
Whether this be a true secretion, or an accompaniment of the death of 
the cells, he is not at present prepared to say. 
In this way Metschnikoff admits that, besides phagocytosis, an extra- 
cellular action of the wandering cells does occur; so that now the only 
point of paramount importance to be agreed upon is the extent to which 
the extracellular activity is manifested intra vitam. Metschnikoff at 
present holds that it plays a very secondary part compared with phago- 
cytosis ; others, like Buchner in Germany, Denys in Belgium, Kanthack 
and Hardy in England, hold that its part is of high importance. Person- 
ally, while holding that phagocytosis has been conclusively proved to be 
of singularly high importance, I cannot but see in this extracellular action 
of active and of disintegrating leucocytes an adjuvant to the former factor, 
and one which under certain conditions is even of greater value to the 
organism in its attempt to neutralise microbic and other irritants. 
Whether the fixed tissue cells of the body have similar " extracellular " 
action upon living irritants, or not, is a matter that has not yet been 
ascertained. There are indications that this may be so. 
Summary. - Thus, to sum up the facts gathered together in this 
chapter, the chief results of recent researches into the functions of the 
wandering cells, as they affect our knowledge of the inflammatory 
process, would seem to be the following: - 
1. That in the higher animals there are several forms of leucocytes. 
2. That a distinction can be made out in the distribution of the 
various forms, some being characteristic of the blood, others of the con- 
nective tissue spaces and of the coelom and coelomic fluid in general. 
3. That the forms of cells accumulating during the inflammatory 
process consequently vary according to the region of injury. 
4. That a variation is to be made out also in the rate of accumula- 
tion of the different forms of cells: the coarsely granular oxyphile 
(eosinophilous), which in the main are pre-existent in the connective 
tissue spaces, being attracted sooner than the finely granular oxyphile 
(neutrophile hsemal) and the hyaline (coelomic) respectively. 
5. That a further distinction is to be made out in the mode of action 
of these cells: the coarsely granular oxyphile never act as phagocytes, 
but possess excretory properties ; the hyaline and finely granular oxy- 
phile are characteristically phagocytic. 
6. That the accumulation of leucocytes is due in part to migration, 
in part to proliferation in situ. 
1. That under certain conditions (what these are and what their 
relative importance have yet to be more fully worked out) the phago- 
cytes are capable of directly incorporating pathogenetic bacteria. The 
main conditions would seem to be the possession by the bacteria of 
relatively weak irritant or pathogenetic properties, and by the organism 
of relatively strong powers of resistance. 
8. That under other conditions (where, for example, the microbes are 
endowed with fuller irritant properties, or the constitutional resistance is 94 
SYS7'EM OF MEDICINE 
lower) phagocytosis may be preceded by an excretory process on the 
part of certain cells, notably the coarsely granular oxyphile, whereby 
apparently the vitality and irritant properties of the microbes undergo 
a diminution. Here again we are as yet ignorant of the exact value of 
all the factors leading to active intervention of these excretory cells. 
9. That the bactericidal and antitoxic action of the blood serum and 
body fluids outside the body is due to the liberation into these fluids of 
bactericidal and antitoxic substances step by step with the disintegration 
of the leucocytes. 
10. That clearly this liberation of bactericidal and antitoxic sub- 
stances by excretion from living cells, and by disintegration, does not 
obtain to the same extent in the fluids within the living body; never- 
theless it does occur, more especially as the result of irritation, and 
its occurrence is fitted to explain those cases in which the amount 
of phagocytosis observable is not co-extensive with the disappearance 
of the microbic irritants. 
11. That where the bacteria are endowed with great virulence, there 
the wandering cells migrating to the region are both fewer in numbers, 
and, being killed, undergo dissolution to a very considerable extent. 
This dissolution may in itself, by the liberation of bactericidal substances 
into the inflammatory exudation, hinder the proliferation of the microbes 
to a greater or less extent. If, however, the dissolution be unaccom- 
panied by a massing of active leucocytes peripherally around the region 
of irritation, then the microbic irritants may be carried away from the 
inflammatory focus, and induce generalised disease. 
To complete this summary I will here add other conclusions deduced 
from a study of the later stages of inflammation and discussed in a later 
chapter ("Upon the part played by the fixed Cells in the Inflammatory 
Process "), viz.: - 
12. In the later stages of inflammation the growing fibroblasts may 
often be seen to contain leucocytes in process of digestion. Presumably, 
therefore, a certain number subserve nutrition. 
13. Others are, in certain cases, recognisable in the lymph-spaces 
outside the inflammatory focus, containing the debris of dead tissue. 
Emigration can therefore occur as well as immigration. 
14. The process of development of wandering into fixed cells has 
been observed ; but this is the exception, not the rule. 
15. The contrary process of development of wandering cells from 
degenerating tissue (muscle fibres) has also been recorded by more than 
one observer. 
Chapter 2. - The Inflammatory Exudation 
Whenever injury to the tissues leads to vascular dilation there is 
an increased effusion of plasma from the blood. The extent of this 
effusion varies greatly; it varies with the tissue affected, the state 
of the organism, and the quality and nature of the irritant. Dense INFLAMMA T10N 
95 
tissue permits of little exudation, while loose vascular tissue, under the 
action of an irritant of no great intensity, may undergo great exudative 
swelling. There is, for instance, a peculiar liability in serous and 
cutaneous surfaces (or more truly in subserous and dermal layers), when 
inflamed, to manifest abundant exudation. Their vascularity and the 
slight external resistance would appear to explain this liability. There 
is not the same tendency to abundant exudation from mucous surfaces 
save where, as in the alveoli of the lungs, the epithelium is reduced to 
a single layer of delicate flattened cells; on the other hand there is a 
marked tendency towards serous infiltration and swelling of the sub- 
mucosa. That some general state of the organism is a factor concerned 
is seen when virulent anthrax bacilli are inoculated subcutaneously into 
an ordinary rabbit and into one that has been rendered immune: in the 
former the exudation is of a serous nature, in the latter little fluid is 
exuded from the vessels. The effect of the quality of the irritant is 
observable upon comparison of the results of inoculation of various 
microbes. Some cause little exudation of fluid. These are in general 
of low pathogenic quality, but not always; certain virulent microbes 
(such as those of . tetanus) lead, when inoculated, to relatively little 
effusion of fluid from the vessels. On the other hand, it may be stated 
definitely that where in a moderately dense tissue the injection of a pure 
culture of a micro-organism leads to well-marked exudation, the micro- 
organism is of high virulence. 
Can any meaning be ascribed to this effusion ? Is it an attempt 
at increased nutrition in the injured region? It has been sug- 
gested, in accordance with Virchow's theory of inflammation, that 
the injury, stimulating the surrounding fixed cells, leads to increased 
local metabolism; and that the exudation is a means of bringing to the 
region the increased nourishment demanded by the increased cellular 
activity. But inasmuch as exudation is most marked in those cases 
where there is most profound and rapid cell destruction, and again at 
the early stage of the inflammatory reaction, when evidences of growth 
and proliferation of the fixed cells of the region may be, and most often 
are, wholly wanting, this view can scarcely be upheld. Yet at a later 
period of the process, and again in chronic inflammation, the overgrowth 
of the connective tissue cells would appear to stand in close relationship 
to the over-nutrition caused by the continued dilation of the vessels and 
the pouring out of excessive lymph into the tissues. There is, appar- 
ently, a close relationship between the increased exudation and inflam- 
matory hyperplasia. 
That the exudation exerts a " flushing out " action is very evident in 
many cases. Thus the inflammation induced by plunging an animal's leg 
into hot water is accompanied by great increase in the amount of lymph 
obtainable from the efferent lymphatics of the part. It is shown also by 
the presence of streptococci in the lymph channels outside the area of 
acute inflammation in erysipelas, by the frequent implication of the 
nearest lymph glands in suppurative disturbances, and by the appearance 96 
SYSTEM OF MEDICINE 
of lesions, due to the direct action of bacterial products, in organs 
far removed from the focus of bacterial proliferation in such diseases as 
diphtheria and tetanus, wherein, as a rule, the bacteria remain strictly 
localised. It is clear that the exudation into an inflamed area can accom- 
plish a removal of irritant matters. It is clear also, from more than one 
of the examples given above, that a process which may be beneficial to 
the region of injury may be harmful to the system as a whole. 
It is interesting to note that this effect of flushing, in part beneficial, 
in part harmful, has, if I may so express it, gained a certain amount of 
recognition on the part of the organism. Where the irritant can be con- 
veyed to the exterior an abundant exudative inflammation generally 
occurs - an abundant flushing; where it can be conveyed into one of 
the body cavities the same holds good; but here a mechanism is often 
called into action whereby the exudate with its contained irritants is held 
within the serous cavity for days and weeks after all signs of active 
inflammation have subsided. The organism, that is to say, would seem 
to restrain its drainage to the general lymphatic system. Where the 
irritant is merely the product of tissue change the profuse exudate is 
rapidly conveyed away; where, on the other hand, the injury is of 
bacterial origin, the passage of lymph from the focus of inflammation, 
is, generally speaking, not nearly so free; it is of thicker consistency 
and drains away slowly. In short, as I have already indicated, where 
the microbe is not too virulent a cellular rather than a serous inflamma- 
tion is produced; and in place of abundant flushing an increased anti- 
bacterial and antitoxic action of the exuded lymph comes into play. 
But besides this 11 flushing out " effect the exudation subserves 
another purpose, namely, dilution of the irritant and reduction of its 
injurious properties, so that it acts with lessened force upon the tissues, 
and permits the wandering cells to be attracted to the region where they 
may exert their functions. Where a comparatively mild physical irritant 
leads to abundant exudation the flushing out action appears to be in the 
ascendant, where microbic irritants cause great local inflammatory 
oedema, judging from the less extensive lymph flow from the region, the 
diluent action must be regarded as the more important. I have already 
pointed out that a relation may be traced between the intensity of 
bacterial irritation and the extent of the exudation. In short, there 
may be great exudation under two apparently opposed conditions: in 
the presence of comparatively mild physical irritants, and in that of 
severe bacterial irritants. In the former case it more especially sub- 
serves removal, in the latter dilution of the poison. 
The fundamental distinction between the inflammatory exudation and 
ordinary lymph is its richness in proteids. Whether we regard lymph 
as a filtrate pure and simple from the blood, or, with the majority of 
modern physiologists, follow Heidenhain in regarding it as the result of 
a selective filtration, it is eminently probable that in inflammation the 
exudate approaches in its composition more nearly to the blood plasma 
than does ordinary lymph. The dilatation of the capillaries, the conse- INFLAMMA TION 
97 
quent thinning of the endothelial layer with, it may be, the opening 
of some lacunae between the individual cells, and the direct action of 
the irritant upon these cells, may all be expected to aid the transuda- 
tion. In this way the amount of proteid matter in the lymph may be 
increased. But equally important must be the addition of proteids due 
to the breaking down of leucocytes and tissue cells. I have already 
discussed this destruction of the cells, and need not here give the evi- 
dence of its occurrence. 
In addition to the proteids the inflammatory lymph may contain 
other substances worthy of more than passing note. Of these the more 
important are ferments, the results of proteolysis (notably fibrin and 
its precursors, and peptones), and in many cases mucin, together with 
bactericidal substances, and, where bacteria are present, the products 
of their growth. 
The presence and amount of these substances depend largely upon 
the intensity and character of the inflammation. Thus the total quantity 
of proteids, and the proportion of fibrin, albumin, and globulin present, 
vary within wide limits. The following table 1 of observations made by 
Dr. Halliburton shows well this variation in proteids, and the difference 
existing between inflammatory exudations and dropsical effusions: - 
Pleural Fluid from 
Sp. Gr. 
Percentage Quantity of 
Total 
Proteid. 
Fibrin. 
Serum- 
globulin. 
Serum- 
albumin. 
Acute pleurisy, Case 1 
1023 
5123 
0-016 
3-002 
2-114 
,, ,, Case 2 
1020 
3-4371 
0-0171 
1-2406 
1-1895 
,, ,, Case 3 
1020 
5-2018 
0-1088 
1-76 
3-330 
Hydrothorax . .1 
Average of three cases J 
1014 
1-7748 
0-0086 
0-6137 
1-1557 
Between the amount of fibrin present in exudations and the amount 
of peptones there is an inverse ratio. Peptones are especially devel- 
oped in connection with suppurative inflammation; and the more an 
inflammation tends to be suppurative the greater is the breaking down 
of the fibrin, as also of fixed and wandering cells, and the more evident 
the production of peptones, until in chronic abscess-formation of fair 
extent the peptones pass into the general circulation, and are excreted 
and recognisable in the urine. 
Into the discussion of the mode of formation of fibrin I need not en- 
ter here, intimately connected as the subject is with the inflammatory 
process. The greater text-books of Physiology enter exhaustively into 
the matter. Suffice it to say that, as in the blood, a direct relationship 
1 These figures are thoroughly in accord with those of other analyses by Reuss, 
Hofmann, Mehu, and Letulle. 
VOL. I 
H 98 
SYSTEM OF MEDICINE 
is made out between the breaking down of leucocytes and the develop- 
ment of this substance in inflammatory exudations. 
It is in connection with inflammation affecting serous and epithelial 
surfaces1 that fibrin is most clearly recognisable, forming, it may be, 
thick coatings of the badly-named "inflammatory lymph" over the in- 
flamed surfaces. This deposit is in all respects comparable to the forma- 
tion of thrombi in the blood-vessels. Here, as there, the deposit occurs 
only when the endothelium has undergone destruction and the roughened 
sub-endothelial tissues are exposed. And here also the fibrin may be 
deposited either in filamentous or homogeneous and hyaline form accord- 
ing to circumstances. 
Leaving out of account coagulation-necrosis as not occurring in 
direct connection with exudates, it may be said that similar fibrin for- 
mation is frequently recognisable in connection with primary inflamma- 
tion of parenchymatous tissues.2 
The beneficial effects of fibrin formation in serous cavities have been 
rendered abundantly manifest by the increase in abdominal surgery. No 
one who has followed any considerable number of operations for appendici- 
tis can have failed to remark how, in case after case, despite the intricacy 
of the abdominal coils and their mobility, the strongly irritant matter pro- 
duced by gangrene of the appendix, or oozing through perforations in it, 
is restricted within a relatively small space by the surrounding fibrinous 
adhesions which form rapidly between the intestinal loops. By this means 
alone the peritonitis is restricted and " regional," instead of being general- 
ised from the onset. Even when inflammation (as in pericarditis) affects 
the whole extent of a serous cavity, the layer of fibrin acts as a protective 
coat closing the lymphatic stomata, hindering the free absorption of the 
morbid material by the lymph and blood-vessels, and filtering bacteria 
out of such fluid as does find its way through to the tissues beneath. It 
is not a little remarkable to call to mind how case after case of purulent 
pericarditis or purulent pleurisy may be examined in which, despite the 
intense suppurative disturbance in the serous cavity, the tissues at the 
other side of the deposit of fibrin - the myocardium or the lung tissue 
- show little or no tendency to abscess formation. Let there be primary 
abscess formation or gangrene in the lung, and perforation of the pleura 
and hydrothorax may supervene; pleurisy, however intense, does not 
lead to this unless complicated by other disease. Let there be primary 
or metastatic abscess in the myocardium, then there maybe aneurysm and 
rupture of the heart; yet such rupture produced by extension inwards of a 
purulent pericarditis is of the utmost rarity. Let there be inflammation 
originating in the submucosa of the intestines, as in enteric fever, and 
1 Of epithelial surfaces, more especially those covered hy a single cell layer, as notably 
the pulmonary alveoli. 
2 Where there are abundant and distensible lymph channels there extensive clotting 
may be seen in the lymph. This is peculiarly well marked in the contagious pneumonia 
of cattle (contagious pleuro-pneumonia). In acute inflammation of various organs, by 
appropriate methods of staining, similar formations of threads of fibrin, often starting 
from cells as centres, may be observed in the tissue spaces. INFLAMMA TION 
perforation may result; general peritonitis, while often due to perfora- 
tion, never - so far as I can call to mind - directly induces that event. 
In all these cases the natural protective layer of the serous surface is 
removed or gravely injured at a very early stage; and the layer of fibrin, 
replacing the serous endothelium, forms an effective barrier. I may add 
that the mucin, extruded so as to form a layer over inflamed mucous 
surfaces, presents a similar protective action. 
Passing now to the ferments and ferment-like bodies present in 
the exudate, I may briefly state that these are not only generated and 
excreted by the pathogenetic bacteria present, but are liberated by the 
breaking down of the wandering cells. Abundant evidence of the exist- 
ence of bacterial ferments capable of acting upon proteids, gelatine, 
sugars, etc., is supplied by the study of the growth of these microbes 
outside the body. That ferments also originate from the wandering 
cells has been demonstrated by Leber, who, placing pieces of copper in 
the anterior chamber of the eye, thereby produced a purulent collection 
devoid of microbes, and showed that the exudate was capable of digest- 
ing proteid matter. 
It would seem, therefore, that, more especially in pyogenetic inflam- 
jnation, the removal of dead tissue cells and dead leucocytes may, to a 
large extent, be due to the action of the inflammatory exudations, apart 
from any phagocytic action on the part of living active cells; although 
this also comes often into play. 
Of the bactericidal substances present in the inflammatory exudate 
I have already treated. Here I need only repeat that the researches of 
Kanthack and Hardy, of Denys, and lastly of Pfeiffer and Metschnikoff, 
fully prove that substances capable either of destroying microbes or of 
hindering their growth are present therein. 
Summary. - To sum up what is known concerning the inflammatory 
exudate, it may be said - 
1. That the exudate varies in amount and in character with (a) the 
nature and intensity of the irritant, (&) the condition of the organism, 
(c) the region of irritation. 
2. That while it undoubtedly augments the nutrition of the affected 
region, increased nutrition at the early stage of an acute inflammatory 
process would not seem to be of benefit or to play any important part. 
At a later stage and in chronic inflammation the increased nutrition in 
all probability aids the hyperplasia. 
3. That in many cases the exudate exerts a beneficial action by 
flushing out the injured area. 
4. That the exudate plays an important part in diluting the irri- 
tant. 
5. That the development of fibrin in certain inflammatory exudates 
is associated with the breaking down of the wandering cells, and is of 
manifest benefit in so far as it circumscribes the inflamed area, and 
prevents the passage of morbid material outwards. 
6. That the exudate may possess digestive functions, causing the pro- 
99 100 
duction of peptones; the ferments being developed from the cells alone 
when the exudate is aseptic, from these and the microbes together where 
pathogenetic microbes are present. 
7. That the exudate may further contain substances, generated by 
the cells, capable of hindering bacterial growth, and of destroying 
pathogerietic microbes. 
SYSTEM OF MEDICINE 
Chapter 3. - The Part played by Blood-Vessels 
The study of the action and function of the leucocytes in inflamma- 
tion has profoundly modified our conception of the inflammatory process. 
When the leucocytes were regarded as purely passive agents, and their 
diapedesis as purely secondary to modified conditions of the blood cur- 
rent and of the vascular walls, the theory of Cohnheim was that most 
generally accepted. And this theory regarded the changes in the vessels 
as of the first importance. Thus it was that for several years our atten- 
tion was mainly concentrated upon the determination of the various 
changes of the vessel walls, and of the mechanism whereby these changes 
were brought about. Nowadays less attention is directed to this side of 
the inflammatory process, and it may be said that during the last ten 
years little advance has been made in determining the mechanism of the 
dilatation that accompanies inflammation. 
The subject, indeed, is beset with difficulties. It is most difficult 
to observe the changes that occur in the cells forming the endothelium 
of the congested vessels ; we are still, for instance, far from being sure 
whether the opinion of Arnold is correct, namely, that the leucocytes, 
and, it may be, a large portion of the exuded plasma, find their way out 
through the dilated stomata between the endothelial cells; or whether 
the leucocytes pass directly through these cells as one soap bubble may 
be passed through another. And when we come to discuss whether the 
inflammatory exudation be a filtration, or whether, on the other hand, it 
be more of the nature of an excretion, or what may be termed a selective 
filtration - certain components of the blood plasma being permitted to 
pass through, while others are withheld - we are met with the difficulty 
that, of the extravasated leucocytes, a varying proportion undergo rapid 
destruction and dissolution. Thus, in analysing the inflammatory 
serum, we are not dealing simply with the extravasated fluid, but with 
a fluid which in addition contains proteid and other constituents derived 
largely from broken-down white corpuscles, and in part, it may be, from 
the modified cells of the inflamed area. 
Though Arnold's observations upon the altered condition of the 
vascular endothelium in inflammation appear at first very convincing, 
upon further study they seem at most to indicate that with dilation 
of the vessels there is an increase in the size of the spaces between the 
endothelial cells. They do not, however, prove that these are other than 
virtual spaces filled with intercellular substance; and indeed Arnold 
himself came eventually to the conclusion that some such substance was INFLAMMA TION 
present tilling them. The fact that viscid, gelatinous substances injected 
into the circulation may be detected passing through these stigmata is 
not a proof that the spaces are actual; all it proves is that the walls 
are weaker in these regions: it must be remembered that increased 
force and increased intravascular pressure are necessary to promote the 
passage of the injected mass along the vessels. The passage of the mass 
through the walls may therefore be an " artefact." 
There is this further difficulty in the assumption that these are actual 
spaces-that in acute inflammation the exuded fluid in general contains 
a smaller quantity of proteids than does the blood plasma. It is true, 
no doubt, that the stigmata are so small they may possibly act like the 
pores of a filter, and consequently may not permit the free passage of 
certain constituents of blood plasma. Yet, granting all this, if the same 
principles be in action as those governing the ordinary (noninflamma- 
tory) transudation, we must, with Heidenhain, be inclined to regard the 
endothelium as playing not a passive, but an active role. To enter into 
the large subject of the nature of lymph would be to pass too far afield; 
recent researches, on the whole, favour the view that the inflammatory 
exudation is not a mere filtrate, but is the result of a selective activity 
on the part of the endothelial cells. 
We have not a little evidence that these cells play an important part 
in the vascular phenomena of inflammation. To their power of taking up 
microbes and acting as phagocytes I have already referred; into their 
connection with the slowing of the blood stream I shall enter later. 
Here I would point out that microscopically these cells can be seen to 
alter during the inflammatory process; they become enlarged and 
project into the lumen of the smaller vessels, and in my experience this 
enlargement affects not only the cell bodies, but also the nuclei, which 
at the same time would seem to contain more chromatin and to stain 
more intensely. In cases of chronic inflammation the enlargement is 
followed by proliferation, notably in the arterioles and capillaries, - a 
process which may lead to the ultimate occlusion of these small vessels. 
And in acute inflammation, according to numerous observers, mitosis is 
to be seen occurring in these endothelial cells at an earlier period than 
in the surrounding tissues. 
A further and very important process intimately connected with the 
proliferation of the endothelium of the capillaries is the formation of 
new vessels as the result of continued inflammation. It is true that 
Rindfleisch and others have described this as being brought about by 
vaso-formative cells situated externally to the vessels; and that others 
have advanced so far as to suggest that there are cells in the newly- 
forming granulation tissue which become hollowed out and gain attach- 
ment to the pre-existing capillaries in a manner wholly similar to that 
observable in the vascular zone of the chicken embryo. I have sought 
for such intracellular development, but never have I seen the slightest 
indication thereof; nor again have I been able to discover cells 
arranging themselves after the method described by Rindfleisch in 
101 SYSTEM OF MEDICINE 
102 
columns or parallel rows preparatory to the passage of blood between 
them and to the formation of a capillary. 
The search for the earliest signs of new capillaries is a matter of 
peculiar difficulty. I will not peremptorily state that Rindfleisch mis- 
took an arrangement of cells not unfrequently seen in granulation tissue 
for stages in the development of new vessels. I will only say that my 
own observations coincide with those of Arnold, and of the majority of 
those who have more recently studied the question, and lead me to regard 
the formation of new capillaries as originating from the endothelium of 
the vascular loops already in existence. 
The first step in the process is often recognisable, in cases of pleurisy 
and pericarditis, in the projection of loops of pre-existing capillaries 
beyond the line which indicates where the serous endothelium used to 
be, and into the fibrinous clot now adherent to the sub-endothelial layer. 
Such loops are markedly distended, and " point," as it were, at right 
angles to the denuded surface. A similar pointing or giving way of the 
wall along the convex margin of the loop is also to be made out not 
unfrequently in newly-developed capillaries. In these there is not, as 
might be expected, a thinning of the endothelium along this outer mar- 
gin, but certain of the cells on the contrary appear large and active. At 
times a small sharp protrusion of the vessel wall can be detected in the 
region of pointing. This is best seen in the capillaries that are them- 
selves but newly formed, and composed of nothing but a layer of endo- 
thelial cells. In this layer the protrusion can be made out to be in 
direct continuity with the endothelial cells of the region. At first it 
is solid, but in the later stages it can be seen to be nucleated, and to be 
growing by proliferation of the endothelial cells which thus jut out- 
wards. Even before any further change is noticeable in this projection 
from the capillary wall it may be seen to be united with a similar pro- 
cess originating from a neighbouring vascular loop. Finally, it would 
appear that the joined processes become hollowed out, and thus are 
developed into fully-formed capillary loops. It seems impossible to 
make precise observations on the phenomena of new vascular formation 
in its successive stages. I can but state that these appear to be the 
steps of the process. By what means the new vascular projections join 
together to form loops we are ignorant. Metschnikoff suggests that 
there must be an attraction between the neighbouring projections - a 
chemiotaxis - leading them to come into apposition; this, however, is 
no more than a suggestion. That they do join is very clear to those who 
have studied granulation tissue, or have observed the vascular network 
connecting the previously separated surfaces of a wound. 
A further function of the vessel walls is to be seen in the slowing of 
the blood current. It is difficult, and in fact impossible, to explain this 
slowing by altered diameter of the arteries and veins. The alterations 
observed in the diameters of the vessels of the inflamed area are such as, 
acting alone, would led to increased rate of flow. Nor again is the 
apparent amount of exudation, and of lymph flow from the affected INF LA MM A TION 
103 
part, sufficient to make it probable that (as Wharton J ones first suggested) 
the slowing is in the main due to the concentration of the blood, relative 
drying of the corpuscles, and consequent increase of friction: while this 
may be an adjuvant we must, I think, find some more potent factor. 
What this factor is was pointed out long ago by Lister, who, in 1858, 
noticed that coincident with the slowing of the blood stream, the cor- 
puscles move sluggishly along the vessel wall as though attracted by it. 
Lister essayed to prove this by an experiment performed previously by 
Weber. He ligatured a frog's leg, then irritated a portion of the web by 
a little mustard, and found that, although the blood current had ceased, 
there was nevertheless an accumulation of corpuscles in the vessels of the 
irritated area, the corpuscles gliding into the affected region and becom- 
ing adherent there. Other observers have shown that this accumulation 
is not due to increased adhesiveness of the red corpuscles, inasmuch as 
similar slowing and stasis may be induced if the blood of the frog's leg 
be replaced by milk and the web irritated. In this case there is a 
gradual slowing of the stream of milk and accumulation of the fatty 
globules in the inflamed area. While in Lister's experiment the transu- 
dation of the plasma might explain the accumulation of the corpuscles, 
in this latter instance, as in ordinary inflammation, the observed transuda- 
tion is insufficient to account for the accumulation and slowing. Although 
I cannot accept his experiment as conclusive, I am forced to concur with 
Lister to this extent, that in inflammation the endothelium of the vessel 
walls becomes altered, the cells becoming enlarged. With this, as evi- 
denced by the conduct of the white corpuscles, they become more 
adhesive, and this adhesiveness with the associated increased friction 
between the vascular walls and contents I regard as the first factor in 
bringing about the slowing of the blood stream. Let the current once 
accelerated be rendered slower by this increased friction, then transu- 
dation may accentuate the accumulation of corpuscles. 
Summary. - While there is very much yet to be learned concerning 
the part played by the blood-vessels in inflammation, and while our 
present knowledge of this branch of the subject can only be regarded 
as very imperfect, the following may, I think, safely be said to epitomise 
what is known at the present time: - 
(1) That the vascular walls, and more especially the endothelial cells 
lining the capillaries, play an active and not a passive part in the in- 
flamed area. 
(2) These cells have the power of throwing out pseudopodia and 
of taking up non-motile bacteria. 
(3) They are larger and more prominent during inflammation than 
they are under conditions of health. 
(4) From them are developed the new vascular loops in cases of 
more chronic inflammation. 
(5) They would seem to become more adhesive in inflammation, and 
by this, in the first place, to lead to the adhesion of the leucocytes and 
red corpuscles to their walls. SYSTEM OF MEDICINE 
104 
(6) Similarly they would seem to cause an increased resistance to the 
passage of the blood current, and in this way tend to slow the rate of 
blood flow. 
(7) The slowing of the stream may further be aided by the passage 
through the walls of increased amounts of fluid from the blood. 
(8) It is impossible by analysis of the inflammatory exudation to 
determine whether this be a mere filtrate or be the result of a selective 
activity of the endothelium. On the whole, taking into account the 
observations made upon ordinary lymph, the latter would appear the 
more probable. 
Other properties of the blood-vessels in respect of inflammation will 
be better discussed in a later section in connection with the discussion 
of the part played by the nerves. 
Chapter 4. - On the Passage of Corpuscles out of the Vessels 
By his researches, Cohnheim (1867) forcibly attracted the attention of 
pathologists to the diapedesis of leucocytes in inflammation - a process 
which had already been described years before by Addison (1843) and 
Waller (1846) in England; and yet earlier (though without grasp of the 
connection between the diapedesis and inflammation) by Dutrochet, in 
France (1828). Cohnheim recognised the amoeboid nature of the leuco- 
cytes, and saw that once outside the vessels they moved actively, but 
eventually he could not discover that their penetration of the vessel walls 
was anything but passive; and this failure on his part to recognise the 
true nature of diapedesis confirmed him yet more strongly in the view 
that the all-important factors in the inflammatory state were the changes 
in the vessel walls, and, it may truly be said, arrested his advance 
towards a fuller comprehension of the subject. 
It must be acknowledged that there is much which would seem to 
support this view of the passivity of the leucocytes. No one is pre- 
pared to attribute active movements to the red corpuscles, nevertheless 
in inflammation a certain number of these escape through the vessel 
walls. In the inflammation affecting some organs, notably the lungs, 
the number effecting a passage is very considerable. If, then, the red 
corpuscles emerge passively, why should not the emergence of the white 
be passive also ? Add to this the very important observations made by 
Cohnheim, that where the circulation is arrested by compression of the 
artery there diapedesis ceases. This, if invariably true, would seem to 
indicate that when once by changes in the vessel the leucocytes adhere 
to the wall, the further passage through that wall is due to the vis a 
tergo of the blood pressure. 
This, however, is not a safe deduction to draw from the experiment re- 
ferred to. When the artery of an inflamed area is compressed the stoppage 
of the blood stream not only reduces the pressure, but also affects the 
quality of the blood and the conditions of the vessel walls ; moreover, it 
must profoundly affect the vitality and activity of the contained leucocytes. IN FLAM MA TION 
105 
These considerations alone render the experiment valueless as a proof of 
the passive nature of the diapedesis. Again the passage outwards of red 
corpuscles does not occur in the earliest stages of reaction to irritation; 
it never precedes the diapedesis of the leucocytes (save where there is 
gross injury), but follows it. A capillary or small vein in the inflamed 
frog's web, for example, may be seen wholly filled with corpuscles, the 
peripheral zone being quite annihilated, and numerous red corpuscles 
lying in immediate contact with the walls; nevertheless at first leucocytes 
only are seen to emigrate. This difference must be due to some special 
property of these cells. The leucocytes in the blood stream are not 
necessarily globular passive agents, but they are capable of independent 
movement. Leber, in his long series of studies, has pointed out that if, 
with due precautions, a hooked glass tube (closed at its outer end where 
it catches into the incision in the wall) be inserted into a large vein 
no thrombosis may be set up around the intravascular portion, and yet, 
upon removal, a large collection of leucocytes may be found in the tube, 
attracted by a drop of mercury placed within it, with normal salt solu- 
tion. (Mercury is a substance which within the tissues leads to an 
accumulation of leucocytes.) Here, then, there must be active attrac- 
tion and active movement of the leucocytes within the blood stream. 
And Lavdowsky has described very exactly what other observers had 
also noted, namely, that in inflammation the leucocytes in the outer zone 
of the blood stream do not simply adhere passively to the wall, but move 
backwards and forwards before they attach themselves and emigrate, as 
though seeking for a point of less resistance. At times this movement 
is in a direction opposite to that of the blood current. 
If, then, both within and without the vessels, the leucocytes can be 
actively amoeboid, it is strange that they should be passive in the pro- 
cess of diapedesis which to the eye has so characteristically amoeboid 
an appearance. 
As above stated, the compression of the artery passing to an in- 
flamed area is in most cases sufficient to arrest diapedesis in that area, 
and I have suggested that this arrest may be due to the altered envi- 
ronment of the leucocytes. Now, if an embryonic form be taken, in 
which the tissues would seem to possess greater inherent vitality coupled 
with less sensibility, the arrest does not necessarily occur. Thus, 
Metschnikoff has noted that diapedesis of the leucocytes can be fol- 
lowed in the tadpole's tail after the animal has been curarised to such 
an extent that the heart has ceased to beat and the blood in the capil- 
laries has been brought to a standstill. 
It is evident, therefore, that with our present knowledge we must 
regard the diapedesis of the leucocytes as an active migration, and must 
look upon the blood pressure, the disposition of the blood stream, and 
the altered condition of the endothelium of the dilated vessels as adju- 
vants in the process. The slowing of the blood stream and the diminished 
pressure in the inflamed capillaries render it more easy for the leucocytes 
to accumulate close to the vessel wall; the dilation of the vessels and 106 
SYSTEM OF MEDICINE 
consequent thinning of the walls, with the opening, perhaps, of larger 
spaces of cement substances or stigmata between the individual endo- 
thelial cells, render it more easy for the leucocytes to accomplish the pas- 
sage ; but the movement from within the capillaries to the tissue-spaces 
outside is an active process due to amoeboid movement of the leucocytes 
themselves. The continuity of the vessel wall once destroyed, other 
cells - red corpuscles - may be pressed passively through the walls. 
If this view be accepted, we are bound to look beyond Cohnheim's 
limit of changes in the vessel wall for the stimulus which, originating in 
the area of irritation, acts upon the vessel wall and the leucocytes in 
contact with it; and, having first set up changes in the former, so reacts 
upon the latter that they emigrate; or, to put it in other words, are at- 
tracted out of the capillaries towards the focus of irritation. It has 
already been shown that the movement of wandering cells in the tissue is 
due to the attraction of a diffusible product of bacterial growth and of 
tissue change, and of sundry organic and inorganic materials-a force to 
which the name of positive chemiotaxis has been given. This chemiotaxis 
must be invoked to explain the active emigration of the leucocytes from 
the capillaries, and again to explain its cessation under other conditions. 
Thus, while the exposed mesentery of a frog is a tissue in which diape- 
desis can be observed with facility under ordinary conditions, if it be 
washed with a weak solution of quinine the leucocytes in the vessels 
remain globular, cease to adhere to the walls, and do not emigrate. This 
fact, first noted by Binz, has been confirmed by several observers, among 
whom Disselhorst made out also that, if these same leucocytes be re- 
moved from the vessels, they exhibit their usual amoeboid movements. 
The quinine has not paralysed them, as Binz supposed; but, as Metsch- 
nikoff pointed out, it has neutralised the previous positive attraction, a 
negative or repulsive chemiotaxis being brought into play. It is diffi- 
cult to see how the above facts can be otherwise explained. 
The view that diapedesis is an active process gains further support 
from, and at the same time explains certain interesting observations 
made by, Bouchard, Roger, and Buffer. These observers have independ- 
ently shown that in sundry instances the results of local injection of viru- 
lent cultures are greatly modified if, shortly before or coincidently, the 
microbes and their products are introduced into the circulation. Thus, 
as Buffer points out, a drop of the culture of the bacillus pyocyaneus in- 
oculated into the anterior chamber of the rabbit's eye leads ordinarily 
to a great migration of leucocytes - to an acute purulent inflammation. 
If, however, the toxins produced by this microbe have previously been 
injected into the circulating blood, no accumulation of leucocytes follows 
inoculation into the eye. Dr. Buffer has also extended most suggestively 
certain observations of Boger. Subcutaneous or intramuscular inocula- 
tion of the rabbit with the bacillus of symptomatic anthrax leads to the 
production of a local abscess with extensive accumulation of leucocytes. 
After simultaneous injections of fluid containing virulent bacilli and 
their products into the vein of the ear and the muscles of the hind leg, INFLA MM A TION 
107 
Buffer found the rabbit dead, within fifteen hours, with a huge tumour 
in the inoculated limb. Here, upon examination, the muscle fibres 
were found widely separated by exudation fluid, in which there had been 
great multiplication of the bacilli; but leucocytes were entirely absent. 
In both of these cases we have therefore diapedesis and determination 
of leucocytes following the purely local action of the toxin; want 
of diapedesis and absence of leucocytes when the toxin at the same 
time circulates in the blood stream. If any large proportion of the 
leucocytes which find their way to a focus of irritation emerge from the 
blood stream, these divergent results are only to be explained by some 
theory which is capable of reconciling the difference in the action of the 
leucocytes when they are circulating in normal and toxin-containing 
blood respectively. 
Now, the results in these two cases are entirely consonant with what 
we know concerning the sensitiveness and reaction to stimuli not only 
of unicellular organisms, but also of the higher animals. Organisms, 
whether lowly or of most complex development, only perceive and react 
to alteration in their environment when the alteration exceeds a definite 
ratio. Thus, as Pfeffer has pointed out, a motile bacterium (the " B. 
termo ") is attracted towards solutions of peptone : if it be already in a 
peptone solution, in order for it to be attracted towards and move into 
a more concentrated solution, this last must be five times as strong as is 
the former. The only possible explanation that I can see of the above 
observations of Buffer and Boger is that the passage and want of passage 
of the leucocytes out of the vessels depends upon the ratio of diffusible 
bacterial products present in the blood stream and in the tissues respec- 
tively. Where the products are localised at one focus in the tissues, 
the leucocytes are attracted out of the unaltered blood, and there is 
active diapedesis ; where there was already a solution of the bacterial 
products in the blood, the ratio of difference between the percentage 
amount of toxin in blood and tissue may be insufficient to stimulate the 
leucocytes; no diapedesis then ensues. 
As is well shown in the experiment with symptomatic anthrax, the 
presence of the bacillus and its products in the circulating blood did not 
prevent inflammation at the region of local injection ; inflammation and 
exudation were abundantly manifest -there was, in fact, a more extensive 
exudation than ever. The irritant - that is to say, the toxic products 
of the bacilli-at the point of injection was in no wise hindered from 
exerting effects upon the fixed cells of the vessel walls, and promoting 
all the changes in calibre and condition of the walls and in the blood 
stream characteristic of inflammation. But with vascular changes, if 
anything more prominent than in the case where local inoculation alone 
had been practised, the leucocytes stayed within the vessels : now the 
only cause to which we can attribute this abstention of the cells from 
emigration, is lack of attraction - certainly not lack of vascular change 
or lack of blood pressure. 
Summary. - I am thus led to the following conclusions regarding 108 
SYSTEM OF MEDICINE 
the passage of cells out of the blood stream into an inflamed 
area: - 
1. The diapedesis of the leucocytes is, as the name implies, an active 
and not a passive process; it is due to active amoeboid movements on 
the part of the cells. 
2. The stimulus leading to diapedesis is that of positive chemiotaxis. 
It is the attraction exerted upon the leucocytes by the diffusible sub- 
stances associated with the irritant. 
3. Irritants, if themselves diffusible, or the diffusive substances 
developed while the irritants are within the tissues, are capable of two 
separate actions : one direct upon the vessel walls, leading to vascular 
changes ; the other through the walls upon the leucocytes, whereby 
emigration may be induced. 
4. These two actions need not (and frequently do not) manifest them- 
selves pari passu. 
5. In relation to diapedesis, the dilation of the vessels, the altered 
rate of blood stream, the altered disposal of the corpuscles in the stream, 
and the modified endothelium, may all be regarded as adjuvants. 
6. The passage of red blood corpuscles from the blood-vessels into 
the inflamed area is passive, due to the blood pressure and to lack of con- 
tinuity of the vessel walls. Such lack of continuity is afforded in many 
instances by the migration of the leucocytes through the walls. 
Chapter 5. - On the Part played by the Nervous System 
If the vascular changes in inflammation were due to reflex influences 
proceeding from the central nervous system, and were in fact controlled 
by the centres in the brain and spinal cord (as has been held by the 
supporters of neuro-humoral theories) then, in the first place, there 
should be a rapid and almost immediate response on the part of the 
vessels of any region on the introduction of an irritant. But this is 
not by any means constantly to be observed. Thus, as Cohnheim 
pointed out, if croton oil be rubbed upon a rabbit's ear more than an hour 
may elapse before the first beginnings of hyperaemia can be detected; 
yet the inflammation eventually set up may be very intense. In the 
second place, section of all the nerves passing to any region of the 
body should have this effect, that injury in the region in question should 
be unaccompanied by the ordinary vascular reaction. But this is not the 
case. Divide all the nerves which supply a rabbit's ear for example, and 
then injure that ear, either by heat, cold, or inoculation of pathogenetic 
micro-organisms, and inflammation manifests itself with all the stages 
recognisable in an ear with intact nerve-supply. The vascular changes 
which accompany inflammation can occur then independently of any 
central nervous influences. 
We can proceed farther, and state that regions deprived of their 
nerve-supply are peculiarly prone to inflammatory changes. But this 
liability to inflammatory disturbances in such regions is not directly due INFLAMMA TION 
109 
to the destruction of vaso-motor tracts and the cutting off of central 
influences from the vessels of the part, but is, it would seem, immediately 
connected with the loss of sensation. Divide the ocular branch of the 
fifth nerve of a rabbit, and, if the eye be not protected, ulceration and 
necrosis of the cornea manifest themselves in the course of a few days. 
Protect the eye, either by bringing the lids together or by placing a 
shade over it in such a way that dust and foreign particles are prevented 
from settling upon the surface, and no such ulcerative disturbance mani- 
fests itself. From this it is clear that the primary cause of the inflam- 
mation is not any trophic change in the region, but is the lack of sensa- 
tion, whereby irritant substances are permitted to gain a lodgment upon 
the outer surface without any attempt being made to remove them. 
That, in addition, there is a lowered vitality in parts deprived of their 
nerve-supply, and that this renders those parts a more favourable seat 
for inflammatory disturbances is more than probable; nevertheless, this 
would not seem to be the primary cause of the increased liability to 
inflammation. [Vide art. on "Nutritional Retrogressive Changes."] 
This, then, in the first place, is clearly recognisable-that the vascular 
changes accompanying inflammation can occur independently of central 
nervous influences. Hence it follows that there must be a peripheral 
nervous mechanism controlling the vessels. It remains, therefore, to 
determine the nature of this peripheral mechanism: is it wholly under 
the guidance of peripheral nerve cells situated in the vessel walls, or 
is it, in part at least, idiopathic ? In the present state of our knowledge 
the answer to this question must be guarded. The more carefully the 
innervation of the various regions is studied, the more clearly is it 
demonstrated that throughout all the tissues of the body there exists 
a wonderfully fine and complicated network of nerve filaments with 
occasional isolated ganglion cells. Yet proof is wanting that this system 
in connection with the vessels is sensorimotor. Indeed, so far as regards 
the heart and ventricular muscle (which may be looked upon as the 
region of the vascular system wherein the motile portion of the walls 
has become specially developed), the researches of Romberg and His lead 
rather to the conclusion that the peripheral nervous system subserves 
sensation alone. 
Dr. H. J. Berkley's careful series of researches recently brought 
together in a Johns Hopkins Hospital Report (Neurology II., 1894) 
throws much light upon the termination of the nerves in various organs, 
and upon the relation of these nerves to the vessel walls. Berkley 
finds in connection with the ventricular muscles a dense network of nerve 
filaments, with small bulbous terminations upon the individual fibres. 
These observations, it must be admitted, tend to weaken the belief in the 
idiomuscular, or, more truly, idioneural action of the heart muscle. 
At the same time, the more the activity of the various tissues is 
studied, the more fully it is seen that many cells retain what may be 
termed reminiscences of an earlier and more embryonic condition in 
which their functions were varied and less specialised. There is an SYSTEM OF MEDICINE 
110 
inherent probability that the endothelial cells can react directly to stim- 
uli, and that they are capable of idiopathic contraction and expansion 
on appropriate stimuli. We have seen that these cells are capable of 
taking up microbes, and thus seem to exhibit an independent activity 
similar to that observed in the amoeba or the wandering phagocyte. If 
these cells, then, are capable of throwing out pseudopodia, and thus of 
enclosing non-motile bacteria, are they not capable of contracting and 
expanding, as a whole, according to the stimulus of altered environ- 
ment ? As a matter of fact, such contractility of the endothelial walls 
of the capillaries has been demonstrated by Klebs and Severini. I can- 
not but conclude, then, that the endothelium of the capillaries is to some 
extent self-regulative or neuro-muscular. It is quite possible - but 
"non-proven"- that the muscular coats of the smaller arteries are 
likewise capable of self-regulation, and respond directly to stimuli. 
This view - that the vascular phenomena of inflammation can occur 
independently of the central nervous system and of the peripheral nerves 
- does not imply that the nervous system, central and peripheral, is 
without its influence upon the process; far from it. We have evidence, 
in the first place, that the state of the vascular walls is modified after 
destruction or severance of the nerves. I do not here refer only to the 
consequent alterations in calibre of the vessels, but also to the changes 
in other properties. Thus Gergen-s, and to a less extent Kutimeyer, 
noticed that after destruction of the spinal cord the blood-vessels of the 
frog permit a larger quantity of fluid, and even particles of granular 
colouring matter, to permeate them. 
In the second place, we have evidence that the central nervous 
system exercises some direct influence upon the inflammatory process. 
From Cohnheim onwards it has been a matter of common observation 
that when all the nerves of a part have been severed, the stages of the 
process succeed each other with greater rapidity. It may be that the 
modified state of the capillary walls, noted in the preceding paragraph, 
is capable of accounting for this fact, and that, in the absence of central 
influences, dilation of the vessels and exudation of fluid lead to the 
cardinal symptoms of redness and swelling, with associated changes in 
the tissue, at an earlier period. 
Of the part played by the different sets of nerves the external ear of 
the rabbit again furnishes an excellent study. This part has a double 
nerve-supply through the auriculars (major and minor) passing from 
the cervical plexus and the sympathetic branches proceeding from 
the superior cervical ganglion: stimulation of the former leads to 
dilation of the ear vessels, of the latter to contraction of the same. If, 
as shown by Samuel, the sympathetics be divided on the one side, 
and the auricular branches upon the other, the ear vessels of the 
former side become widely dilated, and those of the latter markedly 
constricted. Under these conditions, if both ears be subjected to the 
action of water warmed to 54° C., there is a characteristic difference in 
their reaction. In the organ deprived of sympathetic influence the INFLAMMA TION 
111 
congestion and hypersemia become yet more pronounced: an acute 
inflammation sets in which proceeds rapidly to recovery. In the 
opposite ear, with its constricted vessels, no hyperaemia is set up; 
but there is stasis, and gangrene may supervene. These results have 
been confirmed by Roger, who, taking a rabbit and dividing the 
sympathetic on one side and then inoculating both ears with like 
quantities of a culture of the streptococcus of erysipelas, found that the 
erysipelatous process manifested itself much more promptly upon the 
paralysed side, and came to an end at an earlier date. The reverse was 
the case when the auriculars of the one side had been divided: here the 
process was of slower development than on the intact side, and of slower 
course, resulting in mutilation of the organ.1 
The inference to be drawn from these observations is that section of 
all the nerves passing to the rabbit's ear permits the inflammatory process 
to run a more rapid course; section of the sympathetics (vaso-constrictors) 
alone has the same effect; while the uncontrolled action of the sym- 
pathetics after section of the auriculars (vaso-dilators) hinders or prevents 
the manifestation of the ordinary processes of inflammation, and by 
preventing the destruction or removal of irritant matter favours necrosis 
of the tissues. We have yet to learn whether these results are capable 
of a general application, and to discover how far they are borne 
out by clinical observations on diverse cases of localised paralysis. So 
far as they go they afford direct evidence of the power of the central 
nervous system to modify the course of the inflammatory process, while 
they demonstrate admirably how potent an auxiliary is the dilation of 
the vessels in the inflammatory process. 
Other evidence that the state of the nerve-supply of a region influences 
the manifestation of inflammation is afforded in sundry neuropathies. 
In all of these, in the present state of our knowledge, it is difficult to 
trace out the nervous factors associated with the lesions to which 
I refer. Our knowledge of the respective influences of trophic and 
vaso-motor nerves is far too limited to permit us to say more than 
that a relation exists between the condition of the nerve-supply 
of the affected area and the inflammatory lesions there observable; 
that in a certain number of cases inflammation affecting the area sup- 
plied by one branch of a nerve may have associated with it definite 
inflammatory disturbances in the areas supplied by other branches of 
the same nerve, and that, similarly, when inflammation affects a viscus, 
inflammatory phenomena may be sympathetically developed in regions 
innervated from the same area in the brain or spinal cord. I have 
already given examples in support of the first statement: the familiar 
redness, swelling, heat and pain of the side of the face which may 
accompany toothache is an example in support of the second, while the 
condition of labial herpes in pneumonia is an evidence of the results of 
1 Although these results have been criticised by Samuel and other observers, upon re- 
viewing carefully the whole literature of the subject, I cannot but think that the above 
paragraph represents the general trend of more recent work. 112 
SYSTEM OF MEDICINE 
the third. Another example is to be found in the acute nephritis, which 
at times rapidly follows the passage of a catheter, or the impaction of a 
stone in the urethra. It is not unlikely that many of these sympathetic 
inflammations are not direct, but secondary. Thus, the first noticeable 
symptom of catheter fever is suppression of the urine. Such suppression 
might be brought about either by reflex contraction of the renal 
arteries, or, contrariwise, by reflex great dilatation and congestion of the 
vessels of the kidneys. If it be caused by the former then the nephritis 
can only be regarded as secondary, and as due to the injury done to the 
organ by the stoppage of its blood-supply for some little time. 
From the multitude of the factors involved, these examples, taken 
separately, afford at most only a great probability tha!t the nervous 
system can directly originate inflammatory changes. There is, however, 
the clearest proof that the nervous system does possess this power, and 
this is afforded by the results of certain observations upon hypnotic 
effects. There are persons susceptible to hypnotic suggestion, in 
whom the suggestion that a red-hot substance has been placed upon the 
hand will, in the course of a few minutes, lead to great reddening of the 
part supposed to have been burned, and this reddening may be followed 
by great local exudation and swelling - in fact, by all the symptoms 
of acute inflammation. Here then actual inflammatory reaction follows 
supposed injury. 
It is unnecessary to do more than point out the light that this 
intervention of the central nervous system throws upon the subject of 
counter-irritation, and upon the modifications of the course of inflamma- 
tions brought about by idiosyncracy of the individual. 
From what has been said in the preceding paragraphs, it follows 
that: - 
1. Acute inflammation in all its stages may proceed regularly in the 
absence of all centrifugal nervous influences. 
2. The vessels of an injured area are capable of reacting apart from 
central influences; it may be either directly, or under the control of a 
peripheral system of nerve cells. 
3. The central nervous system is capable of modifying the process 
of inflammation. It would appear that when the vaso-dilators alone are 
called into action the successive stages of the process are accelerated. 
When the vaso-constrictors alone are acting the process is retarded. 
4. Centrifugal impulses alone, apart from any local injury, may 
originate a succession of phenomena of inflammation in a part. 
5. Hence, in all probability a nervous and central origin must be 
ascribed to some, at least, of the sympathetic inflammations seen to occur 
in areas supplied by the other branches of a nerve supplying a part 
primarily inflamed; and again in areas supplied from the same region of 
the brain or cord as the inflamed organ. INFLAMMA TION 
113 
Chapter 6. - On the Part played by the Cells of the Tissues 
As a consequence of irritation two opposed processes may be mani- 
fested in the cells of the affected area, - changes leading to impairment 
and death, and changes leading to overgrowth and proliferation; de- 
generation and regeneration. 
Either of these two processes may, it is true, be wholly wanting. 
In very acute suppurative disturbances, destruction of the tissue cells 
and the steps leading to destruction may be the only recognisable 
changes. Again, in the first stage of most injuries, whether of me- 
chanical, chemical or bacterial nature, degenerative changes are wont 
to take the lead. On the other hand, there are irritants so mild that 
little or no cell destruction results from their action; an extreme 
example of this category of inflammations is seen in those epithelial 
overgrowths commonly known as "corns," due, as Sir James Paget 
pointed out in his lectures, to intermittent pressure and irritation of 
moderate intensity.1 Other examples are to be found in the " catarrhal " 
inflammations, in which there is marked initial overgrowth and prolif- 
eration of the cells of mucous membrane; and in tuberculosis, again, in 
which characteristically the earliest effects upon the pre-existing cells, 
produced by the presence and growth of the tubercle bacilli, are those 
of enlargement and multiplication - necrotic changes, as a rule, only 
appearing at a much later stage. Once more, in the later healing stages 
of injuries, cell proliferation may be in the field alone. Nevertheless, 
in a very great number, if not in the majority of inflammations, the 
two processes may be found occurring together - destruction and 
degeneration being in evidence at the focus of irritation, and growth 
and proliferation towards the boundary zone, where the irritant is 
acting in a less concentrated form. 
Although the two processes are thus so frequently associated, it will be 
well, for the orderly review of our subject, to consider them separately. 
Degeneration of the Tissue Cells. - Death of the pre-existing cells 
as an immediate consequence of injury cannot be regarded as one of the 
phenomena of the inflammatory process. Immediate death of the cells 
may be a result of injury, and the disintegration of the dead cells may 
in itself lead the way to all the symptoms of inflammation. But cessation 
1 It may very well be that this is not an extreme example. Neoplasms as a class, 
whether malignant or benign, not improbably develop as a consequence of some irritation 
having an intensity just sufficient to induce cell proliferation, and continued for a time 
sufficiently long to impress upon the cells of the affected tissues the habit of rapid multipli- 
cation. There is evidence both in animal and vegetable pathology favouring this rela- 
tionship between inflammation and neoplastic growth. 
The objection may be raised, with considerable force, that substances which lead to 
cell-proliferation are stimuli and not irritants, and that a line should be drawn between 
inflammation proper and overgrowth the result of irritation. I, for one, would willingly 
make this difference, but while it is easy to draw the line in certain well-marked ex- 
amples, in others, as I shall proceed to show, cellular proliferation is so essential a part 
of the whole inflammatory process that the division becomes impossible. 
VOL. I 
I SYSTEM OF MEDICINE 
114 
of action is not reaction, nor is failure response, and throughout this 
article inflammation has been considered as the reaction following 
injury, and the response to it. Thus immediate death of tissue cells is 
resultant and not reactive, and may be eliminated from the category of 
the essential phenomena of inflammation. 
The same is to some extent true of cell degeneration, but not 
entirely. While it is impossible nowadays to accept Virchow's old 
view, that inflammation is essentially a process characterised by 
increased nutritive changes in the cells of the tissues, it remains most 
probable that in very many cases irritation induces increased, even if 
perverted, activity of certain orders of cells. The proliferation, swelling, 
and more or less rapid degeneration of these cells cannot be wholly 
ascribed to the toxic influence of the irritant, but must in part be 
regarded as a result of over-stimulation and overwork. This is most 
noticeable in connection with catarrhal and parenchymatous inflam- 
mations. In parenchymatous nephritis, for example, such as that set 
up by cantharidin or septic infection, the cells especially affected 
are those whose functions are especially excretory ; and their degenera- 
tion would appear to be intimately related to the performance of their 
functions. Such degeneration, preceded or accompanied, as it so fre- 
quently is, by excessive proliferation, may truly be regarded as reactive, 
and not as wholly and primarily destructive. 
Of the degenerations which affect the tissue cells in inflammation 
(and often at the same time the leucocytes) there are many varieties: 
in fact, according to the nature of the irritant, one, or other, or all the 
degenerations affecting the tissues in different pathological conditions 
may manifest themselves, save, perhaps, simple atrophy and pigmental 
degeneration (as apart from pigmental infiltration). Most commonly 
recognised are cloudy and fatty changes, but mucoid and hydropic 
changes are far more frequent than is generally noted. Even so special- 
ised a change as amyloid degeneration has been observed occurring 
locally in chronic inflammations - as, for example, in gummata; while 
in these same chronic lesions hyaline degeneration in the vessel walls 
is very often to be encountered. 
There is also to be seen in inflammatory disturbances of moderately 
acute type a further form of degeneration, which receives a passing 
mention in the text-books, it is true, but so far has not to my knowledge 
been duly treated as an entity; nor has its significance been fully grasped. 
This is what may be termed " reversionary " degeneration. It is to be 
seen affecting tissues, in which the individual components in the fully- 
formed state are not single cells, but cell complexes or compounds. Such 
compounds are the voluntary muscle and medullated nerve fibres, 
and, as Grawitz has pointed out, the fat cells of connective tissue.1 
These are formed by the fusion and united growth of several cells; 
11 here, and throughout this article, leave wholly out of account Grawitz's " slum- 
bering cell " theory -a theory incapable of actual proof, and at variance with the cell 
theory upon which is based the entire superstructure of modern biology. INFLAMMA TION 
115 
and in inflammation, as under other pathological conditions, the de- 
generation of the cell-compound as a whole manifests itself by a certain 
amount of proliferation of the nuclei (of the muscle fibre, sheaths of 
Schwann, and periphery of the fat cells respectively), protoplasm can be 
observed to accumulate around these active nuclei, and with the assump- 
tion by the component cells of an independent existence the degeneration 
may be said to be complete - that is to say, beyond this point only the 
shell and debris of the original compound are left to be considered. 
All these degenerations are inevitably associated with disturbance 
of the functions of the affected cells, and lead to their death if the 
irritation which has induced them be continued. But death is not the 
final stage to be considered. The ultimate fate of the necrosed cells 
varies according to the situation of the inflamed area, the intensity of 
the irritation, and the specific character of the irritant. From a free 
surface the dead material may be freely cast off. In acute suppurative 
inflammations, whether superficial or deep, and, in general, wherever 
there is an abundant determination of leucocytes, there obtains a diges- 
tion and solution of the necrosed cells; and, as I have already pointed 
out, this is associated with the development of peptones and albumoses, 
and is brought about largely through the extracellular action of the 
leucocytes. When there is a large area of cell destruction, with well- 
developed encystment and limitation of necrosis by granulation tissue, 
there the solution of the dead material and subsequent absorption may 
be incomplete, and a fatty debris left behind, which may eventually 
become infiltrated with lime salts (the calcareous degeneration falsely 
so-called). In tuberculosis, despite the presence of many leucocytes in 
the immediate vicinity, the dead material of the centre of the tubercle 
undergoes very little absorption, but remains as an inspissated, cheesy 
mass. In syphilis, on the other hand, in large gummata, while there 
is similar death of the central cells and absence of removal, fatty 
metamorphosis does not occur nearly to the same extent. 
Lastly, although very little is known about the subject, attention 
must be drawn to the fact that along with the tissue cells the inter- 
cellular matrix undergoes modifications or degenerative changes dur- 
ing inflammation. Among these, in all probability, is to be classed an 
increase in the amount of intercellular mucin, a mucoid degeneration. 
The inflammatory exudate is in many cases rich in mucin, and although 
our knowledge of the changes in the matrix is scanty, the fact that the 
tissue cells in general show little evidence of storage of mucoid or 
mucinogenous material, renders it probable that what mucin is formed 
is either excreted or elaborated between the cells. Connective tissue 
fibrils, which may be regarded as part of the matrix, undergo dissocia- 
tion and swelling, and eventually, in acute inflammation, disappear. 
In chronic disturbances they are especially prone to hyaline change. 
Regeneration of the Tissue Cells; Overgrowth and Proliferation. - In 
the lower animals, as we know, injury and actual removal even of a large 
portion of the body may be followed by the complete reproduction of 116 
SYSTEM OF MEDICINE 
the lost part. In man, however, this reproduction of lost tissue is 
reduced to its lowest point; the higher the tissue the less, and the 
less perfect, the reproduction. Speaking generally, the tissues which 
show the greatest potentiality for reproduction are the least highly 
organised-those composed of similar units. The " connective tissue" 
- the lowest and most widely distributed - retains the largest powers 
of proliferation and hyperplasia. 
In ordinary inflammation hypertrophy and hyperplasia of the con- 
nective tissue cells are absent at the focus of irritation. Here degen- 
eration is predominant. It is in the peripheral zone, awray from the 
maximum concentration of the irritant, that (as shown in case after case 
of Leber's long series of studies upon injury to the cornea), the con- 
nective tissue cells show signs of enlargement and proliferation, that 
they become more swollen and prominent, send out large processes, and 
may exhibit signs of active mitosis. It may be urged that this peri- 
pheral change is not inflammatory, but associated; yet, as I have already 
hinted, the signs of cellular regeneration may manifest themselves at so 
early a stage that it is impossible to disconnect them from the process 
of inflammation. This fact has been brought out with emphasis in 
Ranvier's interesting series of studies on irritation of the peritoneum by 
weak solutions of caustic substances. If a few drops of a 0-3 per cent 
solution of silver nitrate be injected into the abdominal cavity of a rab- 
bit or guinea-pig an inflammation is set up which lasts for some days. 
At the end of twenty-four hours the portions of the serous coat of the 
abdominal contents which have been most affected are found denuded of 
their endothelium - the cells have died and disappeared; but in other 
regions, less strongly affected, the endothelial cells present the reverse 
condition of overgrowth: their nuclei are swollen; the protoplasm, 
instead of forming a flattened plate, is swollen, and presents stellate pro- 
longations anastomosing with those of neighbouring cells. The under- 
lying vessels at this period show abundant evidence of inflammation; 
they are congested, and leucocytes are being poured out into the mesen- 
teric network. Within forty-eight hours there follows upon the inflam- 
matory exudation a rich development of fine filaments of fibrin, and along 
sundry of these filaments the enlarged endothelial cells send processes. 
Some of the cells become enormous, 100 /z or more in diameter. In this 
extension of the cells along the fibrinous framework we have probably 
the commencing formation of organised adhesions. The endothelial cells 
at this stage have become so modified from their previous quiescent flat- 
tened state that even outside the body they exhibit amoeboid movements. 
Up to this time no signs of nuclear division manifest themselves. 
According to Toupet, working under Cornil, it is not until the fourth day 
that mitosis is recognisable in this form of inflammation. But while 
inflammatory congestion, exudation of fluid, and diapedesis of leucocytes 
is proceeding actively, the modified endothelial cells of the regions that 
have not undergone the severest injury are with equal activity engaged 
in what it is difficult to regard as other than a reparatory process. INFLAMMA TION 
117 
As Baumgarten showed in his studies upon the development of 
tubercles, in the irritation set up by the growth of the R tuberculosis in 
the tissue, a like overgrowth with proliferation of the fixed cells occurs 
in the immediate neighbourhood of the bacilli without any primary evi- 
dence of cell degeneration. It is true that of late the researches of Borel 
have thrown doubt upon Baumgarten's observations, but they confirm 
the earlier researches so far as regards the mitosis of pre-existing cells, 
and the absence of degeneration of these in the earlier stages of the 
tubercular growth. Borel would regard all the large epithelioid cells 
of the tubercle as modified leucocytes. For myself I cannot admit that 
he has proved this, careful as his researches seem to be; and until the 
leucocytic nature of these cells be firmly established I am inclined, 
with the majority of histologists, to regard many of them as similar in 
nature and origin to the modified cells just described in connection with 
simple inflammation. 
The difficulty of determining the origin of the growing cells in 
inflammation has formed the greatest trial of the pathologist throughout 
an entire generation, and yet longer; nor can we now assert without 
chance of dispute what cells are mainly concerned in the formation of 
new tissue. 
When we examine newly-formed granulation tissue we can distin- 
guish cells of more than one type - (1) small round cells with polylobu- 
lar and fragmented nuclei, (2) other cells containing oxyphil granules, (3) 
larger cells with a single nucleus and a relatively large quantity of proto- 
plasm, and again (4) cells of varying but generally large size, varying in 
shape, but on the whole having the appearance of spindle cells with single 
oval nucleus and abundant protoplasm. These can be made out easily. 
The first two forms of cells are clearly leucocytes. Further study of 
their fate shows that they disappear; they play no further part in the 
organisation of the tissue save that, as is well shown by Scheltema and 
Nikiforoff, many of them are absorbed by the growing connective tissue 
cells, and thus would seem to aid in their nutrition. The last form 
likewise presents, as such, no difficulties. These are fibroblasts -cells 
in the process of growth into connective tissue. But what is their rela- 
tionship to the previous form, - to the round mononucleated cells with 
fairly abundant protoplasm, - what are these last, and what in short 
is the origin of the fibroblasts, - is it from leucocytes or from pre- 
existing connective tissue cells ? Upon this most difficult question 
more ingenuity and more research have been expended than upon any 
other part of this well-worked field of inflammation. 
There can be no doubt nowadays that a large proportion of the fibro- 
blasts in granulation tissue are developed from pre-existing connective 
tissue cells. The general consensus of recent researches leads de- 
cidedly in this direction; and it is from the laboratory of Ziegler, who 
by his classical observations led pathologists for some years to hold the 
contrary view, that the studies have emanated which most conclusively 
show the part played by the connective tissue; the researches of Krafft, 118 
SYSTEM OF MEDICINE 
Podwyssozki, Coen, Fischer, and Nikiforoff, confirmed and strengthened 
by the researches of Arnold, Marchand, Reinke, and Sherrington, all 
bring forward evidence in one direction. It is the clearly recognisable 
pre-existing cells of the tissue - connective, endothelial and epithelial 
- which show most constantly the signs of nuclear division: every 
stage of enlargement, mitosis and cell division, can be made out in 
them. Even if we did not possess the information afforded by nuclear 
changes, the fact that new tissue is always developed in the immediate 
neighbourhood of pre-existing tissue would in itself point strongly to 
this same conclusion. 
We may rest assured of this much. But can we advance farther, 
and state that all newly-formed connective tissue cells originate from 
the pre-existing cells of the tissue, and that none of them are derived 
from wandering cells ? In the present state of our knowledge the 
answer to this question must be an unhesitating "No." -If we base 
our observations upon the morphology of the cells in granulation tissue, 
we find that with our present methods the large, round, mononuclear 
cells seen therein are undistinguishable on the one hand from large 
hyaline leucocytes, on the other from one stage in the development of 
fibroblasts. If we examine into their properties we find that they act 
as phagocytes incorporating the multinuclear leucocytes. The fibro- 
blasts, according to Nikiforoff's careful studies, have an identical action; 
so also, according to Metschnikoff, Buffer, Borel, and others, have the 
large mononuclear hyaline leucocytes. If we study their mode of divi- 
sion they, like the connective tissue cells, exhibit indirect or nuclear 
division. It may be (as has been more than once suggested) that the 
large mononuclear hyaline leucocytes differ from the other forms in 
being of endothelial origin. Were this so a path would be found out of 
our present difficulty. Certainly the most that can now be said is that it 
is quite possible that among the higher animals this one form of wan- 
dering cell may be contributory to new fibrous tissue formation, quite 
possible that the connective tissue cells which develop as a result of in- 
flammation are not all derived from the pre-existing cells of the region.1 
It must be borne in mind that leucocytes, endothelial, and connective 
tissue cells are very simple forms of tissue, that they are all of like 
mesoblastic origin, and thus being homogeneous, may be more variously 
modified, without impairment of activity, than more highly specialised 
cells. I must here add that in lower forms - in the tadpole's tail, 
for example - Metschnikoff has followed day by day the transition from 
leucocyte into typical connective tissue cell, and that, largely in conse- 
quence of these observations, French pathologists hold the view that the 
leucocytes enter far more actively into new tissue formation than I here 
recognise. The German school, with the exception of Arnold (whose 
1 In this connection may be mentioned the observations of Metschnikoff, confirmed 
by Barfurth, and more recently by Dr. Joseph Griffiths, which show that in the degener- 
ation and disintegration of muscle fibres (of the tadpole's tail) the proliferated nuclei of 
the fibres become the nuclei of individual wandering cells - leucocytes. INFLAMMA TION 
119 
views correspond on the whole with my own), has with Ziegler passed 
over to the opposite camp of connective tissue only from connective 
tissue. For myself I have carefully sifted the evidence adduced by 
either side. What is said above gives, I believe, the estimate of the 
matter for the time being; while what follows gives in brief the state 
of our knowledge of the part played in inflammation by the tissue cells 
in general. 
(1) Two series of changes may occur in the cells of an inflamed tissue, 
which may be included under the terms degeneration and regeneration 
respectively. 
(2) The extent to which one or other of these series of changes pre- 
dominates varies with the nature and intensity of the irritant. 
(3) Degeneration and death of the tissue cells may be a direct and 
immediate result of the presence of the irritant, and then can scarcely 
be regarded as essential phenomena of inflammation. Or they may be 
of more gradual onset, associated with evidence of over-stimulation and 
increased activity of the cells. 
(4) Fatty, cloudy, hydropic and mucoid are the most frequent forms 
of degeneration affecting the tissue cells in acute inflammation; hyaline 
in chronic; other forms are rare. 
(5) The ultimate fate of the necrosed cells varies as the situation, 
intensity of irritant, and specific character of irritant. 
(6) Cell-proliferation is so constant an accompaniment of certain 
forms of inflammation that it is impossible to regard this as an adjunct 
and not as an essential part of the process. 
(7) The tissues which show the greatest potentiality for reproduc- 
tion in consequence of inflammation are those which are least highly 
organised. 
(8) The origin of fibroblasts and new connective tissue cells cannot 
be regarded as entirely determined, but this much would seem to be 
clearly demonstrated: (a) That a large proportion of the fibroblasts are 
derived from pre-existing connective tissue cells. (/?) That in lower 
forms - as, for example, the tadpole - leucocytes can be seen to develop 
into connective tissue cells, (y) It is quite possible, indeed probable, 
that in the higher animals one form of wandering cell, the large hyaline 
mononuclear, contributes to the formation of new fibrous tissue. 
Chapter 7. - On Fibrous Hyperplasia and its Relationship to 
Inflammation 
The succession of changes from embryonic cells to fully-formed tis- 
sue can best be studied in cases where there has been a relatively large 
area of destruction - as, for example, after severe burns, or excision of 
organs or large portions of organs; or again, where inflammation has 
been of a chronic character. 
If healthy granulation tissue be examined, the process of growth is 
seen to originate in the immediate neighbourhood of if not in direct 120 
SYSTEM OF MEDICINE 
connection with the dilated new capillaries. It is around these vessels, 
formed of little more than a single layer of cells, that the fusiform fibro- 
blasts are in greatest abundance. At a later stage, in regions more remote 
from the advancing margin of the granulations, the fibroblasts have a more 
general distribution in the intercapillary spaces, and are more elongated; 
around them may be seen the earliest wavy fibres of white connective 
tissue. These are essentially of cellular origin - as much so as is the 
substance of striated muscle fibres. The elongated fibroblasts not only 
break or extend at their poles into fine processes, but also along their 
sides the protoplasm undergoes modification into fine parallel fibrillae. 
With the continuance of this change the cells become smaller and 
smaller until little is left but the attenuated nuclei, often so flattened 
and narrow as to be scarcely recognisable. It is generally accepted 
that the fibrillar substance contracts with increasing age; certainly the 
newly-formed cicatricial tissue diminishes greatly in volume, and with 
this diminution the previous great vascularity of the part disappears; the 
capillaries shrink until the majority become completely occluded. Thus 
in place of the abundant, soft and succulent granulation tissue, rich in 
cells, blood-vessels and exuded fluid, there is eventually a firm, shrunken, 
anaemic mass of fibrous tissue, with rare flattened nuclei, rich only in 
closely-pressed bundles of white, semi-transparent fibrils. 
Fibrous hyperplasia is to be encountered in almost every tissue of 
the body as a sequence of very diverse morbid conditions. To speak of 
it in any case as " fibroid degeneration " is a misnomer. The overgrowth 
of any tissue, however lowly, is not a degeneration. Fibrous tissue may 
and often does become the seat of degenerative processes, notably the 
hyaline; but that is another matter. To regard every condition of 
generalised or localised fibroid change of the organs of the body as a 
chronic " -itis " is equally erroneous, until we have proof absolute that 
connective tissue only undergoes excessive growth directly or indirectly 
under the stimulus of injury. It is interesting to note the opposed 
tendencies of the two branches of our profession on this subject; 
the surgeons strive to restrict the idea of inflammation to acute pyogenic 
disturbance, the physicians to extend the idea so as to include all 
cases of chronic progressive " fibrosis." I will not say that the latter 
is as untenable a position as the former, for it is a matter of peculiar 
difficulty and delicacy to state what is and what is not an inflamma- 
tory fibrosis; after all, there is more danger of being tossed about 
helplessly in the Charybdis of including too little, than there is of 
striking upon the Scylla of including too much in our idea of inflam- 
mation. 
Here I wish to point out how divergent are the conditions which 
lead to fibroid hyperplasia, and to draw attention to the fact that there 
is reasonable ground for not classing all forms under the one common 
heading, even though the resulting appearances may be undistinguish- 
able and the effects the same. 
Cicatricial fibrosis presents little difficulty; it is plainly the result of IN FLAM MA TION 
121 
inflammation; so too is the fibrous overgrowth upon chronically inflamed 
serous surfaces. Capsular fibrosis is clearly of the same nature; it is 
to be seen around foreign bodies, around chronic abscesses, in the 
walls of tubercular cavities, and encapsulating tubercles, gummata, and 
other neoplasms inflammatory and non-inflammatory. Allied to these 
is the fibroid replacement in old infarcts (including that following 
upon " myomalacia " cordis). Here, studying a series of cases, it can be 
made out that the necrosed material becomes surrounded by a zone 
of inflammation, and that, with the passage of leucocytes into the 
dead area and absorption of the effete material, there is soon manifest 
a new connective tissue overgrowth advancing inwards from the peri- 
phery. 
Among the generalised scleroses there is one form frequently encoun- 
tered which may, without hesitation, be regarded as the accompaniment 
of inflammation. This is seen well in the general interstitial nephritis 
accompanying subacute and chronic parenchymatous inflammation of the 
kidney. Of similar nature are some forms at least of hepatic cirrhosis, 
diffuse syphilitic cirrhosis, the diffuse tubercular cirrhosis to which at- 
tention has more especially been drawn by French pathologists, and an 
extensive pericellular cirrhosis in cattle, which I have of late been 
engaged in studying, due, it would seem, to the abundant multiplication 
of a diplobacillus in the bile capillaries and liver substance. Whatever 
be the immediate cause of other forms of cirrhosis, overgrowths of fibrous 
tissue would appear in these to precede atrophy of the liver cells, and 
to be associated with the presence of an irritant. 
But there are other varieties of fibroid growth concerning which it 
is less easy to arrive at a just conclusion. First may be mentioned the 
replacement or compensatory fibroses. An excellent example of this is 
to be seen in the sclerosis of well-defined tracts of the spinal cord follow- 
ing destruction of the ganglion cells governing those tracts, or sections 
of the fibres, at a point proximal to their trophic cells. 
The fibrosis in these cases is not secondary to a progressive inflam- 
mation, but to a simple atrophy of the nerve fibres. These shrink, and 
their place is taken by fibrous tissue. Another equally instructive 
example is to be found in the dystrophic sclerosis of the cardiac 
muscle fibres to which attention has been called, more especially by 
Drs. Martin and Huchard. This occurs in certain cases of arterio- 
sclerosis, and is best seen in the papillary muscles, the fibroid change 
occurring, not around the thickened arterioles, but at the periphery of 
the area supplied by each. The muscle fibres around the arterioles are 
healthy; but farther away, through lack of nutrition, they have atro- 
phied, and their place is taken by a zone of fibrous tissue which fre- 
quently manifests hyaline degeneration. In this instance the morbid 
condition of the arteries is in itself a hindrance to active dilatation of 
the vessels, and the exhibition of the ordinary accompaniments of in- 
flammation. Indeed this peripheral zone is singularly free from leu- 
cocytes, yet well-marked sclerosis appears nevertheless. 122 
SKSTAJ/ OF MEDICINE 
Can these be regarded as cases of inflammatory fibrous hyperplasia ? 
According to our definition they may: the fibrosis ensues as a reaction to 
injury. It is legitimate to conceive that the dying and atrophic tissue 
elements here, as in the grosser condition of infarct, act as irritants. 
But, on the other hand, the only recognisable evidence of inflamma- 
tion is this very extension of cicatricial tissue; and even this is strictly 
limited in amount, being just sufficient to replace the dead tissue, and 
nothing more. 
Active hyperaemia is not a prominent characteristic of any stage in 
the first instance cited above, and is throughout absent in the second. 
Still, as I showed in an earlier portion of this article when treating 
of injuries to non-vascular areas, active hyperaemia is not absolutely 
indispensable. 
Active hyperaemia is entirely wanting in yet another form of fibrosis 
- that resulting from passive congestion, whether of the blood (as in 
clubbed fingers, in that variety of cirrhosis of the liver which may 
result from obstructive lung or heart disease, and in the spleen of 
portal obstruction), or of the lymph (as in chronic oedema, sclerema, 
elephantiasis and macroglossia). Is this to be regarded as an inflam- 
matory fibrosis ? Everything points to the conclusion that connective 
tissue cells and their progenitors, like the Chinaman and the Polish Jew, 
can thrive and multiply upon a pabulum which is starvation to those 
of a higher standard. In passive congestion, as in obstruction to 
the onward flow of lymph, there results undoubtedly a bathing 
of the tissues with increased lymph. Can this alone account for the 
hyperplasia, or must we invoke the aid of the irritation or stimulus 
of retained effete matters contained in the lymph? This question is 
one that is most difficult to answer. Underlying it are the further ques- 
tions whether one broad explanation can be found to apply to all cases 
of tissue hyperplasia; and whether cell growth in general, under physio- 
logical as under pathological conditions, is due to increased nutrition, or 
to stimulation of the cells, to increased physiological activity of the 
same, or to removal of pressure and other conditions preventing growth, 
or to a combination of all, or nearly all of these. This last question at 
present remains unanswered. In the examples before us of hyperplasia 
following passive congestion, one possible factor, that of removal of 
pressure from the cells, is absent: and we are narrowed down, I think, 
to two of the possible factors named above-relatively increased nu- 
trition, and stimulation by effete matters. If it were shown that there 
are states in which stimulation or irritation by effete matters plays no 
part in the overgrowth of new connective tissue, then we could, I think, 
safely declare that forms of fibrous hyperplasia exist which cannot come 
under the heading of inflammatory fibrosis, and that the fibrosis of 
passive congestion may be included among them. _ 
Now such conditions do exist. That increased nutrition alone can lead 
tohypertrophy of the tissues was established long ago by Hunter's classi- 
cal experiment of transplanting the cock's spur on to the cock's comb, -• IN FLAM MA TION 
moving it from a slightly vascular to a richly vascular region. In the 
ensuing overgrowth there can here be no question of irritation by any- 
thing beyond the normal blood.1 And passing from the general to the 
particular, we have evidence that there is such a condition as fibrous 
hyperplasia due, as it would seem, to increased nutrition unassociated 
with the presence of toxins or other cellular irritants. In his wonder- 
fully painstaking series of observations upon arterial changes, Thomas 
has adduced two cases which he describes, no doubt, as examples 
of endarteritis, but in which the inflammation is not apparent, 
nor indeed any factor other than altered tension of the arterial 
walls leading to altered conditions of nutrition. He shows that 
immediately after birth there is developed a thickening of the intima 
- a connective tissue proliferation immediately below the endothelium 
- of that portion of the aorta lying between the ductus Botalli and 
the passing off of the umbilical arteries. During later foetal life the 
umbilical arteries are the largest branches of the aorta; and, when the 
circulation through them is arrested, the aorta above is too large for 
the amount of blood requisite for the abdominal viscera and the lower 
extremities. The arterial current becomes therefore relatively slowed, 
and presumably, judging by the analogy of what occurs in the adult 
when large branches of the aorta are ligatured, the aortic blood pressure 
is for a time raised. With this slowing and increased pressure there 
appears a compensatory overgrowth of the intima leading to contrac- 
tion of the . vessel and its lumen. Generally speaking, when the area 
of distribution of an artery is diminished, as, for example, when 
a limb is amputated, the artery shows a similar proliferation of the 
intima. In both cases the blood remains healthy, and the intima 
has undergone no injury; the only recognisable change has been a 
slowing of the blood stream, and probably increased blood pressure; 
and as the intima is nourished, not through the vasa vasorum, but 
directly from the main arterial fluid, it would appear that with the 
slowing an increased nutrition is brought into action. I can see no satis- 
factory reason for calling either of these cases an endarteritis. It is quite 
possible that other cases of thickening of the intima are due not to irrita- 
tion, but to increased nutrition brought about by heightened arterial 
tension. The difficulty urged by Councilman that high arterial pressure 
does not invariably lead to overgrowth of the intima is not, in my 
opinion, insuperable. It must suffice if here I point out that it is more 
than probable that certain cases of endarteritis are in no sense of inflam- 
matory origin, or secondary to degenerative changes; but are primarily 
associated with nutritional changes. In this connection it was shown 
by Prof. Roy and myself that when the aorta of the dog is suddenly 
and greatly constricted, and as a consequence the pressure in the 
123 
11 here leave out of account a factor which may be important, hut about which we 
know practically nothing - namely, the effect of altered innervation. I am forced to 
assume, perhaps wrongfully, that, as this factor plays a like part in all the cases under 
consideration, it may for present purposes be disregarded. 124 
SYSTEM OF MEDICINE 
proximal portion of the vessel greatly increased, the plasma of the 
blood is forced into the cusps of the aortic valves, and vesicles of lymph 
make their appearance on the under surface in that region where fibroid 
thickening is most frequent in cases of chronic high arterial pressure. 
Thus, to express briefly the distinction that I would draw between 
inflammatory and non-inflammatory fibrous hyperplasia, I would say that 
where local injury leads to increased nutrition of the connective tissue, 
with increased functional activity of the cells, the ensuing fibrous hyper- 
plasia is to be regarded as of inflammatory origin; where, on the other 
hand, local injury is not recognisable as the primary cause of the cell 
growth, the hyperplasia must be held to be non-inflammatory. In pas- 
sive congestion, obstructed lymph-flow, and increased nutrition conse- 
quent upon arterial change, as in the cases cited above, we can so far 
see no cause for the fibrous hyperplasia beyond altered conditions of 
nutrition; there has been no primary lesion in the affected regions induc- 
ing the reaction. Such cases must be considered as non-inflammatory. 
But while I lay down this distinction, I must impress upon the 
reader that the last word has by no means been said upon this matter, 
and that further research may cause a radical reconstruction of our 
opinions. 
Forms of Fibrous Hyperplasia 
A. Of Inflammatory Origin. 
1. Cicatricial. 
2. Perivisceral. 
3. Capsular. 
4. Replacem ent - 
Gross (of infarcts, etc.). 
Fine (dystrophic sclerosis, etc.). 
Localised 
5. Cirrhotic, associated with parenchymatous 
inflammation, interstitial and lymphan- 
gitic. 
Generalised 
B. Of Non-inflammatory Origin. 
1. Hyperplasia of increased (arterial) nutrition. 
2. " of venous congestion. 
3. t " of lymphatic obstruction. 
C. Neoplastic. 
1. Fibromata. 
Upon the Increased Temperature of Inflamed Areas 
Very little has of late been added to our knowledge in this division 
of our subject: what is to be said appears now to be so well established 
that I need do little more than state the main conclusions. The long 
controversy that raged before these conclusions were fully accepted, and IN FLAM MA TION 
John Hunter's original views shown to be in the main correct, scarcely 
comes within the scope of this article. 
1. The temperature of superficial regions is raised, it may be several 
degrees above the normal, by the onset of inflammatory hypersemia. 
2. The temperature of internal organs when inflamed may be raised 
above the normal, but undergoes no material increase beyond that of 
other unaffected internal organs tested at the same time. 
3. The rise above the normal, which is often present, is an indication 
of the febrile state accompanying the inflammation, and not of locally 
increased heat production. 
4. The increased temperature of superficial areas when inflamed is 
due, not to the production of heat in the part, but to the increased 
quantity of blood passing through it. When the congestion is so great 
that stasis ensues there may be actual decrease in the temperature of the 
part. 
5. The maintenance of high external temperature may exert a 
favourable effect upon the duration and progress of specific inflammation. 
Thus Filehne has recently shown that the course of experimental erysip- 
elas in rabbits is more rapid and more benign when they are kept at a 
high temperature than at a low. We possess no clear evidence that this 
is due to the unfavourable effect of the heightened temperature on the 
growth of the microbes. Pasteur's well-known experiments upon the 
production of anthrax in fowls (ordinarily insusceptible to this disease) 
by lowering their temperature can be explained on other grounds. We 
have abundant evidence that heightened temperature promotes vascular 
dilation: the experiment of Filehne may therefore supply a further 
demonstration of the favourable effects of dilation of the vessels and 
hypersemia in the inflammatory process. 
6. Low external temperature, or the application of cold to the surface, 
contracts the vessels : hence, upon the lines of what has already been 
said, it would appear that 
(a) It is calculated to diminish the amount of exudation. 
(b) It is calculated in consequence to diminish the pain associated 
with inflammation. 
(c) It has no directly good effect upon inflammation due to the 
presence and growth of pathogenetic micro-organisms, but 
may have the reverse effect of preventing the fullest reaction 
on the part of the organism. 
(d) Where the irritant does not itself grow and multiply, or present 
cumulative action, there the application of cold may not only 
be of no harm, but of positive advantage, by lessening the in- 
flammatory reaction and preventing this, where extensive, from 
being itself a cause of further injury to surrounding tissues. 
The increase of systemic heat will be considered in the article on 
Fever. 
125 126 
SYSTEM OF MEDICINE 
PART III. - On the Various Forms of Inflammation 
Chapter 1. - Classification 
The minute changes which characterise the process as it affects one 
or other organ, and the various specific forms of inflammation, will be 
fully described in special articles. I have only to indicate more general 
causes and main varieties. To give a complete classification is impossi- 
ble unless each separate tissue be taken in order, for each tissue presents 
peculiarities either in liability to inflammation, or in the course assumed 
by the process. Even to attempt a classification in broad outline is 
beset with difficulties, for the inflammatory manifestation varies, not 
according to one or two series of causes, but according to four at least; 
the permutations are thus so numerous, and the appearances so varied, 
that to give an adequate scheme of classification would require a diagram 
in four dimensions. These four causes of variation are - 
A. Nature of tissue affected. B. Position of tissue affected. C. In- 
tensity of irritation, or more correctly ratio between resistant powers of 
the organism and intensity of the irritant. D. Nature of irritant. 
A. Nature of Tissue affected. - As I have already shown in the 
first portion of this article, there is in the earlier stages of the process 
a difference in the reaction of vascular and non-vascular tissues, the one 
series exhibiting marked congestion and vascular disturbance, the other 
not. At a later stage, or in more chronic irritation, as new vessels invade 
the non-vascular areas, the changes in the two series do no doubt approxi- 
mate ; but in the earlier stages we may distinguish between an ordinary 
inflammation and " inflammatio sine inflammatione." 
The relative denseness and compactness of the tissues also introduce 
characteristic alterations: a dense tissue, such as bone, does not show 
the signs of reaction to injury to nearly the same extent as does a loose 
tissue - such as the omentum, for example - thus, in the former there 
may be a process almost as atypical as in non-vascular areas. The rigid 
framework of a tissue like bone prevents great vascular dilatation and 
exudation, but at the same time may be the seat of great pain due to 
pressure of the confined exudate upon the nerve endings. The loose 
connective tissue of a structure like the omentum, on the other hand, 
permits great exudation with little or no pain. 
The influence of structure is well seen in comparing the course of in- 
flammation affecting cutaneous, mucous and serous surfaces respectively. 
Where we have to deal with cutaneous surfaces, or surfaces formed of 
squamous epithelium, there the increased exudation, and the resistance 
offered by the layers of flattened cells to the free exit of the exuded 
fluid, lead towards the formation of vesicles or blisters. In the case of 
serous surfaces, which form the walls of a moist cavity, the irritant, 
affecting primarily but one portion of the surface, is very likely to be 
borne into the cavity with the exudate and to set up an inflammation INFLAMMA TION 
extending over a very large portion of the surface. Mucous and cuta- 
neous surfaces, which are not thus the boundaries of cavities, exhibit a 
more marked disposition to the production of localised inflammation and 
of ulcers; the superficial layers indeed of a well-formed epithelium or 
mucous membrane, by the protective powers of their cells, form a defence 
against irritation from without: thus the superficial exudate from a 
region of local inflammation cannot easily produce a superficial exten- 
sion of the process. 
Not only the nature of the tissues, but their function also, profoundly 
affect the character of the inflammatory manifestation. Thus, excretory 
organs, by the very nature of their function, during the attempt to 
remove noxious substances from the system, are especially liable to 
generalised parenchymatous inflammations, - the irritation not being 
local, but affecting at the same time all the cells whose part it is to 
take up and excrete the irritant bodies. 
B. The Position of Tissues. - It is difficult to consider the position 
and relationship of tissues as they affect the inflammatory manifesta- 
tions, without continually touching upon their structure. Nevertheless, 
the two, though very closely connected, do not go hand in hand. 
A familiar instance of modification in form brought about by position 
is to be seen in the result of suppurative inflammation - in the develop- 
ment of ulcerous conditions when the process affects free surfaces, of 
abscesses when it attacks deeper tissues. The process in the two cases is 
virtually the same: there is the same abundant determination of leuco- 
cytes, the same degeneration of them into pus. Yet apart from the 
gross difference in form, there are minor differences between the two. 
There is, for instance, relatively much more serous exudation from the 
free surface of an ulcer than there is into and around an abscess. As 
a general rule, inflamed tissues near a free surface are the seat of more 
abundant exudation. Of this liability for free surfaces to be the seat 
of serous inflammation I have already spoken. The skin, with its thick 
dermal layer, affords a good example : when the full suppurative stage 
is not reached, inflammation affecting the outermost layers of the derma 
is most often of a vesicular or oedematous character; when it affects 
the deeper layers of the derma the serous infiltration is less evident. 
Yet another example of the influence of position in modifying form 
is seen in enteric fever. In this malady, the lymphoid tissue forming 
the Peyer's patches becomes the seat of excessive cellular infiltration 
and proliferation, undergoes necrosis, and is cast off, leaving the well- 
known ulcers. The lymphoid tissue of the neighbouring mesenteric 
gland likewise undergoes great infiltration and enlargement, but necrosis 
rarely implicates the whole of a gland: notwithstanding the previous 
extensive inflammation, the glands commonly recover their normal 
appearance and size. 
Beyond this there are few broad principles to be laid down concern- 
ing the relationship between forms of inflammation and position that 
do not essentially depend upon the structure and functions of the tissues. 
127 128 
SYSTEM OF MEDICINE 
Much, can be said concerning the intimate connection between position 
and liability to inflammation; but this and the allied and most impor- 
tant subject of the protective mechanisms of sundry tissues against 
injury are away from our present point. 
C. The Relative Intensity of the Irritant is a more frequent and 
potent cause of variation. I have already in several places referred to 
the ratio between the resistant powers of cells and the intensity or 
virulence of the irritant as it affects the inflammatory process, and have 
shown how much that was previously vague has been made clear by 
bacteriological research; while, at the same time, it has brought home 
the truth that the various forms of inflammation merge insensibly one 
into the other. 
Broadly speaking, it may be stated, as a result of these studies, 
that, carter is paribus, increased virulence of any given microbe or 
diminished power of resistance on the part of the organism or of the 
tissues, leads to corresponding alterations in the phenomena of inflam- 
mation at the region of inoculation; and vice versa. 
Thus, if a pathogenetic microbe, such as that of anthrax or erysipelas, 
be greatly attenuated, the effects of inoculation into the subcutaneous 
tissues may be scarcely recognisable. If the attenuation be not so extreme 
some hypersemia, a determination of leucocytes, and, relatively, very 
little exudation, will be seen; and in the course of a day or two all 
traces of inflammation may have disappeared. With slightly more 
virulent microbes the migration of leucocytes may be followed by their 
breaking down and consequent abscess formation; with further increase 
of intensity of action the migration of leucocytes may be wanting, 
while the exudation extends and the inflammation rapidly spreads and 
leads to a septicaemia. A like series of changes is observable if the 
strength of virus be constant and animals more and more susceptible 
(or less and less refractory) be inoculated. 
The variation in tubercular lesions, from isolated dense fibroid 
masses to loosely formed cell accumulations and diffuse tubercular in- 
flammation, is evidently explicable on this law. The law holds good 
also, not merely for bacterial products, but for other irritants also. The 
effect of croton oil varies with the strength of the solution applied; and, 
as shown by Samuel, according to the condition of the animal. The 
same is true of abrin and other vegetable extracts. 
Turning to physical irritants, while here the intensity of the irritant 
alone or almost alone is called into play, numerous examples can be 
given of the effects of variation in this one respect upon the inflamma- 
tory manifestation- effects of cold, for instance, varying from chilblain 
through inflammatory oedema to gangrene; of heat varying from 
hypergemia through vesicular inflammation to complete destruction of 
tissue; and, again, effects of caustic substances. In this era of aseptic 
surgery we may forget what was well known to the last generation of 
surgeons, that caustic substances may be employed either to originate a 
benign and reparative inflammation (as in the case of indolent ulcers) ; INFLAMMA TION 
129 
or, in larger quantities or greater intensity, to bring about a state in 
which the death of the tissue elements is far in excess of the subsequent 
repair. Thus then, according to the above-mentioned ratio, inflamma- 
tion in a tissue may vary by insensible gradations from a mere hyperaemia 
up to a spreading suppurative or gangrenous process; and from a purely 
local manifestation to the development of what may be termed an in- 
flammation of the whole organism. 
D. The Nature of the Irritant.-It is clear, then, that it is impos- 
sible to base a classification upon the nature of the irritant: the 
attempt to mark off sharply the inflammations caused by mechanical 
and chemical noxae from those produced by bacteria and their products 
must be given up. Hater's proposition that suppuration can only be 
induced by microbes has been repeatedly shown to be erroneous. 
Thanks more especially to the researches of Councilman, Leber, Grawitz 
and de Bary and Straus (many more names might be mentioned in this 
connection), we now know that many chemical substances are capable 
of causing pus formation.1 Among these may be mentioned turpen- 
tine, croton oil, mercury, copper and silver nitrate. On the other 
hand, although this pyogenetic property is not confined to microbes and 
their products, yet among microbes it is not the common property of all. 
Some, like the bacillus of tetanus, never in themselves induce pus forma- 
tion: others, like the bacillus of tuberculosis, lead characteristically to 
tissue growth and the formation of inflammatory neoplasms rather than 
to pus formation. Even among those which, like the micrococci, are 
highly pyogenetic, the formation of abscesses only occurs when there is 
a definite relationship between the virulence of the microbe and the 
resistance of the organism. The reverse is equally true, that numerous 
microbes, not specially pyogenetic, produce pus under peculiar condi- 
tions. Thus, the bacillus of enteric fever, when it multiplies in the 
middle ear, induces a suppurative otitis, and, as Dr. C. F. Martin has 
shown, it is further capable of originating a suppurative arthritis. 
In fact, under varying conditions the same microbe can induce very 
various forms of inflammation. Thus, Charrin has shown that the B. 
pyocyaneus and its products are capable of inducing in one organ - the 
kidney - pathological conditions so diverse as acute, chronic, parenchy- 
matous, interstitial and thrombotic nephritis, with, in addition, cyst 
formation and amyloid degeneration.2 This same microbe can induce 
acute suppuration in the anterior chamber of the eye; and when inocu- 
lated into the blood cause a haemorrhagic inflammation of the serous 
surfaces. Hence we can proceed further and state that no strict classi- 
fication of inflammation can be made according to the nature of the 
1 While this is so, it must be borne in mind that under ordinary conditions these 
substances very rarely act upon the organism in a state of sufficient concentration to be 
pyogenic. Thus, while it is impossible to make a sharp line of demarcation between 
bacterial and chemical irritants, it holds true in the main for man that suppurative dis- 
ease is an indication of the presence and growth of microbes. 
2 These changes are comparable with the diverse conditions of the kidney in the 
human being brought about by the scarlatinal virus. 
VOL. T 
K SYSTEM OF MEDICINE 
130 
bacterial irritants: it is, however, possible to make a general grouping 
of those affecting man, as follows: - 
(i.) Micro-organisms characteristically leading to pus and abscess 
formation - Staphylococci and streptococcus pyogenes, B. anthracis. 
(ii.) Those leading to abundant exudation with necrosis - B. of 
malignant oedema. 
(iii.) Those leading to cellular infiltration without usually causing 
abscess formation - B. typhi abdominalis, M. gonorrhoeae, B. diphthe- 
riae, etc. 
(iv.) Those inducing characteristically the development of inflam- 
matory neoplasms - B. tuberculosis, B. pseudo-tuberculosis, B. mallei, 
Actinomyces, Aspergillus fumigatus. 
Similarly, chemical substances may roughly be grouped into - 
(a) Substances causing so slight an irritation when introduced into 
the organism as to induce cellular overgrowth only in their immediate 
neighbourhood - such as bland foreign bodies, bullets, etc.; inhaled 
particles of coal, stone, iron, and the like, conveyed into the pulmonary 
lymphatics. 
(&) Substances leading to vesicular inflammation, e.g. blistering 
agents, such as cantharides. (This result, however, depends more upon 
the position than the nature of irritant.) 
(c) Substances leading to cell necrosis, followed by the formation 
of granulation tissue - caustic agents. 
(d) Substances leading to cell necrosis and suppuration, such as 
copper, mercury, mineral acids, etc. (a very rare result in man). 
These lists, from the considerations given above, are necessarily un- 
satisfactory and imperfect. 
Other Considerations. - Among other factors varying the inflamma- 
tory process may be mentioned the duration of the action of the irri- 
tant, which of necessity must modify the extent of the manifestations 
of disturbance in the tissues. A simple aseptic incision, for example, 
leads to a much milder and slighter series of changes than do the 
prolonged presence and growth of the tubercle bacillus. Yet while at 
first it might appear an easy matter to name case after case where the 
irritant has but a momentary action, upon further consideration it is 
found that, in the majority of eases of purely mechanical injury, this 
is not the case; or, to express the matter more exactly, in the case of 
physical injuries, it is not the act of wounding that causes the inflam- 
mation, but the damage inflicted upon the cells of the tissues; as, to a 
very large extent, inflammation is set up by the products of the injured 
and destroyed cells. A bone may be suddenly broken, and neverthe- 
less, even under the most favourable circumstances, pain, swelling, and 
congestion may affect the region of fracture for several days. One or 
other region of the body may be rapidly frozen: the inflammation 
does not manifest itself till after the physical agent has ceased to act, 
but it continues for hours, and even for days. 
There are, moreover, physical irritants of another nature producing SNFLAAfAfA TION 
definitely chronic inflammation; I refer to foreign bodies which have 
gained an entrance into the system. These if bland in themselves may 
nevertheless cause irritation. A good example of the extensive intiam- 
mation which such bodies may set up is seen in the dense fibrous inter- 
stitial tubercular masses developed in the lungs of stone-masons around 
fine silicious particles carried into the lymphatics from the alveoli. 
From such examples it will be evident that no satisfactory distinc- 
tions between bacterial irritants on the one hand, and physical irritants 
on the other, can be founded on the duration of irritation. This factor 
plays no easily recognised part in determining the various forms of in- 
flammation, and consequently I have forborne to place it in the list at 
the beginning of this chapter. 
In thus passing rapidly over the influence of each of the four main 
causes of variation I have of necessity excluded sundry forms of in- 
flammation due to the combined action of two or more. There are, for 
instance, such well-marked forms as the catarrhal and croupous, due to 
the interaction of all four factors: embolic inflammation and lymphan- 
gitis have also been passed over; these, however, are not so much forms 
of inflammation as inflammatory processes occurring in special regions 
as a result of special methods of conveyance of the irritants. 
The factors then are so many, and their interaction so varied, that 
anything approaching to an orderly classification is hopeless. What I 
have here written must be regarded, not as an attempt to formulate 
such a classification, but as an attempt to indicate briefly how the nature 
and position of the tissues, and the nature and intensity of the irritant 
bring about modifications in the process of inflammation. 
131 
Chapter 2. - On Svstemic Changes Consequent upon 
Inflammation 
The results of an acute local inflammatory process are not confined to 
the immediate locality, but associated alterations in the system at large 
have long been recognised; yet while recognised these systemic changes 
have been but little studied: I cannot pass the matter over in silence, 
but my setting forth of it must necessarily be very brief and imperfect. 
I cannot here say more upon the effect of local irritation on the 
nervous system than that, apart from direct reflex action leading to 
changes of nervous origin in the region of injury and the reflexes 
affecting associated regions, the higher centres, and through them the 
system at large, may become affected by paths that it is not always 
easy to trace. 
The disturbances of the nervous system which accompany local injury 
can be but vaguely and indefinitely described. As regards the secondary 
effects, the recent most suggestive work of Prof. Roy and Dr. Cobbett 
upon Shock [yide art. on"Shock " in a later volume] indicates that there 
is here a rich field for yet further research. Of the changes in the general 
circulation, and more especially in the circulating blood, thanks to the SYSTEM OF MEDICINE 
132 
observations of Von Limbeck, Rieder, Lowitz, and Sherrington, we are 
in possession of more exact knowledge. On acute local inflammation 
of some extent the circulating blood becomes inspissated; by exudation 
it loses some of its plasma, while the more solid constituents - the red 
corpuscles - do not escape. The amount of fluid lost to the circulation 
is not equalised by increased entrance of lymph into the circulation: in 
one experiment of Prof. Sherrington the blood remained apoplasmic (i.e. 
its specific gravity remained heightened) for more than sixty hours after 
the infliction of injury. This apoplasmia or diminution in the relative 
amount of plasma in the blood appears to depend in some measure upon 
the extent of the vascular area involved in the inflammation; for example, 
Sherrington shows that when both feet are involved, by plunging the limbs 
in water of 52° C., the apoplasmia is more severe than in experiments 
affecting one foot only. Another well-marked change in the blood concerns 
the leucocytes. As suspected by Lowitz and proved by Sherrington, there 
is, in some forms of inflammation at least, a primary diminution in the 
number of leucocytes per unit volume of blood (leucocytopenia), followed 
by a marked increase in the number of leucocytes in the blood (leuco- 
cytosis). The number of leucocytes was in some instances increased 
sevenfold. In the leucocytopenia of inflammation, the diminution is 
chiefly confined to the finely granular leucocytes-the finely granular 
oxyphile cells of Kanthack and Hardy. These observations of Sherring- 
ton are confirmed by the observations of Everard, Demoor, and Massart. 
Whether the diminution be due to disintegration, or to collection in 
some area of the circulation, is not yet determined. The leucocytosis 
may become obvious within an hour after the establishment of a local 
lesion; and it may be prolonged for several days, even in cases where 
the injury has been of a mechanical nature. Here, again, according to 
most observers, it is chiefly the polynuclear or finely granular oxyphile 
cells which increase in numbers. It is interesting to note that coinci- 
dently the coarsely granular eosinophile cells appear to undergo great 
diminution. I can do no more than point out the existence of those 
blood changes, and further that changes in the number of leucocytes in 
the blood are certainly not accounted for by the number passing from 
the blood into the inflamed area. It would seem that local inflamma- 
tion in some way brings about an over-stimulation of lymph glands, 
whereby an increased number of leucocytes are poured into the blood; 
or it may initiate increased proliferation of the leucocytes already in 
the circulation; but how one or other of these effects is produced is 
at present unknown. Certainly the direct introduction of the products 
of bacterial growth into the circulating blood may lead to a more or less 
pronounced and rapid diminution of the number of leucocytes in the 
blood, and this diminution, as shown by Lowitz, may be preliminary 
to a subsequent increase. 
The further important general disturbance associated with local 
injury, more especially when of bacterial origin, namely, the occurrence 
of fever, will be described in another article. Bacteriological studies INFLAMMA TION 
133 
lead to the conclusion that traumatic fever, at any rate, is largely due to 
the diffusion in the blood stream of soluble bacterial products, and of the 
products of tissue destruction derived from the inflammatory focus. 
Chapter 3. - Conclusion 
In studying thus the reactions of the organism to injury, we 
are impressed by the multifariousness of natural processes; the end 
may be attained not in one way only but in many. "It is not by 
cells of one order alone-by phagocytes - or by leucocytes in general 
and only leucocytes, or merely by the reaction on the part of the fixed 
cells of the tissue, or by vascular changes alone, or by altered tempera- 
ture, or solely by the chemical and mechanical action of the exudate that 
repair is effected. All means are employed to antagonise the irritant and 
to effect healing. The cells of the body, fixed and free, play their part; 
the nervous system aids the process; the bodily humours render efficient 
help; modifications in the vessel walls and blood stream are valuable 
auxiliaries. Diverse processes are employed, now one more particularly, 
now another, according to the needs of the moment, but none exclusively." 
The time has come when, example after example having clearly indi- 
cated the meaning and the tendency of that response, we may securely 
acknowledge the tendency, and see in inflammation not merely the re- 
sponse to injury, but the attempt to repair injury. To object that a 
definition containing this statement is teleological is absurd in the face of 
fact after fact that can be interpreted on this assumption only. What is 
the development of cicatricial tissue lout an attempt at repair ? What 
other meaning tan be ascribed to the increased bactericidal power of the 
inflammatory exudate as compared with that of ordinary lymph and 
blood serum ? Why do leucocytes accumulate in a region of injury? 
Why do some of them incorporate bacteria and irritant particles, and 
others bring about the destruction of these without necessarily ingest- 
ing them ? All these are means whereby irritants are antagonised or 
removed, and reparation and return to the normal sought after. 
It must be kept in mind that attempt to repair may be far from 
repair. Indeed, we frequently find that the reaction to injury is dispro- 
portionate to the strength of the irritant, being either insufficient or ex- 
cessive. The exudation may possess but slight bactericidal powers, or 
may be poured out in such quantities that the microbic irritant, instead 
of being retained in the region of injury, is conveyed outside that region; 
the wandering cells instead of destroying, may undergo destruction; they 
may incorporate bacteria, but not be able to annihilate them; the fixed 
cells may either form an incomplete cicatrix, or continue to proliferate in 
excess. The means of defence on the part of the organism are not so 
much a preparation in advance as an inheritance or an acquirement - 
either a transmission from those forms which, being possessed of the most 
highly developed means of defence, have survived while forms with fewer 
resources have been destroyed; or, on the other hand, an accession derived SYSTEM OF MEDICINE 
134 
from previous successful resistance: not being a preparation in advance, the 
reaction to injury is not exactly proportionate to any and every irritant. 
But the mere statement that inflammation is an attempt to repair 
injury, or that it is the response thereto, is insufficient as a defini- 
tion, for thereby the general disturbances which may accompany the 
changes occurring at the seat of lesion are included; these, however, may 
be excluded without seriously affecting our conception of the process, in 
fact with positive advantage to a clear comprehension of the distinction 
between inflammation and fever. And, further, if what I have urged in 
the chapter upon the part played by the nervous system be correct, 
account must be taken of the fact that the leading phenomena associated 
with the inflammatory process may occasionally present themselves solely 
under the direction of perverted nerve action, and apart from actual local 
injury. 
Hence I am inclined to consider that we can now pass beyond the 
conception of the process with which I began this article, and cannot 
merely regard it as a succession of changes in a part constituting the re- 
action to injury, but can with propriety acknowledge the purpose of that 
succession. From these considerations I am led to define inflammation 
as the series of changes constituting the local manifestation of the attempt at 
repair of actual or referred injury to a part, or, briefly, as the local attempt 
at repair of actual or referred injury. 
So diverse are the opinions of pathologists upon many branches of 
this subject of inflammation, and so great is the amount of recent research 
that I can neither hope that all the conclusions here set down will gain 
acceptance, nor that in these pages, inevitably condensed as they are, I 
have succeeded in recognising and duly acknowledging all Work of primary 
importance. It is possible also that, having been unavoidably prevented 
of late from seeing and discussing with others the results they have ob- 
tained, I may in some cases have viewed facts in a wrong perspective. 
In the rapid progress of our science, much, it may be, that is here set 
forth will be modified. Nevertheless I hold that the conception of the 
inflammatory process indicated in this article is that which embraces the 
largest number of like phenomena, and excludes most satisfactorily those 
which if associated are unessential; and that it is by the study of cellular 
pathology in its strictest sense that the surest advance has been and is 
to be made in our knowledge of this the dominating process in disease. 
John George Adami. 
SELECT BIBLIOGRAPHY 
I. Of Inflammation in General 
1. Bennet. On Inflammation. Edinburgh, 1844.-2. Billroth. Wiener klin. 
Wochenschr. 1892. Nos. 1 and 2. - 3. Bouchard. Semaine mVd. 1891. No. 20.- 
4. Burdon-Sanderson. Holmes's System of Surgery, i. (gives extensive select bibliog- 
raphy).- 5. Burdon-Sanderson. Croonian Lectures, 1892. Vide Lancet, ii. 1892, 
pp. 1027, 1083, 1149, and 1207. - 6. Cohnheim. Vorlesungen, second edition. 
Leipzig, 1882. Translated by Dr. A. B. M'Kee, New Sydenham Society, 1890. - INFLAMMA TION 
135 
7. Cornil et Ranvier. Manuel d'Histologie pathologique, i. - 8. Councilman. 
Dennis's System of Surgery, i. 1895.-9. Hamilton. Text-book of Pathology, i. 
1889 (gives extensive bibliography). -10. HUter. Grundriss der Chirurgie, i. 
1883. -11. Koch. Wundinfectionskrankheiten. Leipzig, 1878.- 12. Leber. Die 
Entstehung der Entziindung. Leipzig, Engelmann, 1891. -13. Letulle. L'Inflam- 
mation. Paris, 1893.-14. Metschnikoff. Pathologie comparee de VInflammation. 
Paris, Masson, 1892. Eng. transl., London, 1894. -15. Neumann. "Uber dem 
Entziindungsbegriff," Ziegler's Beitr. v. 1889, p. 347. -16. Recklinghausen. 
Handbh. d. allgem. Path. 1883. -17. Roser. Entziindung und Heilung. Leipzig, 
1886. -18. Samuel. FircA. Arch. Iv. 1872, p. 380. -19. Samuel. Die Entzund- 
ungsprocess, 1873. - 20. Thoma. "Ueber Entziindung," Berlin klin. Wochenschr., 
1886 (on the suppression of the term "Inflammation"). - 21. Virchow. Cellular 
Pathology. Eng. transl. from second edition by Chance. London, 1860. - 22. Wagner. 
Hdbuch. der allgem. Path. Eng. translation, New York, W. Wood, 1879 (gives older 
literature very fully). - 23. Weigert. " Entziindung," Eulenburg's Realencyclopddie, 
1880, iv. p. 644. - 24. Ziegler. Lehrbuch der allgemeinen pathologische Anatomie. 
8th German edition, 1894. - 25. Ziegler. Rede gehalten am 25 April 1892 zur akademi- 
schen Feier. Freiburg, Lehmann, 1892. 
II. The Comparative Pathology of Inflammation 
26. Greenwood, Miss M. - J. of Physiol, vii. 1886, p. 254; viii. 1887, p. 263 ; 
xi. 1890, p. 576; xvi. 1894, p. 441. - 27. Proc. Roy. Soc. liv. 1893, p. 466, "Inter- 
cellular Digestion." - 28. Hardy. J. of Physiol, xiii. 1892, p. 165, "Blood Corpuscles 
of Crustacea." - 29. Krukenberg. Unters. a. d. physiol. Inst, in Heidelberg, ii. 
1878, p. 273, " Intercellular Digestion." - 30. Le Dantec. Ann. de VInst. Pasteur, iv. 
1890, p. 776, and v. 1891, p. 163. - 31. Loeb. Biol. Lectures, Marine Biol. Lap., 
Wood's Hole, 1893. Boston, Ginn and Co., 1894, p. 43. - 32. Metschnikoff. A. de 
VInst. P. iii. 1889, and No. 14, gives main literature.-33. Pfeffer. Unters. a. d. 
botan. Inst, in Tubingen, vols. i. and ii. - 34. Reinke. Unters. a. d. bot. Inst, in 
Gottingen, 1881. - 35. Stahl. Botan. Zeitung, 1884, Nos. 10-12. 
III. The Steps of the Inflammatory Process in the Higher Animals 
In addition to Nos. 6, 7, 8, 12, 19 and 23, consult-36. Flemming. Virch. Arch. 
Ivi. 1872, p. 146, on "Development of Fibrin in Inflamed Tissues." - 37. Hess. 
Virch. Arch. cix. 1887, p. 365. - 38. Hohnfeldt. Ziegler's Beitr. iii. 1888, p. 343. 
- 39. Jacobs. Beitr. z. Histol. d. acut. Entziindung d. Cornea, Inaug. Diss. Bonn, 
1887.-40. Ranvier. Ctes. rend. d. VAcad. d. Sc. 1891, April 20th, p. 845.-41. 
Senftleben. Virch. Arch. Ixxii. p. 542. - A satisfactory bibliography of this sub- 
ject is given by Burdon-Sanderson, Nos. 4 and 5. For full references to recent work 
upon mycotic inflammation consult Baumgarten's Jahresbericht. 
IV. On the Forms and Varieties of Leucocytes 
42. Ehrlich. Farbenanalytische Unters. z. Histol. u. Klinik des Blutes," 
Gesamm. Mitthl. Berlin, Hirschwald, 1891.-43. Everard, Demoor, and Massart. 
A. de I'I. P. vii. 1893. - 44. Gluge. Observat. noun, microscop, in Inflamm. 1835.- 
45. Gulland. Lab. Rep. R. C. P. Edin. iii. 1891, p. 106.-46. Gulland. J. of 
Pathol, ii. 1894, p. 447. - 47. Wharton Jones. Phil. Trans. 1846, p. 64.-48. 
Kanthack. Med. Chron. New series, i. 1894, pp. 246, 332. - 49. Kanthack and 
Hardy. J. of Pathol, xvii. 1894, p. 81; and Phil. Trans. 1894.- 50. Mesnil. 
A. de VI. P. ix. 1895, May.-51. Metschnikoff. B. M. J. 31st Jan. 1891, and 
No. 14. - 52. Ranvier. "Des Clasmatocytes," Ctes. rend. d. VAcad. des Sc. ex. 
1889, p. 165. - 53. Rieder. Beitr. z. Kenntniss d. Leucocytose, Leipzig, 1892; and 
Atlas d. klin. Microscopie des Blutes. Leipzig, 1892.-54. Rindfleisch. Pathol. 
Histologic, 1861; und Exptelle. Studien ii. d. Histologic des Blutes. Leipzig, 1863.- 
55. Max Schultze. Arch. f. mikr. Anat. i. 1863, p. 1. - 56. Sherrington. Proc. 
Roy. Soc. Iv. 1893, p. 161. - 57. Siawcillo. A. de VI. P. ix. May 1895. -For fuller 
bibliography consult Nos. 46, 48, and 53. 136 
SYSTEM OF MEDICINE 
V. On the Nature of Giant Cells 
58. Borrel. A. de I'Inst. Pasteur, vii. 1893, p. 593.-59. Duenschmann. J. of 
Pathol, iii. 1894, p. 118.-60. Faber, Knud. J. of Pathol, i. 1893, p. 349.-61. 
Koch. Mittheil. a. d. kaiserl. Gesundheitsamt, ii. 1884. - 62. Langhans. Virch. 
Arch. xlii. 1868, p. 382, and xlix. 1870, p. 66.-63. Marchand, P. Virch. Arch. 
xciii. 1883. - 64. Johannes Muller. Ueber den feineren Bau und die Formen der 
Krankhaften-Geschwulste. Berlin, 1838.-65. Ribbert. Der untergang, pathogen. 
Schimmelpilze im Kbrper. Bonn, 1887. - 66. Buffer. A. de I'Inst. P. v. 1891.- 
67. Soudakewitch. Virch. Arch. cxv. 1889. - 68. Stchastny. A. de I'Inst. P. 
v. 1891, p. 225. - 69. Virchow. Pirc/i. Arch. xiv. 1858, p. 47.-70. Weigert. D. 
med. Wochenschr. 1885, and Virch. Arch, cxiii. 1889. - 71. Ziegler. Expt. Unter- 
such. ii. d. Herkunft d. Tuberkelelemente. Wurzburg, 1875. - Earlier literature given 
by Marchand (No. 63), later by Faber (No. 60). 
VI. On Chemiotaxis 
72. Councilman. Virch. Arch. xcii. 1883. - 73. Gabritchewski. A. de I'I. P. 
iv. 1890, p. 346. - 74. Kanthack. See No. 48, and B. M. J., June 18th, 1892. - 75. 
Leber. See No. 12. - 76. Massart, J. A. de 1'1. P. vi. 1892, p. 321.-77. Massart 
and Bordet. J. d. I. Soc. Roy. d. Sc. Med. et Nat. de Bruxelles, 1890. - 78. Massart 
and Bordet. A. de I'I. P. v. 1891, p. 417. - 79. PekelhAring. La Semaine mAd. 1889, 
No. 22, p. 184.- 80. Pfeiffer. See No. 33. - 81. Stahl. See No. 35. - For fuller 
bibliography consult Massart and Bordet, No. 77. 
VII. On Phagocytosis - General Articles 
82. Adami. Med. Chron. Nov. and Dec. 1891.-83. Baumgarten. Ctbl. f. klin. 
Med. 1888, No. 26; Zeigler's Beitr. vii. 1889; Berl. klin. Woch. 1884, Nos. 50 and 
51. - 84. Bitter. Zeitschr. f. Hygiene, iv. 1888, p. 405. -85. Discussion on Immunity 
(Roux, Metschnikoff, Hankin, Behring, Buchner, etc.). Trans. Internal. Congr. of 
Hygiene, London, 1891, vol. ii. - 86. Discussion on Immunity. Internal. Congr. 
of Hygiene Buda-Pesth, 1894 (Metschnikoff, Roux, Buchner, Denys, etc.), Ctbl. f. 
Bakt. 1894. - 87. Discussion on Immunity. Path. Soc. London, 1892 (Woodhead, 
Klein, Hankin, Martin, etc.); Path. Trans. 1892, v.; also B. M. J. of Feb. 20 and 27, 
1892.-88. Lubarsch. Fortschr. d. Med. viii. 1890, No. 17. - 89. Lubarsch. ZeitscAr. 
f. klin. Med. xviii. 1891, p. 421.-90. Metschnikoff. See Nos. 14 and 51.-91. 
Nieczajeff. Verhandl. das X. Internal. Med. Congress, Berlin, 1890, ii. pt. 3, p. 
54.-92. Sanarelli. Ctbl. f. Bakt. x. 1891, p. 514.-93. Sternberg. Am. J. of 
Med. Sc. April 1881. - For the abundant literature on this subject consult Bitter 
(No. 84) and Lubarsch (No. 88), as also the full bibliography (up to 1892) given by 
Sternberg in his Manual of Bacteriology. New York, 1892, and (to 1895) in his Immu- 
nity, Protective Inoculation, etc. New York, 1895. 
VIII. Phagocytosis in Connection with Pathogenic Microbes of Various 
Diseases (for Shortness Names of Diseases alone given) 
Actinomycosis:-94. Marchand. Eulenburg's Realencyclopddie, article "Actino- 
mycosis."- 95. Bostrom. Zeigler's Beitr. ix. 1890. - 96. Pawlowsky and 
Maksukoff. A. de I'Inst. Pasteur, vii. 1893, p. 544. Anthrax:-97. Hess. FircA. 
Arch. cix. p. 365. - 98. Koch. Cohn's Beitr. z. Biol, der Pflanzen, ii. 1876. - 99. 
Lubarsch. Fortschr. d. Med. 1888, p. 4. -100. Metschnikoff. Virch. Arch, xcvii. 
p. 502, and A. de I'Inst. Pasteur, i. 1887, p. 7. -101. Nutall. Zeitschr. f. Hygiene, 
iv. 1888. - 102. Petruschky. Zeigler's Beitr. iii. 1888, p. 357, and Fortschr. d. 
Med. viii. 1890, No. 15. Cholera: -103. Metschnikoff. A. de I'I. P. viii. 1894, 
p. 529. -104. Pfeiffer and Wasserman. Zeitschr. f. Hygiene, xiv. 1893, p. 59. - 
105. Cantacuzene. Recherches sur le mode de destruction du Vibrion Cholerique. 
Paris, 1894. Diphtheria: - 106. Gabritchewski. A. de I'I. P. viii. 1894.- 107. 
Massart. See No. 76. Erysipelas: -108. Metschnikoff. Virch. Arch. cvii. 1887, 
p. 209, and numerous other observers. Gonorrhoea: -109. Neisser and all subse- INFLAMMA TION 
137 
quent observers (for bibliography see Sternberg). Hog Cholera:-110. Metschnikoff. 
A. de VI. P. vi. 1892, p. 289. Leprosy: - 111. Metschnikoff and Soudakewitch. 
Virch. Arch. cvii. 1887, p. 228 (and all recent observers). Malaria: -112. Golgi. 
Gaz. degli Ospitali, 1886, No. 53 (parasites in leucocytes, as distinguished from red 
corpuscles). Mouse Septicaemia: -113. Metschnikoff. A. de VInst. P. v. 1891. 
Pathogenetic Torulae in Daphnia: -114. Metschnikoff. Virch. Arch. xcvi. Patho- 
genic Moulds (Aspergillus, etc.) : -115. Ribbert. See No. 65. Pneumonia (Diplo- 
coccus) : - 116. Gamaleia. A. de VI. P. ii. 1888, p. 445. -117. Isaeff. Ibid. 
vii. 1893, p. 260.- 118. Tchistovitch. Ibid. iii. 1889, p. 337. Relapsing Fever: 
-119. Metschnikoff. Ibid. i. 1887, p. 329. -120. Soudakewitch. Ibid. v. 
1891, p. 545. Suppuration (Staphylococcus pyogenes): -121. Fleck. Die acute 
Entziindung der Lunge. Dissert., Bonn, 1886.-122. Hess. See No. 37. -123. Hohn- 
feldt. See No. 38. -124. Lahr. Ueber d. Untergang d. Staph, in der Lunge. 
Dissert., Bonn, 1887 (and numerous other observers). Swine Erysipelas (" Rouget " 
or " Rothlauf "): -125. Metschnikoff. A. de VI. P. iii. 1889, p. 289. - 126. Schutz. 
Arb. a. d. Kaiserl. Gesundheitsamt, i. 1885, p. 61. -127. Tchistovitch. See No. 118. 
Symptomatic Anthrax (Quarter-evil) : -128. Ruffer. B. M. J. May 24th, 1890. - 129. 
Ruffer. A. de VI. P. v. 1891, p. 673. Tuberculosis: -130. Borrel. See No. 58.- 
131. Metschnikoff. See No. 51. -132. Stschast.ny. Virch. Arch. cxv. 1889, and No. 
68. Vibrio Gamaleia vel Metschnikovi: -133. Metschnikoff. A. de VI. Pasteur, v. 
1891, p. 465.-134. Sanarelli. Ibid. vii. p. 225. 
135. Behring and Nissen. Zeitschr.f. Hygiene, viii. 1890, p. 424. -136. Buchner. 
Arch.f. Hygiene, x. 1890, pts. 1 and 2; Centrlbl.f. Bakt. v. 1889, p. 817, and vi. p. 1. -137. 
Emmerich and di Mattei. Fortschr. de Med. vi. p. 729. -138. Von Fodor. D. Med. 
Woch. 1887, p. 745; and Ctbl.f. Bakt. vii. 1890, p. 753. -139. Hankin. See No. 150.- 
140. Lubarsch. Ctbl.f. Bakt. vi. 1889, p. 841.-141. Nissen. Zeitschr.f. Hygiene, vi. 
1889, p. 487. -142. Nuttall. Ibid. iv. 1888, p. 353. -143. Pekelharing. La Sem. med. 
1892, p. 503. -144. Traube and Gschleiden. Jahresbr. d. Schlesischen Gesell. lii. 1874, 
p. 179.-145. Weigert. Fortschr. d. Med. v. 1887, p. 733. - For other articles consult 
the works of Sternberg previously mentioned. 
IX. On the Bactericidal Action of the Bodily Humours 
X. Upon Extra-Cellular Activity and the Production of Bactericidal and 
Toxicidal Substances from Wandering Cells, etc. 
146. Adami. See No. 82. -147. Buchner. Fortschr. d. Med.x. 1892, Nos. 9 and 
10; Munch. Med. Woch. 1894; Ctbl. f. Bakt. xvi. 1894, p. 738, and No. 86. -148. 
Denys. La Cellule, 1894. -149. Denys and Havel. Arch, de med. exptlie. vi. 1894.- 
150. Hankin. Proc. Roy. Soc. xlviii. 1890, p. 93; Ctbl. f. Bakt. ix. 1892, p. 722; Ibid. 
vols. xi. and xii.; see also No. 85. -151. Kanthack and Hardy. Proc. Roy. Soc. 
Nov. 1, 1892. -152. Kanthack and Hardy. J. of Physiol. 1893. -153. Kanthack 
and Hardy. Phil. Trans. 1894. -154. Kossel. Zeitschr.f. Hygiene, xvi. 1894. -155. 
Metschnikoff. A. de VI. P. viii. 1894, p. 706. -156. Pfeiffer. Zeitschr.f. Hygiene, 
xvi. 1894, p. 268, and xviii. p. 1. -157. Ribbert. See No. 65. -158. Tizzoni and Cat- 
tani. Berl.klin. Wochenschr. 3. 1894. -159. Vaughan and M'Clintock. Med. News 
(N. Y.), Dec. 23rd, 1893. 
XI. On the Part played by the Blood Vessels in Inflammation 
In addition to Cohnheim (No. 6), Hamilton (No. 9), Leber (No. 12), Reckling- 
hausen (No. 16), Samuel (No. 18), Weigert (No. 23), and Ziegler (No. 24), consult 
-160. Arnold. Virch. Arch. liv. 1871, on "Development of Capillaries."-161. 
Charrin and Gley. Arch, de Physiol. Oct. 1890. -162. Israel. Lehrbuch d. Path. 
Anat. -163. Samuel. Virch. Arch, xliii. 1868, p. 552, and li. 1870, p. 178 ("Change 
in Vessel Wall, inducing slowing of Current "). -164. Thiersch. Pitha and Billroth's 
Chirurgie, 1867, i. pt. 2, p. 529 (on " New Formation of Vessels "). - Fuller references 
given in Ziegler (No. 24) and Hamilton (No. 9). 138 
SYSTEM OF MEDICINE 
XII. On the Diapedesis of Leucocytes 
165. Addison. Exptl. and Pract. Researches upon Infl. London, 1843. -166. 
Arnold. Virch. Arch. Iviii. 1872, Ixvi. 1874, and Ixviii. 1875.-167. Binz. Virch. 
Arch, lix., Ixxiii., and Ixxxix.; Arch. f. expt. Path. vii. and xiii. -168. Cohnheim. 
See No. 6. -169. Disselhorst. Virch. Arch, cxiii. 1888, p. 108. -170. Hering. Wien. 
Acad. Bericht. Ivii. 1868, p. 170 (on the "Adhesion of Corpuscles"). -171. Kalten- 
brunner. Exp. circa stat, sanguinis et vasorum in infl. 1826. -172. Kerner. Pfliiger's 
Archiv, vii. -173. Lavdowsky. Virch. Arch, xcvii. -174. Metschnikoff. See No. 
14.-175. Pekelharing. Virch. Arch. ci. 1885. -176. Recklinghausen. Stricker's 
Handb. Article, "Das Lymphgefasssystem." -177. Schklarewsky. Pfliiger's Arch. 
i. 1868, pp. 603 and 657. -178. Thoma. Berl. klin. Woch. 1886. -179. Waller. Phil. 
Mag. xxix. 1846, pp. 217, 298, 397. 
(a) On the Effect of Intra and Extra-Vascular "Toxins" upon Diapedesis 
180. Bouchard. Essai d'une theorie de Vinfection. Verhandl. d. X. Internat. 
Med. Congr. Berlin, 1890. -181. Charrin. Ibid. ii. pt. 3, p. 29. -182. Roger. 
Contrib. a Vetude de Vimmun. acquise, p. 1.-183. Ruffer. A. de VI. P. v. 1891, 
p. 673. - The earlier literature of diapedesis is given in detail by Wagner (No. 22) 
and Hamilton (No. 9). The last (German) edition of Ziegler (No. 24) is also very 
full. 
XIII. On the Part played by the Nervous System in Inflammation 
184. Berkley. Anat. Anz. viii. 1893, Nos. 23 and 24, and ix. 1893, Nos. 1 and 
2; Joum. of Comp. Neurol, iii. 1893, p. 107; Pathol. Studies, Johns Hopkins Univ., 
Neurology, ii. 1894 ("Upon Nerve Endings in Vessel Walls, etc."). -185. Charcot. 
Lemons sur les maladies du syst. nerveux. Paris, 1873, p. 106. -186. Cohnheim. See 
No. 6. -187. Dache and Malvoz. A. de VI. P. vi. 1892, p. 538 (on "Influence of 
Nervous System in Mycotic Inflammations"). -188. De Paolis. Riforma Medica, 
1889, No. 200. -189. Frenkel. Arch. d. med. expt. iv. 1892, p. 638. -190. Gergens. 
Pfliiger's Arch. xiii. p. 591. -191. Klebs. Allg. Pathol, ii. 1889, p. 384. -192. Len- 
hossek. Arch. f. mikr. Anat. xxxix. 1892 (on "Nerve Endings"). -193. Mitchell, 
S. Weir. Injuries of Nerves. Phila. 1872, p. 168. -194. Ochotine. Arch, de med. 
expt. iv. 1892, p. 245.-195. Retzius.' Biol. Untersuchungen, Neue Folge, iii. 1891, 
p. 49, and iv. -196. Roger. Comptes Rend. Soc. de Biol. 3rd May 1890, and 22nd 
Nov. 1890.-197. Rutimeyer. Arch. f. expt. Pathol, xiv. p. 384. -198. Samuel. 
Virch. Arch. cxxi. -199. Saviotti. Virch. Arch. 1. 1870, p. 592 (on "Dilation and 
Contraction of Arteries according to Nature of Irritant").-200. Severini. La con- 
trattilita dei capillari, 1881. - 201. Wagner, A. Arch. f. klin. Chirurg. xi. 1869, 
p. 1. 
XIV. On the Part played by the Connective Tissue Cells in Inflammation 
202. Arnold. Arch. f. Mikr. Anat. xxx. 1887.-203. Baumgarten. Virch. 
Arch. Ixxviii. 1879; Ueber Tuberkel und Tuberkulose, i. Die Histogenese des Tuber- 
kulosenprocesses. Berlin, 1885.-204. Borrel. See No. 58. - 205. Coen. Ziegler's 
Beitr. ii. 1887.-206. Cornil and Ranvier. See No. 7. - 207. Discussion at the 
Tenth Internat. Med. Cong. Berlin, 1890. (Ziegler, Marchand, Grawitz.) Verhandl. 
ii. pt. 3, p. 1. - 208. Fischer. Untersuch. ii. die Heilung von Schnittzvunden der Ilazzt. 
Inaug. Diss. Tubingen, 1888.-209. Flemming. Virch. Arch. Ivi. 1872, p. 146. 
- 210. Grawitz. D. Med. Wochenschr. 1889. No. 23, on " Slumbering Cells." - 211. 
Grawitz. Virch. Arch, cxviii. 1889.- 212. Griffith, J. J. of Pathol, ii. 1894 
(on " Development of Wandering from Fixed Cells "). - 213. Gull and Sutton. Med.- 
Chir. Trans. Iv. 1872, p. 273.-214. Huchard. Traits des maladies du coeur. Paris, 
1889 (on "Dystrophic Sclerosis").-215. Krafft. Ziegl. Beitr. i. 1884. - 216. 
Marchand. Ibid. iv. 1888. - 217. Metschnikoff. Biol. Centrbl. 1883, p. 561; 
A. de VI. P. vi. 1892, p. 1 (on " Development of Wandering from Fixed Cells -218. 
Nikiforoff. Ziegl. Beitr. viii. 1890, p. 419.-219. Podwyssozki. Ibid. i. 1884, DOCTRINE OF FEVER 
139 
and ii. 1886.-220. Ranvier. Comptes rend, de I'Acad. d. Sc. 1891, p. 843.-221. 
Reinke. Ziegl. Beitr. v. 1889.-222. Roy and Adami. B. M. J. 15th Dec. 1888. 
- 223. Scheltema. D.Med. Woch. 1887, p. 463. - 224. Sherrington and Ballance. 
J. of Physiol. 1889, p. 856.-225. Soudakewitch. A. de VI. P. vi. 1892, p. 13.- 
226. Stricker. Studien a. d. Inst. f. exp. Pathol. Vienna, i. 1870. - 227. Toupet. 
Des modifications cellul. dans Vinfl. simple du peritoine. Thesis, Paris, 1887.-228. 
Ziegler. Exp. Untersuch. ii. die Herkunft der Tuberkelelement. Wurzburg, 1875. 
- 229. Ziegler. Untersuch. ii. pathol. Bindgewebs- und Gefassneubildung. Wurz- 
burg, 1876.-230. Grawitz, No. 211, gives a very full bibliography up to 1889 of the 
part played by the connective tissue cells. Consult also Virchow (No. 21), Cohnheim 
(6), Metschnikoff (14), and Ziegler (24). The later German editions of Ziegler's 
Handbook contain a very judicial discussion of the relationship of fibrous hyperplasia 
to inflammation. 
XV. On the Temperature Changes in Inflamed Areas 
231. Billroth and Hufschmidt. Arch. f. klin. Chirurg. vi. 1864, p. 373. - 232. 
Hunter, John. On the Blood, Inflammation, and Gunshot Wounds. London, 1793. 
- 233. Huppert. Arch. d. Heilkunde, xiv. 1873, p. 73. - 234. Jacobson and Bern- 
hardt. Med. Centibl. 1869, No. 19. - 235. Laudien. Ibid. 1869, No. 19. - 236. 
Schneider. Ibid. 1870, No. 34.-237. Simon. Holmes's System of Surgery, 1860, 
article " Inflammation." - 238. Weber, O. Deutsch. Klin. 1864, Nos. 43 and 44. 
J. G. A. 
THE DOCTRINE OF FEVER 
This essay is divided into two parts. In the first, which is intro- 
ductory, the subject is treated in the order of time. Beginning with 
Virchow an account is given of his doctrine of Fever; then follow the 
doctrines of his most distinguished contemporaries and successors in the 
field of Pathology - Traube, Liebermeister, Senator, Leyden, Cohnheim. 
The second part, entitled " Recent Researches," relates to the years 
which have elapsed since Cohnheim's death in 1874. The aspects of 
each branch of the subject of Fever are dealt with under the following 
heads : -Disorder of Nutrition, Thermogenesis, Pyrexia, Cerebral Heat- 
Centres, Antipyretics, ^Etiology. 
In a concluding section I have endeavoured to set forth that view of 
the nature of Fever which, in my judgment, harmonises best with our 
present knowledge of the subject. 
Part I.-Historical Retrospect, 1850-1883 
Of the scientific conceptions relating to the origin and nature of 
diseases, out of which the science of pathology, as we now understand it, 
was built about fifty years ago by Virchow and his immediate prede- 
cessors, none were more fundamental than those relating to fever and 
inflammation. These conceptions were so entirely unconnected with 
the theories which had previously been taught under the name of 140 
SYSTEM OF MEDICINE 
General Pathology that, in tracing the development of our present 
knowledge, no advantage would be gained in going farther back in 
our retrospect than the middle of the present century. 
Johannes Muller - whose teaching was the spring of the great move- 
ment in all matters relating to the nature of disease, of which Virchow 
was the exponent - had compared fever to a reflex process of which the 
phenomena were the response to stimulation of the spinal cord by means 
of "organic nerves." About the same time the discovery by E. H. 
Weber of the inhibitory nerve of the heart had suggested new ideas 
as to the way in which the central nervous system governs the cir- 
culation. He had shown that this influence is exercised, so far as the 
heart is concerned, by two channels of which the actions are antagonistic, 
that of the one exciting, that of the other quelling. As regards the blood- 
vessels, constricting or tonic nerves had been discovered, but it remained 
for Schiff to find out that there are also nerves which control vascular 
tone. 
Out of the principle of antagonism which the discovery of Weber 
involves, there developed in the fertile mind of Virchow the notion (he 
declined to call it a theory)1 of fever as a neurosis, which was expressed 
in his treatise on Pathology published in 1853. Students of pathology 
were taught by him for the first time that fever was not an over-activity, 
but a paralytic state; that its excesses - the over-action of the heart, the 
" tension of the whole vascular system," " the abnormal production of 
heat " - were the expression of failure of control, of weakness rather than 
strength. But of the way in which this control was exercised, or how it 
failed, he could at that time give no explanation; he contented himself 
with suggesting that the " moderating centres " could influence not 
merely the heart and blood-vessels, but also the " Stojfweclisel," what we 
now call metabolism. According to Virchow, the nervous system in 
fever loses its control over all the organic processes, and in this the 
essence of the febrile state consists. 
In 1855 Traube (1) made the discovery that in fever the elimination 
of nitrogen is increased.2 The fact seemed to indicate that if fever be a 
neurosis, there must either be " trophic nerves " by which the chemical 
processes of the organism can be controlled - for how else could an 
affection of the nervous system bring about tissue disintegration ? - or we 
must suppose, as did Dr. Parkes, that the cause of fever, the catalytic 
agent of which Virchow wrote, directly attacks the tissues. Traube's 
explanation, however, differed from both of these, for he thought that 
the admitted increase of disintegration of albuminous compounds was 
secondary to the disturbance of the circulation. Of the nature of this 
disturbance he framed a theory which, whether true or not, exercised a 
greater influence than any other on the progress of investigation. It may 
1 " Das Alles ist gewiss sehr wenig und geniigt auch nicht annahernd um eine Theorie 
darauf zu bauen."- Virchow, Handb. der Pathol., p. 36. 
2 It is noteworthy that the paper in which this discovery was made known is one of 
three pages. THE DOCTRINE OF FEVER 
be shortly stated as follows: - Traube, like Virchow, assumes the exist- 
ence of a fever-producing agent, but holds that its action is exercised, 
not on inhibitory, but on tonic vaso-motor nerves ; that the first physio- 
logical result of this influence is contraction of the peripheral arterioles, 
and consequently a rapidly diminished flow of blood to the surface; the 
temperature of the skin declines, and a rapid rise of internal temperature 
follows. To the increase of the difference between the external and 
internal temperatures he attributes the rigor of accession. The decline 
of temperature is due to nothing more than the cessation of the vascular 
spasm. So hard and fast a statement of what happens in fever was 
found difficult to accept; and it soon appeared that it was not in accord- 
ance with observation. In the initial stage its utility as a " working 
hypothesis " consisted in this, that it gave prominence to the influence 
of the nervous system on the liberation of heat at the surface, and to the 
adjustments by which this liberation is adapted to the requirements of 
the organism; thus investigation was guided in a direction which the 
event has proved to be the right one. 
Liebermeister wras the first pathologist who attempted to investi- 
gate fever calorimetrically, the outcome of his work being firstly to 
demonstrate that even when the surface loss is entirely annulled by 
raising the temperature of the environment to such a point that no heat 
is parted with, the increase of bodily temperature is not so rapid as in 
the initial stage of many fevers; and that, consequently, the latter could 
not be explained on Traube's principle; secondly, to give prominence to 
two doctrines of his own, which for a long time were very generally 
accepted. Liebermeister's doctrines were - (1) that in fever, as in health, 
constancy of temperature is ensured by the adaptation of production to 
discharge, not of discharge to production, as Traube taught; and (2) 
that in fever bodily temperature is regulated in the same way as in 
health, with this difference that the norma has become several degrees 
higher. In fever the organism, according to Liebermeister, strives not 
towards the temperature 98-6° F., but towards 104° or 106°, as the case 
may be. Liebermeister's inference from his experiments, that arrest of 
surface loss is inadequate to produce pyrexia, will not, as we shall see, 
bear experimental criticism. To the theory stated above much greater 
interest attaches, because if illogical in form, it conceals an important 
truth. An abnormal norma may be a contradiction in terms, but the 
fact that the bodily temperature in continued fever approaches a certain 
limit which it does not tend to exceed, is one which will not be dis- 
puted.1 Its meaning, however, will be more advantageously discussed in 
a subsequent paragraph. 
141 
1 There are many distinguished pathologists who still hold to Liebermeister's doctrine 
that in fever the temperature is adjusted to a new norma. The facts which seem to sup- 
port it may be exemplified in the following experiment: - 
It is possible either to raise or to depress the temperature of a healthy person by 
gradually cooling or warming the water of a warm bath in which he is placed. If by this 
means you depress the temperature of his body as much as 1 degree F. he shivers, if you 
raise it to the same amount he perspires. Repeating the experiment on a fever patient 142 
SYSTEM OF MEDICINE 
At this point the subject was taken up by Senator, the most 
successful, if not the ablest, of all the investigators of fever. We have 
seen that although Traube and Liebermeister differed very widely in 
their views, they agreed with Virchow in regarding fever as a disorder of 
that function of the nervous system by which constancy of temperature 
is maintained-the function of thermotaxis. Traube, being both a 
physiologist and a physician, was guided by the application of physio- 
logical inferences to clinical facts, Liebermeister very largely by obser- 
vations relating to the treatment of fever by the tepid bath. Both 
recognised regulating centres, but as regards the way in which they 
act their views were antagonistic; the one relied on vaso-motor nerves, 
the other on the control of heat-producing chemical processes by the 
nervous system. To Senator it appeared that the time had come for 
investigating the subject from all sides, experimental and clinical. Fever 
comprehends vascular, thermal, and metabolic phenomena, and no in- 
vestigation seemed likely to be of value unless all three were dealt 
with. 
In the laboratory, Senator compares for the first time the discharge 
of heat of animals in which fever had been produced artificially, with the 
previous heat loss of the same animal and with the heat loss after re- 
covery, employing, at the same time, the best methods then available 
for measuring the respiratory exchange and the elimination of nitrogen. 
One of the most noteworthy results was that, while the nitrogenous 
waste was considerably increased, there was no increase whatever of the 
consumption of fat, and no evidence of any greater increase of the 
respiratory exchange than could fairly be attributed to the existence 
in fever of conditions more favourable to the discharge of carbonic 
acid gas. 
As regards the discharge of heat, measured calorimetrically by a 
method far more accurate than that of Liebermeister, the results were 
negative. In the initial stage the surface heat loss appeared to be 
diminished, but it could be ascertained that this diminution was compen- 
sated later. In respect of the discharge of nitrogen, Senator's clinical 
observations confirmed and extended what had previously been observed, 
and showed in this respect a complete correspondence between natural 
and artificial fever. He estimated the rate of elimination of nitrogen in 
many instances to be more than double, i.e. to be increased in a degree 
out of all proportion to any increase which could be supposed to take 
place in the rate of heat production. 
At the time that Senator published his Researches on the Process of 
Fever (1873), Leyden was engaged in clinical investigations of the same 
subject (4), with results which differed from Senator's in some points of 
importance. The absence in animals of any marked increase of the 
you obtain a similar result, with this difference, that if the temperature is say 104° F., he 
shivers at 103'7° and perspires at 104'3°; whereas the healthy person, whose normal tem- 
perature is 98'8°, shivers at 98'3° and sweats at 99'2°. The explanation is that it is the 
change of temperature that produces the reaction, and the direction which determines its 
character - shivering if it is descending, sweating if it is ascending. THE DOCTRINE OF FEVER 
143 
respiratory discharge of water and carbon dioxide had led Senator to 
conclude that in fever the only essential change in metabolism relates to 
the increased disintegration of proteid. On this point, however, Senator 
was for the most part guided by experiments on animals. Leyden, 
therefore, directed his efforts to ascertain the condition of the respiratory 
exchange and thermogenesis in man. Considering that in continued 
fever there is no obvious indication of increased thermolysis, it was 
desirable to test this by more exact observation. For this purpose he 
employed a method of calorimetry which can be used clinically without 
inconvenience to the patient. Enclosing a limb in a cylindrical calori- 
metrical chamber, he estimated the loss of heat by escape of water, 
evaporation and radiation of the limb in relation to the surface, and 
calculated therefrom the whole surface-loss of the body, with the result 
that in fever, even when there is no visible perspiration, the thermolysis 
may be 40 per cent greater than in health. Having arrived at this 
result by clinical observation he had recourse to experiment (5), in the 
hope of confirming it by investigating the respiratory exchange in 
animals. The result was that in all cases the rise of temperature was 
accompanied by a corresponding increase of the discharge of carbon 
dioxide, the amount and duration of which was such as to preclude the 
possibility of attributing it to the greater activity of the respiratory 
movements. Shortly after the completion of these observations a series 
of experiments were made under Ffliiger's direction (6), in which both 
the oxygen intake and the output of carbon dioxide in normal and 
fevered animals were compared. These led the great physiologist to 
incline to Liebermeister's view, that normal regulation consists in the 
adaptation of production to discharge, and that increased production is 
an essential element of fever. 
By way of conclusion to this retrospect T propose to state summarily 
how the question of fever presented itself to the two pathologists most 
competent to discuss it, - Senator and Cohnheim. 
Cohnheim, like Pfluger, in the Lecture on Fever which concludes the 
second volume of his General Pathology, sums up in favour of the doc- 
trine that the nervous system presides over thermogenesis no less directly 
than over thermolysis. He accordingly seeks for evidence of increased 
production of heat throughout the whole febrile process. 
In the initial stage, particularly when the rise of temperature is rapid, 
he admits that the cutaneous circulation is restricted, but not that this 
restriction is the cause of the rise. The sensation of chill is due to the 
suddenness of the diminution of temperature at the surface: when the 
change occurs gradually, it is absent. It is succeeded, in the fastigium, 
by a feeling of warmth which means that the constricted vessels relax. 
He leaves undecided whether this is due to the intervention of inhibitory 
nerves or not, but emphasises the fact, as evidence of vaso-motor disturb- 
ance, that the more favourable state of the cutaneous circulation which 
characterises the beginning of the fastigium is liable to interruption by 144 
SYSTEM OF MEDICINE 
the recurrence of chills, in which the skin becomes dry and the tempera- 
ture tends to rise. The critical sweating is of course regarded by Cohn- 
heim as a sign of increased flow of blood to the surface, which he does not 
hesitate to attribute to the influence of dilating nerves. Of cutaneous 
nerves of secretion little was known at the time when he wrote. 
The remarkable fact that in fever the diurnal range of variation is 
much greater than in health, Cohnheim attributes rather to fluctuations 
in thermogenesis than to changes in the circulation. This view seems 
to him supported by the consideration that in relapsing fever the efficient 
cause of pyrexia is plainly the presence of spirilla in the blood, and that 
these would influence thermogenesis rather than surface loss. Had he 
known how close is the relation between the successive stages of ague 
and the life history of the organism which causes it, he would have been 
confirmed in his conclusion that in periodical fevers the periodicity is 
a function of the cause, not of the disease. 
In common with Virchow and all modern pathologists, Senator 
regards fever as a disorder of temperature regulation, but for him the 
term regulation connotes " regulation by the cutaneous circulation." It is 
thermolysis, not thermogenesis, that is in the first instance disordered. 
This disorder is most marked in the initial stage, but exists in the fasti- 
gium, declining towards its close. Its presence manifests itself in dry- 
ness of the skin and maintenance of the high temperature, but of these 
two neither is caused by the other; both are directly dependent on the 
nervous system. 
Finally, Senator regards the relation between the constituents of 
fever as a loose one: he believes there is no absolute inter-dependence 
of the disorder of nutrition and the pyrexia. The only invariable 
causal relation is that which subsists between pyrexia and disorder 
of the cutaneous circulation. 
Part II. - Recent Researches 
i. The Disorder of Nutrition in Fever. - (a) The Respiratory Ex- 
change. - When, after a pause of several years, the investigation of the 
febrile exchange of material was resumed both from the clinical and the 
experimental side, the new methods for measuring the normal exchange 
which had in the meantime been devised, and the discoveries they had 
rendered possible, afforded to the pathologist advantages which he did not 
before possess. With reference to the gaseous exchange particularly, the 
apparatus devised by Professor Zuntz had rendered it possible to measure 
the oxygen intake and the discharge of carbon dioxide in man for very 
short as well as for longer periods, with an accuracy which had before 
been attainable only in investigations on small animals; and by this 
means very important new information had been obtained as to the 
respiratory exchange in man, particularly by Lehmann and Zuntz's ex- 
periments on the fasting men Cetti and Breithaupt. It was under these THE DOCTRINE OF FEVER 
145 
conditions that Dr. F. Kraus, using the same apparatus and method, 
entered on his investigation of the respiratory process in human fever, 
his aim was to obtain data relating to the febrile exchange of gases in 
such form that the rate of discharge of carbon dioxide and that of the 
oxygen intake should be determined at short intervals, and that, in order 
to secure constancy and uniformity as regards the state of nutrition of 
the patient, each period of observation in fever should begin at a sufficient 
interval of time (sixteen hours) after the last meal, and be repeated in 
convalescence. The general result of this inquiry was that in all cases of 
acute fever there is increase of respiratory activity (i.e. greater frequency 
and depth of respirations), and that, whenever this is the case, the actual 
intake of oxygen is increased, but that when the febrile state is pro- 
longed this effect soon subsides, notwithstanding the continued abnormal 
elimination of nitrogen. It was further found that in man, as in animals, 
/CO A 
the respiration quotient remained unaltered. As regards the 
degree of augmentation of both factors the results were in satisfactory 
accordance with those yielded by observations on artificial fever. They 
were further confirmed by a subsequent series of observations on the 
febrile state induced in tuberculous patients by the use of tuberculin. 
The observations of Dr. Loewy in the Charite and Moabit hospitals 
at Berlin were made in the same way, with perhaps even greater exacti- 
tude, and particularly with more careful attention to the state of the 
patient and the stage of the disease. The results differed in some respects 
from those of Kraus, but the differences were of little moment. Thus it 
was found that although there was usually augmentation of the oxygen 
intake with or without increase, depth, or frequency of respiration, this 
was only observed when the temperature was actually rising; so that Dr. 
Loewy was led to regard this effect as a character of the initial stage, and 
to associate it with the shivering of the skeletal muscles and the increased 
tone of the vascular muscles which are the concomitants of this stage. 
In many cases the respiratory quotient remained the same; but in 
others there was a diminution, which might have been regarded as a con- 
sequence of the febrile state had not the general principle which serves as 
the pathologist's guide in all investigations relating to febrile metabolism 
been attended to, namely, that the comparison of the pathological state 
with the normal, as a guide to the correct interpretation of the results, 
can only be relied upon when care is taken to compare data relating 
to the same individual at different times; or, if this cannot be done, to 
make the comparison between normal and fevered individuals in the 
same physiological conditions as regards nutrition. The exact observa- 
tions already mentioned by Lehmann and Zuntz (9) as to the two fasting 
men afforded the information. By comparing Loewy's results with theirs, 
it is seen that the diminution of the respiratory quotient which he observed 
in his fever cases was normal for a person on fever diet. 
The general result is that in man the respiratory exchange is not 
materially altered in fever either in quantity or quality, and that when it 
VOL. I 
L 146 
SYSTEM OF MEDICINE 
is increased the increase is not to be regarded as an essential character of 
the febrile state, but rather as an effect of some abnormal form of muscular 
activity. Comparing this statement with the experimental results ob- 
tained by Liebermeister, which led him to believe that in the initial stage 
the respiratory exchange was often doubled or trebled, the reader will at 
once see that the key to the apparent discrepancy is to be found in 
oxidation processes which are associated with muscular contraction, but 
have only a secondary connection with fever. 
(6) The Discharge of Nitrogen. - The fact that the rate of discharge of 
nitrogen by the kidneys in fever is equal to or even greater than that 
which prevails in health, notwithstanding that the intake of nitrogen is 
reduced to a minimum, has been long familiar to pathological students. 
First discovered and made known by Traube (10) in 1855, it was in- 
vestigated clinically by Ringer in 1859, experimentally by Naunyn 
(1870), Senator, and many others. It has also been long known that 
on the whole the elimination of nitrogen runs with the temperature 
(Huppert, 1866) (12); that the daily discharge is often more than double 
what it would be in a healthy person on fever diet; that although the 
increase of nitrogen elimination begins, as was observed by Ringer, 
before the temperature rises, the rate of elimination is greatest, hot 
during the initial stage, but at an early period in the fastigium, and 
finally that defervescence is often followed by an epicritical increase. 
The discharge of nitrogen affords much plainer indications in fever 
than the respiratory exchange; it unquestionably denotes that proteid 
material is being disintegrated; and the rate at which this takes place 
can be easily estimated from that of the discharge of nitrogen. The 
fevered, like the starved organism maintains itself on its own proteid 
and fat. It discharges nitrogen by the kidneys, carbon chiefly by 
respiration. Modern methods of research enable us to determine the 
rate of both discharges with exactitude, and thereby to ascertain how 
much proteid and how much fat the organism uses per hour or day 
for its maintenance. Such investigations are required, not for the pur- 
pose of confirming the well-established observation that in fever disin- 
tegration of proteid is increased, but with a view to the much more 
difficult question whether the febrile disorder of metabolism is of the 
same nature as that which occurs in inanition, and is dependent on the 
inability of the individual to take nourishment, or is partly or wholly the 
result of some change in the living substance of such a nature as to render 
it more prone to disintegration. As already indicated, the only way to 
answer this question is by comparing the exchange of the fevered indi- 
vidual with that of the normal man who abstains from food, or of the 
animal which is deprived of it. In animals the comparison can be made 
with a degree of exactitude which cannot be approached in man. The 
method to be followed, therefore, consists in first ascertaining with pre- 
cision what happens in artificial fever, and then using the data so obtained 
as a basis for our observations on man. And it is important to notice 
that in relation to a question like the present, the common objection that THE DOCTRINE OF FEVER 
147 
the processes of nutrition in a small rodent cannot be applied to man does 
not hold. If our object were to obtain data for a general view of the 
whole process of nutrition in man, those furnished by observations on the 
rabbit, for example, would be inadequate. But the question now before 
us is much more elementary. If it can be shown that fever can be pro- 
duced in the rabbit, and that it is accompanied by a disintegration of 
proteid which is obviously of the same nature as that which we observe 
in man, we are justified in using the precise knowledge which the experi- 
mental method affords us, as a key to the interpretation of clinical obser- 
vations made under circumstances less favourable to perfect accuracy. 
As regards the rabbit it has been further, and with much more reason, 
objected that its nutritive process is subject to irregularities which it is 
difficult to account for, and which unfit it for observations the value of 
which depends on the constancy of the observed phenomena. But even 
this objection admits of an answer; for it has been found that, in animals 
deprived of food, a condition is very soon reached in which the discharge 
of nitrogen becomes constant. This constancy obviously denotes that the 
nitrogenous material derived from the food last taken has been used up. 
In inanition where, as has been said, the organism feeds upon itself, 
the ordinary process of life is so modified that tissue no longer maintains 
its integrity. It wastes, and by wasting supplies the material for the 
maintenance of systemic life. In the rabbit this waste is sufficiently 
constant for the purposes of investigation. Thus Dr. May in his recent 
research on the exchange of material in fever, found that in eight rabbits 
on the third and fourth day of inanition, the daily discharge of nitrogen 
was (with little variation) 0-055 per cent of the body weight: it could 
be assumed, therefore, with certainty that when, by inducing fever, this 
amount was increased - e.g. to 0-066 per cent - this increase was due to 
exaggeration of the normal elimination of nitrogen. That in fever, as in 
inanition without fever, the increased discharge of nitrogen represents 
disintegration of tissue can scarcely be doubted; but the immediate cause 
of this disintegration admits of discussion. In the absence of disease, if 
I may so express myself, the tissues of the starved body yield to necessity. 
Sugar, derived from the digestion of amylaceous food, being no longer 
available for the maintenance of respiration, proteid goes to meet the in- 
exorable requirements of the organism. In fever there is no prima facie 
reason for supposing that a new process is brought into existence, or that 
the state of things is not the same as in inanition. But the question can- 
not fail to suggest itself whether in fever the organised material is more 
labile than it is in health, i.e. that the direct injury which it receives 
from the fever-producing cause (the nature of which will be discussed 
later) renders it less able to resist the demand of the organism. The 
grounds for this very generally accepted assumption are as regards the 
initial stage of fever not very substantial. Eventually the living mate- 
rial of the body no doubt suffers from the continuance of high temperature 
and defective nutrition; but there is no reason for supposing that this 
damage is the precursor of the general disorder. In favour of the opposite 148 
SYSTEM OF MEDICINE 
view - namely, that the disintegration is essentially dystrophic - there 
are several arguments. If the proteid disintegration of fever were of a 
different nature from that of inanition, we should expect that the prod- 
ucts would be different. It has indeed been suggested that the presence 
of acetone in the urine in febrile diseases indicates that is so; but the 
investigation of the cases of voluntary starvation (Cetti and Breithaupt) 
by Lehmann and Zuntz have shown that acetonuria belongs as much to 
inanition as to fever. We know also that this condition is an accom- 
paniment of many wasting diseases (particularly cancer) in which fever 
is absent. Another reason for the same view is that in fever the nitro- 
genous waste can be diminished by a suitable diet. In fever glycogen 
disappears from the liver, and cannot be replaced by the administration 
of amylaceous food: this obviously means that the supply of carbohy- 
drate in the organism is exhausted early, and that in consequence the 
organism begins almost at once to feed on itself. This consideration 
led Dr. May to make experiments for the purpose of ascertaining whether 
in his fasting rabbits the extra consumption of proteid could be pre- 
vented by the administration of grape sugar, i.e. of a carbohydrate ready 
for immediate metabolism. In an inanition without fever the diminu- 
tion of nitrogenous waste was immediate, and amounted to 25 per cent. 
In fever it was about the same, showing that the febrile waste may, in 
the first instance, be entirely dystrophic. It is a question for clinical 
observation whether in the human subject good might not be done by 
following out the same principle. 
2. Production of Heat (Thermogenesis). - To some readers it may 
appear superfluous to inquire whether thermogenesis is increased in 
fever; for it might seem to follow from the increased temperature of 
the body that more heat is produced. A moment's consideration will, 
however, convince any one who is willing to take the trouble to reflect, 
that constancy of temperature depends not on the quantity of heat gen- 
erated by the consumption of food, or on the quantity lost at the sur- 
face, but on the power which the organism possesses of so controlling 
either production, or loss, or both, that the normal temperature shall not 
fluctuate in either direction. In fever it cannot be questioned that this 
power of control is so impaired or weakened as to make it inadequate 
for its purpose; the way in which this is brought about will be consid- 
ered in the next paragraph. What we have now before us is the fact 
that in fever the production of heat is on the whole somewhat increased 
and the reason why it is so. 
It is now nearly thirty years since Frankland determined, by a series 
of calorimetrical experiments made at the Royal Institution, the " heat 
values " of the chief constituents of food. These data, combined with 
what was known or could be ascertained as to the quantities of each 
constituent consumed daily in maintaining the animal machine, enabled 
physiologists to estimate approximately the total quantity of heat con- 
sumed therein in a day or an hour. The endeavour was made at the 
same time, by the employment of calorimetrical methods, to measure the THE DOCTRINE OF FEVER 
149 
same quantity directly. The results of these early efforts have given 
place to more precise ones, for we are now not only able to state the heat 
values of the various nutritive substances with much greater correctness 
than before, but are able to measure with like precision the quantity of 
heat which each substance actually produces physiologically, i.e. when it 
is consumed by the organism as food, and to show that the two values 
agree. It is also found that the total heat production of the body in a 
given time, as measured directly, equals the sum of the heat values of the 
various substances consumed during the same period. We have therefore 
in our hands the experimental proof of what Mayer told us half a century 
ago, namely, that food is the sole source of animal heat. The production 
of heat in fever must be estimated in the same ways as the production in 
health, i.e. either by determining the quantity of each nutritive material 
used, and adding the corresponding heat values, or by direct calori- 
metrical measurement. In fever the organism consumes, as we have 
seen, its own proteid and fat. The data and methods which we now 
possess render it possible, as is well exemplified in Dr. May's research, to 
estimate the rate of each of these processes of consumption in fever, and 
to compare the results obtained under the same nutritive conditions in 
health. By such comparison it was found, in the rabbit, that the fevered 
animal produces and discharges something like ten per cent more heat 
than the healthy under the same conditions of nutrition, and that this 
is due, not to the disappearance of fat, but to the consumption by the 
fevered organism of its own proteid; for, while the consumption of fat is 
approximately the same in both cases, the nitrogenous waste in fever is 
about 25 per cent greater.1 In another recent research, in which 
the excellent calorimetrical method of Professor Rubner was used, the 
maximum increase of heat production in fever was determined under the 
same conditions and on the same animal by direct measurement. The 
result thus obtained closely accorded with the estimate founded on the 
quantities of proteid and fat consumed. The increase never exceeded 10 
per cent, but was often less, and in some experiments wms so inconsiderable, 
that the author was unable to say more than that while in the rabbit 
there may be an increased production and discharge of heat in fever, the 
possibility of fever without such increase cannot be excluded (14). 
3. Pyrexia.-We now come to the most important part of our 
inquiry. Why does the bodily temperature rise above the normal ? I 
have already explained why the dictum of Liebermeister, that in fever 
the organism is adjusted to a higher normal, cannot be accepted as it 
stands. The truth which it encloses may be expressed by saying that, in 
consequence of the injurious action of the fever-producing cause, the 
organism loses its power of keeping itself at the normal temperature. In 
this very modified form Liebermeister's principle is now accepted by all 
pathologists. All that is asserted is that the organism possesses and 
exercises the power of adapting its temperature to a norma, that norma 
1 See p. 57 of Dr. May's paper. I much regret that space will not allow me to give 
details. 150 
SYSTEM OF MEDICINE 
being the temperature which is most conducive to its own interests, and 
that this power is impaired in fever. It leaves untouched two other 
inquiries, viz., (1) in what part of the organism the power is vested, and 
(2) why the departure from the normal moves upwards and not down- 
wards. Let us consider these two questions separately. 
It is conceivable that in an organism consisting of cells, all of which are 
similar to one another in physiological endowment, i.e. without a nervous 
system, each cell might be able to govern its own chemical, i.e. heat-pro- 
ducing processes, in such a way as to maintain a constant temperature; 
but this could only happen if all of the cells were under the same con- 
ditions, i.e. inhabited the same environment. Identity of endowment 
without identity of environment would not bring about the required 
result, viz., identity of temperature. It need scarcely be said that though 
conceivable, no such organism is possible. Constancy of temperature is 
met with only in animals of advanced organization and highly-developed 
nervous system; and in them constancy of temperature presents itself 
exclusively in internal parts. Of external parts the temperature is 
variable. The circulation affords an efficient mechanism by which out- 
side variability is used for the maintenance of inside constancy. In other 
words, such a relation is kept up by the circulation between surface and 
interior as to ensure equability of the latter. The existence of such a 
relation implies the agency of a nervous system to maintain it. It there- 
fore needs no experimental evidence to prove that to this system must 
be assigned the " thermotactic " function. This being admitted, we may 
go a step farther. From what we know of the mode in which the 
nervous system co-ordinates functions, it may be assumed that thermotaxis 
is conducted by a " centre " or " centres "; that it or they receive im- 
pressions of " too warm " or " too cold " by afferent channels in those 
parts in which it is their business to maintain constancy, i.e. normality; 
and that they (the centres) are able to influence " thermolytic " or ther- 
mogenetic processes accordingly. The organism, represented by the 
"centres," recognises as normal the temperature which in the phylo- 
genetic development of the species has established itself as most advan- 
tageous. If, therefore, we speak of impairment of thermotaxis, we mean 
that the centre loses its power more or less of responding to impressions 
of abnormality in the parts with which it is in relation by afferent 
channels. If so, why does the defect show itself in one direction only ? 
If fever implies paresis of the regulating centre, why does the tempera- 
ture rise, never fall ? To this there is but one answer, and that a very 
simple one. A good horse needs the bridle only, not the whip. The 
heat-producing activities of the organism tend to exceed, not to fall short 
of its requirements. So long as this tendency is operative, pyrexia must 
result from mere impairment of the regulating function. It is not until 
it ceases, as happens in many instances as death approaches, that fever 
becomes collapse (26). 
So far we may proceed independently of experimental evidence. In 
approaching the question which next presents itself-the question where THE DOCTRINE OF FEVER 
151 
the thermotactic centre or centres are to be found, and how they act in 
fever - we may, I think, take as our guide the principle that, whatever 
the agency which in health prevents the temperature of the body from ris- 
ing above the normal, it must be that agency which in fever is disordered. 
If so, the question how this control is normally exercised - how the 
organism deals with its surplus production, is one of great pathological 
interest. The best way of answering it is by another inquiry. How 
does the organism deal with increase of surplus, when the increase is 
dependent on conditions which are not those of disease ? There are two 
such conditions - food and exercise - both which are under the control 
of the will. In the fasting animal the effect of feeding is to double or 
treble thermogenesis. By muscular exertion it may be increased in 
somewhat similar proportion. The storage of heat and consequent 
increase of temperature in either of these two cases would be disastrous, 
were the latter not promptly got rid of by some arrangement of unfailing 
efficiency. In the case of food it is conceivable that the organism might 
be able to protect itself by putting a stop to the thermogenetic chemical 
processes to which the taking in of food gives rise; but there is no way 
in which the heat produced by muscular exertion could be so dealt with 
as not to increase the temperature of the body other than increased 
liberation of heat at the surface. The physiological processes which are 
connected with the discharge of heat at the surface are presided over by 
two systems of nerves (secreting and vascular) which are closely associated 
with each other functionally and anatomically. The secreting nerves 
which are distributed to the sweat glands, and the inhibitory vascular 
nerves by the stimulation of which the minute arterioles of the skin dilate 
so as to increase the vascularity and heighten the colour of the skin, come 
from centres which are situated in the bulb and spinal cord. The two 
systems of nerves follow the same lines and are very similarly distributed. 
That the dilating nerves and hidrotic nerves are very prompt and efficient 
agents in guarding against increase of temperature can hardly be doubted, 
for in all known instances in which the temperature tends to rise they 
at once manifest their activity. In fever this activity fails ; considera- 
tions which we have already had before us suggest that this power of 
responding is still present, but is impaired. We have now, with a view 
to this hypothesis, to inquire how far it is supported by clinical observa- 
tion and experiment as to the phases of the cutaneous circulation and of 
the secreting function of the skin. In this inquiry we shall have to do, 
not with production and discharge, but with the behaviour of the vessels 
and glands, and with the centre or centres by which they are regulated. 
When the accession of pyrexia is marked by rigor the skin exhibits 
the conditions which were regarded by Traube as belonging to the whole 
process. It is obvious that in many fevers, particularly ague, there is 
in this stage of accession "spasm of the extreme vessels"-anaemia of 
the skin. This is followed by an opposite condition which, although 
neither so marked nor so constant as the previous pallor, is by contrast 
sufficiently obvious. If, at the beginning of the fastigium the surface 152 
SYSTEM OF MEDICINE 
be exposed, rigor is apt to return, as if the shuddering contraction of 
the muscles were a reflex evoked by the cooling of the skin. 
Whenever pyrexia ends in a distinct crisis, i.e. a sudden return of the 
bodily temperature to the normal, that return has associated with it 
changes in the skin still more favourable to the discharge of heat; 
eventually it resumes its normal condition, but before doing so the circu- 
lation becomes more active and sweat breaks out abundantly. Thus in 
typical fevers we have two states which are easy to appreciate - the 
anaemic dryness of rigor and the warm, hyperaemic moisture of deferves- 
cence. Between the two comes the fastigium, during which the vascular 
condition, even if not markedly hyperaemic, is abnormal and variable. 
Of this we have plain indications in the observation that even rough 
measurements of the surface temperature show such differences between 
corresponding parts on opposite sides of the body, and between the tem- 
peratures of the same part at different times, as are never observed in 
health. This is further shown by the abnormal way in which the skin 
responds to stimulation. In prolonged fevers, particularly typhoid, it is 
observed that if a pencil is drawn firmly over the skin the path it has 
followed becomes after a few seconds traceable by its relative paleness. 
This blanching lasts for several minutes, spreading slightly as it fades. 
In animals the evidence that the cutaneous vascular system reacts ab- 
normally in fever is much more precise. It is a quarter of a century 
since Heidenhain (15) showed that whereas in health the effect of reflex 
stimulation of the vaso-motor centre is to increase the cutaneous circula- 
tion, and thereby bring down the temperature of the blood, this is not 
the case in fever, but rather the contrary. There is no dilatation of the 
cutaneous vessels, no increase of the temperature of the extremities - a 
result which we can best explain by saying that the normal vascular re- 
sponse to stimulation takes place less readily than before; or, in other 
words, that the nerves and centres which preside over that response are 
no longer capable of discharging their function efficiently. 
The subject is one in respect of which results as valuable can be ob- 
tained by clinical investigation as by experiments on animals; for of the 
three criteria by which the physiologist judges of the quantity of blood 
containedin apart-its volume, its temperature, and its colour-the first 
two can be as well observed in man as in animals, and the third better. 
The changes of volume of the limbs in fever have been very successfully 
examined by Dr. Maragliano of Genoa, with the aid of Mosso's plethysino- 
graph. By a preliminary series of experiments it was first ascertained 
that in healthy persons, after a meal, the volume of the arm, as thus 
measured for a number of hours, slowly declines as the time which has 
elapsed since taking food increases, and that the rate of this decline is 
uniform. The same method of observation was then appliedto a variety of 
typical fevers. In ague it was found that the accession of an attack is 
marked by a very obvious diminution of volume, which is antecedent to the 
rigor; and that in the crisis likewise an increase of volume is always the 
harbinger of the critical thermolysis. The measurements given, however. THE DOCTRINE OF FEVER 
153 
seem to show that, in intermittent fever at all events, the interval 
between the expansion of the arm and the fall of the temperature is 
much longer than that between the contraction and the rise. In some 
cases in which the fastigium lasted for some time with a temperature of 
over 104°, the critical expansion was preceded by a gradual enlargement 
of the arm which could be observed for hours before there was any 
change in the readings of the thermometer. 
As regards the temperature of the surface we possessed until lately 
very little reliable information. The best clinical observations, so far as I 
know, are those recently made by Dr. Geigel at Wurzburg, by a thermo- 
electrical method, of which it is sufficient to say that the apparatus con- 
sists of a single pair of junctions, one of which can be applied to the skin, 
the other being in a vessel containing oil at known and constant tem- 
perature. Simultaneous measurements were made of the temperature 
at four different spots - some covered, others exposed - and compared 
with readings of the temperature in the rectum taken during the same 
period. The results, which are of special interest in connection with the 
Genoa observations, may be best stated according to the stage in the 
febrile process to which they relate. In rigor it was found that the sur- 
face temperature sinks very considerably, and consequently that the 
difference between the surface and internal temperature-the latter ris- 
ing while the former falls - rapidly augments. On this subject the data 
given are so unequivocal that the often-repeated statement, that while 
the patient shivers the skin becomes hotter, can no longer be made. As 
regards the period of defervescence, it is as clearly shown that the fall of 
the blood temperature is preceded by rise of surface temperature - that 
while the internal parts are still at fever heat the temperature of the 
skin rises-in consequence of the more ample afflux of blood to the sur- 
face, the relation between this afflux and the critical sweating being 
most strikingly shown by the temperature curves. Another interesting 
point is that in the fastigium, notwithstanding that to the hand the 
skin feels hot and dry, its temperature is only a little greater than in 
health - less than that which it attains as defervescence approaches. 
We have thus perfect harmony between what has been learnt from 
the observation of surface temperature and the results of plethysmo- 
graphic measurement. Increase of volume of the extremity and increase 
of the temperature of the surface mean the same thing, viz., that the 
flow of warm blood as supplied through the skin is augmented. It is 
thus that the organism reacts promptly and effectually against any 
increase of the temperature of the blood. 
4. Cerebral Heat Centres. - Although it may be doubted whether 
the pyrexia, which is produced by stimulation or injury of the brain, 
comes under the designation of " fever," the facts relating to this subject 
cannot be passed over in the present discussion. For in some instances 
the pathological state observed, if not fever, so much resembles it that it 
cannot fail to be of interest to compare the one with the other. Space 
will not allow me to refer in any detail to the older observations relating 154 
SYSTEM OF MEDICINE 
to the effects of severance of the spinal cord in the cervical region and 
of injury of the bulb. It is sufficient to say that the observed effects of 
section of the spinal cord were such as to show that the animals experi- 
mented on were incapable of maintaining constancy of temperature, while 
on other grounds it seemed probable that the antagonistic functions of 
production and discharge of heat were presided over or regulated by 
different parts of the intracranial nervous system. Since 1880 the 
question of the localisation of these functions has assumed a different 
aspect. In that year Dr. Wood of Philadelphia discovered that injury 
of a certain part of the cortical motor area which surrounds the crucial 
sulcus in the dog produced pyrexia. Soon afterwards it was discovered 
independently in Paris and in Berlin that a therinogenetic region exists 
on the medial side of the corpus striatum, the excitation of which, 
whether by puncture or electrical currents, gives rise to a similar increase 
of temperature. The conditions and results of the experiment were 
most carefully investigated, under the guidance of Professor Zuntz, by 
Aronsohn and Sachs (20), who found that the therinogenetic region corre- 
sponded in position to the nodus cursorius of Nothnagel, and was strictly 
limited. It was also found that the pyrexia, which did not come on until 
some time after the injury, was accompanied by an increased elimination 
of nitrogen, so that at first sight it might appear as if a genuine fever 
had been produced. There are, however, points of difference by which 
the one pathological state may be distinguished from the other. The 
" hyperthermic " state produced by puncture is found to differ from true 
febrile pyrexia above all in the absence of those vascular conditions of 
the skin which we have seen to be so characteristic. The bodily tempera- 
ture rises gradually to a febrile height (105° F. to 106° F.), and then as 
gradually subsides; but there is no rigor, nor is the subsidence preceded 
by any vascular dilatation. The vessels, indeed, are so incapable of 
responding in the normal way to their environment, that if the animal 
be placed in a warm chamber at 37° C. it becomes hyperpyrexic, yet the 
ears remain pale as before. These facts seem clearly to indicate that the 
disorder of vascular innervation due to puncture is of a different kind 
from that of fever, the regulation of temperature being almost, but as we 
shall see farther on, not completely in abeyance; whereas in fever the 
power of guarding against excessive thermogenesis is weakened in much 
less degree. There being this essential difference between brain pyrexia 
and that of fever, how are we to account for the fact that in Aronsohn 
and Sachs' very elaborate investigation there was found to be increase 
not only of the respiratory exchange, but of the elimination of nitrogen 
(20). The answer is that although Dr. Binger's observation (1859), 
confirmed as it has been, both clinically and experimently - that in the 
accession of fever increased metabolism precedes rise of temperature - 
clearly proves that in fever the high temperature is not, as some have 
thought, the sole cause of the nitrogenous waste, yet the evidence that the 
latter may have this origin is quite as conclusive. A temperature of over 
104°, if it continue, produces tissue waste, however it is itself brought THE DOCTRINE OF FEVER 
155 
about. The simplest mode of raising the bodily temperature of an animal 
without inducing any other disorder consists in subjecting it to a tem- 
perature just sufficient to prevent a discharge of heat from its surface. 
Thus, by placing a dog in a chamber at 37° C. its body temperature may 
be easily maintained at a point approaching that of fever. The result 
is to produce both of the effects which follow brain puncture. The 
increase of the nitrogen elimination lasts for two or three days, and is 
quite as great as that observed (20) in Aronsohn and Sachs' experiment. 
5. Antipyretics. - The discovery about fourteen years ago of several 
bodies which possess the power of reducing temperature in fever, and 
the investigations of their action by various observers, have contributed 
very materially to the elucidation of the phenomena of febrile pyrexia. 
Of these bodies kairin, of which the properties were first made known 
in 1882 by Professor Filehne (21), acts more promptly than any other. 
Next to it comes antipyrin, which was discovered two years later, and 
was also first examined by Filehne (22), and has since held its ground 
as an antifebrile remedy. I allude to them, not with any reference 
to their therapeutic value, but because the phenomena of their physio- 
logical action are well known, and throw light on the process which 
they counteract. 
In man the effect of kairin, as Filehne expresses it, is to "open all 
the sluices for the escape of heat from the surface." In animals it is 
equally prompt. The rate of surface loss, as measured calorimetrically 
by Dr. Richter (23), exceeds by 25 per cent the previous fever rate, and 
the normal rate by 75 per cent. As the effect, which is of short duration, 
passes off the discharge of heat diminishes to a point below the normal. 
The same year that these observations were recorded, Dr. R. Gottlieb 
(24) applied the more exact calorimetrical method of Rubner in obser- 
vations on antipyrin - with this difference, however, that his investiga- 
tion related not to artificial fever produced by the introduction of pyro- 
genetic substances, but to the brain-puncture pyrexia referred to above. 
The results distinctly prove that in the normal animal the diminution of 
temperature produced by antipyrin is due entirely to increase of surface 
loss. Notwithstanding that it has been clearly proved that antipyrin in 
repeated doses in man is known to diminish the discharge of nitrogen 
(25), it is clear that the increased metabolism which this implies has 
nothing to do with the antipyretic action, for the increase of surface loss 
more than covers the diminution of temperature. In brain pyrexia the 
increase of surface loss after antipyrin is much greater than in health, 
and probably greater than in fever, for the previous constriction of the 
cutaneous vessels is greater. The fall of temperature to which this gives 
rise is also much greater, but still is not so great as it would be if the 
whole excess of heat loss were at the expense of the organism. It there- 
fore appears that even in brain pyrexia the power which the organism pos- 
sesses of compensating loss by increased production is not entirely absent. 
That the two antipyretics act primarily by augmenting the surface loss 
we have even more direct evidence from their effect on the temperature 156 
SYSTEM OF MEDICINE 
of the skin and of the volume of the extremities; and we have here 
the additional advantage that in both of these points we can base our 
conclusions on observations at the bedside. Maragliano (loc. cit.) found 
that the action of kairin and antipyrin in continued fever as well as in 
ague can be readily observed by the arm-plethysmograph. It manifests 
itself by an expansion of the limb which accompanies the diminution 
of temperature; and in typhoid it can be observed that the passing off of 
the effect and the return of the pyrexia is attended by a corresponding 
diminution of the volume of the arm. As regards the temperature of 
the skin, equally satisfactory results are supplied by Geigel, to whose 
thermo-electric measurements reference has already been made. It is 
shown that in all cases in which antipyrin produces its characteristic 
effect the diminution of central temperature is preceded by increase of 
surface temperature, clearly indicating that the mode of action of the 
drug is to diminish the temperature of the blood by increasing the rate 
at which it flows towards the superficial parts of the body. 
It thus appears that increased volume of the extremities, increased 
temperature of the skin, and increased discharge of heat from the surface 
(as measured calorimetrically) are the characteristic phenomena of anti- 
pyretic action in man and in animals. It need not be pointed out that 
these phenomena are physiologically correlated. They plainly indicate 
that antipyretics act on that part of the nervous system which presides 
over the inhibitory or dilating vascular nerves. The bearing of this fact 
on the question of the nature of fever lies in this, that they afford clearer 
evidence than can be obtained otherwise, that the power which the ner- 
vous system possesses of regulating the loss of heat at the surface is ad- 
equate to bring about changes of bodily temperature as great as those 
which take place in febrile pyrexia. What they do not prove is that 
fever is nothing more than a disorder of thermotaxis. 
6. etiology of Fever. - It is now thirty years since Otto Weber and 
Billroth investigated the fever which is produced by the introduction of 
septic material into the circulating blood or into the cellular tissue, and 
showed in what respect the artificial fever resembled or differed from 
surgical fever. It was soon afterwards found that the products of acute 
inflammation give rise to fever under similar conditions. And when, at 
a later period, it was recognised that these products owe their infective 
properties to the presence of microphytes (as we then called them), the 
inference naturally followed that the power of producing fever was also 
dependent on the presence of those organisms. 
At that early period (1872) the methods now familiar to the patholo- 
gist of discriminating between different kinds of bacteria were unknown. 
When some eight years later Dr. Koch taught us how to do this, and thus 
founded the science or rather technique of bacteriology, it seemed likely 
that the fever-producing property would turn out to be an endowment of 
particular species, and that by using pure cultivations it would be possible 
to induce fever experimentally with much greater certainty than had 
before been possible. This expectation, whether rightly or wrongly THE DOCTRINE OF FEVER 
157 
entertained, has not been realised. There are several species which are 
phlogogenetic, but none which can be relied upon to produce fever. 
The one which has lately appeared to answer the purpose best is the 
bacillus of Rouget (the erysipelas of swine), but others, as for example 
the bacterium coli communis, and the ordinary chaplet-coccus of acute 
abscesses, are also available. 
The question whether the micro-organisms themselves or their prod- 
ucts produce fever is an old one. In 1875 I prepared a substance, which 
I ventured to call pyrogen, from putrid extract of flesh, by first destroy- 
ing all bacterial life by the addition of alcohol in sufficient quantities to 
precipitate most of the proteids it contained, separating the precipitate 
by filtration, evaporating the clear filtrate, and redissolving in water. 
This sterile product produced fever, but was deprived of that property 
by filtration through porcelain, whence I conjectured that the pyrogenic 
substance was perhaps a body analogous to the unformed ferments or 
enzymes (26). About the same time, experiments made at Dorpat by 
pupils of A. Schmidt proved that the obscure constituent of the blood to 
which he attributes the property of exciting coagulation has also that of 
producing fever, so that the introduction of any material which either 
contains fibrin-ferment, or gives rise to its formation in the circulating 
blood, has the same effect (27). It thus became possible to explain why, 
when transfusion with lamb's blood was in vogue, the operation, notwith- 
standing antiseptic precautions, was always followed by fever. I think 
we may associate with these old observations the discussions which have 
recently taken place on the production of fever by the injection of extracts 
of fresh tissues (muscle, liver, thyroid, etc.) (28), which have this in com- 
mon with transfusion of blood derived from animals into the circulation 
of man, that in both instances there is disintegration of cells. 
As regards ferments, it has been shown that all the commercial 
enzymes are apt to cause fever when introduced into the circulation or 
into the cellular tissue, but inasmuch as in certain recent experiments 
pure enzymes prepared at Heidelberg under Prof. Kilhne's direction were 
found to have no such property, it may probably be assumed that in the 
others the effect is to be attributed to the albuminous products of diges- 
tion of which they largely consist. This seems the more probable when 
we remember that albumoses derived from very different sources have been 
found to be actively pyrogenetic, the most striking instance being that of 
the " deutero-albumose " found by Prof. Kiihne to be a constituent of 
tuberculin. A fever-producing albumose has also been obtained by 
Prof. Krehl from cultivations of bacterium coli commune (29). 
The discovery by Koch of the remarkable way in which the sub- 
stance just mentioned influences the organism of tuberculous individuals, 
whether human or animal, stirring up in the neighbourhood of the dis- 
eased parts inflammation attended by pyrexia, seems to be calculated to 
throw considerable light on the genesis of fever - and all the more since 
it has been discovered, not only that extracts similarly prepared from other 
micro-organisms have the same action, but that proteids of non-bacterial 158 
SYSTEM OF MEDICINE 
origin act in a similar way. For a recent publication of Dr. Matthes 
(30) seems to show that, in common with the deutero-albumose prepared 
from tuberculin, the similar product obtained by peptic digestion pro- 
duces both in man and animals the well-known local and constitutional 
effects of tuberculin, if tuberculous disease exist, but no reaction what- 
ever in healthy individuals. It has indeed been found possible to 
obtain a proteid body from the same source, which produces tuberculin 
effects in smaller dose than those of tuberculin itself. 
Several questions present themselves in connection with this subject 
of which it would be premature to speak at present - such as the rela- 
tion between the group of proteids and the toxins which appear to play 
so important a part in the specific infective processes, and the relation 
between the extraordinary physiological activity of these bodies and 
their chemical properties. 
The fact that severe injuries, such as simple fractures, which are nec- 
essarily attended with a certain amount of disintegration of tissue, are 
known to be followed by febrile reaction (31), sometimes of great inten- 
sity, notwithstanding that the reparative process is not in the slightest 
degree interfered with, and that the integrity of the skin affords a certain 
guarantee for the exclusion of bacterial contamination (29), seems to con- 
firm the inference of Charrin, from the experiments already referred to 
on extracts of fresh tissues, that in the bodies of all cells " thermogenic 
substances " - or rather materials from which they can be generated - 
are contained. However this may be, it is clear that the property of 
inducing febrile reaction is by no means confined to substances which 
depend for their existence on bacteria. Susceptibility to the action of 
fever-producing substances is not only very different in animals of dif- 
ferent species, but depends largely on individual peculiarities, whether 
natural or acquired. We have already seen how it is increased by the 
previous existence of certain organic diseases, and it may be added that 
in experiments on artificial fever a "fresh" animal is usually found to be 
less susceptible than one which has been previously " fevered." 
Conclusion 
Although I have endeavoured in the preceding paragraphs to state 
the leading facts and considerations relating to the origin and character- 
istic phenomena of fever in such a way as to enable the reader to draw 
his own inferences, it may, perhaps, be convenient that I should state 
the views which I am inclined to adopt. 
In the concluding paragraph of the essay on fever which I published 
in 1875, I set against each other two possible alternatives (26). Either 
fever originates in disorder of the nervous centres, producing pyrexia and 
as a secondary result disorder of nutrition, or it originates in a disorder 
of protoplasm to which the nervous phenomena are secondary. Although 
the second of these hypotheses seemed at that time preferable to the first, 
I did not think that either afforded a sufficient explanation of fever so THE DOCTRINE OF FEVER 
159 
long as the problem of the normal relation between temperature and. ther- 
mogenesis remained unsolved. Since that time considerable progress 
towards this elucidation has been made. By the labours of Rubner the 
relations between the heat values of the constituents of food and the pro- 
duction of heat, in animals, has been ascertained with such exactitude as 
to afford a safe basis for investigating the relations between production 
and loss in various conditions, while from Professor Zuntz and those who 
have worked with him we have received, very complete information as 
to the way in which the organism reacts to variations in the tempera- 
ture of its environment in either direction. The researches of Zuntz 
show conclusively that the only reflex apparatus for regulating tempera- 
ture which is always at work is that which governs the loss of heat at the 
surface. At the same time, it is obvious that, when required, the organ- 
ism can bring the other kind of regulation into play. No one doubts 
that shivering and the other almost involuntary muscular movements 
which are occasioned by exposure to cold are in a sense reflex. Even in 
a vigorous person the effect of the cold bath is to induce a tendency to 
the performance of such movements, the obvious purpose of which is 
to augment the production of heat (as can be readily shown if the 
respiratory exchange be measured), and so to compensate the increase of 
surface loss. But the reflex of shivering has in it a psychical element; 
it is associated with the sensation of chill, and may be resisted by a 
strong effort. When this tendency to shudder is resisted, the excessive 
intake of oxygen and output of carbon dioxide was no longer observable 
(as Professor Zuntz found when he made himself the subject of experi- 
ment). Yet, notwithstanding the absence of any evidence of increased 
thermogenesis, the temperature was maintained, so that the augmenta- 
tion of respiratory exchange was evidently accessory, not essential. 
Whether in small animals such as mice, in which the surface loss of 
heat per unit of body weight must be more than ten times as great as 
in man, there is anything like a reflex regulation of thermogenesis in- 
dependent of muscular activity, is a question not yet decided. Dr. 
Pembrey's researches on the subject do not seem to make it probable; for 
he finds that the power of regulating the respiratory exchange depends 
on the development and activity of the neuro-muscular system. 
In Dr. Macalister's admirable Goulstonian Lectures on Fever it is 
suggested that thermogenesis, thermolysis, and thermotaxis must be 
regarded as three separate functions of the nervous system. It seems at 
first sight difficult to see how, under conditions tending to bring down 
the bodily temperature, the cooling of the body can be prevented in any 
other way than by the direct influence of the nervous system on the pro- 
duction of heat. We have learned from Zuntz's experiments that the 
exercise of this influence is not essential. The key to the apparent 
difficulty is to be sought for in the consideration, that in a warm 
blooded animal of constant temperature the supply of heat is always 
potentially in excess. It is obvious that in a warm room more heat is 
produced than is wanted, but not so obvious, though equally true, that 160 
SYSTEM OF MEDICINE 
in the cold of winter the body temperature would rise at any moment 
if surface loss were suspended or annulled. In the two cases the 
" mechanism " is the same. It, therefore, does not seem necessary to 
imagine more than one regulating centre in constant operation - that 
which presides over surface loss. 
The last question to be discussed is that of the relation between 
pyrexia from cerebral puncture, and febrile pyrexia. 
The question is one of words. If the word fever be understood to 
mean the reaction of the organism to a fever-producing substance 
introduced into the circulating blood and conveyed thereby to the parts 
on which it acts, then the pyrexia of cerebral puncture is not fever. 
In the present paper the term has been used in this sense only. The 
study of puncture pyrexia is of great interest in enabling us to 
determine which of the phenomena of fever are or may be secondary to 
the rise of temperature, and in what degree they may be attributed to it, 
but it cannot be admitted that the two processes are identical or even 
kindred. In nosology difference of cause is a distinction which over- 
rides all others. 
J. Burdon-Sanderson. 
REFERENCES 
1. Traube. " Zur Fieberlehre," Gesammelte Beitriige, vol. ii. p. 679, 1864. - 2. 
Liebermeister. " Ueber Warmeregulierung und Fieber," Volkmann's Klin. Vortriige, 
Nos. 18 and 19, 1870. - 3. Senator. Untersuch. uber den fieberhaften Process und 
seine Behandlung. Berlin, 1873.-4. Leyden. "Ueber die Respiration im Fieber," 
Deutsches Arch.f. klin. Med. vol. vii. p. 536, 1870. -5. Leyden and FrAnkel. " Ueber 
den respiratorischen Gasaustauscb im Fieber," Virchow's Arch. vol. Ixxvi. p. 136, 1879. 
- 6. Finkler. " Ueber das Fieber," Pfluger's Arch. vol. xxix. p. 89, 1882. - 7. Kraus. 
" Ueber den respiratorischen Gasaustauscb im Fieber," Zeitschr.f. klin. Med. vol. xviii. 
p. 160, 1891. - 8. Loewy. "Ueber den Einfluss der Abkfihlung auf den Gaswechsel 
des Menschen," Pfluger's Archiv, vol. xlvi. p. 189, 1890.-9. Zuntz and Lehmann. 
" Unters. an zwei hungernden Menschen," Virchow's Archiv, vol. cxxxi. Sup. p. 173.- 
10. Traube and Jochmann. " Zur Theorie des Fiebers," Gesammelte Beitriige, vol. ii. 
p. 286, 1855.-11. Ringer. "On the Connection between the Heat of the Body and 
the excreted Amounts of Urea, etc.," Medico-Chir. Trans, vol. xlii. p. 361, 1859. -12. 
Huppert. " Ueber die Beziehung der Harnstoffausscheidung zur Kbrpertemperatur im 
Fieber," Arch, der Heilkunde, vol. vii. p. 1, 1869. -13. May. "Der Stoffwechsel im 
Fieber," Zeitschr. fur Biologie, vol. xxx. p. 1,1894. -14. Nebelthau. " Calorimetrische 
Unters. am hungernden Kaninchen im fieberfreien und fieberhaften Zustande," Zeitschr. 
fur Biologie, vol. xxxi. p. 293, 1894. -15. Heidenhain. "Ueber bisher unbeachtete 
Einwirkungen des Nervensystems auf Kbrpertemperatur," Pfluger's Arch. vol. iii. 
p. 504, 1870. -16. Stern. " Ueber das Verhalten der Warmeregulation im Fieber," 
Zeitschr. fur klin. Med. vol. xx. p. 63,1892. -17. Maragliano. "Das Verhalten der 
Blutgefasse im Fieber und bei Antipyrese," Zeitschr.f. klin. Med. vol. xiv. p. 309,1888. 
-18. Geigel. "Die Hauttemperatur im Fieber und bei Darreichung von Antipy- 
reticis." Reprint from Verhandl. der physikal-medicin. Ges. zu. Wurzburg, vol. xxii. 
1888.- 19. H. C. Wood. Fever, a Study in Morbid and Normal Physiology. 
Washington, 1880. - 20. Aronsohn and Sachs. "Die Beziehungen des Gehirns zur 
Korperwarme und zum Fieber," Pfluger's Arch. vol. xxxvii. p. 232,1885. - 21. Filehne. 
"Ueber neue Mittel welche die fieberhafte Temperatur zur Norm bringen," Berlin. 
Klin. Woch. 1882, No. 45. - 22. Filehne. "Ueber das Antipyrin," Zeitschr.f. 
klin. Med. vol. vii. p. 641, 1884. - 23. Richter. " Experimentalunters. fiber Anti- 
pyrese," Virchow's Arch. vol. cxxiii. p. 118, 1891. - 24. Gottlieb. "Calorimetrische 
Unters. fiber die Wirkungsweise des Chinins und Autipyrins," Archiv f. exp. Pathol. THE GENERAL PATHOLOGY OF NUTRITION 
161 
vol. xxviii. p. 167, 1891.-25. Umbach. "Ueber den Einfluss des Antipyrins auf 
die Stickstoffausscheidung," Arch. f. exp. Pathol, vol. xxi. p. 1, 1886.-26. Burdon- 
Sanderson. "On the Process of Fever." Reprint from Practitioner, Part iii. p. 13, 
1876.-27. Edelberg. "Ueber die Wirkungen des Fibrinfermentes im Organis- 
mus." Archiv f. exp. Pathol, vol. xii. p. 283, 1880.-28. Rouques. Substances 
thermogenes extraites des tissus animaux sains. Paris, 1893. - 29. Krehl. "Ver- 
suche uber die Erzeugung von Fieber bei Thieren," Arch. f. exp. Pathol, vol. xxxv. 
p. 222, 1895. - 30. Matthes. "Ueber die Wirkung einiger subcutan. einverleibten 
Albumosen," Deutsches Archiv f. klin. Med. vol. liv. p. 39, 1895. - 31. Volkmann 
and Genzmer. " Ueber septisches und aseptisches Wundfieber," Klin. Vortrage, No. 
121. Leipzig, 1877. - 32. Pembrey. Journal of Physiol, vol. xv. p. 401, 1893.-33. 
Macalister, D. Goulstonian Lectures on Fever. Macmillan and Co. 1887. 
J. B.-S. 
THE GENERAL PATHOLOGY OF NUTRITION 
The life of the individual is dependent upon the life of the cells or 
derivatives of the cells, which together make up the organs and tissues of 
the body. Every cell possesses the property of taking up from the fluid 
medium by which it is surrounded the substances which are necessary 
for its vital activity, and of casting out the waste products. 
It was John Hunter who said: "Every individual particle of the 
animal matter is possessed of life, and the least imaginable part which 
we can separate is as much alive as the whole." 
Owing to differentiation of structure and specialisation of function, 
certain master tissues (e.g. glandular, nervous, and muscular) possess, in 
addition to their general functions of repair and waste, a special function 
peculiar to each tissue involving storage of material. The mammary gland 
before lactation occurs is in a quiescent state; its cells are living and 
awaiting the natural physiological stimulus which will arouse their 
special function of elaboration and secretion of milk ; but, prior to this, 
the cells are still the seat of that perpetual circulation of matter termed 
metabolism, constructive and destructive - activities common to all 
living protoplasm. 
Physiologically, the cells of the body are dependent upon one 
another and upon the circulating blood which, as it streams slowly 
through the capillaries, brings into harmonious relation the effects of 
each and all of their vital activities. This functional harmony between 
the different tissues is brought about by the blood, and serves to maintain 
a constant in the chemical composition and temperature of that fluid; 
the maintenance of this constant is essential to the well-being of all the 
cells of the body. There is thus an interdependence of all the tissues; 
if one suffers, all suffer. 
The dictum of Virchow, Omnis cellula e cellule, is a fundamental 
principle underlying all physiological and pathological problems. The 
fertilised ovum may be looked upon as the fusion of the essential portion 
VOL. I 
M 162 
SYSTEM OF MEDICINE 
of the male sperm cell with the female germ cell, and with this process 
there is a fusion of the properties and attributes of the germinal plasm 
of the parents. This cell possesses, then, specific properties which dis- 
tinguish it from every other cell in existence; likewise all the cells which 
are derived from it by segmentation possess specific vital properties which 
make them differ from the cells which constitute the tissues and organs of 
another animal. We may not be able to show by chemical analyses and 
microscopical examination any differences in the tissues of two individ- 
uals ; they may seem identical; the distinction, however, appears in the 
differences of adaptation in the cells of the organism to their environ- 
ment, individually and collectively. The instability and mobility of the 
material substance of the cell constitutes its life: no portion of the 
living body is stable, but new formation and regeneration are continually 
taking place during life, even after completion of the growing period. 
Many examples of these processes could be cited, viz., the epithelium 
lining the alimentary and respiratory tracts which is continually being 
destroyed and replaced; likewise the epithelium covering the surface of 
the body, and the never ceasing disintegration and new formation of the 
blood corpuscles. The mechanism by which cells are enabled to take up 
nutrient material from the surrounding lymph and to cast out their waste 
products is unknown to us. It is a specific property of the protoplasm 
of the cell, controlled in the higher differentiated tissues by nervous 
impressions which not only (as may be proved in the submaxillary gland) 
directly control the functional activity of the epithelial cell elements, but 
also the amount of blood flowing through the gland. In health there is 
a constant adaptation of repair to waste; and, although the organic form of 
the cell or fibre is generally preserved, the contents are continually under- 
going molecular and chemical changes, with conversion of potential into 
kinetic energy, consumption of oxygen and organic substances, and the 
liberation of carbonic acid, water, and other waste products. The energy 
is replaced and the tissue waste repaired by the circulating blood. This, 
however, necessitates a constant in the quantity, quality and temperature 
of the blood, which can only be affected by the assimilation of oxygen, 
food and water in such proportion as to make up that which is lost to the 
body by disassimilation in the tissues, and elimination by the lungs, skin 
and kidneys. " A man can live a few minutes without oxygen, a few days 
without water, and a few weeks without food" (Waller). 
The balance of nutrition maybe maintained when the export is repaired 
by a corresponding import; and physiologists have shown that the mini- 
mum daily income required by a healthy man performing his average 
daily work, and maintaining his usual body weight, is 5 per cent of that 
body weight - 1 per cent being solid food, 1 per cent oxygen, and 3 
per cent water. These amounts may be modified by various circum- 
stances, such as climate, work, age, convalescence from illness, lactation, 
and the like. 
An infant or growing child requires not only food for repair but also 
for new growth. A mother during lactation, over and above the normal THE GENERAL PATHOLOGY OF NUTRITION 
163 
amount of nourishment, requires a suitable excess to provide the milk 
necessary for the suckling infant. 
If digestion and assimilation are normal the blood will be maintained 
at a constant in its chemical composition; should there be, however, an 
insufficiency of the intake, inanition will follow. Inasmuch as the in- 
take of food is always intermittent, and owing to exigencies in obtaining 
it is at times very much so, certain tissues and organs of the body pos- 
sess storage functions which provide reserve material upon which the 
blood can draw as required. The storage of fat in the connective tissue 
and liver cells of the body represents so much potential energy. The 
glycogen in the liver is a store of carbohydrate which is continually being 
utilised in maintaining an average constant of sugar in the blood. The 
sugar is used up continually by the muscles in the production of energy, 
but if more than a certain quantity exist in the blood, it would be 
injurious; consequently the liver intercepts the intermittent supply of 
carbohydrate material in the form of glucose absorbed by the portal 
blood, converts it into glycogen, and stores it in its cells to be used as 
required (Bernard). Probably all the cells of the body possess the 
power of oxygen storage ; we have definite proof of its existence in the 
muscles. The muscles of the frog can contract and produce heat and 
work in an atmosphere of N with liberation of CO2 and other waste 
products ; and the muscles of warm-blooded animals will display similar 
functional activity (when stimulated) for some time after the circulation 
has ceased. During sleep and rest the tissues are storing up materials 
for their functional activity, and this has been most clearly shown by the 
histological appearances of the cells of secreting glands during rest and 
during activity. Another very important factor complementary to de- 
structive metabolism, in connection with the maintenance of the normal 
composition of the blood, is what is termed the internal secretion of glands. 
Blood - the Nutrient Fluid and Medium of Exchange. - The quantity 
of blood in the body is about ^th of the body weight, and its mode 
of distribution is varied in accordance with the functional needs of the 
tissues. Certain organs and tissues, requiring large quantities of blood 
to perform their functions, are highly vascular in proportion ; the supply 
to a part is regulated automatically by the vaso-motor nervous system, 
and the physiological stimulus which excites the activity of an organ 
may also determine an increase of blood to the part. Thus, experimen- 
tally, an increase of urea in the blood causes an expansion of the kidney 
due to vaso-dilation, which signifies an increased flow of blood associated 
with the secretory activity of the organ. 
There is an essential similarity between the composition of protoplasm 
and that of the normal human body - between the normal human body 
and the circulating blood which provides it with nutrition ; for, during 
gestation in utero, a new body is entirely built up from the maternal 
blood; and there is also an essential similarity between milk, the natural 
food of the suckling animal, and the composition of the body - withone 
important exception to be mentioned hereafter. The cells of the body 164 
SYSTEM OF MEDICINE 
assimilate from the blood organic proximate principles representing so 
much potential energy, which they convert into kinetic energy in the 
form of mental and bodily work. 
Cell activity, then, depends upon chemical action, and the products 
of cell activity are carbonic acid, water, and nitrogenous waste products, 
of which urea is by far the most important. 
To restore to the blood that which it has given up to the tissues 
requires daily ingestion of a certain amount of food in the form of organic 
proximate principles: proteids, carbohydrates, fats, water, salts and 
oxygen. The proximate principles which enter into the composition of 
the human body are composed of fourteen elements, united in various 
combinations to form complex energy-producing organic substances and 
simpler inorganic substances - the latter incapable of producing energy, 
but still essential for nutrition, water making up at least two-thirds of 
the body weight. The elements contained in the body, and therefore in 
the blood, are C. H. 0. N. S. P. Fe. Na. K. Mg. Ca. Cl. F. Si. Although 
many of these exist in very small quantities, yet in all probability they 
are essential to the blood for the proper nutrition of the cells of the 
body. Even fluorine, which exists only in minutest traces, is essential 
to the formation of the teeth and bones. 
" The law of the minimum " holds as good for the nutrition of the 
human body as it does for agriculture; that is to say, the food must 
contain not less than certain quantities of the above elements, and in 
such forms as can be assimilated. Iron is the element of great impor- 
tance in connection with the function of oxygenation of the tissues, 
by means of the iron-containing haemoglobin. The iron in the body of 
an average-sized man is 3 to 5 grammes, the greater part of which is 
contained in the blood in the form of haemoglobin; the rest is combined 
with nucleo-albumins of the tissues. Bunge points out that the ash of 
a bitch's milk corresponded with the ash of the body of the puppy in 
every respect save one - there was six times less iron. The explanation 
of this doubtless lies in the fact that the young animal acquires its store 
of iron during its development in utero. The proportional amount of 
iron to the weight of the body is highest at birth, and gradually dimin- 
ishes with the development of the animal during lactation. These facts 
may explain the wonderful effect of small doses of iron and cod liver 
oil on the nutrition of ill-nourished, rickety infants, and the advisability 
of not deferring weaning or not adhering too long to a purely milk diet, 
but of using food which supplies more iron. 
We obtain in our food enough of all the inorganic salts save one - 
sodium chloride ; but our diet is by no means deficient even in this. No 
animal can live if its food be deprived of salts. It has been suggested 
that as the blood loses a large amount of its inorganic salts, and these 
are not replenished by the food, there are no bases to unite with the 
S. 0 3 formed by the oxidation of the sulphur of the disintegrated pro- 
teids. It is probable that the salts favour osmotic changes by their 
power of diffusion; and certain salts, especially sodium chloride, play THE GENERAL PATHOLOGY OF NUTRITION 
165 
an important part in nutritive exchange by holding in solution in the 
blood and muscle plasma certain proteids of the globulin class. The 
important part played by lime salts in the formation of bone and by 
potash salts in the tissues is well known. [Vide articles Rickets and 
Scurvy.] 
Proteids are essential to restore to the blood those proteid substances 
which have been used by the tissues for repairing waste. Muscular 
energy can be obtained from proteid, but normally it is obtained from 
carbohydrates and fat, a more economical method. It has been 
found, however, that proteids alone can repair tissue-waste, and that if 
proteids are not contained in the food in proper proportion the tissues 
feed on themselves. In inanition or starvation, on the other hand, a 
selective process seems to take place, and the tissues which are of the 
least consequence suffer the most. Fat rapidly disappears, muscle wastes; 
so also do many of the glands, the spleen, and liver, and even the blood 
itself; but the circulating medium nourishes the nervous system and 
heart, so that the master organs essential to the life of the individual 
may be supported at the expense of the less important tissues. This 
vicarious nutrition may be considered as a defensive power of the organ- 
ism to resist dissolution of the nervous system and heart. 
Dr. Barlow (in the Bradshaw Lecture, 1894) has shown that condensed 
milk or even sterilised milk is not an efficient substitute for the natural 
food of the suckling infant, and that infantile scurvy may be occasioned 
by their sole use. It is a noteworthy fact that although animals can live 
on milk alone, yet if a mixture be made of all the supposed constituents 
of milk which, according to the present teaching of physiology, are 
necessary for the maintenance of the organism, the animals fed on it 
rapidly die. Does milk then, besides carbohydrates, fat, proteids, salts 
and water, contain other substances indispensable to the maintenance of 
life? 
Of like importance in nutrition are certain phosphorus-containing 
substances in the body, viz., a phosphuretted fat termed lecithin, indis- 
pensable for the constructive metabolism of the central nervous system 
and red blood corpuscles; and nuclein, which consists of an organic 
phosphorus-containing acid, termed nucleic acid, in combination with 
proteid. The amount of P varies in different forms of nuclein, as 
the sulphur varies in amount in different forms of proteid. Nucleic acid 
contains C. H. 0. N. P but no S. The nucleus of a cell serves two functions 
- the nutritive and the formative; it exercises a controlling influence on 
the nutrition of the cell, and it is in the nucleus that the first evidences 
of cell-proliferation are manifested. The essential portion of the male 
sperm cell, namely, the head of the spermatozoon, chemically consists 
entirely of nucleic acid. 
The composition of cells is mainly spongioplasm and hyaloplasm; the 
former is the mesh work in which the latter more fluid protoplasm is 
contained. The spongioplasm stains readily, and is therefore called 
chromatin, a body which contains both P and Fe. Experiments seem 166 
SYSTEM OF MEDICINE 
to show that the daily output of uric acid is derived from destructive 
metabolism of nucleo-albumin. If this represent the total N derived from 
the waste of nucleo-albumin, it shows how very small is the destruction 
of the fixed framework of the cell elements, and how carefully are these 
highly complex organic bodies preserved from waste. The fluid which 
surrounds and bathes every cell of the body is a transudation from the 
blood; and it is the property of every anatomical element to take from 
the fluid the materials which it requires, to incorporate them for a time, 
to utilise them in various ways according to its special function, and to 
give back to the fluid various waste products or bye-products, the out- 
come of its functional activity. There is thus going on in the cells a 
continual and associated process of recomposition and decomposition - of 
constructive and destructive metabolism - a nutritive exchange essential to 
all forms of physiological function, whether it be of body or mind. 
The deficient supply of blood or deficient quality of the blood is, then, one 
of the causes of nutritive derangement, and of cell-degradation and death. 
Another cause may be, the failure on the part of the organism to eliminate 
the waste products which accumulate in the blood, causing injury to the cell 
elements, as in uraemia. 
There is yet another cause of defect of nutrition due to alteration of 
the blood, which lies in the interdependence of each and all of the tissues 
of the body upon one another. No part can be removed without some 
effect upon the rest of the body. We may note, for example, the pro- 
found effect on nutrition and on the male character produced by early 
castration; and recently various other organs have been shown to 
exercise a very considerable influence upon the blood and tissues by 
acts complementary to their special functional activity. I refer to those 
glands believed to have an internal secretion passing into the blood 
and playing an important part in metabolism; and I shall now consider 
certain of these functions. 
I. The Liver.1 - Minkowski has shown that, after extirpation of the 
liver in birds, uric acid is in great part replaced by ammonia and lactic 
acid. It is impossible to extirpate the liver in warm-blooded animals ; 
but Murchison always taught that nitrogenous waste products of 
tissue-metabolism were converted by the liver into urea. It is known 
that in acute yellow atrophy leucin and tirosin appear in the urine. 
There is not the slightest doubt that urea is far less poisonous than its 
antecedents; moreover, urea favours urinary secretion, and may be con- 
sidered a physiological diuretic. The experiments of Hahn, Masson, 
Pawlow, and Nencki have shown that in dogs carbamate of ammonia 
may be made to accumulate in the urine, that it is highly poisonous, and 
that it arises from tissue metabolism and disintegration. They also 
found that the injection of sodic carbamate into the circulation of dogs 
was poisonous only to those animals in which the portal current had 
been diverted into the vena cava, the portal vein ligatured, and the liver 
thus thrown out of action (fistula of Eck). This suggests that the car- 
1 As this is mostly new work the names of the observers will be mentioned in the text. THE GENERAL PATHOLOGY OF NUTRLTLON 
167 
bamate of ammonia is converted into urea by the liver. When the hepatic 
artery is simultaneously ligatured there is a great increase of carbamate 
of ammonia. It has been shown that small quantities of this salt exist 
in the blood, and animals in which the liver is normal suffer no ill effects 
from its injection; whereas those in which the liver has been put out of 
action die of peculiar nervous phenomena. These observers think the 
intoxication of the organism by the products of cellular activity is a 
complex process, and that their experiments show that one function of 
the liver is to destroy and transform poisons arising in the organism 
from cellular activity. Their long series of experiments indicate that 
the liver protects the organism from poisoning by the products of its 
own cellular activity; and they make it probable that certain compli- 
cations arising in hepatic insufficiency of various kinds are due to car- 
bamate of ammonia. It is probable, however, that this is one only of 
many nitrogenous antecedents of urea. 
The liver, again, standing as a safeguard between the portal and 
general circulations, protects the body from the influence of toxic sub- 
stances produced by the alimentary canal or taken into it. The re- 
searches of M. Bouchard have proved that, for the same quantity of 
nitrogen, urea is forty times less poisonous than ammoniacal salts; and 
in his recent work on Auto-intoxication he has demonstrated that this 
function of the liver diminishes in an enormous proportion the toxicity 
of the waste products. 
II. The Pancreas. - Recent researches and clinical observations have 
shown that this organ, besides its digestive functions, discharges into 
the blood certain products without which the organism is incapable of 
utilising the glucose normally contained in the blood; hence this accu- 
mulates and gives rise to glycosuria or pancreatic diabetes. Von Mer- 
ing and Minkowski have proved that animals from which the pancreas 
has been completely extirpated become glycosuric. Lancereaux and 
other clinicians had previously called attention to lesions of the pan- 
creas in association with diabetes. But the trouble does not seem to 
come from the accumulation in the organism of a poisonous substance, 
for no effect is produced on a healthy dog by injecting into its system 
the blood of an animal which has become diabetic by extirpation of the 
pancreas. Gley succeeded in tying all the veins of the pancreas and 
produced glycosuria; and other experiments seem to show that the pan- 
creas has normally a function of elaborating and turning into the blood 
a glycolytic ferment, necessary to enable the tissues to utilise the sugar 
contained in it. Complete extirpation of the pancreas (like complete 
extirpation of the thyroid) must be attained in order that the sugar 
may thus accumulate in the blood. 
III. The Thyroid Body. - As early as 1856 Schiff proved that dogs 
in which he had completely extirpated the thyroid gland, presented 
numerous troubles and alterations of nutrition analogous to those 
observed in man after thyroidectomy. He put forward the hypothesis 
that the thyroid elaborated a substance which passed into the circulation, 168 
SYSTEM OF MEDICINE 
and which played an important role in the nutrition of the nervous 
system. This has since been verified experimentally and clinically. 
[Vide art. Myxoedema.] 
IV. The Pituitary Body. - Experiments by Gley have shown that in 
a rabbit which had survived thyroidectomy, destruction of the hypo- 
physis cerebri would lead to trophic troubles similar to those produced 
in the dog by total extirpation of the thyroid. [Vide article Acrome- 
galy, a peculiar hypertrophy associated with disease of pituitary body.] 
V. The Suprarenal Capsules. - Addison pointed out a peculiar pig- 
mentation of the skin associated with caseous degeneration of these 
glands. Brown-Sequard has shown that extirpation caused great dis- 
turbances of nutrition, often followed by death. In all cases of ablation 
of these organs there is accumulation of pigment in the blood, and also, 
according to the researches of Abelous and Langlois, of poisonous prod- 
ucts of unknown nature. Schafer and Oliver have lately shown that 
injection of suprarenal extract into the circulation of animals is followed 
by an enormous rise of blood pressure. They have come to the conclu- 
sion that the medullary portion of the gland secretes a material which 
increases the tone of all muscle tissue especially of the heart and 
arteries. 
Bradford's experiments also show that the kidneys, besides the func- 
tions of elimination of waste products, possess another concerned with 
the metabolism of the tissues. [Vide art. Gen. Path. Dis. of Kidneys.] 
The spleen, in contradistinction to the above-mentioned organs, can be 
removed without producing any notable physiological effect beyond 
compensatory hypertrophy of the lympathic glands. 
Influence of the Nervous System upon Nutrition.-The influence of 
the mind upon the nutrition of the body is well known: anxiety, mental 
strain, with associated insomnia, are followed by lowered nutrition and 
general wasting of the body. Many neuroses - such as hysteria, epi- 
lepsy and insanity - are associated with failure of nutrition and general 
wasting of the body; and this condition also obtains in certain cases of 
nervous exhaustion in highly intellectual persons. Improvement of the 
nutrition of the body is often followed by improvement of the mental 
state, as in mania, melancholia, hysteria and neurasthenia. 
The question before us, however, is not whether derangement of the 
nervous system may prevent assimilation, but whether the nervous 
system exercises a direct trophic influence upon the tissues ? We have 
undoubted proof within the nervous system that nerve-cells exercise 
a trophic influence upon nerve-fibres; but are there nerve-fibres which 
can modify the "nutritive exchanges" of the cells independently of the 
vascular or other known changes ? In reply I shall treat of the experi- 
mental data, reserving clinical incidents for the articles Hypertrophy, 
Atrophy and Necrosis. 
Intracranial section of the fifth nerve produces inflammation of the 
eye, ulceration of the cornea, and suppuration and destruction of the 
eyeball of the same side; but it is asserted that these accidents do not THE GENERAL PATHOLOGY OF NUTRITION 
169 
occur if the eyelids are sewn together, and the delicate surfaces of the 
conjunctiva and cornea thus protected from the injury of foreign bodies, 
especially microbes.1 
Section of the cervical sympathetic is said to produce in a young 
rabbit an increased growth of the ear; section of the facial nerve to 
produce an increase in size of the maxillary bones: doubtless in both 
cases the results are due to increased vascularity, and consequent 
increased nutrition of those parts. 
Section of the anterior roots or motor nerves offers perhaps the best 
evidence of trophic influence, for the wasting of the muscles is then 
much more rapid and extensive than disuse of the muscles would 
produce; and it is attended by electrical changes with " reaction of 
degeneration." Some physiologists object that the effects may be due 
to disuse, irritation, or vascular changes; but in my opinion they are a 
proof of direct trophic influence, for Professor Sherrington and I have 
produced complete disuse of the muscles of the limb by section of all 
the posterior afferent roots of a limb - the anterior motor roots being 
left intact. Animals kept alive three months had never been seen since 
the operation to use the hand or foot of the limb thus deprived of sen- 
sation, yet on stimulation of the cortical centre or of the nerve presiding 
over these muscles, a contraction was obtained even more readily than 
on the sound side. Certainly the assumption of a direct trophic influ- 
ence of the nervous system upon the cells and tissues of the body helps 
us to explain many important clinical phenomena; but it cannot be 
asserted that the clinical facts afford indisputable proof of the existence 
of independent trophic nerve fibres. 
The Acquired or Inherited Specific Properties of the Blood and 
Tissues. - On the failure of nutrition in wasting diseases such as phthisis, 
cancer, infectious diseases, the reader is referred to special articles; so 
also on the effects of poisons such as lead, alcohol and phosphorus. 
The " durability of life " of the cells of each and all the tissues of the 
body depends largely upon specific inherited properties of longevity. It 
may happen that all the organs of the body possess an inherited 
longevity, that if environment be favourable all the tissues will pass 
through all the stages of growth and natural decay, terminating in 
gradual dissolution ; and the organism pass out of the world as un- 
conscious of death as of birth. On the other hand, there may be 
an inherited defect in the "make-up " of one particular tissue, rendering 
it susceptible to disease and degeneration. Should such a tissue be 
endowed with an important function which cannot be assumed by another 
1 Professors Goltz and Ewald showed (at the International Physiological Congress held 
at Berne 1895) a dog in which the spinal cord from the last cervical segment downwards 
had heen removed. The muscles of the bladder and rectum preserved their tonus, and 
there were no trophic changes in the skin, hair, and nails; but of course all the striped 
muscles of the lower limbs had completely wasted. Inasmuch as the spinal ganglia and 
sympathetic ganglia had not heen destroyed, it may he inferred that the absence of 
changes in the skin and appendages depended upon integrity of the former, and the 
preservation of the smooth muscle fibres of the viscera on the integrity of the latter. 170 
SYSTEM OF MEDICINE 
tissue, then the whole of the tissues of the body would suffer either from 
the effects of mal-assimilation or non-removal of the waste products; and 
the local disease would then cause a derangement of nutrition of the 
whole organism and perhaps a general dissolution. 
REFERENCES 
In the chapter upon nutrition the following authors have been consulted: - 
1. Foster. Text-book of Physiology, 5th ed. - 2. Waller. Human Physiology, 
2nded. - 3. Bunge. Physiological and Pathological Chemistry. Translated by Woold- 
ridge.-4. Bernard, C. Physiologie Generate; Les phenom'enes de la vie.-5. Paw. 
Physiology of the Carbo-hydrates.-6. Duval. Cours de Physiologic.-7. Gamgee. 
Physiological Chemistry. - 8. Halliburton. The Animal Cell. Goulstonian Lecture, 
1893; Chemical Physiology and Pathology. - 9. Virchow. Cellular Pathologie. -10. 
Cohnheim. Allgemeine Pathologie. -11. Bouchard. Les Maladies de ralentissement 
■de Nutrition; Lemons dans les auto-intpxications dans les Maladies. -12. Charcot, 
Bouchard, and Brissaud. Traite de medecine, vol. i. -13. Roger. " Quelques 
Travaux recents sur le Role du Foie dans les auto-intoxications," Revue generate des 
sciences. -14. Schafer. Presidential Address Physiological Section of the British 
Association, Oxford, 1894. -15. Barlow, Dr. Infantile Scurvy and its Relation to 
Rickets. Bradshaw Lecture, B. M. J., Nov. 19th, 1894. -16. Schafer and Oliver. 
*" Effects of Suprarenal Extract," Journal of Physiology, July 1895. 
Progressive and General Failure oe Nutrition 
General arrest of nutrition of the tissues of the body will produce 
somatic death. General wasting or inanition may arise from diseases such 
as cancer or stricture of the oesophagus; destruction of the mucous 
membrane of the stomach by corrosive fluids or disease; uncontrollable 
vomiting and hysterical anorexia; pressure of growths upon the thoracic 
duct; cancer of the pyloric end of the stomach, and cancer of the pan- 
creas. Whether cancer produces its characteristic cachexia by interfering 
with digestion and assimilation, or whether some products escape from 
the growth into the blood, or some substance is taken from the blood 
by the growth, thus altering its composition, is at present matter of 
speculation; but certainly the sarcomata, which are of mesoblastic 
origin, do not produce the same marked effect upon nutrition as car- 
cinomata. 
There are a number of diseases which produce general wasting by 
increased destructive metabolism accompanied by fever, by haemorrhages, 
or by exhaustive discharges from the body, in none of which the process 
of repair is adequate, and a progressive failure of nutrition ensues; 
such are fevers, phthisis, diabetes, prolonged suppuration, dysentery and 
albuminuria. 
General wasting from exhaustive diseases is always attended by a 
certain amount of tissue metamorphosis and degeneration, as in coagu- 
lation necrosis, hyaline degeneration, fatty degeneration, lardaceous 
degeneration, etc., - the location of the tissue change depending upon 
the nature of the disease and the ability of the organ or tissue under THE GENERAL PATHOLOGY OF NUTRITION 
171 
abnormal conditions of nutrition to maintain the equilibrium between 
repair and waste. 
In general wasting of the body from starvation the various tissues 
are affected unequally: 97 per cent of the fat is lost, 30 per cent of the 
muscle, 28 per cent of the blood, and of the'heart only 2 per cent. 
Wilks and Moxon point out that in cancer the heart usually wastes very 
much, in one case being reduced to 4 oz.; whereas in phthisis it does 
not atrophy, although there may be extreme emaciation of the body. 
Perhaps in the former it is partly disuse-atrophy, owing to the pro- 
gressive diminution of the amount of blood and tissue. 
In old age there is a gradual wasting of all the tissues of the body 
(the heart sometimes excepted). There may be a simple atrophy of cell 
elements without structural modification, due to a lowering of the vital 
activities of all the tissues, or various degenerative processes common to 
senile decay. 
Retrogressive Disturbances mf Nutrition 
A. Necrosis or Tissue Death.-Necrosis of a tissue may be partial 
or complete. The essential specialised cells of an organ or tissue may 
die, while the mechanical supporting tissues remain and undergo pro- 
liferation. Since the former cannot regenerate, the latter fill up the 
gap. If tissue death or necrosis occur in situations favourable to the 
presence or introduction of micro-organisms, then we have no longer an 
aseptic, but a septic necrosis, or gangrene ; of this there are two varieties, 
moist or spreading, and dry. In the former the conditions are favourable 
to the growth and spread of the putrefactive microbes, in the latter they 
are not; hence the process is usually limited by a " line of demarcation." 
Causes and Pathogeny 
Traumatic. - (1) Mechanical injury, such as violent contusions or 
tight bandaging. (2) Heat and cold. (3) Chemical, such as strong 
corrosives, acid or alkaline. (4) Electricity. These causes produce 
complete death of the tissue as a rule, and are, at any rate at the onset, 
aseptic. 
Mechanical injury produces death of the tissue by inducing blood 
stasis, and by its direct effect upon the tissue elements. 
Heat produces death by coagulation; several very important al- 
buminous substances, e.g. myosinogen and fibrinogen are coagulated at 
56° C. This would indicate that the tissues and fluids of the body 
exposed to this temperature would solidify, and thus inevitably be killed. 
Temperatures below 16°-18° C. destroy living protoplasm; the nature 
of the tissue and the period of time to which it is exposed to abnormal 
conditions of temperature will determine whether it can be restored to 
functional activity. 
Corrosive Fluids. - Strong acids produce immediate death by coagula- 172 
SYSTEM OF MEDICINE 
tion of the blood and tissues. Strong alkalis disorganise the tissues by 
liquefaction producing a s'oft eschar. 
Electrolysis. - At the*negative pole the eschar is soft and resembles 
the destruction produced by alkalis, whereas at the positive pole the 
eschar is dry, yellowish^ and. similar to the effect produced by acids. 
B. Necrosis by Disturbance of the Circulation. - All causes which 
bring about stasis of the blood in the capillaries, such as inflammation, 
pressure, haemorrhage, or blocking of the venous outflow of a part, will 
cause necrosis by arrest of nutrition. Again, if the arterial supply of a 
part be cut oft by ligature, embolism, thrombosis, or slow degeneration 
and obliteration of the vessel, anaemic necrosis results. The arrest of the 
circulation need not be permanent; it suffices if it persist a certain time. 
The more highly specialised a tissue the briefer its vitality when deprived 
of blood. The gray matter of the central nervous system, the epithelium 
of the intestine and the kidneys, can live but a short time (one to two 
hours, Cohnheim) without their blood-supply. So if one of the above 
causes should lead to anaemia of a specialised tissue, death of the special- 
ised cell-elements has generally occurred before the circulation can be re- 
established. This is particularly liable to happen in organs having 
terminal arteries. [ Vide arts. Thrombosis, Acute Perforating Ulcer of 
Stomach and Duodenum.] Direct injury, if severe, produces tissue- 
necrosis by complete arrest of nutrition of a part; but those remoter 
causes which consist in the weak defence of the organism against in- 
jury, although subsidiary, are quite as important. Thus comparatively 
trivial immediate causes may produce a spreading necrosis and circulatory 
disturbances of nutrition, which in a healthy individual could easily be 
overcome. The predisposing causes are : - 
(a) Disturbances of Innervation. - We have argued that division of 
the fifth nerve proves no more than that the loss of innervation of the 
cornea causes sloughing, by abolishing the reflex defensive mechanism of 
the tissue against microbes. Section of the posterior roots in monkeys 
produces sores upon the feet, but section of an equal number of roots 
supplying the upper limb produces no sores upon the hands; the hand 
is not subjected to the same direct injurious influences of pressure and 
microbic infection. Charcot maintained that acute decubitus occurring 
upon the buttock of the paralysed side in some cases of apopletic hemi- 
plegia was a proof of the existence of direct trophic influence. He stated 
that when certain patients had only lain on the non-paralysed side, and 
every precaution had been taken about the urine and faeces, yet within 
some hours or days a purplish erythematous rash might appear, and 
bullae form and burst, leaving a red, sore surface followed by an eschar 
and usually by sloughing out of the mortified part. Local infection 
may then ensue and become general. In acute myelitis the bed-sores 
occur over the sacrum and heels. Dejerine and Leloir, also Pitres and 
Vaillard have shown that changes in the peripheral nerves often occur 
in cases of hemiplegia with acute bed-sores. 
Trophic changes occur in Morvan's Disease and syringomyelia; of THE GENERAL PATHOLOGY OF NUTRITION 
the former painless whitlows are an essential feature. The perforating 
ulcer of locomotor ataxy is another example of tissue-necrosis due to 
changes in the peripheral sensory nerves. Herpes has been observed as 
a complication of gangrene. Whatever view be taken of the existence of 
trophic nerves, the important fact remains that disturbances of the normal 
nervous influences, vaso-motor and sensory, of the skin directly modify 
the nutrition of the parts, and interfere with the defensive action of the 
organism against microbic invasion. 
Raynaud's Disease is a local asphyxia which is often followed by 
symmetrical dry gangrene of the extremities. The observer after whom 
the disease is named considered it to be due to constriction of the small 
arteries owing to vaso-motor spasm. A number of cases, however, have 
been brought forward showing endarteritis obliterans. [TT'de art. 
Raynaud's Disease.] It is possible also that acute perforating ulcer of 
the stomach may be induced by reflex vaso-motor spasm. 
(b) Lowered Vitality of the Tissues. -Age is relative; the vital reaction 
of cells is partially dependent upon inherited specific properties and 
partially upon present conditions of nutrition. Premature decay of tissue 
may be inherited or acquired, and death ensues as soon as the vital energy 
is unable to cope with the antagonistic influences of its environment. 
Senile decay and death, however, come sooner or later to the healthiest 
tissues in the most favourable surroundings; it comes when the original 
vital capacity is exhausted, when the mainspring of life is worn out. 
Whether then the lowered vitality of the tissues be premature or natural, 
the tendency to necrosis and gangrene is much greater when an im- 
mediate cause exists, such as direct injury or disturbance of nutrition. 
Many diseases are specially liable to be followed by gangrene and bed- 
sores. Gangrene of the scrotum, penis, and even of the nose, has been 
known to occur in cholera (Fagge). In typhoid fever, Liebermeister 
points out that gangrene and necrosis of bone may occur; chancres may 
lead to spreading gangrene, and gonorrhoea to sloughing of the penis. 
Bed-sores are very apt to arise even during convalescence. During and 
following typhus fever gangrene is not infrequent, and noma of the 
cheek and vulva is not uncommon after measles. Gangrenous dermatitis 
occasionally occurs in ill-nourished, tuberculous or syphilitic children. 
[Vide arts. Varicella, Vaccinia.] All these consequences are due to 
lowered vital resistance engendered by the disease, to lowered defence 
of the tissues against microbic infection and multiplication, so that 
microbes gaining entrance to the tissue find a suitable soil for develop- 
ment. 
Gangrene of the Lung [yide art. Lung] ; Gangrene of Extremities [yide 
Diabetes]. See also Phagadcena Tropica. 
The entrance of certain poisons into the blood - e.g. ergot of rye, 
anthrax, snake poison, plague micro-organisms - is followed by necrosis. 
With regard to ergot it has been supposed that this is due to constric- 
tion of the small arterioles by the poison; but instead of the arterial 
pressure being increased, it is diminished. No doubt many factors are 
173 174 
SYSTEM OF MEDICINE 
at work in the gangrene of ergotism. Acute necrosis of the jaw in 
phosphorus poisoning may also be mentioned. 
Secondary Gangrenes. - The presence of gangrene in one part of the 
body may be followed by secondary foci elsewhere. They generally appear 
in the lung conveyed by an embolic process. It is obvious that the 
parts most open to infection by the microbes present in the environ- 
ment are most liable to a gangrenous inflammation. Therefore gangrene 
especially occurs when the parts affected are in relation to the alimentary 
canal, the respiratory tract, and the external skin. It only occurs 
in the nervous system in cases where profound infective ulceration 
has penetrated the dura mater. It hardly ever occurs in the liver, 
spleen, kidneys or bones: it generally spreads, but its progress may be 
arrested by antiseptics and the actual cautery. Eschars produced by 
physical or chemical agents in healthy people do not spread, as a rule, 
because the tissues are destroyed or form an unsuitable soil for the 
development of micro-organisms. 
Morbid Anatomy and Pathology of the Different Forms 
of Necrosis 
i. Coagulation Necrosis.-Weigert has shown that when a part of 
the body rich in protoplasm dies, it usually undergoes coagulation 
necrosis. In order that coagulation may take place a coagulable 
material must be present. In all parenchymatous tissues, except the 
brain, the intercellular fluid is coagulable lymph. When cells die from 
arrest of nutrition,, as in embolism and thrombosis, the first evidence of 
death is a change in the appearance of the nucleus and chromatic sub- 
stance:'when the organ has been washed free from blood by normal 
saline solution there are practically no naked eye appearances of a recent 
infarct; but examined microscopically it is found that the cells or cellular 
structures do not stain with haematoxylon, and that the nuclei have either 
altered in appearance or disappeared. Halliburton has shown that he 
can prepare from many tissues a nucleo-albuminous substance, which 
rapidly brings about coagulation of blood or lymph. The cells deprived 
of nutrition die, liberating a nucleo-albuminous material, and this reacting 
upon the coagulable lymph that has penetrated from without, produces a 
coagulation within the cell. Cohnheim, who gave the name of coagulation 
necrosis to this necrotic change, considered it to be due to the interaction 
of the fibrino-plastin and fibrinogen. The process of arrest of nutrition 
must not be too protracted, or degenerative processes, such as fatty change, 
may ensue and render the process of coagulation impossible. The pro- 
toplasm of the cells which have undergone coagulation necrosis somewhat 
resembles coagulated fibrin in appearance. Often small, transparent, 
hyaline masses are seen, and sometimes the cells have a homogeneous 
appearance. The nucleus may be indistinct, absent, swollen up, finely 
granular, or confused with the contents of the cell. Later the products of THE GENERAL PATHOLOGY OF NUTRITION 
175 
necrosis disintegrate and are absorbed. According to Weigert, these 
appearances are found in white infarcts, atheroma, caseous degeneration 
of tumours and glands, waxy degeneration of muscle, and the superfi- 
cial necrosis of the tissues in diphtheria. 
Waxy degeneration of muscle (Zenker) is an example of coagulation 
necrosis. After death muscle fibre invariably coagulates, but preserves 
its striation. Under various pathological conditions, such as continued 
fever, certain muscles (e.g. rectus abdominis) undergo a peculiar change. 
To the naked eye the fibres appear dull and semi-opaque; micro- 
scopically they are found to have lost their striated appearance, the 
contents of the sarcolemma are broken up into lustrous homogeneous 
lumps, and between the fibres there is a proliferation of the connective 
tissue cells. 
2. Colliquative Necrosis. - Sometimes the dead tissue elements are in- 
filtrated with a serous effusion, and then undergo liquefaction. In a burn 
the cells are killed by the action of the heat, and with them the ferment 
that would produce coagulation of the transudation of the blood. The 
dead cells absorb the fluid and swell up, forming a vesicle; or, if the 
blood be coagulated in the vessels, non-coagulable serum will escape and 
produce liquefaction of the tissues. Colliquation may follow upon 
coagulation. In croupous pneumonia the liquefaction of the coagulated 
products is probably owing to the action of organised ferments. 
Thrombi also break down and liquefy. In the brain colliquative necrosis 
occurs as the result of vascular occlusion ; the tissues undergo softening 
and are rapidly destroyed. The cerebro-spinal fluid, which probably 
represents the lymph of the central nervous system, is a non-coagulable 
fluid. Hence liquefaction instead of coagulation of the tissues results, 
and the final part of the process may be the formation of a cyst or 
cicatrix. 
3. Fat Necrosis. - Balzer first described this condition in the 
pancreas and surrounding mesentery. Fitz has shown that it is con- 
nected with acute pancreatitis. Whether it be due to a change pro- 
duced by the steapsin on the fat and to the extension of inflammation 
from the pancreas, or, as Rolleston suggests, trophic in origin and due to 
disturbance of the abdominal sympathetic, is not decided; but I am of 
opinion, from two cases which I have recently seen of acute pancreatitis 
with fat necrosis, that the process is due to infective micro-organisms. 
4. Caseation or Tyrosis is a mode of termination of necrosis. 
5. Gangrene or Septic Necrosis, of whatever form, is preceded or 
accompanied by abnormal sensations in the part. It may be coldness or 
a dull aching, not infrequently severely lancinating or burning. When 
the integument is involved the pain is more intense, and when an in- 
ternal organ is affected it may be absent. 
Varieties of Gangrene. -Dry -or mummification. Spontaneous gan- 
grene is very liable to occur in old people with atheromatous or calcified 
arteries. It is limited in extent and chronic in progress. Several causes 
usually combine to bring about the morbid process: of these are enfeebled 176 
SYSTEM OF MEDICINE 
circulation, due to cardiac failure in a remote and dependent part of the 
body, as the toes or foot, rarely the fingers; and the diseased condition of 
the arterial wall, by which a gradually extending thrombosis is favoured. 
The thrombus may extend as far as the popliteal artery, and yet the 
gangrene be limited to the toes or a portion of the foot. Stasis in the 
arteries and capillaries of the part, due to feebleness of propulsion, pro- 
duces the gangrene; and this stasis may be determined by slight injury 
or abrasion, the cutting of a corn, or any such cause of local inflamma- 
tion. Putrefactive organisms may be present in the skin, but they 
require moisture to develop in the tissues: this they do not get, be- 
cause it evaporates from the surface, especially when the skin separates 
and peels off. As putrefaction cannot take place there is little or no 
odour in this form of gangrene. Frost-bite and ergotism lead to mummi- 
fication, and a physiological example of the process is the necrosis of the 
umbilical cord. The affected part is generally livid, owing to the con- 
tained blood, and the changes in colour are due to its alteration: it be- 
comes withered, black and dry because no more fluid reaches the part, 
and the remainder evaporates. An inflammatory zone - the line of 
demarcation - separates the dead part from the healthy. Occasionally 
dry gangrene may go on to moist gangrene; the latter is a necrosis 
accompanied by putrefaction, and is especially apt to occur in situa- 
tions which are in direct or in indirect communication with the air, e.g. 
in the lungs, the alimentary canal or the integuments. When septic 
micro-organisms reach a necrotic part rich in blood, or other fluid, de- 
composition rapidly sets in, and changes occur in the colour of the part, 
which assumes a bluish, livid appearance; the epidermis is frequently 
raised into bullae and blebs, and a very foul odour arises, due to the 
formation of various gases which sometimes produce emphysema. 
One form of gangrene, the acute spreading, is due to a specific micro- 
organism. The tissues undergo destruction unequally: the blood and 
softer tissues are first broken up; and, if examined microscopically, 
broken up blood corpuscles are found, colouring the part, and undergo- 
ing transformation into granular pigmentary derivatives of hsemoglobin. 
The cell-nuclei disappear, and the protoplasm is turbid and breaking up 
into granules. Muscle fibres lose their striation, and the sarcolemma 
contains only fatty and granular matters. The connective tissue fibres, 
owing to the swelling up of the interfibrillary substance, break up into 
their primitive fibrillae. 
Nerves, owing to their fibrous tissue sheaths, resist dissolution much 
longer than muscles; but the nerve fibres themselves at a very early 
period undergo changes in the myelin sheath similar to degeneration. 
Among the chemical products of decomposition are large quantities- of 
fat which arise even in tissues where there is no fat, such as the lung. 
Fatty acids-caproic, caprylic, butyric, valerianic-are formed to which, 
and to ammonium sulphide and hydrogen sulphide, the foul odour 
is in great measure due. Microscopic examination of the dirty gray, 
grayish black, or yellowish gray semi-fluid mass into which the tissues THE GENERAL PATHOLOGY OF NUTRITION 
177 
are eventually changed, might show crystals of tirosin, leucin balls, 
characteristic needles of margarine, and triple phosphates with gran- 
ules of black or brown pigment. Virchow has shown that a rosy colour 
can be obtained by the action of nitric acid upon a gangrenous part - 
the " erythro-proteid reaction." Unless surgery intervene, the powers 
of the individual to cope with moist gangrene are insufficient; the 
organisms are diffused by the lymphatics, and finding a suitable soil 
with warmth and moisture, they grow more rapidly than they can be 
destroyed by the phagocytes. 
Impaired Nutrition.1 - It has been shown that permanent arrest 
of nutrition causes cessation of function and death of a tissue. We 
have now to consider those morbid processes in wdiich impairment of 
nutrition and a proportional diminution of function ensues. "A cell is 
not nourished, but nourishes itself." Tissues will, therefore, undergo 
atrophy or degeneration when their component cells are unable to 
maintain equilibrium between repair and wraste. The main factors of 
impaired nutrition of tissues are - 
1. Absence or recession of the normal physiological stimulus. 
2. Inherent defect of the cell elements to nourish themselves, therefore 
premature decay. 
3. Deficiency in the quality or quantity of the blood and lymph supply. 
Any of these factors, singly or combined, may lead to a rapid or 
gradual retrogressive change of the tissue elements terminating in atro- 
phy and degeneration (both stages towards death); and in some cases 
the nutritional changes are so extreme that death of the tissue elements 
does occur. Morbid retrogressive nutritional changes occurring in the 
master tissues - glandular, muscular, or nervous - and in the vessels, 
must of necessity be progressive and cumulative, and sooner or later 
lead to somatic death. 
Several abnormal products may arise in the tissues as the result of 
impaired nutrition. These substances may originate within the cell ele- 
ments of the tissue from the destructive metabolism of its protoplasm, 
or be brought by the blood and deposited in the tissue; thus the pro- 
cesses of degeneration are divided into two groups - metamorphoses, or 
degenerations proper, and infiltrations. The two conditions are often 
associated, and to draw a hard and fast line between them is difficult. 
The metamorphoses are fatty, mucoid, colloid, and lardaceous or 
amyloid. The normal metabolism of the cell is altered, resulting in 
chemical and histological changes of its protoplasm, and the metamor- 
phosis may continue until the cell is entirely destroyed. In the earlier 
stages function is impaired, and in the later stages it may be completely 
arrested. 
The infiltrations are fatty, calcareous, and pigmentary; the new 
material is not a product of the cell protoplasm, but a deposition from 
1 For the effect upon nutrition of inflammatory processes, vide article " Inflamma- 
tion " ; in which also atrophic processes arising from inflammatory action are dealt with. 
N 
VOL. I 178 
SYSTEM OF MEDICINE 
the blood. Since the change is not usually accompanied by destruction 
of the histological elements, the structure and function of the tissues are 
much less altered than in the metamorphoses. 
ATROPHY AND FIBROSIS. - The various examples of arrested 
development-such as microcephaly, anencephaly, amyelia, and con- 
genital malformations - are not, properly speaking, atrophic processes 
due to impaired nutrition, but rather to an inherited developmental 
defect; so that to them the term Agenesis is more appropriate. The 
peculiar condition termed by Virchow Hypoplasia or Aplasia, observed 
frequently in chlorotic girls, is associated with imperfect development 
of the aorta and larger arteries, accompanied by a remarkable degree of 
elasticity. The heart is frequently dilated and the left ventricle hyper- 
trophied. These cardio-vascular conditions are associated with imper- 
fect development of the uterus and genital organs. 
Atrophy from absence or recession of the normal physiological stimulus. 
- There are many examples of physiological disuse atrophies, e.g. of the 
ductus arteriosus, the ductus venosus, the thymus gland, and the invo- 
lution of the gravid uterus after parturition. Nutrition and functional 
activity are interdependent, the two falling off together. The muscles 
and glands offer excellent examples of tissues which undergo atrophy 
from disuse; and bones likewise which no longer subserve the statical 
purposes of the organism - a familiar example of which is the wasting 
of the alveolar portion of toothless jaws. An example of disuse atrophy 
in the viscera is afforded after left lumbar colotomy by the dwindling of 
the large bowel to a scarcely pervious cord. 
Cohnheim states - " Nor is it all important whether the failure of a 
muscle to contract or of a gland to secrete be caused by defective inner- 
vation or by occlusion of its duct." He attributes the greatest share in 
the atrophy to the abeyance of functions. No doubt the falling off in 
volume of the thigh muscles which occurs in ankylosis of the knee-joint 
is very great, but experiments upon animals made by Dr. Sherrington1 
and myself lead us to believe that the atrophy of the muscles and 
reaction of degeneration which occur in infantile paralysis are some- 
thing more than the effect of disuse; and that the muscles depend for 
their nutrition upon a physiological stimulus which is continually pass- 
ing from the anterior horn cells of the spinal cord by the anterior roots 
and motor fibres of the muscles. If the posterior roots of the lumbo- 
sacral plexus, or of the cervico-brachial plexus, be divided proximal to 
the ganglion, the apaesthetic limb is not moved by the animal (even after 
the lapse of months), there is loss of tonus in the muscle, and a disuse 
atrophy, yet apparently no degeneration occurs; the muscles can still be 
made to contract by stimulation of appropriate regions of the cortex 
cerebri, or of the nerves going to the muscles, as readily, if not more so, 
than on the uninjured side. If the anterior roots had been divided the 
1 " Experiments upon the influence of sensory nerves upon movement and nutrition 
of the limbs," Proceedings of the Royal Society, vol. Ivii., by F. W. Mott, M.D., and 
C. S. Sherrington, M.D., F.R.S. THE GENERAL PATHOLOGY OF NUTRITION 
179 
muscles would have degenerated more rapidly, and no such results from 
stimulation could have been obtained. The atrophic effects are still 
more marked if both anterior and posterior roots are divided. 
It is necessary to mention a few examples of correlative atrophy due 
to absence or recession of the normal physiological stimulus after ampu- 
tation of limbs, especially when this has occurred in utero. Atrophy of 
the tracts and centres in the spinal cord and brain, which are concerned 
with the innervation of the part, may occur. Thus there is atrophy of 
the posterior column of the same side and of the antero-lateral of the 
opposite, and of that portion of the cortex cerebri which is normally 
concerned in voluntary movements of the limb. Atrophy of the frontal 
lobe of the left hemisphere has been found associated with atrophy of 
the opposite lateral lobe of the cerebellum. Atrophy of the fillet and 
the posterior column nuclei has resulted from porencephalon of the cen- 
tral convolution of the cortex cerebri. 
Atrophy of structures which undergo premature decay owing to 
inherent defect of the cell elements adequately to nourish themselves.- 
Deference to the articles on " Primary Progressive Myopathic (Pseudo- 
hypertrophic) Paralysis," and to "Friedreich's Disease," will show that 
the only etiological factor which has been definitely shown to have 
a causal relation to atrophy of muscle and nervous elements in these 
diseases respectively is heredity. Facial hemiatrophy and scleroderma 
from their distribution would suggest a tropho-neurosis, although some 
authorities consider the condition as a primary wasting of the connec- 
tive tissue structures for which no reason is known. 
It is probable that inherent defect of the cells to nourish themselves 
is the determining cause of atrophy and degeneration, when the nutrient 
supply of the tissue is deficient in quantity or altered in quality. These 
two factors co-exist, and may occasion a general atrophic or degenerative 
process in one or more of the master tissues of the body. 
When glandular, muscular, or nervous tissues begin to undergo 
nutritional change and decay, the effects become progressive and cumu- 
lative in proportion to the functional importance of the organ or tissue 
to the general nutrition of the body: for this reason in death from dis- 
ease we seldom find the morbid change limited to one organ. 
In all those chronic degenerative affections of tissues occasioned by 
such extrinsic causes as alcohol, accumulation of nitrogenous waste prod- 
ucts in the blood, syphilis, and other toxic agencies (e.g. lead, etc.), 
the degenerative process may commence simultaneously in a number of 
different tissue elements - glandular, muscular, nervous and cardio- 
vascular : as we have less reason to believe that the above-mentioned 
extrinsic factors vary than the intrinsic, we must look to other causes 
for determining the seat in which the toxic agent will primarily produce 
the atrophy and decay. These causes may be found in the occupation 
and habits of the individual.1 Given stress upon an organ or tissue, plus 
1 Edinger has lately pointed out the importance of the occupation and habits of the 
individual in determining the primary seat of the degenerations of the nervous system, 180 
SYSTEM OF MEDICINE 
defective quality and quantity of nutrient supply, degeneration ensues. 
When, therefore, owing to changes in the blood and changes in the 
cardio-vascular system, waste is in excess of repair, atrophy and degen- 
eration must occur. 
Hereditary factors play a very important part in determining the 
primary seat of decay; and experience teaches that the more these fac- 
tors enter into the equation of life, the more the value of x (the life of 
the individual) proportionately sinks; by no art of the physician can 
they be removed or modified. On the other hand, toxins can be coun- 
teracted by antitoxins, and injurious occupations and habits can be 
modified or abandoned. Rarely does one of these etiological factors act 
alone; as rarely are degeneration and atrophy found limited to a single 
organ or tissue, and the present discussion among pathologists whether 
atrophy of nervous, glandular or muscular elements be primary or be 
secondary to the fibrous and vascular change, is of value in showing that 
the older pathologists were wrong in assuming that the associated fibrous 
and vascular changes are in all cases the primary cause of the atrophy; 
it is probably as erroneous to assume that the converse is invariably the 
order. 
As inflammatory stasis, thrombosis and embolism may cause necrosis, 
so may chronic degenerative changes in the cardio-vascular system be 
the primary factor in many instances of impaired nutrition and decay; 
although here again we are met by the argument that arterio-sclerosis 
is itself a primary degenerative process, and the associated inflamma- 
tory changes secondary. Cirrhosis of the liver is usually cited as an 
example of an organ which undergoes a primary irritative hyperplasia 
of the fixed connective tissue elements, by the cicatrisation of which the 
epithelial cells are gradually strangled and undergo atrophy from default 
of nutrition. Even in the hypertrophied stage, however, degenerative 
changes may have begun in the liver cells, and this is likely enough, 
seeing that they are only separated by delicate capillary walls from 
the blood containing the toxic agent. It must, however, be conceded 
that the liver cells depend upon the portal blood (which contains the 
toxic agent) for their functional activity, and upon the blood of the 
hepatic artery for nutrition. The liver is accordingly a debateable 
ground of these rival views. I am in favour of the view that the 
greater proportion of atrophic degenerative processes are due to primary 
retrogressive nutritional changes of the specialised cell elements. The 
more highly specialised in function an organ or a tissue the larger the 
more especially in tabes and neuritis. He instances the frequency of ataxy in occupations 
involving much standing; as in officers, railway officials, etc. The relations of overwork 
of the brain to the production of general paralysis has often been asserted. Amyotrophic 
lateral sclerosis very frequently commences in the legs, but recently I have investigated 
two cases in which, apparently, occupation determined the seat of the initial symptons in 
the hand and arm of the right side. One patient was a cooper who wielded all day long 
a 4-lb. hammer; the other a woman who earned her living by sewing. It is usually the 
right hand which is first affected in lead palsy with wrist drop. I have lately emphasised 
the importance of rest in preventing a localised paralysis in diphtheria from becoming 
generalised.- Vide International Journal of Clinics, 1895. THE GENERAL PATHOLOGY OF NUTRITION 
181 
supply of nutriment, and the more likely are tissues of great physiologi- 
cal activity to undergo degeneration. The cell elements of special func- 
tion, when destroyed, are unable to regenerate, and repair by fibrous 
tissue takes place. This is particularly well shown in the central nervous 
system. Systemic sclerosis of a small but defined tract of the spinal 
cord or brain can be produced experimentally by cutting off the fibre of 
an afferent or efferent tract from the cells of which these fibres are but 
outgrowths - e.g. ablation of the thumb area of the cortex cerebri of 
the monkey produces atrophy of a definite number of fibres of the op- 
posite pyramidal tract, which is followed by a corresponding sclerosis 
extending only as far as did the degenerated fibres, viz., to the second 
dorsal segment of the cord. Section of posterior roots proximal to the 
ganglion is followed, in uncomplicated cases, by degeneration and subse- 
quent sclerosis of the posterior column of the same side. The area of 
fibrosis is limited to the defined area which may be microscopic, and has 
absolutely no tendency to spread: it is an attempt at repair; the useless 
waste products of degeneration are removed by phagocytes, and fibrous 
tissue fills up the gap. Many authors now believe that the primary sys- 
temic degenerative processes of the central nervous system - such as 
locomotor ataxy, general paralysis of the insane, lateral sclerosis, amyo- 
trophic lateral sclerosis, progressive muscular atrophy, and the sclerosis 
met with in pellagra, pernicious ansemia and ergotism - are caused by 
nutritional changes in the ganglion cells of the spinal ganglia, spinal 
cord and brain. Golgi1 has shown that every nerve cell possesses one 
process, the " neuron," which becomes the axis cylinder process of a 
nerve; and a number of protoplasmic processes, or dendrons, which serve 
a nutritive function by absorbing the necessary products from the 
lymph space in which they lie. 
Degenerative changes of the cell are manifested by alterations in the 
number and complexity of the " dendrons," and, in the neuron, by a 
reversion to the embryonic character and type, followed by degeneration 
commencing in its terminals and collaterals. 
Atrophic Degeneration of Afferent Tracts of the Central Nervous Sys- 
tem. - Tabes dorsalis is the best example, and there is much to support 
the theory of Marie, that the primary change is a nutritional de- 
fect of the ganglion cells on the posterior root. In this disease the 
afferent fibres of the peripheral and central nervous system suffer, which 
suggests impaired nutrition of the ganglion cells, the outgrowths of 
which form the sensory tracts. In alcoholic neuritis both motor and 
sensory fibres suffer; and if we explain the changes of the peripheral 
nerves in locomotor ataxy by chronic inflammatory changes, why do 
the motor fibres which are bound up with the sensory escape ? why, if it 
1 According to Ramon y Cajal and Lenhossek, the dendrites play the part of con- 
ductors the same as the axis cylinder process. The dendrites are, however, receptive in 
function, whereas the axis cylinder processes are cellulifugal, and if the dendrites do 
represent agents of nutrition, they would only act by increasing the surface of absorption 
of the cell to which they belong. 182 
SYSTEM OF MEDICINE 
be due to a primary vascular change in the spinal cord, should it be con- 
fined to definite tracts of the posterior column ? It is more probable that 
the etiological factor syphilis and the inherited want of durability of the 
sensory nerve cells determine the seat of this morbid change. 
Atrophic Degeneration of Efferent Tracts of the Nervous System. - 
Progressive muscular atrophy, Idiopathic (?) lateral sclerosis, Amyo- 
trophic lateral sclerosis are all dis- 
eases affecting efferent tracts, and 
the primary change is impaired nu- 
trition, degeneration, and atrophy 
of one or both of two sets of gan- 
glion cells and of their outgrowths, 
viz.: - 
1. The large multipolar cells of 
the anterior horns of the spinal cord 
and their axis cylinder processes 
which form the motor nerves. 
2. The large pyramidal cells of 
the central convolutions of the cor- 
tex cerebri and their axis cylinder 
processes which form the pyramidal 
fibres of the spinal cord. 
If the lower segment of the 
motor path be affected the muscles 
also undergo progressive atrophy. 
In most cases of progressive mus- 
cular atrophy the nutritional deg- 
radation of the spinal nerve cell is 
primary, and the pyramidal tract 
changes are secondary. In amyo- 
trophic lateral sclerosis the two pro- 
cesses coexist: they are, however, 
pathologically one and the same. 
The degeneration of the pyramidal 
tracts in amyotrophic lateral sclero- 
sis can only be explained by suppos- 
ing that the disease is a primary 
impairment of nutrition of the 
ganglion cells. Cases have been 
recorded in which all the symptoms 
of lateral sclerosis - exaggerated, 
superficial, and deep reflexes - 
occurred, and yet no sclerosis of the pyramidal tracts; probably only 
the collaterals, in which the axis cylinder processes terminate, were de- 
generated, and thus the physiological connection between the cortical 
centres and the spinal centres was interrupted, (a) Cases have been 
observed in which the degeneration could only be traced (Fig. 5) as 
Fig. 5.-Diagrammatic representation of Cortical 
Pyramidal Cell, with n, neuron, and d, den- 
drons representing the upper segment of the 
voluntary motor-path; Col., collateral passing 
to corpus callosum. Neuron passing through, 
I. C, internal capsule ; C. C, crus cerebri; P, 
pons; Jf, medulla, where decussation occurs' 
The neuron is seen to give off collaterals in 
its course, and to terminate in a fine brush- 
work of collaterals around the dendrons of the 
anterior cornual cell. THE GENERAL PATHOLOGY OF NUTRITION 
183 
Figs. 6 and 7. - Microphotographs of two Pyramidal Cells from a case of General Paralysis of the Insane, 
magnified 400 diameters. The specimen is stained by the Golgi quick method, and the two cells 
were found in the same section at no great distance from one another. Fig. 6 represents a largo 
Pyramidal Cell with its branching dendrons in a fairly healthy condition ; these are connected with 
mossy-looking g\\a cells (or rather lymph spaces surrounding cells), which are seated upon a perivas- 
cular lymphatic. According to Cajal, these cells may act as local vaso-dilators by contraction of 
their pseudopodia. From the middle of the base of the cell is seen a neuron giving off a collateral. 
Fig. 7 is a large Pyramidal Cell undergoing atrophic degeneration. 184 
SYSTEM OF MEDICINE 
far as the medulla, (b) in others as far as the pons, (c) in others as far 
as the crus cerebri, (d) in others whither the fibres of the internal 
capsule were atrophied and the cortical cells had in part disappeared or 
atrophied. 
These facts become intelligible if we suppose that the most remote 
parts of the cell will be the first to suffer from impaired nutrition. 
General paralysis of the insane is probably a similar patholo- 
gical process to tabes and amyotrophic sclerosis, but one affecting 
also the higher centres of the brain. The periencephalitis by many 
authorities, however, is considered as primary [yide article "General 
Paralysis 
Atrophy of the cell elements of glands, as of the kidney, may be due 
to defective blood-supply consequent on change in the arterial walls; 
the very conditions which are said to give rise to changes in the arterial 
walls may likewise cause degenerative change of the epithelial elements: 
yet in those cases in which the kidney is not much shrunken, but in 
which the arterial changes are great, the primary degeneration is prob- 
ably in the arteries, e.g. syphilitic renal disease. In the granular con- 
tracted kidney the opinion that the primary change is a fibrosis, causing 
atrophy of the epithelium of the uriniferous tubules, is being given up in 
favour of the inference that a retrograde nutritive change with secondary 
fibrosis occurs. 
Atrophic Changes of Muscle. - In the heart fibrous tissue is frequently 
found replacing muscular tissue; and this condition is termed fibroid 
heart, as if the fibrous tissue overgrowth were the morbid change that 
produced the atrophy of the muscular fibres. On the contrary, most of 
such cases are primary degenerative atrophy of the muscular fibre owing 
to impaired nutrition. When a branch of the coronary artery is blocked 
by thrombosis or embolism, coagulation necrosis of muscular fibres takes 
place, and myomalacia results. Although insufficient for the specialised 
elements, the nutrient supply of the fibrous tissue is unaffected; it 
receives in fact excess of nutriment, and undergoes a compensatory 
hyperplasia, which really amounts to a process of repair, and should be 
considered as a healing process as much as the fibrous tissue formation 
which unites the two parts of a severed muscle. Perhaps the best 
example of primary atrophy of muscle with secondary fibrous over- 
growth of connective tissue and fat is afforded by Duchenne's paralysis, 
in which pseudo-hypertrophy occurs. Erb's paralysis is the same disease 
in the atrophic form; in it there is no overgrowth of fibrous tissue, but 
atrophy of the muscle only, - a clear proof that the muscular atrophy in 
the former is not consecutive to the fibrous overgrowth. 
Looking upon tissues as composed of living protoplasmic units 
specialised and non-specialised in function - the former endowed with 
high metabolic activities, the latter with low - nearly all the nutriment 
which goes to healthy gland, muscle or nervous matter, is utilised by the 
special cell elements. Where fibrous connective tissue exists alone the 
blood-supply is extremely small and the metabolic exchange trifling; THE GENERAL PATHOLOGY OF NUTRITION 
185 
consequently the connective tissue of an organ with a large vascular 
supply would, by receiving excess of nutriment, undergo hyperplasia 
(yide Hypertrophy) if the specialised element were unable to utilise 
that nutriment. Thus coexistent with atrophy of one there is hyper- 
trophy of the other; the latter resulting from the former, and not the 
converse. For the microscopical changes observed in these organs and 
tissues the reader is referred to the special articles. Pulmonary emphy- 
sema may be mentioned as an example of atrophy of blood-vessels and 
interalveolar connective tissue (particularly the elastic); but this is 
always associated with changes in the epithelium, and generally with 
degenerative conditions in other organs. 
Mechanical Congestion is by some authors regarded as a cause of 
atrophy of the specialised cell elements by un- 
due pressure, e.g. cyanotic atrophy of the liver 
in prolonged mitral disease. 
Fatty Infiltration, side article " Obesity." 
FATTY METAMORPHOSIS.-Fatty degen- 
eration is one of the most frequent and most 
important of the pathological conditions asso- 
ciated with lowering of function and destruc- 
tion of cell protoplasm. It is of especial interest 
to the physician, as it often affects vital organs and tissues, and is the 
cause of death in many diseases and in certain forms of poisoning. 
Fatty metamorphosis of the cell protoplasm may be a physiological 
process - as when the uterus undergoes involution after parturition; or 
the cells of the ruptured Graafian follicle undergo fatty degeneration, 
forming the corpus luteum ; or the central cells of the acini of the mam- 
mary glands form colostrum corpuscles. The above-mentioned instances 
of fatty degeneration show that rapidly proliferating cells will undergo 
retrogressive nutritional change unless supplied with a proportionate 
supply of nutriment. The uterus undergoes this retrogressive meta- 
morphosis because the foetus - the physiological stimulus which deter- 
mines the increased flow of blood to the organ - has been expelled. 
The central cells of the mammary acinus undergo fatty degeneration 
because the peripheral cells require and take all the nutriment. For 
the same reason, probably, fatty degeneration occurs in the centre of 
new growths, especially when they are of rapid formation. 
It is probable that the cells, thus deprived of adequate nutriment, 
behave like the starving animal, and liberate vital energy by using up 
their own protoplasm. In the starving animal, however, there is no de- 
position of fat granules in the cell, but atrophy only. If, however, a 
poison, such as phosphorus or CO, be administered to starving animals, 
then the urea eliminated is increased and fat is formed. Both these 
poisons interfere, as we shall see, with oxidation processes; the former 
by a process not satisfactorily explained, the latter by turning out the 
oxygen from its combination with haemoglobin. The fat which accumu- 
Fig. 8. - Atrophic Liver Cells 
' from Cyanotic Atrophy of the 
Liver in different stages of de- 
generation (x 400 diameters). 
- Hamilton. 186 
SYSTEM OF MEDICINE 
lates in muscle fibres undergoing fatty degeneration is formed for the 
most part out of organ proteid by the splitting up of the latter into an 
amido product which will be oxidised into urea, fat remaining behind if 
there be insufficient oxygen for its combustion. Another source of fat 
may be the decomposition of lecithin; concerning this source, however, 
there is a difference of opinion. 
Experimental Pathology of Fatty Degeneration.-Voit and Bauer 
showed that animals which had been starved, and were eliminating a 
constant of N in the form of urea, after the administration of small doses 
of P, suddenly eliminated a great increase of N; while at the same time 
the oxygen taken in and the CO2 given out were considerably diminished. 
These facts are clearly associated with the macroscopic, microscopic, and 
chemically demonstrable fatty degeneration of the striped muscles, the 
heart, the liver and kidneys. In 100 parts of the dry substance the 
ether extract is 
Healthy Dog. 
Phosphorismus Dog. 
Muscle 
. 16-7 per cent 
42-4 per cent 
Heart 
9-2 „ 
20-4 ,, 
Liver 
10-4 „ 
30-0 ,, 
It might be said that the diminution of 0 intake and CO2 output was 
due to blood destruction, but the experimenters were unable to find 
evidence of this. 
According to Gaule, some of the fat may arise from the formation 
of lecithin. He maintains that the primary change in phosphorus 
poisoning is in the nucelus. According to Krehl, only a very inconsider- 
able portion of the fat in fatty degeneration of the heart arises from this 
source, and the lecithin is not appreciably increased. Slow poisoning by 
carbon monoxide produces fatty degeneration. This gas turns out the 
oxygen, forming a more stable compound with haemoglobin than does 
oxygen, and produces the same effect on the tissues as profound anaemia, 
viz., deprivation of oxygen. But prolonged insufficiency of oxgyen means 
also a lowered vitality of the cell elements; and it may be that the cause 
of the fatty metamorphosis of the cell protoplasm in this form of poison- 
ing as well as in phosphorus poisoning can be thus explained. The fact 
that CO, administered to starving dogs, increases the urea output, shows 
that there is an increase in destruction of organ proteid and deposition 
of fat owing to insufficiency of oxygen. The object of using starved 
animals is, of course, to prove that the increased N must come from 
tissue metamorphosis. But in phosphorismus the same result is not 
explained by alteration of the blood; and in my opinion too little stress 
has been laid upon tissue respiration. We have seen that the cells nour- 
ish themselves and, probably by virtue of nucleo-albumins combined 
with ferric oxide, they have the power of taking up oxygen and storing 
it in the protoplasm. It is possible that P may interfere with this 
oxygen storage by the tissues; hence less oxygen could be taken up by 
the blood, less CO2 given off, and no appreciable change in the haemo- THE GENERAL PATHOLOGY OF NUTRITION 
187 
globin value would be evident. Starving animals from whom large quan- 
tities of blood have been abstracted pass an increased amount of urea.1 
Litten showed that rabbits and guinea-pigs, which had been kept three 
to six days in an atmosphere of 36° C., showed fatty degeneration of 
the heart, the striped muscles, the liver and kidney. This would seem 
to indicate that a high temperature maintained continuously in animals 
which have a relatively low capacity of heat dissipation (thermolysis), 
produces fatty degeneration, and supports the view that fever may pro- 
duce fatty degeneration. Experiments upon such animals as rabbits are 
not always to be accepted as conclusive ; and Naunyn has shown that such 
animals may be kept thirteen days at a temperature of 36° to 40° without 
any fatty metamorphosis, provided they receive abundance of green 
food and the warm chamber be properly ventilated. In fever there is cer- 
tainly increased organ proteid destruction; but according to Krehl, there is 
no parallelism in man between the height of the fever and the fatty degen- 
eration of the muscles. Much would depend upon the effect of the toxins 
upon the muscles, the nerves, and their endings in the muscles. 
Diseases in which Fatty Degeneration Occurs. - In the different grave 
forms of anaemia, particularly pernicious anaemia and haemorrhagic pur- 
pura, fatty degeneration of the muscular substance of the heart occurs, 
whereas other muscles in the body are not affected. It may occur after 
severe haemorrhage. We may then ask, Why should the heart undergo 
this degeneration and other muscles escape ? Several factors seem to be 
at work in producing the metamorphosis of the cell protoplasm. In 
chlorotic anaemia the haemoglobin value of the blood may fall as low as in 
pernicious anaemia; yet in the former fatty metamorphosis seldom, if ever, 
occurs, whereas in fatal cases of the latter it is never absent. Other 
factors then are present besides deficiency of oxygen. In both diseases 
the work done by the heart is increased. In pernicious anaemia there 
must be other causes, possibly one or more of the following: the dim- 
inution of the quantity of blood; the alteration in the quality as shown 
by the great diminution of the specific gravity; the great deficiency 
of iron in the pigment of the blood, and consequent diminution of the 
oxygen carrying value ; and the presence of toxins in the blood. That 
many of these factors act together in producing the metamorphosis of 
the cell protoplasm is clear, and that the heart muscle is selected, and 
the voluntary muscles spared, proves that not the least important factor 
is work with inadequate repair of waste; for while, on the one hand, the 
feeling of languor and indisposition to work, which is a prominent 
symptom of anaemia, imposes rest upon the voluntary muscles, and there- 
fore a lowered metabolism in conformity with the depressed vital activities 
of these tissues, the heart on the other hand must, by its automatic 
activity, do even more work in order to supply the necessary oxygen and 
1 Araki, working in Hoppe Seyler's laboratory, showed that one effect of lessened oxy- 
gen supply was the presence of lactic acid in the urine, sometimes of sugar and albumin. 
Poisoning by CO, curare, and strychnine gave corresponding results, as also after epileptic 
seizures when the respiration was retarded. Diminution of oxidation processes is a factor 
common to all these conditions, and doubtless a primary cause of the abnormal metabolism. 188 
SYSTEM OF MEDICINE 
nutrition for the nervous system. It would be of interest to see if the 
diaphragm is similarly affected j1 for on account of the " air hunger " it 
must do proportionately more work than other striped muscles. There 
are, moreover, certain other facts in pernicious anaemia which support the 
theory of the origin of fat by the disintegration of organ proteid, viz., 
the abundance of subcutaneous fat and the large amount of N eliminated 
by the urine - generally more than can be accounted for by the food. 
Another frequent cause of fatty degeneration of the heart is partial 
occlusion of the coronary arteries by atheroma. A large proportion of the 
cases of fatty degeneration of the heart in people who have passed middle 
age are of this origin. Sometimes one or both coronary arteries maybe 
obstructed with or without valvular disease, and the occlusion may be so 
great that the artery may admit a bristle with difficulty. As one cor- 
onary artery, or a branch of one, may be obstructed, the fatty degener- 
ation may be local, affecting only one side of the heart - more often 
the left which has the most work to do; but the auricles are usually 
not affected in such cases. 
Certain toxic agencies, besides phosphorus and carbon monoxide, pro- 
duce fatty degeneration, viz., arsenic, antimony, sulphuric acid, nitric acid, 
chronic alcoholism and, lastly and most importantly, toxins - the prod- 
ucts of microbic infection and growth. 
Finally, fatty degeneration may be the expression of the gradual run- 
ning down of the vital mechanism : we have supposed that every particle 
of living protoplasm is endowed with a certain amount of endurance, 
and when the limit of the life of the cell is approached, fatty degeneration 
occurs: in this way we can explain the senile fatty metamorphosis of 
cartilage cells and the excess of fuscous pigmentation of the ganglion 
cells of the central nervous system ; most of such pigment being really 
of a fatty nature. We thus see that fatty degeneration is the result of a 
lowered vital activity of the cell or fibre, and the conditions which give 
rise to it are complex, but depend essentially upon - (1) Failure of 
nutrition of the cell, which makes it unable to compensate the waste by 
repair; (2) Breaking down of the cell protoplasm and formation of 
amido antecedents of urea and of fat out of organ proteid; (3) Insuffi- 
ciency of oxygen-supply by the blood, or incapability of the cell itself 
to take up sufficient oxygen to oxidise the fat, hence accumulation of a 
deposit within the cell or fibre. 
Fatty Degeneration of the Nervous System. - We have seen how fat 
can be formed from proteid; can it be formed from lecithin, an important 
constituent of nervous matter ? To this subject I have given particular 
attention, and I shall therefore set forth at some length the reasons why 
I cannot agree with Cohnheim in assuming that lecithin cannot be so 
split up as to form a neutral fat. We know that muscle fibres, when 
separated from their motor nerves, are unable to nourish themselves, and 
are said to undergo fatty degeneration. If such muscles be hardened in 
1 Just before going to press I have examined the diaphragm in a well-marked case of per- 
nicious anaemia, and found a considerable number of fibres undergoing fatty degeneration. THE GENERAL PATHOLOGY OF NUTRITION 
189 
Muller's fluid, and then placed in Marchi's fluid, the fatty deposit will be 
stained black. Ordinary adipose tissue treated in the same manner stains 
black. The fatty matter of the healthy central nervous system does not, 
but if a nerve fibre be cut off from the cell of which it is an outgrowth, 
that nerve fibre undergoes Wallerian degeneration, and both axis cylinder, 
and myelin sheath, when treated by the method mentioned above, stain 
intensely black. The myelin has undergone a chemical change, and the 
staining reaction would seem to show that the product was the same as 
that of degenerated muscle, viz., neutral fat. We know that lecithin 
can easily be decomposed into glycero-phosphoric acid, stearic acid and 
cholm; the radicle glyceryl may unite with stearic acid to form fat, the 
phosphoric acid combine with alkalies, and the cholin be decomposed. 
It appeared to me that if phosphorus were diminished in degenerated 
nervous tissue this decomposition had very likely occurred. I resolved, 
therefore, to ascertain whether this were the case. To obtain absolutely 
fair comparison, I had estimated1 the organic phosphorus contained in 
two halves of spinal cords in which unilateral degenerations had been 
produced in one case experimentally, in the other by disease. A man 
with left hemiplegia from thrombosis of the right middle cerebral artery 
died three weeks after the onset. The spinal cord was stripped of its 
membranes, and divided longitudinally down the middle. The right 
half contained 10'74 per cent of lecithin in the dried ethereal extract: 
the left half 8'15 per cent. If we allow for the direct pyramidal tract, 
which was well marked, the loss of lecithin in the degenerated pyra- 
midal tract coming from the right hemisphere would be about 3 per cent. 
This chemical change is not complete at once after section of the 
nerve fibre; it takes from six to twelve days to obtain the black staining, 
which shows that there is a slow process of disintegration and death. 
In the neighbourhood large numbers of leucocytes can be seen carrying 
away the granules of fat. It is possible that extensive degeneration 
may produce an auto-intoxication; and in many chronic brain diseases 
- such as alcoholic insanity and general paralysis of the insane - the 
lecithin of the brain tissue is greatly reduced in amount (Kowalewsky), 
and the perivascular lymphatic sheaths and subarachnoid are filled with 
fatty products of its disintegration, staining by the Marchi method like 
degenerated nervous matter. 
Toxins, the chemical products of certain pathogenic micro-organisms, 
sometimes produce fatty degeneration of the muscles. Dr. Sidney Mar- 
tin has found intense fatty degeneration of the muscles and segmental 
degeneration of the nerves to result from injection of the diphtheritic 
toxin. I have observed intense fatty degeneration of the heart in a case 
of diphtheritic paralysis, but I could find no degeneration of the nerve 
trunks. It has seemed to me that toxins which produce degeneration 
act either upon the motor endplate like curare, or upon the nerve cell; 
but the effect of the poison is manifested in the former case by fatty 
11 am indebted to Mr. Percy Richards, F.C.S., for making these examinations ; the 
results will be published jointly, and full details given. 190 
SYSTEM OF MEDICINE 
change of the muscle, in the latter by degeneration of the outgrowth of 
the nerve cell (viz., the nerve fibre), as well as of the muscle. Acute 
atrophy of the liver is probably due to microbial infection, and acute 
fatty degeneration of the cells occurs. 
Naked Eye and Microscopical Appearances of Fatty Degeneration. 
The Arteries. -Fatty degeneration in this situation is not of importance 
clinically except when it occurs in the vessels of the central nervous 
system and retina, as it may in poisoning from phosphorus, etc., and in 
the grave anaemias, when it may lead to rupture and haemorrhage. 
The cells in the adventitia of the small vessels of the brain are the 
first to show fat granules collected around their nuclei. Fatty degener- 
ation is seldom met with in the middle-sized arteries, especially those of 
the limbs; it is very common in the aorta, occurring as opaque, whitish 
Fig. 9-Microphotograph of Heart from a fatal case of Diphtheritic 
Paralysis, stained by the Marchi method, showing early fatty 
degeneration. The fine black granules in the fibres are parti- 
cles of fat stained by the osmic acid. Mag. 250. 
Fig. 10. -A few fibres more highly 
magnified, 
streaks or spots scarcely, if at all, elevated above the surface. The fatty 
change occurs in the stellate cells of the subendothelial coat; and the 
tissue thus degenerated may give way so that a very shallow breach of 
the lining surface is produced. 
The Heart. - As before said, the whole muscle substance may be 
affected, or only the inner surface of the heart, which then assumes a 
peculiar pale, streaked appearance, seen especially in the musculi papil- 
lares and columnse carneae of the left ventricle, sometimes in the right 
ventricle, never in the auricle. This form of degeneration is produced 
by less severe nutritional defects of the organ; but when there is marked 
obstruction of the main branches of the coronary artery by atheroma, THE GENERAL PATHOLOGY OF NUTRITLON 
191 
idiopathic anaemia, or phosphorus poisoning, the general form of degen- 
eration of the organ exists. The walls of the organ have a yellowish 
appearance instead of dark red; they are flabby, lacerable, and frequently 
present a " tabby-cat " or " thrush breast" appearance. From a large expe- 
rience in the examination of hearts, I am certain that fatty degeneration 
may be overlooked unless a microscopical examination be made after 
staining with osmic acid. I once thus found the organ, in a case of 
fatal syncope occurring in diphtheritic paralysis, extremely degener- 
ated ; yet the heart had been passed as normal on macroscopic exami- 
nation. It was rather pale and tough but, examined microscopically, 
the muscle fibres were found to be extremely degenerated: the tough- 
ness was possibly due to coagulation necrosis. 
Fig. 11. -Microphotograph of a Section of Liver from a case of Per- 
nicious Anaemia. stained by the Marchi method. The black 
granules and droplets of very varying size seen within the 
liver cells consist of fat stained by the osmic acid. Mag. 300. 
Fig. 12. - A few cells much more highly 
magnified. 
Microscopical Changes in Fatty Degeneration of Muscle Fibres, 
etc. - The fat granules occur first as fine molecules scattered through the 
fibre ; only in advanced cases do they run together in droplets, and even 
there they never form drops (vide Figs. 9 and 10). At first the muscle 
fibres do not lose their striation, but as the process advances the striae 
become less marked, until eventually they may be entirely lost. Ober- 
steiner has recently described a peculiar form of interfibrillary fatty 
degeneration of the muscles of the tongue in a case of tabes dorsalis: the 
hypoglossal nucleus was intact. In the liver cells and renal epithelium 
the fat droplets vary greatly in size, from fine granules up to drops which 
nearly fill the cell; so that it is sometimes extremely difficult to deter- SYSTEM OF MEDICINE 
192 
mine whether the liver cells be the seat of fatty infiltration or degenera- 
tion (yide Figs. 11 and 12). 
Fatty changes in the kidney are common, due to secondary degenera- 
tion of the epithelium and inflammatory products, e.g. large white and 
small white kidneys [vide article " Diseases of Kidney Primary fatty 
degeneration of the cells of the liver and kidney occurs in phosphorus, 
arsenic, and antimony poisoning, especially in the first named. 
Ziegler has pointed out that fatty degeneration may accompany 
lardaceous disease. 
As the cells of the fixed tissues may undergo fatty metamorphosis, 
so may the cells of fluids, e.g. pus cells; and of coagulated fluids, e.g. 
casts. It was once believed that fatty degeneration was the same process 
as the formation of adipocere, but Kraus has shown that aseptic tissues 
can be kept a considerable time without appreciable increase of fat. 
Adipocere is the result of the action of living organisms upon dead tissues, 
like the ripening of cheese; here compounds of the fatty acid series - 
caprylic, caproic, and butyric acids - are formed which unite with am- 
monia and alkalies to form soaps; whereas in fatty degeneration a neu- 
tral fat is formed. 
Fatty degeneration occurs in atheroma [vide article "Diseases of 
Arteries The arcus senilis is usually considered a sign of degeneration. 
It was formerly thought to be a fatty degeneration occurring in the cornea; 
but it is shown to be a deposit of matter (fat or colloid material staining 
black with osmic acid) in the lymph spaces. It very probably comes 
from elsewhere; as it has been met with in fat young women, it is not 
a definite sign of degeneration. Fat in cells or tissues can be recognised 
microscopically by the colourless, highly refractive droplets with a dark 
contour, insoluble in acetic acid, soluble in alcohol and ether. They 
stain black with osmic acid. There is no reliable means of distinguishing 
fatty accumulation within a cell from fatty degeneration. In the latter 
stages of fatty degeneration, when the cells are dead and in great part 
destroyed, the whole tissue may be broken down into an opaque yellowish 
white detritus such as occurs in atheroma. In the debris are found 
characteristic crystals of cholesterine - rhombic in shape, with a corner 
notched out - and feathery crystals of margarine. 
Cloudy Swelling, parenchymatous or granular degeneration or albumi- 
Fig. 13. - Cloudy Swelling of Liver Cells 
(x 350 diameters). -Hamilton. 
Fig. 14. - Same treated with acetic acid, 
-Hamilton. 
nous infiltration, is a condition which often precedes fatty degeneration, 
and was first described by Virchow as affecting the special cell elements of THE GENERAL PATHOLOGY OF NUTRITLON 
193 
organs in a state of parenchymatous inflammation. It is a chemical and 
structural change in the protoplasm of the cell, or fibre, which becomes 
swollen and indistinct in outline and structure; the nucleus also is ob- 
scured by the precipitation of fine granules of an albuminous nature 
(vide'Figs. 13 and 14). These granules are feebly reactive to light, 
hence dusky in appearance; they are not stained by osmic acid, nor are 
they soluble in ether, but they dissolve in dilute acetic acid and caustic 
potash: they cannot be fat therefore, although fat granules often 
coexist as the morbid process advances. It occurs with especial fre- 
quency in the specific fevers - typhoid, diphtheria, scarlet fever, etc. - 
and especially affects the liver, kidneys, heart, and voluntary muscle 
fibres; but probably all protoplasmic structures suffer. The change is 
not due to the pyrexia per se, but in all probability to the action of the 
toxins which are producing the fever. Cloudy swelling is the first 
change noticeable in poisoning by phosphorus, arsenic, antimony, carbon 
monoxide, and the mineral acids, thus preceding the fatty degeneration. 
To the naked eye the organs appear swollen and frequently anaemic; 
the tissue often has a lustreless appearance, but it is softer than natural. 
The change is well marked in the liver, but its most serious effect is 
upon the heart: the muscle fibres become slightly opaque, pale, soft, 
finely granular, and their striae indistinct; such a condition is frequently 
found in acute myocarditis. 
In acute desquamative nephritis the epithelial elements of the urin- 
iferous tubules, especially of the cortex, undergo cloudy swelling which 
terminates very often in fatty degeneration. 
Calcareous Degeneration. - The blood, the lymph, and most of the 
tissues of the body contain lime salts; two-thirds of the weight of bone 
is made up of earthy matter. Calcareous deposition in a tissue may, 
therefore, be due to precipitation of the lime contained in the tissue, to 
precipitation of lime normally contained in the blood and lymph, or to 
excess of lime circulating therein, derived from disintegrative processes 
occurring in bone (e.g. caries, osteomalacia, or senile atrophy). Deposi- 
tion from this last cause is termed metastatic. 
Calcification of a tissue is most frequently a sign of senescence; it 
occurs generally in dead or dying tissue. It is not, however, exclusively 
an attribute of old age, for it has been known to occur in early life or 
childhood; a remarkable case has been described of calcification of 
the middle-sized and smaller arteries in a lad the subject of dorsal 
caries: calcification does not indeed necessarily depend upon the age 
of the part, as it may occur in the foetal tissues of the placenta. 
It is very prone to occur in dead tissue, and Litten has shown that 
the process of calcification is intimately associated with coagulation of 
the albumin of the tissue. "If the renal artery in an animal be 
ligatured, and the ligature removed after an hour and a half, so as to 
allow the circulation to return, the only noticeable change is an exuda- 
tion of albuminous substance into the Malpighian bodies. When the 
blood has continued to flow for twenty-four hours there is a precipita- 
o 
VOL. I SYSTEM OF MEDICINE 
194 
tion of calcareous salts to such an extent that the organ may become 
as hard as stone." 
Calcareous deposits contain calcium phosphate (Ca^PO^ traces of 
carbonate and minute quantities of magnesium phosphate and carbonate 
- sometimes very minute quantities of fluoride of calcium and 'oxide 
of iron. The mineral matter, therefore, corresponds closely with that 
of bone. Calcified tissues are readily distinguished from true bone by 
the fact that when acted upon by HC1 and the lime salts thus dissolved 
out, bone corpuscles and lamellae are seen to be absent. 
Appearances: (1) Macroscopic Examination. - Calcified tissue often 
feels and looks like bone; it breaks with an irregular surface, and presents 
a yellowish and grayish aspect; this is the case when it occurs in plates 
or spicules, but owing to simultaneous fatty degeneration of the tissue 
it may have a mortar-like appearance and consistence: small whitish or 
yellowish concretions of varying size and form may be seen and felt in 
the soft detritus (e.g. in caseating glands and atheroma). 
(2) Microscopic Examination.-The infiltration of the lime salts occurs 
both within the cells and in the intercellular substance, especially in 
the latter situation, where they first made their appearance as a fine 
precipitate of opaque, round or irregular granules, which look black by 
transmitted light. As the process advances these increase in number, 
until ultimately the structure of the tissue may be lost. Thus portions 
of tissue may be converted into masses having a black, irregular outline 
and a homogeneous, glistening appearance. Usually the cell elements 
of the tissue are enclosed and obscured by the precipitated lime salts; 
but in some situations (e.g. the brain) the ganglion cells are the seat of 
deposition. The deposition within cells is best studied in this situation. 
The granules look like highly refractive particles, and are soluble with- 
out development of gases in HC1. The nucleus remains free from the 
deposit, but gradually diminishes in size as the lime accumulates within 
the cell. The dendrons are often affected, the neuron very seldom. 
Calcification of the ganglion cells has been found in fractures of the 
skull, not due, however, to excess of lime in the blood (metastasis) so 
much as to death of the nerve cells and alterations in the circulation. 
Causes of Calcareous Precipitation. - If the lime salts be held in solu- 
tion by the carbon dioxide present in the blood and lymph, then lowered 
metabolism of the tissues, and enfeebled circulation, such as occur in 
senile decay, would by default of carbonic acid favour precipitation of 
the calcareous salts of the lymph; there is some evidence in favour of 
this hypothesis: arteries are extremely liable to calcification of their 
walls, veins are not. Incrustation of the walls of the left heart is com- 
mon, of the right heart not; calcification of the renal glomeruli which 
normally contain arterial blood is common. Since the CO2 tension in the 
pulmonary veins is extremely low, and yet calcification is never seen in 
them, there must be other factors which cause precipitation of the lime 
salts in arteries; such are all conditions which lower or destroy the 
vital endurance of the tissues forming the walls - occupation involv- THE GENERAL PATHOLOGY OF NUTRITION 
ing mechanical strain, diseases associated with high arterial tension, 
toxic conditions of the blood (e.g. alcohol and syphilis), and lastly old 
age. 
Calcification is very liable to occur in dead, dying or decaying 
tissues; it is often found associated with or following fatty degeneration, 
especially caseation; e.g. atheroma, caseous tubercular glands, caseating 
foci in the lungs, and old infarctions. Many new growths undergo 
calcification in the centre, where nutrition is impaired, e.g. sarcoma 
of muscle, fibro-myomata of uterus, carcinomata, psammomata and 
endotheliomata of the dura mater. Calcification of old inflammatory 
products, especially when occurring on serous membranes, is not un- 
common ; and we can thus account for the calcareous plates met with 
in the pleura, pericardium and peritoneum. The muscular walls of the 
heart and granulations resulting from valvular endocarditis often are 
the seat of calcareous deposition; likewise phleboliths of varicose veins 
are probably calcified granulations or thrombi. 
Dead tissues lying in the midst of living tissues are prone to calcifi- 
cation and petrification, e.g. lithopeedium of extra-uterine gestation. 
Calcareous infiltration occurs in process of time in abnormal or 
vitiated secretions of organs. Calcareous concretions are thus met with 
in the salivary glands, pancreas, tonsil, articulations, and synovial 
sheaths; and in the interior of cysts (particularly colloid cysts) of the 
thyroid and kidney. 
Results. - As a rule calcification is associated with death of the 
tissue and loss of function; it is not a cause, but an effect, and always 
means lowered vitality if not death of the tissue. Calcification of 
muscle fibres does not necessarily mean necrosis, but it indicates great 
depression of function. 
Calcareous deposition may be salutary, e.g. when calcification of the 
inflammatory products surrounding parasites (such as trichinse of muscle, 
pentastoma dent., and echinococcus of the liver) encapsulate the parasite, 
and either render it inert until the capsule is dissolved in the stomach of 
another animal, or until it is actually infiltrated with lime and destroyed. 
Calcification of the cartilages of old people is not at all uncommon; 
it is met with in the larynx, trachea and rib cartilages; it is, however, 
a provisional process prior to ossification. Likewise inflammation or 
disease of cartilage may be followed by vascularisation and ossification. 
The comparatively frequent occurrence of bony anchylosis in old people 
proves clearly enough that if the joints once become fixed from patho- 
logical causes, ossification of the articular cartilages will occur. 
Pigmentary Degeneration.-The pigments found in the tissues •are - 
(1) Intrinsic - those which normally exist in the body or arise from pig- 
ments already in the body. These pigments are either derived from the 
colouring matter in the blood - hematogenous, or are non Jiematog enous. 
(2) Extrinsic - those which enter the body by the lungs, skin, or 
alimentary canal. 
A pigment containing sulphur, which is probably non-heematogenous, 
195 196 
SYSTEM OF MEDICINE 
is a normal constituent of the skin in some races and individuals, and 
consists of blackish or brownish granules contained in the deeper cells 
of the "rete Malpighii." Under certain circumstances this pigment is 
increased; for instance, round the nipples in pregnancy and in parts of 
the skin exposed to the air, and especially to the sun's rays. Intensi- 
fication of the normal pigment of the skin is met with in certain 
pathological conditions; notably in Addison's disease, scleroderma, 
leprosy, tuberculosis, and the cancerous cachexia. In wasting diseases 
generally the fat has a deep yellow colour, and the muscle assumes a 
deep brownish-red appearance, due to intensification of the normal 
pigment. The pigmentation of the skin in Addison's disease, in 
leprosy, and in scleroderma is probably due to changes in the nervous 
system (vide special articles). Leloir has shown that an atrophy of 
nerve fibres occurs in parts affected with vitiligo. i 
According to Unna, the epidermis may take on a brown colour by 
keratinization, a process in which water and oxygen are taken from the 
cells, and the sulphur relatively increased thereby. He thus accounts 
for the pigmented appearance presented by the skin in icthyosis and 
xeroderma. 
Hoematogenous pigmentation. - A certain number of pigments met 
with in the body are certainly derived from the blood pigment, viz., the 
bile pigments, bilirubin and biliverdin, urobilin (which is identical with 
hydrobilirubin) and haematoidin. In pernicious anaemia the peculiar 
old wax appearance is in part due to urobilin jaundice. All these pig- 
ments are iron free, and give a play of colours with fuming nitric acid. 
When blood corpuscles undergo destruction, as in large extravasations 
of blood, two substances may be formed - (a) Haemosiderin and (6) 
Haematoidin. The former substance, containing iron, turns black with 
ammonium sulphide, and gives the prussian blue reaction with ferro- 
cyanide of potassium acidulated with hydrochloric acid; it takes the 
form of granules of varying size which are frequently found within 
leucocytes. Haemosiderin may also be found in the renal epithelium, 
in the fixed cells of the connective tissue, and also in lymph channels 
and lymphatic glands, whither it is carried by leucocytes. Organs 
which are allowed to undergo putrefaction, and contain a large quantity 
of haemosiderin, turn black owing to formation of sulphide of iron. 
This often happens in pernicious anaemia, where a very large amount 
of this substance is found in the liver owing to disintegration of the red 
corpuscles. Haemosiderin in large quantities may be found in the liver 
and spleen in severe forms of malaria, owing to the destruction of the 
red coTpuscles, and from the action on the blood of certain poisons, such 
as arseniuretted hydrogen and toluyl-endiamine. 
Hoematoidin, a pigment which is iron free, may be formed from 
extravasated blood, e.g. in apoplexy. The brain substance in the 
neighbourhood of the haemorrhage is stained an orange-red colour, 
and microscopical examination reveals minute orange rhombic plates or 
granules of haematoidin. The deposit of pigment in the skin from Fig. 1. ffaernaloeddi' Crystals 
from old haemorrhage 
into the brain x400Dirvres: 
Fig 2. Haematmdiru granules in^ 
liver cells, Cyanotic atrophy oh 
liver x 400Elams 
Fig. 3. Cells from a melanotic 
sarcoma/ * 400I)earns 
Fig. 4 Extraneous pigmenlaliorv 
Particles of coal &soot fronv 
a coat miners lung along 
with some pigmented catarr- 
hal cells, x 400 Diams. THE GENERAL PATHOLOGY OF NUTRITION 
197 
changes in the extravasated blood is the cause of the characteristic 
colour of syphilitic eruptions and ulceration. Recently Treacher Collins 
has shown that haemorrhage into the anterior chamber of the eye is 
followed by a rusty staining of the cornea, due to imbibition by osmosis 
of blood pigment, and conversion of the same into its derivatives 
haemosiderin and hcematoidin. 
In malaria, in consequence of the destruction of the red corpuscles 
by the plasmodium malariae, two kinds of pigments are formed: a pig- 
ment contained within the organism itself, black in colour, which does 
not give the iron reaction; another, haemosiderin, found in the liver, 
spleen, and marrow of bone. 
Melanin is a pathological pigment which does not arise from the 
blood; it can only be formed by the action of living protoplasm, and 
melanotic tumours are found usually to have originated in some tissue 
the cells of which normally contain pigments, e.g. the choroid coat of 
the eye. Melanin contains no iron, it has a black appearance in mass, 
but examined microscopically by transmitted light it is of a brownish 
or sepia colour; it is soluble in alcohol, ether, mineral acids and 
solution of caustic potash, and is bleached by chlorine; these tests 
serve to distinguish granules of melanin from particles of carbon, etc. 
[wide Plate]. 
Various pigments are found normally in the cells of the central 
nervous system, e.g. the locus cseruleus and locus niger; and the gan- 
glion cells of the brain, spinal cord, and sympathetic ganglia of human 
adults contain a fuscous pigment which occurs in the body of the cell, 
usually in the neighbourhood of the nucleus. This pigment is seldom 
present in children, and I have not been able to find it in monkeys and 
other animals. In young adults it is of a bright yellow colour; in old 
people it is darker and usually more abundant; it stains black by the 
Marchi method, and is therefore a fatty derivative. Whether it be 
really increased in certain diseases, or only more evident on account of 
atrophy of the rest of the cell substance, we do not yet know; in pro- 
gressive muscular atrophy many of the cells appear infiltrated through- 
out with pigments. 
Pigments derived from extraneous sources are introduced into the 
tissues of the body by the respiratory and alimentary systems. Anthra- 
cosis is the pigmentation of the lungs and bronchial glands caused by the 
inhalation of fine particles of carbon which are taken into the lymphatics 
by leucocytes. Most adults have their lungs somewhat pigmented from 
this cause, but when, owing to occupations such as coal mining, etc., 
enormous quantities of coal dust are inhaled, the lungs may be abso- 
lutely black in colour. 
Argyria, a condition of bluish discoloration of the skin, was occasion- 
ally seen in times gone by when nitrate of silver was used for long 
periods in the treatment of epilepsy. 
HYPERTROPHY. - An organ is said to be hypertrophied when all 198 
SYSTEM OF MEDICINE 
parts of it undergo an abnormal increase, not due to degeneration or to 
elements foreign to its normal structure. 
The term hypertrophy should not be applied to malformations, such 
as a large finger; or to excessive development of the organism as a 
whole, the result of congenital influences; but rather to " the enlarge- 
ment of an organ, partial or complete, beyond its usual limits as the 
result of increased function or of some unusual condition of the corre- 
sponding or correlated organ " (Bland Sutton). 
Hypertrophy should, moreover, be distinguished from simple over- 
growth, as of uncut hair or nails. 
Without increased blood-supply to the part hypertrophy cannot 
take place, but increased functional activity implies increase of nutri- 
tion brought about by vaso-dilation; this in its turn is induced by the 
stimulus acting on the vaso-motor nerves of the small arteries. In 
glands there exist definite vaso-dilator nerves; when the gland is active 
the vessels dilate by the excitation of these nerves. 
Functional and Compensatory Hypertrophy. - The increased size of 
a hypertrophied organ may depend upon two factors; namely, numeri- 
cal hypertrophy or hyperplasia, and simple hypertrophy or the increase 
in size of its constituent elements. The two may go hand in hand; 
for example, the development and increased size of the muscles used 
in particular occupations or exercises are the result of an increase in 
size of the fibres due to increased nutrition. "Work-hypertrophy" is 
a natural attribute of working organs. 
Another example of physiological hypertrophy is the gravid uterus, 
wherein muscular fibres of the organ increase both in number and in 
size. Kblliker showed that these unstriped muscle fibres are eleven 
times longer and four times broader than in the normal state. Another 
example is the mammary gland cell, the elements of which, owing to 
the physiological stimulus of gestation, undergo hyperplasia. 
Compensatory Hypertrophy in Disease. - Of this there are many 
familiar examples. In dual organs - as the kidneys, testicles, lungs, 
and ovaries - when, either from congenital absence of one of the pair 
from disease or from removal, the whole of the particular function is 
carried on for some considerable time by the other, the latter undergoes 
compensatory hypertrophy. 
Hollow viscera with muscular fibres in their walls afford examples 
of hypertrophy of muscular substance; e.g. the walls of the general 
cavities of the heart undergo compensatory hypertrophy when increased 
functional activity is demanded by increased resistance in front: such 
is the hypertrophy of the left ventricle in chronic Bright's disease, and 
of the right ventricle in pulmonary obstruction and mitral stenosis. 
The hypertrophy of the left ventricle in aortic regurgitation may be 
explained by the increased functional activity and proportionally in- 
creased quantity of blood driven into the coronary arteries at each 
systole. Hypertrophy of the muscular coat of the bladder in stricture 
of the urethra, of the stomach in stricture of the pylorus, of the THE GENERAL PATHOLOGY OF NUTRITION 
199 
intestines above a permanent stricture, serve as further examples of 
compensatory hypertrophy of hollow viscera. 
Enlargement of the left lobe of the liver, when the right has been 
destroyed or its growth checked, is an example of partial hypertrophy of 
an organ. 
An increase of the lymphatic glands after removal of the spleen 
affords an example of compensatory hypertrophy of a correlative structure. 
Two factors are concerned in all these functional compensatory hyper- 
trophies : increase of nutrition, owing to increased blood-supply, and 
the physiological stimulus which excites the constituent cells or fibres 
of the organ to assimilate more nutriment. A cell is not nourished, 
but nourishes itself. 
The forms of hypertrophy so far described may be looked upon as 
beneficial - even as physiologically normal; but examples of hyper- 
trophy occur which are essentially abnormal, e.g. enlargement of the 
thyroid in Graves' disease, of the spleen in leucocythemia, of the 
lymphatic glands in Hodgkin's disease. 
I can but allude to a number of curious pathological forms of 
hypertrophy, namely, leontiasis ossea of Virchow, which is characterised 
by multiple hyperostosis of the face and cranium; osteitis deformans, 
in which there is general increase of size with a marked morbid change 
of structure, in the form of a curious combination of condensation and 
hardening with softening and rarefaction; hypertrophic pneumic 
osteo-arthropathy, a curious disease described by Marie. Hypertrophy, 
or perhaps a pseudo-hypertrophy of the pituitary body, is frequently 
associated with an enlargement of certain parts, such as the hands, the 
feet, and lower part of the face, due to an osseous proliferation and new 
formation of spongy bone (vide descriptions of these morbid states in 
their respective chapters). The causes antecedent to these peculiar 
morbid hypertrophies are not understood. It is possible that some are 
due to the irritation of living organisms; for microbes may act upon 
animal cells, not only in a destructive manner, but as formative 
stimuli. 
Friction or pressure, giving rise to hyperaemia of the cutis vera, 
causes increased cell proliferation of the epidermis; but certainly this 
hyperplasia would not occur if the nerves to the part were destroyed. 
The irritation of the nerve ending serves not only to determine an in- 
creased flow of blood to the part, but also increased formative activity 
on the part of the cells of the rete Malpighii. 
Increased blood-supply to a limb may cause lengthening of a bone, 
of which an epiphysis remains ununited. Further, a chronic venous 
obstruction leads to excessive transudation from the blood; this does 
not give rise to hypertrophy of muscular or glandular tissues, but to a 
fibrous hyperplasia which, as it progresses, may lead to shrinking of the 
organ at the expense of the essential cell elements. In obstruction to 
the return of lymph from a lower limb, as in elephantiasis commenc- 
ing in infancy, the limb not only increases in bulk generally, but, rela- 200 
SYS TEAT OF MEDICINE 
tively to those of the opposite limb; the bones become manifestly 
augmented both in thickness and in length. 
Hypertrophy of bone has also been produced experimentally in 
animals by prolonged administration of small doses of phosphorus; 
and this effect has been attributed to diminished waste: it might also 
be explained by this substance acting as an irritant, thereby causing 
increased formative action. "Hyperplasia" is applied only to increased 
growth of pre-existing elements, normal in type and situation. Regen- 
eration can only occur when matricular cell elements still exist to pro- 
liferate, and it must be borne in mind that highly specialised cell- 
structures- e.g. muscle, glands, and the central nervous system - show 
very little power of regeneration when injured. It is especially the 
fibrous connective tissues and epithelial tissues which possess capacities 
of proliferation and regeneration. Large areas of epithelium may be 
destroyed and yet regeneration occur; and skin grafting is a familiar 
example of the inherent formative activity of the cells of the epidermis. 
Cartilage offers an example of a non-vascular connective tissue which 
is incapable of self-repair; losses of substance are filled up by fibrous 
tissue. The periosteum, on the other hand, may be looked upon as the 
best example of the regenerative capacity of fibrous tissue. 
F. W. Mott. 
REFERENCES 
1. Virchow. Cellular Pathology.-2. Cohnheim. Allgemeine Pathologic.- 
3. Billroth. Surgical Pathology. Sydenham Translation. - 4. Ziegler. General 
Pathol. Anatomy. Translation by M'Alister.-5. Paget. Lectures on Surgical 
Pathology.-- 6. Halliburton. Text-book of Chemical Physiology and Pathology.- 
7. Klebs. Allgemeine Pathologie. - 8. Charcot and Brissaud. Traits de medecine.- 
9. Hamilton. Text-book of Pathology. -10. Hallopeau. Pathologic generate. -11. 
Cornil and Ranvier. - Manual of Pathological Histology.-12. Wilks and Moxon. 
Pathological Anatomy. -13. Lancereaux. Traits d'anatomic pathologique. -14. 
Gowers. Diseases of the Nervous System, -15. Fagge. Edited by Pye-Smith. 
Principles and Practice of Medicine. -16. Dejerine. Anatomic des Centres Nerveux. 
-17. Journal of Pathology. 
Special Articles 
1. Bauer. Sitz.-Ber. d. Miinchener Akad.-2. Fraenkel. " Einfluss der vermin- 
derten Sauerstoff-Zufuhr auf den Eiweiss-Zerfall," Virchow's Archiv, 67 Bd.-3. Krehl. 
" Ueber fettige Degeneration des Herzens," Deutsche Archiv fur klinische Medecin, 
vol. li. - 4. Collins, Treacher. Transactions of the Ophthalmological Society 1895, 
vol. xv.-5. Marie. Lemons sur les maladies de la moelle. -6. Grasset and Rauzier. 
Traite des maladies du systems nerveux.-7. Pilcz, A. " Beitrag zur Lehre von der 
Pigmententwickelung in der Nerven-Zellen," Arbeiten aus dem Institut fur Anatomic 
und Physiologic des Centralnervensystem. Obersteiner.-8. Unna. Lehrbuch der spe- 
ciellen pathologisch Anat. d. Hautkrankheiten. - 9. Litten. Arc/iw f. path. Anat. 
vol. Ixxxiii. p. 508. -10. Weigert. " Coagulationsnekrose," Central!), f. path. Anat. 
October 1891. -11. Marie and Marinesco. " Sur 1'anatomie path, de FAcromegalie," 
Archiv de med. exp. 1891. -12. Martin, S. "Discussion on Diphtheria," Medicine 
Section, Brit. Med. Association, 1895. - 13. Gowers. Article, " Hypertrophy and 
Dilatation," Section, Diseases of the Heart, Reynold's System of Medicine. -14. Roux. 
Der Kampf der Theile imOrganismus: Ein Beitrag zur Vervollstandigung der Zweckmass- 
igkeitslehre. Leipzig, 1881. -15. Weigert. " Die Lebensauserrungen der Zellen unter 
pathologischen Verhaltnissen," Jahresbericht der Senckenbergischen naturforschenden GENERAL PATHOLOGY OF NEW GROWTHS 
201 
Gesellschaft, 1886, S. 75 ff. -16. Edinger. " Eine neue Theorie uber die Ursachen 
einiger Nerveukraukheiten insbesondere der Neuritis und der Tabes," Sammlung 
klinischer Vortrdge. N. F., Nr. 106. 1894. -17. Ramon y Cajal. " Algunas con- 
jeturas sobre el mecanismo anatomico de la ideacion asociation y atencion," Neurolo- 
gisches Centralblatt, ~Nr. 18,1895. Referat. -18. Araki. "Formation of Lactic Acid 
and Sugar in the Urine," Zeitschrift f Ur physiol. Chemie, vol. xv. pp. 335-370. 
F. W. M. 
GENERAL PATHOLOGY OF NEW GROWTHS 
Syllabus. - General Remarks on the Pathological Anatomy of 
Tumours; their Classification; Limitation of the term "Epithelium" 
Metaplasia; Heterology; Sarcoma; Carcinoma. 
PATHOGENESIS. - Definition of Tumour impossible; Relation to 
a Variations" ; the three chief Hypotheses, viz. (1) Spermatic influence, 
(2) Embryonic residua, (3) Irritation; Objections to the first; Illustra- 
tions of the second; the Parasite doctrine; Comparison between the clini- 
cal course of Malignant Tumour and Tuberculosis; Auto-inoculation; 
Grafting and Feeding Experiments ; Koch's four Postulates; Attempts to 
cultivate a specific Microphyte; Protozoic theory; Koch's first Postulate, 
the histological demonstration of a Micro-organism in the Tissue; Koch's 
second Postulate; Remarks on Treatment. 
General Pathology of New Growths. - (1) General Considerations 
on their Structure. - In no subdivision of Pathology is the contrast 
between Pathological Histology and Pathogenesis more striking than 
in the case of tumours. 
Of their histology little remains uninvestigated and unknown; of 
their pathogenesis, though much may be surmised, nothing can be said 
to be known. For this reason the classification of tumours can at pres- 
ent be constructed only upon an histological foundation. The clinical 
course of tumours raises a primary division between the benign and the 
malignant, but nothing is known of the etiological difference underlying 
the two; it is not inconceivable, indeed, that the difference in clinical 
history may be referred to a mere histological or anatomical basis. 
Histologically all new growths may be classed in two series, viz., 
those of mesoblastic and those of epithelial origin. In this classification 
it is most convenient to understand by epithelium tissue of epiblastic 
or hypoblastic descent; such new growths as arise from endothelium are 
included in the category either of endothelioma or sarcoma. Although 
there is not a universal agreement amongst histologists so to limit the use 
of the word, in the case of tumours such a limitation is of considerable 
value. 
The source of a tumour is the pre-existing tissue - more precisely, the 
cells of the part in which it arises. Among normal tissues a transforma- 202 
SYSTEM OF MEDICINE 
tion of one variety into another has long been recognised, and has received 
from Virchow the distinctive name of metaplasia. This term is of especial 
use in the present subject, since it serves to divide such a process from 
one of degeneration. Such mutations are met with in the whole series 
of connective tissues, as exemplified between cartilage and common con- 
nective tissue, or between connective tissue and bone. 
One variety of epithelium, again, may undergo conversion into 
another; of this many illustrations are furnished during embryonic 
development, and in after life under various circumstances of irritation 
or exposure; as, for instance, when in cases of inversion and prolapse 
within or beyond the vagina, the columnar-celled epithelium of the uter- 
ine mucosa becomes transmuted into one of the stratified squamous-celled 
kind. It is important, however, to notice that elements of epiblastic or 
hypoblastic descent are never, after their full development or evolution 
is reached, converted into any of the forms of connective tissue. In the 
case of new formations a tumour constructed of one variety of connective 
tissue, say cartilage, may arise from another ; under these circumstances 
the resulting cell growth does not precisely repeat the character of the 
mother tissue. 
Sometimes the "heterology" (Virchow) (1) is apparent only, and is 
due to the origin of the growth in the embryonic or developmental resi- 
dues of a tissue with which the new formation is really homologous. 
Of this nature may be the striped muscle fibre (muscle plates) in 
certain sarcomata of the kidney, of cartilage (Meckel's or pinnal) in 
tumours of the parotid gland, and in chondromata arising within the 
cancellous tissue of bone. 
The most extreme instances of heterology is afforded by the growth of 
epithelium in connective tissue which is witnessed in the metastasis of car- 
cinoma. Under these circumstances, however, the metastatic formations 
do not arise from the organ in which they appear, but from the epithelial 
elements, perhaps chromatiniferous fragments of them, transported to it. 
Clinically the great division of tumours, as already noticed, is indi- 
cated by the terms innocent and malignant - or simple and infective. 
The marks characterising malignancy are the infiltration of the surround- 
ing tissues by the growth, and the production of new foci in the neigh- 
bourhood of the primary tumour, or in parts far distant; and, as a 
consequence of this, the local recurrence after operative removal of the 
primary tumour, or the reappearance of the disease in lymphatic glands 
or internal organs. Certain of these characters, however, or others 
clinically allied to them, are encountered occasionally in the case of 
benign growths. The multiplicity of some benign tumours - e.g. soft 
fibromata, lipomata, cutaneous papillomata, etc. - may equal that of the 
most malignant. In such cases, however, it is to be observed that the 
growths in any given instance are confined to a particular system or 
extension of tissue such as the subcutaneous, the skin, the nerves, the 
bones, etc.; they do not arise by metastasis from a primary tumour, as 
they do in sarcoma or carcinoma, but indicate a predisposition confined to GENERAL PATHOLOGY OF NEW GROWTHS 
203 
a particular tissue, or mark the incidence of a wide-spread irritation 
affecting it. Nor is circumscription invariably met with in simple as 
contrasted with malignant new growths; some soft fibromata are as 
continuous with the skin and subcutaneous tissue as sarcomata, and 
certain lipomata are altogether indefinable from the surrounding fat. 
The rate and degree of the secondary infection or metastasis is 
extremely variable, both in sarcoma and carcinoma; and depends (so far 
as can be at present judged) upon the anatomical relations, vascular and 
lymphatic, of the primary growth: in the case of "rodent ulcer" 
metastasis, whether glandular or other, is unknown, howsoever long 
the local disease persist, and however wide and deeply spread it 
may be. 
Under malignant tumours are comprised the anatomical forms of 
sarcoma and carcinoma. A sarcoma may be defined as a malignant 
tumour of connective tissue origin, the blood-channels of which ramify 
between its cells; secondary infection, as a rule, takes place through the 
blood stream as distinguished from the lymphatic. The histological 
structure of sarcomata varies within wide limits. In their most typical 
forms they consist throughout of embryonic connective tissue, round or 
spindle celled; but this may undergo partial conversion into fibrous 
tissue, cartilage, or bone - the sarcoma being designated accordingly, 
fibrifying, chondrifying, or ossifying. This complex character may arise 
in another manner, namely, by the production of embryonic or sarcoma- 
tous tissue out of, that is through the division of the elements of a 
previously simple tumour. 
In either of these circumstances the histological determination of 
such a new growth becomes extremely difficult; it may be impossible to 
decide whether it should be named a sarcoma, or regarded as a fibroma 
in process of rapid growth. The only histological criterion at present 
available lies in its cellularity; if this be pronounced, and the concomi- 
tance of a proper inflammatory process can be excluded, the border line 
of simple growths is crossed. 
By a carcinoma is most conveniently understood a malignant tumour 
of which epithelium forms the essential constituent, i.e. tissue of epi- 
blastic or hypoblastic descent. Such new formations are characterised 
by an alveolar construction, the blood-vessels being confined to the stroma 
of connective tissue which forms the walls of the alveoli holding the 
epithelium. It is for this anatomical reason that secondary infection 
takes place, not by the blood-vessels, but the lymphatics. When the 
growth arises from an investing epithelium the alveoli are themselves 
lymph spaces into which the epithelium has bored, and equally so when 
a carcinomatous glandular epithelium is no longer confined by the base- 
ment membrane of acini or ducts. 
As a rule the epithelium of a carcinoma retains the type of the 
normal tissue from which it arises, and the cells even their physiological 
properties. Carcinomata arising in the ducts of the breast are of the 
columnar celled variety; in the acini, spheroidal celled; from the in- SYSTEM OF MEDICINE 
204 
vesting epithelium of the nipple, squamous celled: and these characters 
are repeated in the metastatic growths. 
Pathogenesis. - As in other problems of biology, so in the case of 
tumours, when the basis of any classification is critically examined 
definition is found impossible; at the best it is merely an artifice by 
which the mind is aided in the apprehension of facts. So, at the outset 
it is impossible to define what is to be and what is not to be reckoned as 
a tumour. 
The relation of inflammation to tumour production will be referred to 
later. But apart from this, tumours pass by insensible gradations into 
what are by general consent regarded as morphological variations. The 
line between highly accentuated anatomical tubercles of the bones and 
osteoma can only be drawn arbitrarily; and certain new formations may 
be referred to the class of " variations," even though unrepresented in 
normal morphology. 
The life history of many osteomata will justify this. For, unlike 
most other tumours, their period of formation and growth coincides with 
that of the rest of the skeleton: they do not exhibit the independence 
which is so remarkable in the great majority of tumours whether simple 
or infective; and they may be held as allied in their nature to the ab- 
normal masses of tissue classed as accessory thyroids, supernumerary 
mammae, and the like. 
Perhaps the best illustration of this is afforded by the fatty accumu- 
lations on the buttocks of the Bushwoman. Arising sporadically in a 
European such would undoubtedly be classed as diffuse lipomata; the 
buttock, in fact, is a recognised seat of fatty tumours. Yet they are so 
common among the females of the race mentioned as to rise almost to an 
anthropological feature. The protuberance itself is regarded as a mark 
of beauty, which is perpetuated and increased by sexual selection, and 
probably arose as a variation confined in the first place to a few 
individuals (2). 
Setting aside such a class of new formations, which may be explained 
as variations not surpassing many of those encountered in the progess 
of mammalian descent, the theories of pathogenesis may be reduced to 
the three following: - 
1. Spermatic influence. 
2. Embryonic residua. 
3. Irritation. 
1. Spermatic Influence.-The first theory views the growth of a 
tumour as due to the spermatic influence of certain cells upon those con- 
tiguous, the latter being, as it were, fecundated and incited to subdivision 
by the former. Assuming this view to be correct, it would explain only 
the method of extension, not the origin of a new growth. Whence come 
the cells which possess the supposed influence ? Although difficult to GENERAL PATHOLOGY OF NEW GROWTHS 
205 
disprove in the case of tumours of the connective tissue series, a fatal 
objection to this view is furnished by carcinomata. The explanation of 
the secondary formation of squamous-celled or columnar-celled carci- 
noma in a lymphatic gland by transformation of the leucocytes or cells 
of the stroma into squamous or columnar epithelium cannot be admitted; 
there is no histological evidence of it, and it is contrary to the funda- 
mental observations of normal histology. Klebs (3) has suggested that 
the leucocytes, which are not infrequently met with between and in the 
cells of malignant tumours, are the spermatic elements. But it is in- 
calculably more probable that such leucocytes are engaged in a process 
of phagocytosis (they are met with in abundance about the necrosed 
epithelium of a squamous-celled carcinoma); or that they have been 
ingested by the larger more vigorously growing cells of the tumour, a 
fate they meet in the formation of scar tissue where they are consumed 
by the connective tissue corpuscles. 
2. Embryonic Residua. - This view, originally foreshadowed by 
Virchow in regard to chondromata of bone, was extended by Cohnheim 
so as to cover the whole field of tumour production; on this account it 
is often spoken of as Cohnheim's theory (4). 
It assumes that, during the process of embryonic development, more 
cells may be generated than are actually necessary for the formation of 
a particular organ or tissue; and that in such cells, which may remain 
long dormant, tumours have their source - the embryonic residua re- 
taining their biological potentiality for multiplication. 
The theory relates the growth of a tumour to a physiological cause, 
viz., to the inherent capacity which embryonic tissue in general possesses 
for growth. That certain tumours so arise can scarcely be denied: the 
growth of central chondromata of bone is an instance, though here the 
redundance may affect the growing parts after the date of birth. 
We may cite, again, the growth of chondromata from the synovial 
membranes of joints ("Pedunculated bodies"), where the new forma- 
tions arise in the groups of cartilage cells contained in the secondary 
processes of the fringes; for these elements may themselves be regarded 
as relics of the cartilaginous matrix about the sites of primitive joint- 
formation, the articular cavities being formed by the solution of the 
mesoblastic tissue intervening between the primordial cartilage of the 
future bones. Such chondromata are unknown in connection with 
the synovial sheaths of tendons or bursee, or known only in rare cases 
that allow of explanation. The large adenomata, again, which lie 
between the rectum and coccyx (sacral or coccygeal tumour), and have 
their origin in the post-anal gut, may be cited as another example; or 
the cystic epithelial tumours of the jaws which, as evidenced by their 
structure, almost as certainly arise in redundant portions of enamel 
organ: or, among malignant new formations, the melanotic sarcomata 
which appear in congenital moles, the latter being visible excesses in 
the development of normal tissue. Beyond the category of solid forma- 
tions, or tumours properly so called, a large number of cysts have their 206 
SYSTEM OF MEDICINE 
source in the remains of canals which should normally disappear or 
undergo atrophy during development or growth: such are the cysts of 
the parovarium, of the par-epididymis, of Gartner's duct in the female, 
or Muller's duct in the male, of the urachus, the post-anal gut, the 
thyro-lingual duct, and others. 
The hypothesis receives confirmation, too, in the woody masses or 
xylomata which arise in the dormant buds of exogenous trees. Thus 
it is satisfactory in a certain number of instances, but unconvincing 
when applied to the whole; for it not only assumes the presence of 
such residual elements in every case, but it ignores the equally possible 
action of a continuously working irritant, such as an animal or vegetable 
parasite would furnish, for which there are equally apt analogies in the 
various galls of the vegetable kingdom, some of which display a high 
grade of organisation. 
3. Irritation. - Under this heading may be comprehended irritative 
causes in the wider sense, without attempting to draw a line between 
irritation and inflammation. It is not, indeed, possible to separate tissue 
overgrowth which arises out of inflammation from the class of tumours; 
hyperplasia is the immediate result in both. It is in this connection that 
trauma becomes included in the pathogenesis of new growths. There is, 
for example, none but an arbitrary distinction between osteoma affecting 
the facial bones and the diffuse hyperplasia which Virchow has named 
leontiasis ossea. Some such formations have a traumatic history; others, 
of recurrent attacks of erysipelas. The local hyperplasias which result 
from purely mechanical causes pass insensibly into the new formations 
known as tumours. In this sense tumours may even form around foreign 
bodies. One of us has described a large example of lamellar fibroma, 
found between the bladder and rectum, in the centre of which was a 
small piece of steel, evidently the immediate cause in its etiology: the 
other factor was probably the accident of a position which the functions 
of the bladder and rectum make one of incessant movement. 
Undoubtedly, however, the most modern development of this irrita- 
tive theory and the most definite is the parasitic. In the matter of 
malignant growths more particularly it has much to recommend it, and 
from this aspect the hypothesis may be discussed more fully than either 
of the preceding. It has been urged that, if true of malignant forma- 
tions, benign growths must be relegated to a like cause. This by no 
means follows. Cohnheim's theory is equally adequate to account for 
certain new formations ; and there is no a priori reason why all should 
arise from an identical cause. The great feature of malignant tumours 
is their metastasis, or, to adopt the parallel furnished by the infective 
granulomata, their infectiveness. The clinical history of a case of sar- 
coma or carcinoma is so closely like that, for example, of tuberculosis, 
that it is quite within the truth to assert that there is no feature in the 
last-named disease which is not paralleled in the others, as will appear 
from the following considerations : - 
The primary tumour in the case of carcinoma is seated most fre- GENERAL PATHOLOGY OF NEW GROWTHS 
207 
quently, as statistics show, at sites where an infection from without 
would most readily take place. The metastasis by lymphatics or blood- 
vessels in carcinoma and sarcoma is such as occurs in tuberculosis; 
and it may be restricted to the lymph-glands, or be as wide-spread as a 
generalised tuberculosis (general sarcomatosis or carcinomatosis). 
Even the glandular infection which occurs at times in tuberculosis 
without primary lesion has its counterpart in the squamous-celled carci- 
noma of the inguinal glands in chimney sweeps, in whom there may be 
no discoverable primary growth on the penis, scrotum, or lower limbs. 
And the latency of glandular infection is equally represented in 
tuberculosis and carcinoma: a breast, for example, is removed for mam- 
mary carcinoma, and four years later, without any local recurrence, the 
axillary glands may be found diseased. A tubercular lesion may result 
from direct infection, or may appear primarily in an internal part, i.e. in 
a situation other than cutaneous or mucous surface. The sarcoma 
that grows at the end of a long bone after injury is comparable with the 
tubercular osteitis ensuing under similar circumstances. Injury is the 
determining cause; the other factor is a " constitutional " one. Whether 
the latter named be held to consist in a congenital want of resistance to 
an infective virus, or in the actual presence, acquired or inherited, of the 
virus in a resting or latent condition, the hypothesis equally suits both 
forms of disease. In short, the abstruse problems of predisposition 
and heredity offer the same difficulties in malignant neoplasms and in 
tuberculosis. 
Auto-inoculation from one carcinomatous labium to the other has 
long been recognised; and an instance is authenticated of the trans- 
ference of carcinoma from an ulcerating tumour of the breast to the 
skin of the paralysed arm in contact with it. The many examples of 
intestinal (e.g. caecal) carcinoma associated with numerous lesser growths 
in the colon; of gastric carcinoma associated with similar disease of the 
bowel; of oesophageal carcinoma associated with that of the stomach, or 
of multiple growths in the oesophagus itself, point also to the possibility 
of an auto-inoculation of the same kind as that of the intestine witnessed 
in tubercular phthisis. Strictly speaking, however, such facts only show 
that the disease is transferable in the same individual without proving 
that a parasitic virus is present in the cells transferred. Although both 
carcinoma and sarcoma have been grafted from one animal to another, 
success has as yet only attended the experiments made between animals 
of the same species. No authentic instance (i.e. none satisfying modern 
criticism) is at present forthcoming of the grafting of human carcinoma 
upon any of the lower animals. One of the best examples of transference 
from animal to animal is recorded by Hanau of Zurich, who has success- 
fully engrafted squamous-celled carcinoma from a rat, with such a growth 
on the vulva, upon a series of other rats, by inserting portions of the 
tumour into the peritoneal cavity. In one case, where death ensued 
after three months, the abdominal cavity was filled with nodules which 
presented the typical histological structure of squamous-celled carcinoma. 208 
SYSTEM OF MEDICINE 
We have ourselves carried out a considerable number of such experi- 
ments between the human subject and lower animals (5). Our method 
consisted in transplanting portions of tumours recently removed by 
operation into the abdominal cavity, subcutaneous tissue or muscles. 
The tumours used were twenty-three scirrhous carcinomata of the breast 
and six sarcomata: the animals were monkeys, dogs, rabbits, white rats, 
three sheep and one cat. At times the entire tumour was placed in the 
peritoneal cavity after the superfluous fat had been removed from its 
exterior. On other occasions portions were cut from it and pushed in 
different directions into the abdomen. The tumour after its removal 
was kept at the body temperature in an incubator, and transferred to 
the animal in from half an hour to an hour and a half after removal. 
Sometimes pieces of as many as three different tumours were placed at 
different dates into the same animal. 
The result of all these experiments was negative. The pieces of 
transplanted tumour invariably underwent coagulation necrosis, in one 
case subsequent calcification, and were found either lying encapsuled 
in the tissues, or to have been completely absorbed. In two instances 
an entire scirrhous carcinoma of the breast inserted into the peritoneal 
cavity (dog) entirely disappeared, the abdominal wound having itself 
healed without discharge of the graft. In the first of these the tumour 
was one and a half by three-quarters of an inch; the animal was quite 
well 700 days after the experiment, and, on its being killed, all the viscera 
were found healthy. 
The same negative results attended certain feeding experiments 
carried out on white rats. We fed two white rats, male and 
female, with fourteen fresh scirrhous carcinomata. The experiments 
extended over a period of seven months, during which the animals 
remained well and several litters of young were born. They -were 
undertaken to ascertain whether infection of the stomach or intestines, 
such as ensues in some instances from the ingestion of tuberculous 
material, could be induced. On killing the rats the pylorus and other 
parts of the alimentary tract were found to be quite normal. In one 
experiment a small piece of the growing edge of a recently removed 
scirrhus of the breast was inserted into the anterior chamber of a rabbit's 
eye. The corneal incision healed perfectly, but the graft, after under- 
going slight diminution in bulk, remained unchanged; two months 
later, on killing the animal, it was found adherent to the iris by one 
aspect and to the back of the cornea by the other. In all this the experi- 
ments, both negative and positive, indicate not the common order of 
infection, but that of grafting, whether in animal or vegetable tissues. 
They do not prove, when successful, that the cause of cancer is a para- 
sitic virus, but only that a portion of a malignant tumour will continue to 
grow in the body of a second individual as it- would have done in the 
body of the first. Even when the spot has been previously prepared 
by an experimentally caused inflammation, no other result has yet been 
obtained; as in Mr. D'Arcy Power's experiments of placing pieces of GENERAL PATHOLOGY OF NEW GROWTHS 
209 
human scirrhus into the vaginae of rabbits previously kept irritated or 
inflamed by the application of linimentum iodi. 
Finally, if the positive results attained do not prove the existence 
of a parasite, it must be borne in mind likewise that the negative do 
not disprove it. The method of transmission in infective diseases is 
not always so direct and simple as such grafting experiments presuppose. 
It has been shown, for example, that malaria cannot be transmitted 
between birds by the injection of blood containing the haematozoon; 
and we ourselves had found that psorospermosis could not be induced in 
the scarified skin of the rabbit by rubbing in psorospermial material 
obtained direct from the livers of other rabbits. 
The endemic location of cancer, comprehending sarcoma and carci- 
noma, is a highly remarkable fact in the history of malignant tumours. 
One of the most noteworthy instances of it is recorded by Mr. Law Webb. 
In a group of cottages forming a certain village in Shropshire nine 
cases of cancer had been treated in fifteen years. The dwellings are 
grouped together, and do not occupy much more than an acre of ground. 
All the inhabitants use water from a certain pump situate by the road- 
side, and close to a very filthy hovel. There are twenty houses in all; 
one cottage, enjoying a bad pre-eminence for dirt and discomfort, fur- 
nished three of the nine cases. In none of the whole series were the 
patients related by blood. 
In the neighbourhood of this hamlet are two houses under one roof 
with a drain system and water-supply common to both. Calling these 
Nos. 1 and 2, twenty-six years ago a man, set. 28, living at No. 1, suf- 
fered from cancer of the rectum, of which he died. The house was next 
occupied by a man and wife. The former, two years after the death of 
the previous tenant, was treated for cancer of the stomach, to which 
malady he succumbed. His widow continued to live in the same house, 
and died ten years later from cancer of the rectum. Before her death 
a woman in house No. 2 was found to be suffering from carcinoma of 
the breast, which proved fatal in eight months. The first house was 
next occupied by three spinsters, one of whom died of cancer of the 
uterus, and a second with cancer of the stomach. 
In connection with the high mortality which obtains in Devonshire 
we may cite a remarkable instance, the details of which were communi- 
cated to us by Dr. R. Ackerley of Surbiton. In a large house in Ashbur- 
ton, situated on low ground, the cellars of which are below the level of 
a small stream which runs through the town about twenty yards from the 
house, four cases of cancer have occurred in the last thirteen years: (1) 
A lady who had occupied the house for many years died from cancer of 
the breast; (2) The next occupant, after residing at least seven years in 
the same house, died from the same disease; (3) her husband died 
two years ago of carcinoma of the larynx; (4) the second wife of the 
last mentioned, whom he married five years ago, has lately had her breast 
removed for scirrhus. Four other deaths from cancer have been certified 
VOL. I 
P 210 
SYSTEM OF MEDICINE 
in the last four years in persons who had long resided within a hundred 
yards of the same house. 
Cancer has, moreover, a certain geographical distribution. Its dis- 
tribution in England and Wales has been carefully drawn out by Mr. Havi- 
land (7). His conclusions are that the disease is most prevalent along those 
river courses which seasonally flood their banks, such as the Thames, the 
Severn, the Mid Devon and Yorkshire rivers; and that wherever, from 
the nature of the rocks forming the water-shed, the floods are much dis- 
coloured by alluvium, and where, from the flatness of the country, the 
floods are retained and not easily drained off, there is found the greatest 
mortality from cancer. [Vide art. on Med. Geography of Gr. B.] 
Koch's Four Postulates. -Notwithstanding the negative results of the 
inoculations detailed, the parasitic theory of malignant new growths is 
so well grounded that during the past few years the whole of the work 
on the subject has been directed by it. 
After the rise of modern bacteriology the first attempts made were 
to cultivate a specific microphyte from such tumours. In this country 
we undertook a considerable series of such experiments (8). We con- 
fined ourselves to the use of spheroidal-celled carcinoma of the mamma, 
for the reason that in external carcinomata the problem is complicated by 
the chances of a saprophytic or adventitious infection; in three instances, 
however, sarcomata were employed. The media comprised nutrient 
gelatine, nutrient agar, human blood serum obtained from placentae, etc., 
and fluid media, such as hydrocele fluid and human placental blood serum. 
Portions of the tumour immediately after its removal were cut by means 
of knives previously sterilised by heat, and transferred to the tubes of 
nutrient media on the loop of platinum wire. In some cases the tubes 
were incubated at the body temperature; in others kept at that of the 
room. The results were uniformly negative, with a few exceptions 
due to accidental contamination from the air or otherwise during the 
manipulations the experiments involved. 
Although different conclusions have been reached by certain con- 
tinental observers, it is now universally admitted that these were based 
on experimental error. Up to the present time no specific microphyte 
has been cultivated from malignant tumours. 
The failure of evidence in this direction led to the suggestion that 
the hypothetical microparasite might belong to the animal series, and be 
a protozoon. 
In considering this new phase of the problem, the fulfilment of Koch's 
four postulates must equally be insisted upon. In the case of malaria, it 
is true, no culture of the hsematozoon has at present been accomplished, 
and yet the causative role of the latter is accepted; but here the exist- 
ence of a living protozoon in the blood does not allow of denial. In the 
case of cancer, on the other hand, this, Koch's first postulate, namely, the 
demonstration of a microzoon in the blood, juices, or tissues, is itself 
in dispute. In sections of carcinoma there are certain appearances 
which are interpreted by different observers as indicating the presence of GENERAL PATHOLOGY OF NEW GROWTHS 
a protozoon. A full historical account of the minute histology of carci- 
noma in this relation is given by Noeggerath up to the close of 1891. 
The more important observations since then are those of Soudake witch, 
Foa, and, in this country, of Ruffer. The work of Ludwig Pfeiffer is 
an attempt to compile the life history of a protozoon from the study of 
sections of malignant tumours, but the histological misinterpretations 
it contains are so numerous as to destroy whatever value it might 
otherwise have. Ruffer has simplified the subject by reducing the 
hypothetical parasite to a very few definite forms, and we may here 
cite his description, to the accuracy of which we can ourselves testify. 
As seen in the protoplasm of the epithelial cells of the growing edge, say 
of a mammary scirrhus, the fully-grown parasite consists essentially: - 
(1) Of a central round, oval, or slightly irregular nucelus, sometimes 
connected by fine delicate rays with the periphery. 
(2) Of a variable amount of surrounding protoplasm, almost, if not 
quite, filling a capsule (now and then the protoplasm exhibits a series 
of peripheral granules). 
(3) Of a doubly contoured capsule confining the whole. 
What of its life history, and especially its mode of reproduction? 
If we turn to the more thoroughly known of the microzoa parasitic 
in the lower animals, a distinct life history, often a very complex one, is 
to be traced; and a portion of this may be passed outside the body of 
the host. 
The multiplication of the bodies described in carcinoma is alleged to 
take place by binary division, and groups of considerable numbers may 
be met with in the epithelial cells. 
Certain appearances characteristic of a protozoic life history have 
been described, such as falciform spores and spore cysts. 
As to the former, the opinion of Metschnikoff has yet to be contro- 
verted, viz., that the appearances in question result from nuclear de- 
generation. Indeed, bodies of similar forms may be seen in degenerating 
tissues from sources altogether different. Other such particles within 
the cell body pertain to the nuclei of ingested leucocytes or lymphocytes, 
and yet smaller ones possibly represent the residua of chromatin result- 
ing from the irregular mitoses so frequently observed in the epithelial 
cells of carcinoma. 
As spore cysts have been described - 
(1) Aggregations of polynuclear leucocytes in spaces between the 
epithelial cells, such as may be produced in the rabbit's vagina after 
repeated application of linimentum iodi. 
(2) Cell invaginations, the protoplasm of which is highly vacuolated 
and the cell membrane unusually pronounced; and, as free spores, the 
particles resulting from degenerative fragmentation of the nucleus and 
destruction of the cell. 
In squamous celled carcinomata the keratinising cells themselves 
have been erroneously viewed as parasites. The disproof of this is 
furnished by the readiness with which every intermediate phase may 
211 212 
SYSTEM OF MEDICINE 
be traced between- normal epithelial cells and those which cease to take 
any nuclear stains. 
As to the particular body in question, it closely approaches certain 
of the results of hyaline degeneration the products of which are equally 
distinguished by their affinity for fuchsin, and are met with, as was shown 
by ourselves, in various non-cancerous formations, diphtheritic tonsil, 
caseous lymphatic glands, etc. (14). One test the body in question cer- 
tainly stands - that of constancy ; it may be demonstrated in the grow- 
ing edge of every carcinoma: and nothing identical has, in our opinion, 
been hitherto produced in epithelium by artificial methods of irritation. 
The bodies seen in the epidermis raised by a common blister stain 
with differential dyes like nuclear chromatin (those of carcinoma stain 
in general like the nucleolus); they lie in spherical spaces in the cell 
body; and, what is most important of all, there is no other structure in 
the cell representing the nucleus ; they are, in short, shrunken nuclei 
lying in peri-nuclear vacuoles, possibly compressed by the accumulation 
of fluid around. 
As related to the first postulate of Koch, reference may next be made 
to certain questions in the chemistry of carcinoma. It has been shown 
that the capsule of encapsulated protozoa consists at times of chitin or 
of cellulose - both of them substances altogether absent from the tissues 
of vertebrates. Is either present in a carcinoma ? This question can 
be answered in the negative. The investigation was carried out for us 
by Gregor Brodie at King's College, London, under the direction of 
Professor Halliburton, as follows: - 
Method. - The tumour is cleared of surrounding fat, but the growing 
edge is carefully left; it is then minced on a sheet of glass, and boiled in 
20 per cent solution of caustic soda for ten minutes, the tissue being in 
this way dissolved; whilst hot the fluid is filtered through asbestos, the 
process being hastened by means of a vacuum pump. A yellowish 
residue, indicating the presence of fats in excess, remains on the surface 
of the asbestos. Should chitin or cellulose be present it would also re- 
main on and in the asbestos, seeing that it is insoluble in caustic soda. 
Boiling caustic potass (5 per cent) is run through the filter, and then 20 
per cent of the same boiling solution; the precipitate on the asbestos is 
next washed with boiling distilled water. Nearly the whole of the pre- 
cipitate, or at least of the pale yellow portion, disappears in this process. 
The caustic potass is then neutralised by drawing through the asbestos 10 
per cent hydric sulphate, first cold and afterwards boiling, and finally 
boiling distilled water in order to remove all trace of the acid. The 
presence of chitin or cellulose is now tested thus : - 
Cellulose is soluble in concentrated hydric sulphate, chitin in concen- 
trated hydric chloride. A small amount of hydric sulphate is poured on 
the filter, and after five minutes drawn through. The addition of dis- 
tilled water to the pale brown filtrate gives a precipitate. The fluid is 
then filtered through the asbestos, the precipitate appearing on the sur- 
face of the latter as a pale yellow film. Were cellulose in solution in GENERAL PATHOLOGY OF NEW GROWTHS 
213 
the clear filtrate, it would be demonstrable by boiling the fluid in order 
to convert that substance into dextrose or grape sugar, which is recognis- 
able by boiling with Fehling's solution. No reaction, however, with 
Fehling's solution is obtainable. 
To remove any fatty acids remaining, or constituting the precipitate 
on the asbestos, the latter is washed with cold alcohol, hot alcohol, and 
finally warm ether; a film of faint brown colour still remains on the 
filter. The test for chitin is next carried out. Chitin is insoluble in 
strong hydric sulphate, but soluble in strong hydric chloride. 
Concentrated hydric chloride is poured in small quantities on the 
filter, and the filtrate tested; dilution of part with water gives no pre- 
cipitate of chitin; the remainder is evaporated in a capsule over a water 
bath; the thinnest pale yellow film remains on the side and bottom of 
the vessel. This alcohol at once dissolves, proving it to be fatty acid 
remaining over from experimental error. 
Is there albumose in a carcinoma ? 
We were induced to look for such a body in consequence of its 
discovery in cultures of pathogenic bacteria; it seemed to us that a 
like substance derived from the agency of a specific micro-organism might 
possibly exist in malignant growths. 
The method adopted was as follows: - 
The tumour, scirrhus of the breast, is minced and pounded in a 
mortar with 50 per cent glycerine and distilled water, to which is added 
a little thymol. Before applying the test to the extract, it is ascertained 
that the reaction is not acid, and that no trace of decomposition is present. 
An equal bulk of trichloracetic acid (10 per cent solution) is added, and 
the mixture boiled five minutes in a beaker to bring about the precipita- 
tion of the globulins and albumin; it is then filtered. The direct albu- 
mose tests next applied to the clear, faintly opalescent filtrate are nega- 
tive in result. 
A drop of strong hydric nitrate gives no precipitate; cupric sulphate 
solution gives no precipitate; caustic potash solution gives, after the 
addition of the latter, not a rose colour (albumose), but a violet - an 
ordinary proteid reaction possibly due to a trace of acid albumin not pre- 
cipitated by the trichloracetic acid (Brodie). Two possible fallacies may 
be here noticed. If putrefaction be allowed to arise before the applica- 
tion of the test the ordinary albumose resulting from that process would 
have been formed. There is, however, a more subtle source of possible 
error. The reaction of a carcinoma or sarcoma immediately after removal 
is alkaline; in a few hours it becomes acid: in this the morbid tissue 
resembles those of the body in general - not only muscular, but glandular 
also. In muscle a post-mortem formation of albumose is actually brought 
about by the acid reaction allowing the pepsin, which circulates in small 
quantity through the body, to digest the proteid. It is quite possible 
that a trace of albumose might thus be formed after tissue-death if the 
examination of the growth be deferred. 
Koch's Second Postulate. - Seeing that no spores or other indispu- 214 
SYSTEM OF MEDICINE 
table evidences of a protozoon have been histologically demonstrated in 
malignant tumours, the proof of a parasite must depend upon its cultiva- 
tion outside the body. And it is in this direction that our own latest 
work has lain (15). We were induced to carry it out, also, for the 
theoretical reason that the want of success attending the transplantation 
of carcinoma from man to the lower animals might be due to the 
fact that it was necessary for the parasite to assume a phase outside 
its host in order to transmit the disease. Although at one time we 
employed fluid media in test-tubes, very dilute broth, very dilute agar, 
milk (to all of which 6 per cent glycerine was added), potassium oxalate 
plasma (dog), we ultimately abandoned these methods as not ensuring 
sufficiently natural aeration. 
We also fed worms with pieces of mammary scirrhus placed in 
sterilised sand and water, with the idea that it might be necessary for 
the hypothetical protozoon to pass through the body of some lower form 
in order to acquire an infective quality for man and animals. The 
experiment failed; although the cancer was devoured the worms died, 
doubtless because the sterility of the sand had deprived them of all other 
kinds of nourishment. 
Again, we buried mammary carcinoma in garden soil and sub- 
sequently inserted portions of the tumour (exhumed after six weeks) 
into the abdomen of rats, but without obtaining any positive result. 
Our final method of experiment consisted in the use of sterilised sand 
and water as a culture medium, and of deep capsules of different 
diameters as well as Petri dishes, in the place of test-tubes. Portions 
of the growing edge of the tumour were cut with knives previously 
sterilised by heat, and then transferred to the sand in the neigh- 
bourhood of a littoral which was made by so tilting the sand that 
the water did not completely submerge it. The capsules were afterwards 
stored in a laboratory between sterilised double dishes, the covers of 
these being raised for a short distance with wooden blocks soaked in 
solution of corrosive sublimate. From most of the smaller deep 
capsules the covers were removed as they were placed between the 
double dishes; the Petri capsules were kept covered throughout. 
Occasionally a small quantity of beef peptone broth was added to 
the water. The examinations were conducted by removing some of 
the sand from the littoral in the neighbourhood of the pieces of 
tumour with a sterilised glass rod to a sterilised slide; the sand 
so removed is gently stroked with the rod, the slide being so inclined 
that sufficient fluid leaves the sand to make a microscopic preparation. 
Many such experiments were made both with mammary carcinoma and 
different sarcomata; most of the latter were of the melanotic variety 
from recently killed horses. 
In all the experiments carried out with carcinoma we confined our- 
selves to the typical scirrhus of the breast for the reason that, in the case 
of new growths involving superficial parts like the lip or tongue, there 
exists the possibility of infection with purely saprophytic protozoa; some GENERAL PATHOLOGY OF NEW GROWTHS 
215 
of which occur normally in such mucous canals as the vagina and 
intestine. 
The examinations were made at different intervals up to periods of 
five months. In none of the series were any indications of protozoic 
life encountered. Active amoebae were found on four or five occasions 
in different Petri capsules infected with mammary scirrhus and squa- 
mous-celled carcinoma; but this observation was limited to the earlier 
experiments in which the sources of fallacy were not rigidly excluded. 
In all cases a growth of bacteria ensued, and the purpose of adding 
broth to the fluid was to favour this, in order that pabulum might thus 
be furnished for the growth of any protozoa present. 
It need hardly be said after this that infection experiments carried 
out upon animals by means of such sand, or the grafting of portions of 
tumours incubated in fluid media, have yielded negative results in our 
hands, whether the sand were introduced into the venous current in 
dogs, into the peritoneal cavity of rats, or rubbed weekly for many 
months into the scarified skin. 
In the various experiments so performed the sand actually used was 
teeming with amcebse, which later observation proved to be adventitious 
and non-pathogenetic. Similar experiments made with sand infected with 
the pump-water from the cancerous village referred to in the earlier part 
of this article were likewise negative; nor did the feeding of white rats 
with food to which this water was added lead to any different result. 
Treatment. - It would be outside the purpose of the present article 
to deal with the operative procedures practised in the surgical treatment 
of cancer, or to do more than mention the chief remedies which have 
been tried from time to time in the treatment of malignant disease. In 
considering this subject the occasional spontaneous disappearance of 
certain tumours must be borne in mind. Such a disappearance has been 
observed not only in benign growths, like fibro-adenomata of the breast 
and uterine myomata, but also in sarcomata. 
In the museum of St. Bartholomew's Hospital, London, is the cast 
of the head of a man twenty-four years of age, who about six years 
before admission was struck with the fly-wheel of an engine; a few 
months later a tumour commenced to grow at the stricken spot, and 
after reaching the size of a sparrow's egg disappeared in about the space 
of six months. Six or eight tumours which subsequently grew in dif- 
ferent situations on the head afterwards diminished in size. On his 
admission there was a large tumour near the middle of the anterior 
border of the left parietal bone, its longest diameter being five inches; 
and in addition the six or eight smaller growths before mentioned. 
The chief formation was excised in March 1890, and histologically pre- 
sented the structure of a fibro-sarcoma. Mr. Butlin has recorded the 
partial disappearance of what was presumed to be a sarcoma of the 
testicle in a boy. In this case tumours previously removed from the fore- 
head and front of the ear exhibited the structure of round-celled sar- 
coma; both testicles subsequently enlarged, but the right afterwards 216 
SYSTEM OF MEDICINE 
underwent marked diminution in size; many growths appeared about 
the same time in various other parts of the body: the administration of 
mercury had not the slightest effect. It is not impossible that the 
above case was one of malignant lymphoma or generalised lymphoma- 
tosis, rather than of true round-celled sarcoma; the partial disappear- 
ance of such formations is a well-known clinical phenomenon, especially 
during the administration of arsenic. 
Considerably more voluminous growths of a tissue that has been by 
some compared with sarcoma, though it has histologically the structure 
of granulation-tissue (granuloma fungoides), have been known to un- 
dergo complete disappearance quite independently of any local treat- 
ment. The difficulty occasionally presented in the differential diagnosis 
of malignant tumours and syphilomata must also be borne in mind. 
As a matter, possibly, of interest we may state that, in search of a 
protective vaccine, we have tried the effects of subcutaneous injection 
of a 50 per cent glycerine extract of both carcinoma and sarcoma, hope- 
less cases being selected for treatment. 
The injections in one case of mammary carcinoma exceeded fifty in 
number, no less than ten different carcinomata being employed. In one 
instance of recurrent sarcoma of the mamma the glycerine extract of four 
different sarcomata was used. No local reaction ensued, such as is ob- 
served after the injection of "tuberculin" in cases of tuberculosis; and 
the procedure in no case retarded the growth and multiplication of the 
tumours. The use of fresh sheep serum was equally inefficacious in car- 
cinoma, i.e. the serum of an animal in which malignant disease is so rare 
that it may be considered to enjoy a natural immunity. Amongst other 
methods may be recounted Fehleisen's inoculation of erysipelas, the 
interstitial injection of methyl violet, the passage of electric currents, 
and more recently the injection of the combined toxins of streptococcus 
erysipelatis and bacillus prodigiosus (Coley). The effect of the last-men- 
tioned treatment, like that of Fehleisen, is a local and not a general one. 
The serum of animals into the circulation of which cancer juice has 
been introduced has also been used therapeutically. This method we 
based upon the results obtained with serum antitoxins in general, and 
we are at present engaged in putting it to the test: the same idea has 
independently served as a basis of recent work abroad. 
Up to the present the only hope has lain in early removal before the 
infective elements of the tumour have been widely transported into the 
surrounding tissues or to distant parts of the body. The most successful 
operator is he who, knowing the pathology of the disease, appreciates the 
value of free and careful excision. The incisions must be planned to pass 
through parts believed to be healthy, no knife which has been infected 
with the juice of the tumour must be used for the division of healthy 
tissues, lest the seeds of recurrence be sown along the fresh cut surfaces, 
and not only must lymph glands be removed, but lymphatic vessels. In 
certain localities the operation for cancer conducted on these principles 
may permanently rid the patient of the disease. Excision of carcinoma of PRINCIPLES OF DRUG THERAPEUTICS 
217 
the lip may be completely successful; so, in a certain percentage, is that 
of mammary carcinoma, whilst the free removal of the rectum is followed 
by better results as regards respite from recurrence than that of any 
other part. 
Samuel G. Shattock. 
Charles A. Ballance. 
REFERENCES 
1. R. Virchow. Die krankhafte Geschwiilste.-2. Charles Darwin. Descent of 
Man, sec. ed., chap. xix.- 3. Klebs. Allgemeine Pathologic, Bd. ii. p. 524. - 4. 
Cohnheim. Vorlesungen ii. allgem. Path. 1877.-5. Shattock and Ballance. "An 
Experimental Investigation into the Pathology of Cancer," Proc. Royal Society, vol. 
xlviii. 1890.-6. Law Webb. Birmingham Med. Review, December 1892, p. 342.-7. 
Haviland. Geography of Heart Disease, Cancer, and Phthisis, 1875. - 8. Shattock 
and Ballance. " Cultivation Experiments with New Growths and Normal Tissues, 
together with Remarks on the Parasitic Theory of Cancer," Trans. Path. Soc. vol. 
xxxviii. 1887.-9. Noeggerath. Beitrage zur Struktur u. Entwickelung des Carci- 
noms, 1892. -10. Soudakewitch. Annales de I'Institut Pasteur, March 1892. -11. Foa. 
" Uber die Krebsparasiten," Centralblatt fur Bakteriologie u. Parasitenkunde, Bd. xii. 
No. 6, August 9, 1892. -12. L. Pfeiffer. Die Protozoen als Krankheitserreger, 1890. 
-13. Armand Buffer. Journal of Pathology, October 1892, et seq.-14. Shattock 
and Ballance. British Med. Journal, 1891. -15. Shattock and Ballance. "An 
Attempt to cultivate Parasitic Protozoa from Malignant Tumours, Vaccinia, Molluscum 
contagiosum, and certain Normal Tissues, together with Infection Experiments carried 
out with the Culture Media, and a Note on the Treatment of Cancer," Proceedings Royal 
Society, vol. lix. 1895. -16. Butlin. Trans. Path. Soc. London, 1878. 
S. G. S. 
C. A. B. 
PRINCIPLES OF DRUG THERAPEUTICS 
I. Introductory 
The work of the great Italian anatomists, Vesalius, Fallopius, Eustachius 
and others in the latter half of the sixteenth century, led eventually to 
the overthrow of the Galenic system of drug therapeutics ; but the in- 
fluence of the anatomists in this direction was by no means immediate. 
The early editions of the London Pharmacopoeia, which was first published 
in 1618, probably indicate fairly well the method on which drugs were 
used in England at that day for the cure of disease. In that of 1632 
most of the formulae are copied from the works of Greek and Arabian 
physicians, - from Galen, Avicenna, Rhazes, Haly-abbas and Mesue,- 
the name of the physician being given in each case at the head of the 
formula. Some, however, are of more modern date; John of Arderne 
(1370) is responsible for twTo compounds, and from Fernlius many are 
derived. We note many substances and processes introduced by the 
alchemists; vitrum antimonii and acetate of lead, for example, are 
amongst the remedies, and several of the preparations are made by dis- 218 
SYSTEM OF MEDICINE 
filiation. We also see the influence of the discovery of the New 
World on medicine, for guaiacum, cubebs, sarsaparilla and sassafras are 
amongst the official substances. There is a great variety of com- 
pounds ; almost all are very complex, many of them containing 30 to 50 
ingredients; into the " Antidotus Magna Matthioli Adversus Venena et 
Pestem " there enter 131 ingredients. There was certainly no lack of 
curative agents; in the list of simples we find 160 roots, 30 barks, 
16 woods, 220 herbs, 90 flowers, 96 fruits, 136 seeds, and 50 gums; 
besides juices and some other special parts of plants. The animal 
kingdom furnished 190 items. The fat of 22 animals, the excrement of 
11, and the urine of 5, occupy places in the official list of remedies; man 
is included in each case. Sweat was an official remedy, so too were the 
ossa triquetra of the human cranium. The brains of the leopard and of 
the sparrow, the lungs of the fox, and the body of the viper are found 
among the official animal substances. Sixty syrups and 180 waters were 
official. 
The discovery of the circulation by Harvey, and the advances made 
in the knowledge of the structure and functions of the body by Willis, 
Glisson, Malpighi, and others, together with the advancement of chem- 
istry and physics, led, during the seventeenth century, to the formation 
of new hypotheses concerning disease and its treatment. Van Helmont 
taught that life was connected with the presence in man of a kind of 
personal spirit (Archeus), which from its seat in the epigastrium 
presided over the functions of the body. This Archeus sometimes went 
wrong, owing to external or internal influences, hence diseases arose. 
Later we find chemical and mechanical theories of disease. By Sylvius 
and Willis acidity and alkalinity, or fermentation in the fluids of the 
body, were supposed to cause disease; whilst Baglivi and other Italian 
observers, and still later Archibald Pitcairn in this country, laid chief 
stress on the mechanical changes connected with the tissues and the cir- 
culation as causes of disease. All the advocates of these theories either 
contributed something to the knowledge of the treatment of disease by 
drugs, or by their works instigated further inquiry : to Willis and Syden- 
ham we owe the greatest advances. 
Willis was one of the first to lay stress on the importance of a knowl- 
edge of the structure of the different organs as a guide to the use of 
drugs; and in his Pharmaceutike rationales (1676) he first gives an account 
of the minute structure of the alimentary canal audits various parts, and of 
the arteries; he then describes the action of emetics, cathartics, diuretics, 
diaphoretics, cordials, hypnotics, and opiates. Further on he deals with 
the lungs and bronchial tubes, and the changes in respiration in diseases 
such as phthisis, haemoptysis, and other lung ailments, giving the indica- 
tions for treatment and the remedies which in his opinion answered these 
indications. He likewise points out what he regards as the rational 
treatment for jaundice, ascites, tympanites, and anasarca. In a third 
portion of the work he deals with the causes and treatment of haemorrhage, 
and with blisters, issues, etc. The practical outcome of the work of Willis PRINCIPLES OF DRUG THERAPEUTICS 
was of less value than the spirit of his teaching; his pathological ideas 
about animal spirits and fermentation as causes of disease were very 
crude; he was much influenced in his conclusions by old theories of the 
action of morbid materials, and the indications of the qualities (heat, 
cold, etc.), of drugs; above all, he too readily supposed that the drugs 
under which his patients recovered had cured them. His prescriptions 
are complex, and contain not only a large number of useless agents, but 
such remedies as the human skull, viper's flesh, millipedes, etc. Yet 
when he dealt with subjects controlled by anatomical knowledge, he 
made valuable additions to the existing therapeutical means. 
Sydenham professes to recognise the value of anatomical knowl- 
edge, but we find little of it in his work. Like Hippocrates, he 
sought to aid the natural progress of those changes or " commotions " in 
the blood and fluids of the body which he regarded as the causes of acute 
disease, and to help nature in her struggle to remove morbid matters. 
He advocated the removal of the immediate causes of disease, but had 
no belief in the possibility of dealing with remote causes. By close 
observation he attempted to determine definite lines for the administra- 
tion of drugs; he also sought to discover specific remedies, such as he 
held cinchona to be for ague. He preferred vegetable drugs to animal 
or mineral, because the animal are too like, and the mineral too unlike 
the tissues of the body. His prescriptions were more simple than those 
of Willis, and they are almost free from absurd constituents. But if 
we examine the prescriptions of both Willis and Sydenham we cannot 
but see that, with the exception of emetics, purgatives, bitters, and car- 
minatives, very few of the drugs they used had the powers which were 
claimed for them; and that the art of medicine suffered no loss when a 
large proportion of the drugs in which they had faith were consigned to 
oblivion. Under such circumstances we cannot be surprised that the 
Pharmacopoeia of the middle of the seventeenth century showed no 
signs of improvement. In that of 1677 we find the drugs and compounds 
almost as numerous as in the Pharmacopoeia of 1618; indeed some of 
the remedies in the latter are even more extraordinary than any in the 
earlier Pharmacopoeia. Not only is human urine set forth as a remedy, 
but care is taken to distinguish Urina hominis pueri impuberis from 
Urina hominis adulti! 
It is interesting to note that in this Pharmacopoeia we find for the 
first time jalap, serpentary, digitalis and cinchona; and that the names 
of Galen and the Arabian physicians cease to appear at the head of the 
formulse copied from their works. 
At the end of the seventeenth century the theories of Boerhaave, Hoff- 
mann, and Stahl considerably influenced therapeutic practice. The two 
former looked on health and disease as the outcome of chemical and 
physical conditions acting on tissues endowed with vital properties, 
which Hoffmann thought due to the presence of an ether-like fluid 
existing both in the solids and the blood; Stahl attributed everything 
to soul or spirit. Though both Boerhaave and Hoffmann looked upon 
219 220 
SKS'T'AJ/ OF MEDICINE 
the solids of the body as playing an important part in disease, they did 
not consider them as alone concerned. The former, holding that acridity 
or viscosity of the humours shared in the production of disease, pre- 
scribed medicines with the view of rendering them less viscid; the 
latter, though attributing disease chiefly to excessive or defective con- 
traction of the solid tissues (spasm or atony), nevertheless prescribed 
alteratives for the humours, and evacuants for defective excretions. 
Stahl, on the other hand, was led by his animistic views to deny the 
efficacy of medicine almost entirely: he even threw doubt on the use of 
opium and cinchona bark. Though all these eminent men, and many 
others, added something to the general fund of knowledge concerning 
therapeutics, the treatment of disease by drugs improved but slowly, 
and was dominated by strange conceits and superstitions. 
Scorpions, earthworms, woodlice and viper's flesh, also the excre- 
ment of the dog, goose, horse and pigeon, appear in the Pharma- 
copoeia of the Royal College of Physicians of London of 1721. The 
formulae were somewhat less complex than in the previous century ; 
but one, 11 Mithradatinm," contains 49 ingredients; another, " Theriaca 
Andromachi," 63, including viper's flesh ; and one of the Confectiones, 
50, amongst which appear bezoars, corals, pearls, and the flesh, liver 
and heart of the viper. 
Amongst the drugs which appear for the first time are the follow- 
ing : - Canella alba, tartar emetic, secale cornutum, stramonium, gam- 
boge, ipecacuanha and senega. Chemical knowledge has not reached 
the physicians, for the minerals are still divided into sulphurs, salts and 
earths; arsenious acid being included among the sulphurs. Twenty-five 
years later the Pharmacopoeia of the College of Physicians indicates a 
considerable change. The compounds are much simpler, and with 
a few exceptions they are not unlike those of the present day in the 
number of their ingredients. 
The Mithradatinm, however, still contains 46 ingredients, and the 
Theriaca Andromachi 62. The long list of animal substances has dis- 
appeared, but a few extraordinary materials are still met with: crab's 
claws, the so-called " crab's eyes," viper's flesh (in an ointment), bezoars,, 
woodlice and red coral are still official. On the other hand some useful 
remedies seem to have dropped out. Nux vomica, digitalis, senega, 
hyoscyamus, stramonium, male fern, and secale cornutum are no longer 
official. Spirit of nitrous ether is official for the first time. A large 
number of useful oils are introduced, and the chemistry is much more 
advanced. 
During the latter half of the eighteenth century very great advances 
were made in all the sciences bearing on medicine. Haller founded 
Physiology. Chemistry had advanced greatly. Barthez, in France, 
advanced a more tenable vitalistic theory of the nature of disease, and 
Cullen's Materia Medica was in every respect a great advance on any 
which had preceded it. The London Pharmacopoeia, published in 1788, 
and that of Edinburgh, which appeared in 1780, reflected the rapid PRINCIPLES OF DRUG THERAPEUTICS 
221 
advance of knowledge in Physiology, Pathology, Chemistry and Medi- 
cine which now occurred. The excessively complicated formulae, which 
the older Pharmacopoeias contained, were swept away. The numerous 
absurd animal substances present in previous Pharmacopoeias were almost 
entirely omitted. Digitalis, senega and male fern recovered their place 
in the London Pharmacopoeia; and cascarilla, kino, calumba and quassia 
were introduced. 
The last years of the eighteenth and the first years of the present 
century were marked by a fresh outbreak of theories concerning the 
cause and cure of disease which had, for the time being, a considerable 
influence on the treatment of disease by drugs. 
Brown, a pupil of Cullen, maintained that the tissues of the body 
possess excitability; that life is the outcome of the action of stimuli, 
such as warmth, food, etc., on this excitability, which is uniformly 
diffused in all tissues; that sthenic diseases are due to excessive, and 
asthenic to defective excitement. All remedies are stimuli, and only 
differ in their power. Strong stimuli, such as opium, musk, ammonia 
and camphor, are useful in asthenic diseases; but, if given in excess, 
they may, by producing over-excitement, lead to debility: other sub- 
stances, such as purgatives, emetics, etc., produce less excitement than 
is requisite for health, and are antisthenic, or debilitating. Brown held 
that, for the most part, diseases are asthenic, and his treatment therefore 
consisted chiefly in the exhibition of stimulants. He looked upon 
sthenic and asthenic conditions as affecting the entire economy, and took 
little note of local changes, holding that excitability is uniformly dif- 
fused ; and that it cannot be augmented in one part only, for then it 
would be unevenly distributed. This doctrine was largely accepted, and 
modifications of it were promulgated both in Italy and in France. 
Rasori held views not unlike those of Brown. Broussais also 
taught that life is due to stimulation; that to live is nothing else 
than to be excited: but, he considered that different diseases possess 
different degrees of excitability; and further, that as the sum total of 
excitability in the body is always the same, augmentation in the one 
part occasions diminution elsewhere. He looked upon all medicines as 
either stimulants or debilitants, but strongly upheld the view that all 
so-called general diseases have a local origin. Fevers, for instance, he 
believed to depend on gastro-intestinal inflammation. He classified 
medicines as debilitants, direct stimulants, and revulsives; and, like 
Rasori, he looked upon undue irritation as the cause of most diseases; 
practically, he recommended only debilitating agents in the treat- 
ment of disease. The English, Italian and French systems had, during 
the first two or three decades of the nineteenth century, great influence 
in determining the use of drugs, and the doctrine of Broussais affected 
treatment until after the middle of this century. But with increasing 
knowledge of Chemistry, Physiology and Pharmacology, belief in the 
Brunonian and allied systems gradually declined. 
The last theory of disease and its cure which I shall notice is that of SYSTEM OF MEDICINE 
222 
Hahnemann, who, at the end of the last century, made the theory that 
" like cures like " the central point of a new system of therapeutics. Hip- 
pocrates pointed out the occasional value of similars, that is, of drugs which 
produce symptoms similar to those observed in the disease for which they 
are given; so, too, did Galen, and some later writers. But Hahnemann was 
the first who raised the proposition that like cures like into a natural law; 
and he conjoined with this view a belief in the power of infinitesimal 
doses. He formulated new theories to account for disease and the curative 
action of his drugs. He held that a spiritual power (the vital force) ani- 
mates the human body, and that disease consists in a diversion of the 
automatic vital force into an abnormal direction. Drugs rightly selected 
can produce, in his opinion, a disease like to, but stronger than that for 
which they are given, and such medicinal diseases are more easily over- 
come by the spiritual or vital force than natural diseases. In selecting 
a drug for any particular ailment, it is therefore necessary to choose one 
which produces symptoms like to those which are present in the natural 
disease for which it is given. He said that knowledge of pathology, 
or of the causation of disease, is useless. The powerful action of 
infinitesimal doses he attributed to the fact that in their preparation 
succussion and trituration were much used, and these processes in his 
belief increased enormously the spiritual or dynamic power of the drug. 
The theories of Hahnemann on the nature of disease and drug 
action have long died out; but there are still a few believers in the 
so-called law of "similars," and in the efficacy of drugs given in 
infinitesimal doses. 
With Brown, Broussais and Hahnemann, another phase in the 
history of drug treatment closed. With them the theoretical systems 
of treatment, which had succeeded one another since the sixteenth cen- 
tury, came to an end. Therapeutics became rational. A tendency in 
this direction had long been manifest; with the increasing knowledge 
of Chemistry, Anatomy and Physiology during the seventeenth and 
eighteenth centuries, truer conceptions of the causes of diseases became 
more general; and it came to pass that drugs were increasingly used for 
the removal of causes apart from belief in any abstract generalisations. 
Alkalies were given for acidity, even though chemical theories of disease 
were discarded. The knowledge that the bronchial tubes are surrounded 
by muscle led to the tentative administration in asthma of substances 
such as opium and ether, without relation to any theories; and the good 
effects observed from evacuants in many ailments led to their ex- 
tended use, without any definite regard to Sydenham's theory of aid- 
ing nature. 
Morgagni's great work on Pathological Anatomy, published in 1795, 
threw a flood of light on the conditions of disease, and Bichat not only 
pointed out the importance of considering changes of tissues, as well as of 
organs, but urged that the true use of medicine is to restore organs and 
tissues to a normal state; and, by the discovery of the influence which 
drugs have on tissues and organs and the functions they subserve, the PRINCIPLES OF DRUG THERAPEUTICS 
223 
way was cleared for the next great step in therapeutic progress. The 
advances of chemistry gave facilities, previously wanting, for exact in- 
vestigation of the action of drugs. Stoerk, indeed, in 1762, had pub- 
lished a good account of the action of henbane, aconite, and some other 
drugs on the healthy organism, together with the therapeutic inferences 
he drew from this action; we find, however, few records of similar inves- 
tigations, and at the end of the eighteenth century very little had been 
ascertained as to the exact manner in which drugs influence the body, or 
as to those constituents of drugs on which their properties are now known 
to depend. The progress of chemistry had indeed led to a search for 
active principles in vegetable substances; but Cullen (in 1778) threw 
doubt on the value of any attempts to determine them. In the early 
part of the nineteenth century, however, chemists were enabled to 
separate several important alkaloids. Morphia was discovered in 1816, 
quinine in 1820, strychnine in 1818. These discoveries facilitated those 
investigations into the action of drugs on the various organs and tissues 
of the body and their functions, of which Magendie was the pioneer, and 
have so largely influenced the therapeutic theories and practices of 
the present day. Magendie showed that it was possible to determine not 
only the organ on which a drug acts, but even the part of the organ. 
By a series of striking experiments he demonstrated that strychnine 
produces its tetanising effects not by influencing the nerves or muscles 
but by acting on the reflex centres of the spinal cord; and the methods 
by which he showed this have been more or less a model for all who 
have forwarded the work which he so ably initiated. Soon chemists 
throughout Europe were busy in attempting to separate the active 
principles from all the well-known drugs; and physiologists were equally 
active in trying to determine exactly the organs on which these principles 
act and the manner in wrhich they affect them. Foremost among such 
workers was Claude Bernard, to whom, more than any man in this cen- 
tury, we are indebted for the progress made in the comprehension of the 
action of drugs; as, not only by his experiments on the physiological 
effects of many drugs, but also by his discovery of the part which 
the vaso-motor nerves and the muscular coat of the arteries play in the 
circulatory system, he prepared a way for the further investigations on 
the vascular system, which have led to the discovery of some of the 
most powerful means we possess for relieving suffering and saving life. 
His successors have been continuously occupied in following out the 
researches which Magendie initiated; and every year we see additions 
made to physiological and pharmacological knowledge, which, immedi- 
ately or at some future time, will enable us to treat disease with increasing 
certainty. When it had been sufficiently demonstrated that substances 
derived from the mineral, vegetable and animal kingdoms have a specific 
effect on disease, and that this action in the case of animal and vegetable 
substances could be traced to the chemical compounds they contain, the 
method in which the structure of these compounds influences their effects 
became a subject of investigation. Blake in 1842 came to the conclusion SYSTEM OF MEDICINE 
224 
that all salts having the same base exert a similar action when introduced 
into the blood, and that a close relation exists between the chemical 
properties of substances and their physiological results. 
We have now found that it is possible in many instances to form an 
idea, from the composition of a drug, of its influence on the body; 
that this influence may be altered in certain directions by modifying its 
chemical structure, and that new substances may be built up chemically 
to fulfil pharmacological and therapeutical requirements. 
The advances of recent years have been chiefly in the direction of 
the discovery and production of new agents calculated to exercise definite 
pharmacological actions, of determining their exact influence, as well as 
that of the older drugs, on the various parts of the body and on the lower 
forms of life, of ascertaining the minute changes which take place in dis- 
ease in the various organs, and of discovering the relation which exists be- 
tween micro-organisms and the production of disease on the one hand and 
the products of the micro-organisms and the cure of disease on the other. 
II. Present Principles of Drug Therapeutics 
We give drugs in disease for two purposes: - 
1. To restore health directly by removing the sum of the conditions 
which constitute disease. Here we act empirically, with no definite 
knowledge, - often indeed with little idea of the action of our drugs, but 
on the ground that in our hands or in those of others they have restored 
health in like cases. 
• 2. To influence one or more of the several tissues and organs which 
are in an abnormal state, so as to restore them to or towards the normal; 
with the hope that if we succeed in our purpose recovery will take 
place. This purpose we effect by means of the influence which the 
chemical properties of drugs exert on the structure and functions of the 
several tissues and organs. Minute information, therefore, of the nature 
of the drugs and their action is essential for their proper employment. 
Nature of Drugs. -Drugs were formerly looked upon as simple sub- 
stances having, amongst other attributes, the power of curing disease, 
indeed the popular idea concerning them has not advanced beyond this 
view; but physicians now refer their influence to the textural and 
functional changes they are capable of effecting in definite portions of 
the body by virtue of their total composition, or that of certain chemical 
substances they contain. Not only do the elements of which a drug is 
constituted affect its action, but the way in which these elements are 
grouped and combined is of importance. 
The effect which several of the elements exert in their compounds 
have been traced by Brunton, Ringer, Harnack, Binz and others. It has 
been shown that chlorine and bromine, potash, lime, and many other 
metals, always tend to act on certain tissues in a definite manner, 
unless their influence be neutralised by other elements with which they PRINCIPLES OF DRUG THERAPEUTICS 
225 
are in combination. It has been shown also that small groups of ele- 
ments may play a similar part in more complex compounds, that the 
action of NH2 and NO2, for example, can be as distinctly traced in the 
compounds in which they occur as that of chlorine or potassium or cal- 
cium. A compound containing the group NH2 stimulates the medulla; 
a drug containing the group NO2 acts on the vessels and dilates them. 
On the other hand, in many of the organic compounds we are quite 
unable to trace the effects of the several elements; and it is rather the 
manner of grouping of the elements which seems to confer on the com- 
pounds their pharmacological and other properties. Two compounds 
may contain exactly the same elements and the same number of atoms 
of each, yet if these atoms be differently arranged the compounds may 
differ entirely in pharmacological and other properties. Methyl nitrite, 
and nitro-methane have the same formula (CH3 NO2), but the oxygen and 
nitrogen atoms in the two substances are joined together in a different 
way. The result is they act quite differently: the nitrite dilates the 
vessels; nitro-methane has no such action. 
In the more complex organic compounds the addition or removal of 
one of these small groups of elements often greatly alters the pharmaco- 
logical effect. Fraser and Crum-Brown showed many years ago that 
by replacing an atom of hydrogen in conine by one of methyl (CH3) 
a great change in properties was effected. Conine paralyses the nerve 
endings alone, the methyl compound depresses the spinal cord. It is 
not always possible to anticipate the influence which the addition or 
subtraction of one or more of these groups will have on complex com- 
pounds which, like the alkaloids, are made up of a very large number 
of simpler groups. The result doubtless depends on the place which 
the added group takes amongst the other groups, or the effect produced 
by the subtraction on the arrangement of the other groups. Though 
the character and arrangement of the groups in a compound do not 
certainly indicate the action, yet they often give a good clue to it; 
they point to the manner in which the compound breaks up when 
taken into the system, and suggest the new combinations which may 
be formed. Again, they often indicate modifications and additions by 
which new compounds may be produced for the fulfilment of needs. 
Thus, for example, by adding the group NH,, H.CO to the group C.C13, 
COH (chloral) we get a compound chloralamide (C.C13, CHO, HCO, 
NH2) which has the soporific properties of chloral, but does not so 
deleteriously affect the cardiac and respiratory system. By the substi- 
tution in sulphonal of a molecule of ethyl (C2H5) for a molecule of 
methyl, trional is formed, which appears to have in some cases a better 
effect than sulphonal. Many of the modern remedies are the outcome 
of a knowledge of the influence exerted by various groups, and by the 
manner of arrangement of such groups in a compound. 
In the laboratory we can easily so modify the composition of medic- 
inal agents as to transform them into compounds having very different 
pharmacological effects. 
y 
VOL. I 226 
SYSTEM OF MEDICINE 
If morphia (C17, H18, NO2 (OH) ) be boiled under pressure with water 
acidulated with hydrochloric acid, it loses a molecule of H2O, and is 
converted into apomorphia (C17, H17, NO2). If it be heated with soda 
and methyl iodide, codeia (Cn, Hls, NO2, OCH3) is formed. Pilocarpine, 
when heated with dilute hydrochloric acid, is converted into jaborine, a 
compound allied chemically to pilocarpine, but resembling atropine in 
its pharmacological effects. 
The changes which can thus be effected in a drug outside the body 
may also be produced within the body; moreover these changes may 
vary with the conditions of the body. It is important, therefore, to 
determine the changes which can occur in chemical compounds under 
varying circumstances. 
In drugs derived from the mineral kingdom the grouping of the 
elements is simple; the influence of the drug often depends almost 
entirely on one of the elements present - as, for example, in the com- 
pounds of iron and mercury - and we can easily comprehend all the 
possible alterations which such drugs may undergo in the system. 
In the case of organic compounds belonging to the fatty and aromatic 
series, again, we may sometimes trace out the nature of the decompo- 
sition which goes on in the body, and estimate the effect of any new 
compounds which may be formed; but when we administer very complex 
substances, like the alkaloids, it is often impossible in the present state 
of knowledge to determine what changes, if any, take place; we cannot 
know, therefore, the nature of the effects which may be produced. 
Still more difficult is it to determine definitely the action of crude 
vegetable drugs, the effects of which are due to the alkaloids, glucosides, 
oils, etc., which they contain. In many instances more than one of these 
active principles are present, and not unfrequently we find these closely 
related chemically, being probably derived one from another in the 
chemical processes going on in the plant. 
The number of active principles in a plant is largely influenced by 
the circumstances connected with its growth, such as temperature, nature 
of soil, and so forth. Stenhouse found that broom grown in the sun 
contains four times as much alkaloid as that grown in the shade. Not 
only so, but the relative amounts of the various active principles will 
vary somewhat as the conditions under which the plant is grown are 
favourable to the occurrence of chemical changes, or the reverse. 
From all these causes the effects of crude vegetable drugs, and there- 
fore of the galenical preparations obtained from them, are apt to vary; 
and this variation is at times increased by differences in the method of 
preparation. Hence arises, perhaps, the divergence of opinions so often 
noted with regard to the therapeutic powers of certain drugs. The process 
of " standardisation " which has been already adopted in two instances 
in the British Pharmacopoeia, and is likely to be extended, will to a certain 
extent obviate this source of error; for the standardised preparations will 
contain a uniform amount of the alkaloidal principles contained in a plant. 
But if the relative quantities of these principles vary under different con- PRINCIPLES OF DRUG THERAPEUTICS 
227 
ditions of growth, the effects of preparations apparently identical will 
still be liable to corresponding variation; this may occur especially 
where drugs contain substances easily modified, as in the case of atropine 
and hyoscyamine. Ladenberg has given reasons for believing that the 
latter is changed into the former even by the process of extracting the 
alkaloid. Examples of such readiness to change, however, must be rare. 
Notwithstanding all these possible sources of error the action of 
drugs on the system is moderately constant; but not until we are much 
better acquainted than we now are with the chemical nature of drugs 
shall we be able to explain the very diverse therapeutic results which 
are recorded. 
The Nature of Pharmacological Action.-By the word "pharmaco- 
logical action " is meant the action of remedial agents on tissues and 
the function they subserve in health and disease.1 
The ultimate nature of the influence which drugs exercise on 
organised material cannot be absolutely determined; but, as Schmiede- 
berg has said, it must be chemical - using the word chemical in a broad 
sense. 
When a pharmacological agent comes in contact with a tissue its ef- 
fects may be purely chemical; it may act in virtue of its acid or alkaline 
properties, or by leading to decomposition of a purely chemical nature. 
It may also effect changes in the tissues by coagulating the albuminous or 
gelatinous materials contained in them; but, beyond this, it may alter 
their functions and vitality, without, so far as we can tell, producing 
chemical change in the strict sense of the term. When, for example, we 
pass through the muscle of a frog a very dilute solution of barium 
chloride, or expose it to a similar solution, the function of the muscle 
is distinctly modified, as shown by its increased contraction to stimuli, 
and by the prolonged duration of the contraction. By acting on the 
muscle of the heart or the vessel walls, their functions and vitality 
may also be altered; the systole of the heart is strengthened and pro- 
longed, and the vessel walls are contracted. But if, after producing 
these effects on voluntary muscle, heart or vessel, we take means to wash 
the tissues through with a nutrient fluid containing no poison, the mus- 
cles and organs will resume their normal functions. We can, moreover, 
antagonise the effect of chloride of barium by means of a weak solution 
of potash, or by a solution containing NO2, combined with a compara- 
tively inactive base (sodium). In the latter case, however, NO2, though 
neutralising the modification effected by barium on the function of the 
muscle, joins with it in depressing vitality, and the muscle quickly 
1 The word pharmacology was formerly applied to the consideration of medicines 
generally, including their physical characteristics and mode of preparation; and in this 
sense it is still often used in other countries. In England it signifies that department of 
therapeutics which concerns the effect of remedies as distinguished from their therapeu- 
tic application. It is well that the term " pharmacology " should be taken as including 
the action of drugs on morbid as well as on healthy tissues; otherwise it would be 
synonymous with physiological action, and we should have no term applicable to the 
investigations of the action of drugs on morbid tissues. 228 
SYSTEM OF MEDICINE 
dies. A minute quantity of calcium chloride, on the other hand, whilst 
affecting the contractility of muscle, tends to prolong vitality. Now 
in these cases there is no evidence that any chemical change takes 
place; the influence is apparently molecular rather than chemical, for if 
positive chemical change took place it is not probable that the effects 
could be so easily abolished, either by the removal of the barium, or by 
the addition of substances between which and the barium chloride no 
chemical change takes place. The exact process by which the molecule 
of the drug acts on the ultimate elements of the muscle fibre in order 
to produce change in function is beyond our knowledge. It seems prob- 
able that the influence of chemical compounds on the muscular, nervous, 
and all other tissues of the body, is similar to that which occurs in the 
skeletal muscles or heart removed from the body. The functions of the 
tissues are altered by the influence which the molecules of the chemical 
compounds exert upon them, and their vitality raised or depressed. It 
is in this way that strychnine and physostigmine respectively stimulate 
and depress the spinal cord, that curare paralyses the nerve endings, that 
atropine paralyses the vagus endings and centre, and that the tissues 
engaged in secretion or excretion are stimulated or depressed. Most sub- 
stances at first increase and then decrease the functional activity of 
muscle; in some the stimulating, in others the depressing effect is more 
marked: in some substances, indeed, no primary stimulating effect is 
observed. The same is the case with regard to the action of drugs on 
the other tissues within the body. Remedial agents for the most part 
first stimulate and then depress the functional activity of the parts they 
influence; but the stimulation may be more marked than the depressing 
effect, or vice versa; or it may be entirely absent. 
The effect in all cases may be looked upon as " molecular," that is, it 
may be produced without ascertainable chemical or structural change. 
If the supply of the chemical compound in the blood cease, it is sooner 
or later washed out of the tissue by the circulating fluid, and the normal 
function is restored. In experiments on muscle tissue it can be shown 
that some substances, such as the nitrites which powerfully alter func- 
tional activity and vitality, can be easily washed out, and the muscle 
thus restored to its normal condition. Other substances, such as barium, 
are washed out with difficulty. It is probable that there is a similar 
difference in the influence of drugs on all tissues, and that this in part 
accounts for the well-known difference in the duration of the action of 
medicines. The removal of a drug from the tissues which it has tem- 
porarily influenced, unless the effect have been very strong, is followed 
by a return to the normal state ; but it seems probable that under some 
conditions the continued interference with the function of a part is 
followed by nutritional changes of a permanent character. It is from 
this cause probably that alcohol in time leads to those changes in muscle 
and nerve which are characteristic of its prolonged imbibition. 
In order that drugs taken by the mouth may act on various parts of 
the body, such as the spinal cord, brain and nerve endings, it is evident PRINCIPLES OF DRUG THERAPEUTICS 
they must be absorbed and carried by the blood to these several parts. 
The absorption of active principles no one now questions, though in 
earlier days it was denied. Cullen held that medicines act almost 
entirely by the influence they exert on the mucous membrane of the 
stomach and intestines; and in the first decades of the present century 
the necessity for the absorption of a drug antecedent to its action was 
doubted by many. Drugs carried by the blood do not affect the tissues 
equally: one exercises its influence on the tissues of the cord, another 
on those of the cerebrum, a third on the respiratory centre, and so on. 
To explain this we must assume that tissues have a selective affinity, 
and that, as the blood circulates through them, each retains or submits 
to the material which is in functional relation to itself. 
Perhaps the most difficult part of pharmacological action to determine 
is the influence of remedial agents on the blood and nutritional proc- 
esses. There can be no doubt that some agents markedly affect the 
heemoglobin in the corpuscles, as shown by the cyanosis they produce; 
others, like chlorate of potash, are under certain conditions capable of 
causing dissolution of corpuscles, and there can be little doubt that the 
alkalinity of the plasma may be increased or decreased. But over and 
above these effects it would seem as if some substances, such as alcohol and 
arsenic, are capable of modifying the metabolic changes - delaying or 
accelerating them; but whether such results are due to a primary alter- 
ation in the blood, or to a direct influence of the alcoholic molecule on 
the tissues, is not known. 
Besides influencing the functions of tissues in the manner which has 
been distinguished as molecular, drugs may produce direct structural 
changes in tissues. Apart from all chemical action, they may excite 
irritation and inflammation such as that which is produced by mechanical 
agencies. In this way they may produce important effects not only on the 
tissues with which they come in contact, but also on parts remote from 
them. By the irritation produced in the nerve endings in the tissue a 
centre with which these nerves are connected may be altered, and other 
tissues supplied by this centre may have their function and vitality 
increased or decreased. The vomiting produced by emetics, and the 
nutritional changes which occasionally seem to follow external applica- 
tions, may be thus explained. 
The influence of pharmacological agents under the abnormal condi- 
tions present in disease is by no means always the same as in health; 
the difference is, however, usually quantitative rather than qualitative. 
A weak walled heart, for example, is much more easily influenced by 
digitalis than a healthy one. The functions of the kidney can never be 
affected in health as at times they may be in certain diseases. Anti- 
pyretics exert, on those parts upon which they act, a different effect in a 
febrile as compared with a normal condition. Lastly, mercury and iodide 
of potassium have special action on certain forms of diseased tissue 
which we do not see in health. This is probably due to the fact that in 
the diseased conditions they act upon new tissue of a less stable character 
229 230 
SYSTEM OF MEDICINE 
than normal tissue; or it may be that new compounds are formed with 
the mercury or iodide which are easily broken up and destroyed. 
As already pointed out, the pharmacological action of a drug is apt 
to be influenced by changes which the chemical processes of the body 
effect in the drug itself. Such changes may occur in the gastro-intestinal 
canal, in the blood, in the tissues, or at the moment of excretion. Hence 
the chemical composition of a drug is not unfrequently the key to its 
pharmacological action. 
Principles on which Drugs are Selected. - Rational Therapeutics. - 
When a case of disease presents itself for treatment the first step is to 
determine whether any drug be known which has cured an exactly 
similar case. This can only be done, of course, when full knowledge of 
the clinical features and pathology of the case has been obtained. If no 
such drug is known one of two plans is adopted: we may select a 
remedy on the ground of analogy, because it has done good in an instance 
so like the present one that it may reasonably be expected to be again of 
service. If experience and analogy fail recourse must be had to such 
pharmacological knowledge as we may possess; that is, we may select a 
drug capable, directly or indirectly, of causing the return of one of the 
abnormal tissues and organs to a normal state. 
Whether a drug be selected in the first place on analogical or 
on pharmacological grounds will largely depend on the bent of the 
observer. Some see analogies quickly, others more readily resort to 
reasoning. The same treatment may result from either attitude of 
mind. 
The chief point in which the modern method of selecting a drug 
differs from that formerly employed is, that when empirical knowledge 
does not appear available we employ methods of reasoning founded more 
directly on the pathology of the disease and on drug action, instead of on 
metaphysical or fanciful theories as to the nature of disease and of 
remedies. Nevertheless, it must be pointed out that in the application 
of pharmacological knowledge to the cure of disease we still use hypothe- 
ses ; and on the correctness of these our results must depend. The patho- 
logical changes in every ailment are more or less complex and wide-spread; 
the immediate influence of remedial agents is more limited: hence when 
we desire to restore health by urging the tissues and organs towards the 
normal state we have to make choice of the pathological condition which 
shall first be dealt with; and this we do in accordance with certain im- 
perfect inductions to which experience has led us. We assume in each 
case either (1) that in diseased conditions there is naturally a return to 
health, or (2) that if the apparent cause of the ailment be removed cure 
will follow, or (3) that by the restoration of tissues and organs, which 
are the special seat of pathological changes, to their normal textural and 
functional state, or to a state approaching the normal, we promote cure; 
and further, that when organs are caused by drugs to resume their nor- 
mal function, their improved condition may continue even when the 
drug is withdrawn. PRINCIPLES OF DRUG THERAPEUTICS 
The first assumption is one on which Hippocrates and Sydenham 
relied, and it lies at the root of much of our therapeutic reasoning. Expe- 
rience proves to us that many diseases tend to terminate in recovery; but 
that, nevertheless, pathological changes at times occur in their course 
which, unless prevented by suitable remedies, will terminate life. Yet 
we often fail to save life by dealing with sudden causes of danger. The 
removal of the apparent cause, or of the more marked pathological condi- 
tions in a disease, does not always lead to a favourable termination. Each 
of these generalisations, however, holds good in a large number of cases; 
and in selecting a drug apart from the teachings of experience we found 
our judgment on our pathological and clinical knowledge; we decide 
under which of these generalisations the case before us falls, and then 
with the aid of pharmacological knowledge we select a drug to fulfil one 
of the following indications - a drug which will (a) so influence some 
organ or organs as to avert the tendency to death, (&) remove the appar- 
ent cause of the ailment, (c) restore as far as possible the tissues and 
organs, which are the special seat of pathological changes, to a normal 
state. In addition to these indications we are manifestly called upon 
to (d) relieve pain and suffering. 
Our success will depend on the correctness of our judgment as to 
whether the case really comes under the generalisation we employ, and 
on the correctness of our pharmacological knowledge. 
It is apparent that in one sense indication c includes a and b. In 
averting death or removing the apparent cause, however, we do not 
necessarily deal with the special seat of pathological change. We always 
meet indication a at once, and then indication b if we can. 
Experience and Analogy. - The cases in which experience founded 
on simple observation can be trusted in the selection of a drug are few. 
The same collocation of symptoms and conditions are rarely repeated; 
yet, unless they are, when we select a drug on the ground that it has 
before done good, we act on analogy rather than on actual experience. 
In times past the judgments formed on the ground of experience of the 
action of medicines were very fallacious; to this the enormous number 
of medicines then used and now discarded are witnesses. Yet the dis- 
covery of mercury, quinine, arsenic, and many other remedies, is an 
evidence of the value of simple observation. Want of knowledge of the 
natural history of disease, of pathology and of pharmacology, is the cause 
of the errors which are made when experience is trusted alone. 
Belief in a drug of no value is easily engendered if the natural course 
of disease be unknown; defect of pathological knowledge and observa- 
tion leads rather to the misapplication of useful remedies. Quinine 
rarely fails in ague; but in a counterfeit of ague, say in the fever caused 
by suppuration in the liver due to gall stones, it is useless. 
Pharmacological knowledge corrects many of the errors to which 
simple experience is apt to lead; the want of it permits their continu- 
ance. If a drug have no active properties it is surely devoid of medicinal 
effect unless.it be a food; for medicinal action is the outcome of the 
231 232 
SYSTEM OF MEDICINE 
effects of active principles on tissues. It is always possible that in any 
particular drug the active medicinal agent may have escaped notice; but 
in the present state of chemical science it is not likely that undiscovered 
principles reside in such substances as sarsaparilla and hemidesmus: yet 
these drugs are given on the testimony of experience, - a testimony no 
stronger than that which has supported scores of other agents eventually 
discarded. If the indications given by the pharmacological examination 
of a drug are opposed to experience in its favour, the latter must almost 
certainly be at fault. 
Experience and analogy, then, should only be trusted within narrow 
limits; but when we can combine the indications of experience with those 
of pharmacology we strengthen both. The influence, for example, of 
antimony in eczema, especially when combined with magnesium sulphate, 
has often been vouched for on the ground of experience; but not more 
strongly than has been the case with scores of useless agents. It can be 
shown, however, that antimony does, in the frog, influence the epithelium 
very markedly, as does arsenic; and this, without proving its remedial 
value, distinctly adds to the probability that those observers are right 
who hold antimony to be useful in some forms of eczema. 
The value of the antitoxins and of thyroid extract is vouched for by 
many careful observers. Pharmacological knowledge is certainly not 
opposed to the probability of their usefulness; it rather supports it. On 
the other hand, it has so far given no support to a number of new animal 
substances brought forward recently, many of them on analogical grounds 
founded on some error in observation. To the use of analogy in drug 
therapeutics we owe great advances, especially in early times - it has 
been a great inciter to experiment, and is so still. Guided by due knowl- 
edge of the course of disease and of pathology it leads to increased knowl- 
edge; but as used in times past it has burdened our Materia Medica 
with much rubbish, as recoveries following the use of substances suggested 
by analogy have been looked upon as cures. It was by false analogy 
that mercury came so much into use in inflammations. When mercury 
was found to influence so markedly the swellings and thickening occur- 
ring in syphilis, it was used by analogy in all the forms of inflammatory 
disease which cause swellings and thickenings. As many of these nat- 
urally subsided thereafter, mercury was thus credited with a curative 
power in inflammation. It would be going too far to say mercury has 
no influence in inflammatory changes. There are probably conditions in 
which it is of service, but the facts that it is now so little used, and that 
no apparent evil has followed its abandonment, indicate that the views 
formerly held, and apparently grounded on experience, were, to a large 
extent, erroneous; and that the employment of analogy may, in this 
instance, have been productive of evil. 
(a) Method of averting the Tendency to Death. -We find not unfre- 
quently in the progress of acute diseases, and sometimes under other 
circumstances, that death seems to be impending by the failure in func- 
tion of one organ when the condition of the others is compatible with PRINCIPLES OF DRUG THERAPEUTICS 
continued life; and this even when in the organ affected there is no 
evidence of fatal structural change. 
The cardiac and respiratory systems are most commonly those in 
which such failure takes place. Suddenly or gradually, during the 
course of many diseases, the condition of the pulse points to failing heart 
action which threatens life; or again the blood changes essential to the 
continuance of life are imperilled by failing powers of the respiratory 
centre, or by paroxysmal obstruction to the entrance of air into the lung. 
These things may happen even though the heart and lungs are not the 
seat of any considerable pathological changes. 
In case of heart failure we may fulfil the indication of averting the 
tendency to death by giving drugs which (a) strengthen the power of 
the heart or (/?) decrease the work it has to do. 
(a) In selecting drugs to strengthen the heart the whole of their 
pharmacological properties must be borne in mind. Digitalis is one of 
the most effective agents we have for increasing the power of the heart's 
action, but it contracts the vessels and is long in acting. By contracting 
the vessels it is capable of doing harm in certain cases of heart failure, 
especially in gouty people with tendency to high arterial pressure; because 
of the slowness of its action (especially when taken by the mouth) it is 
often given in vain in cases where the heart's failure is urgent. On the 
other hand, where the heart's failure is gradual and the arterial pressure 
low, digitalis is called for. Strophanthus does not contract the vessels, 
and seems to act more quickly; whether it acts as powerfully as digitalis 
is a point on which we are not agreed. Strychnine, as a heart stimulant, 
acts more rapidly than digitalis ; when given subcutaneously its effects 
can often be noted in a few minutes; and, though perhaps they do not 
last so long as those of digitalis or strophanthus, they are more perma- 
nent than those of the volatile cardiac stimulants. Strychnine, moreover, 
has the advantage of being a respiratory as well as a cardiac stimulant: 
ammonia shares this advantage with strychnine, but it is more evanes- 
cent in its influence on the heart, although perhaps more immediate in 
its effects. The injection of ether subcutaneously is the most powerful 
means we have of immediately stimulating a failing heart, but its action is 
probably even more transitory than that of ammonia; though, owing to 
the fact that it can be injected subcutaneously, it is more frequently em- 
ployed in urgent depression of the heart's power. The cardiac stimula- 
tion produced by smelling ammonia is of course of a reflex nature. 
Although ammonia has undoubtedly a stimulating effect on the heart, 
increasing both its force and frequency, it is not always easy to determine 
its utility in this direction. It is possible the condition of the stomach 
at the moment influences its cardiac effects to some extent. So far as it 
is converted into chloride it can have little action on the heart, although 
the chloride may stimulate the respiratory centre. 
(j8) Of drugs which act by dilating the vessels, and thus relieving the 
heart in its work, there is one-amyl-nitrite - which dilates the vessels in 
about ten seconds, and is therefore applicable in the most urgent cases. 
233 234 
SYSTEM OF MEDICINE 
As its influence on the circulation, however, ceases in two or three min- 
utes, this drug, though of great value in immediate exigencies, must not 
be relied on for continuous action. 
Nitrite of sodium and nitro-glycerine exert a distinct influence in from 
two to four minutes, but their effects continue for two or three hours; 
they are therefore serviceable in cases where we want to relieve the 
heart's action for a considerable period, though useless where instant 
effect is required. 
Vessel dilators are of special use in warding off evil where cardiac 
failure is not accompanied by vascular dilatation. In certain forms of 
cardiac degeneration it would appear as if periodic waves of increasing 
arterial contraction become a grave source of danger, and these may be 
well met by the quickly or by the more slowly acting vessel dilators 
according to circumstances. 
It is possible in some cases to combine a cardiac stimulant with a 
vessel dilator; indeed the vessel dilators may have at first a slight 
stimulating effect on the heart, even if, in large doses, they eventually 
depress it, which, however, is not definitely proved. The combination 
of a nitrite with ether is thus often distinctly advantageous in the relief 
of cardiac failure. 
Any lethal tendencies of drugs used in cases where life is in the 
balance must always be borne in mind. It can be shown by experiments 
on animals that a slight excess of digitalis over the amount required to 
stimulate the heart may cause an immediate and permanent cessation of 
the beat; and there is reason to believe that in some forms of cardiac 
degeneration digitalis is capable of stopping the heart's action suddenly. 
On the other hand, in certain other ailments, such as pneumonia and 
delirium tremens, it would appear that the heart can bear large quantities 
of digitalis without injury. Unlike digitalis, strychnine seems to have no 
lethal effect on the heart even when given in large medicinal doses; and 
we rarely see indications of the physiological effects of strychnine on the 
nervous system following their use. The powerful effects of the nitrites 
on the circulation make us cautious in the use of these agents, the more so 
since, as before said, they are capable of depressing the contractile power 
of the heart: it is worthy of note, however, that, considering the extent 
to which they have been used, grave evil has very rarely been attributed 
to them; this may be due to the fact that the molecular influence they 
exert on tissue is not so permanent as in the case of many other drugs: 
It has been shown that they can readily be washed out of muscle tissue, 
which then resumes its normal function. 
In cases where life is immediately threatened by defective blood 
changes due to failure of the respiratory centre, or to paroxysmal obstruc- 
tion to the entrance of air into the lung, we may in the first place 
administer substances which have a directly stimulant action on the 
respiratory centre; of these perhaps the most useful are ammonia and 
strychnine. 
Belladonna has also a powerful effect on the centre; it has an influence, PRINCIPLES OF DRUG THERAPEUTICS 
too, in relaxing undue contraction of the muscles of the bronchial tubes 
if it occur. In using it, however, we must bear in mind its wide influ- 
ence over many other systems of the body. 
In paroxysmal obstruction to the entrance of air into the lung the 
nitrite will often be found of value; one or two drops of liquor trinitrini, 
or a drachm of a 3 per cent solution of nitrite of ethyl, or two grains of 
sodium nitrite, will very often remove perilous dyspnoea by relieving the 
spasm which interferes with the entrance of air into the bronchi. 
Even when we cannot remove the causes which lead to defective 
aeration of the blood, we may sometimes temporarily neutralise their ill 
effects by the inhalation of oxygen. It is quite true that in most cases 
where oxygen is used no permanent good is effected; but it is very 
commonly employed where the causes which lead to defective aeration 
are continuous : as a means of removing temporary cyanotic conditions 
oxygen is distinctly useful. 
The reduction of hyperpyrexia occurring in the course of acute dis- 
eases is another instance of the use of drugs in warding off a tendency 
to death; but here drugs are probably of less value than other means. 
If drugs are employed quinine is by far the best remedy for this purpose, 
but less than 10 grains is generally useless. The employment of anti- 
pyrine, antifebrin, or phenacetin is very questionable practice. 
(6) Removal of the apparent Cause of the Ailment. - In the removal 
of remote causes of disease drug treatment takes but little part. A 
foreign body in the stomach or intestines may be the cause of the 
pathological conditions leading to colic, vomiting or diarrhoea; and 
we employ pharmacological knowledge in the selection of emetics or 
purgatives for their removal. 
Micro-organisms, too, may be looked upon as the cause of a large 
number of ailments. Proof is yet wanting that we can destroy micro- 
organisms in the blood and tissues by so-called germicidal substances 
such as perchloride of mercury, the sulphites, carbolic acid, etc.; even 
on external surfaces and on mucous membranes, as in ringworm and 
diphtheria, these substances often fail to destroy them, though they are 
capable of checking their growth. 
Most of the other conditions usually called " causes " of ailments are 
really abnormal conditions of tissues and organs giving rise to groups of 
symptoms. In the series of antecedents which constitute collectively the 
true cause of an ailment, we often stop in an arbitrary manner at one of 
them and call it the cause of the collocation of phenomena by which the 
disease is signified. Practically by the word cause is usually meant the 
most remote of the antecedents which it is in our power to influence by 
drugs; it is by no means always the most manifest. 
In considering whether it be possible to remove an apparent cause we 
have first to decide whether it is really in action, next whether it goes far 
enough back in the chain of antecedents, and, lastly, how far drugs can 
influence it. A gumma may have been the direct cause of a hemiplegia; 
we may remove the cell deposit by mercury or iodide, but yet no im- 
235 236 
SYSTEM OF MEDICINE 
provement may take place, for further structural changes have occurred. 
The gumma may not still be the cause of the loss of power, although at 
first it was. Again, cerebral symptoms may be due to changes in the 
vessel walls and high arterial tension - the latter being the outcome of 
the products of imperfect metabolism, which in their turn may have 
originated in imperfect digestion. To treat the high tension will not 
suffice; it does not go far enough back in the order of events : we must 
treat the imperfect metabolism or the indigestion. Lastly, the limit of 
the action of drugs comes to be considered : in the case of gout, syphilis, 
and a few other ailments, we can definitely affect structural change by 
drugs; in most cases, however, our power to remove a cause by drugs 
ceases as soon as it consists of definite statical tissue change. 
The indication to remove the cause might of course be included in the 
next one relating to the removal or diminution of the special pathologi- 
cal changes present; yet practically in selecting a drug we have always 
first in our mind this question of cause, and it often leads to the selec- 
tion of an apparently subordinate lesion for treatment. In nothing is 
the judgment more exercised than in determining whether we shall deal 
with the remoter or with the more immediate or evident causes of the 
case before us. After all, however, the removal of a remote cause, like 
the removal of the immediate factors threatening death, is only an 
instance of the general statement that when empirical treatment fails 
or is not possible, we try to cure by restoring individual organs as far 
as possible to a normal condition. 
(c) Restoration of Tissues and Organs which are the Seat of Special 
Pathological Changes. - The influence of drugs in restoring organs to 
their normal state depends, of course, on the tissue changes they are ca- 
pable of effecting - using the word tissue changes in its widest sense to 
indicate changes which we cannot physically determine, as well as those 
we can. This tissue change, again, is the outcome of the action of ele- 
ments or groups of elements in a drug on one or more areas of the body. 
The general methods adopted when the blood is in an abnormal state 
may be mentioned first. In some cases we have evidence that the normal 
constituents of this fluid are defective; in others we have reason to 
believe that substances not ordinarily contained in it are present; or that 
some of the normal constituents may be present in excess. In the first 
place we may attempt directly to make up the deficiency. We do this 
when we give iron in anaemia; for recent evidence does not tend to sup- 
port the views of Schmiedeberg, and some other observers, who have 
asserted that in the use of iron nothing is added to the blood, and that 
its effects are due to changes brought about by it in the intestines. 
Another example of adding a constituent wanting in the blood is seen in 
the administration of the thyroid gland; and bone marrow acts like iron, 
if indeed it have any effect at all. To remove abnormal substances 
present in the blood various means are adopted. If we have reason 
to suppose that the products of imperfect metabolism are present 
we may attempt to promote their excretion by the kidneys or bowels. PRINCIPLES OF DRUG THERAPEUTICS 
237 
It is possible, though by no means proved, that such products are 
excreted by the bowels; it seems likely that saline diuretics may 
also help to remove them. Another, and often a more effective plan 
is to prevent absorption of the contents of the intestine in the upper 
part of the intestinal canal by means of saline purgatives, such as sul- 
phate of soda and sulphate of magnesia; a third is to give drugs which 
are supposed to facilitate the burning up of the intermediate products 
of metabolism. Alkalies, for example, are sometimes used for this 
purpose. 
There seems reason to think it possible in certain cases directly to 
antagonise and destroy the effects of some toxic matters which cause 
disease. This at least seems the way in which the newly-discovered 
antitoxins act. It is supposed, for example, that the diphtheria and 
tetanus antitoxins act directly on the toxins, annulling their noxious 
influence. May it not be, too, that quinine, and likewise mercury, re- 
spectively antagonise the poison of the plasmodium in ague and the 
unknown toxic agent which exists in the blood in syphilis ? 
The chief effects of disease on other tissues and their functions 
which may be influenced by drugs are connected with - (a) Inflammation 
and its results. (/?) Other morbid processes which lead to cell growths, 
(y) Increased or defective function with or without ascertained physical 
changes. 
Though inflammation may be, on the whole, a protective process-the 
reaction against some injurious material as Metschnikoff thinks - yet, 
as he also points out, its local effect on tissues essential to life may be 
destructive [yide art. Inflammation]; drugs are therefore used to mitigate 
or limit it. External inflammations may be dealt with by local stimulants 
or local sedatives. In conjunctivitis, for example, very dilute solutions of 
zinc sulphate are applied to the inflamed surface, and manifestly tend to 
subdue the process. They are supposed to act by contracting the dilated 
vessels. It would seem at times as if substances, such as atropine and 
morphine which depress the functions of the sensitive nerve endings in 
tissues, have a beneficial effect in relieving external inflammation. In- 
flammatory processes in the gastro-intestinal canal may be affected in a 
similar manner. It seems probable that minute doses of irritants, such 
as ipecacuanha and iodine, may sometimes act in the stomach and intes- 
tines as very dilute solutions of sulphate of zinc act on an inflamed con- 
junctiva. 
Furthermore, in the stomach and intestine we may affect inflam- 
matory tissue favourably by altering its surroundings, by removing 
irritating material from the surface of the inflamed membrane, and per- 
haps by supplying an unirritating covering in the shape of bismuth. 
This supposition, however, to account for the good effects which bismuth 
undoubtedly produces in irritated conditions of the stomach and intestine 
is very doubtful. It is at least as probable that an extremely small 
amount of the bismuth, in contact with the mucous membrane, becomes 
decomposed, so that some soluble bismuth is formed, which, being at issue 238 
SYSTEM OF MEDICINE 
irritant, acts as the zinc sulphate does on the conjunctiva. All inflam- 
mation of parts which can be reached directly by local applications are 
amenable to similar treatment. We can act, for example, on the inflamed 
mucous membrane of the bladder by sedatives, or by slightly stimulating 
and germicidal substances which are taken into the mouth, carried by 
the blood to the kidney, and there excreted, as, for example, buchu and 
copaiba. It is quite possible, too, we may be able to influence the lining 
membrane of the tubes of an inflamed kidney, but definite proof that we 
can do so with advantage has not yet been given. It must be borne in 
mind that the whole surface of the gastro-intestinal mucous membrane, 
from the fauces downwards, acts to some extent as an excreting surface; 
so that we may influence inflammatory processes therein by the excretion 
of substances previously absorbed. There is some reason to believe, for 
example, that the advantages of chlorate of potash in inflammation of 
the fauces are connected with its excretion by the mucous membrane, 
and are not entirely due to its local influence at the time it is swallowed. 
What power have we of effecting inflammation of organs which cannot 
be reached directly, or through the processes of excretion ? It was for- 
merly held that in antimony, aconite, and calomel, we have substances 
which directly limit the inflammatory processes in tissues; but no proof 
of this has ever been brought forward, and belief in it is waning. It is 
probable that we have some power to act indirectly on inflammatory proc- 
esses in the internal organs. We can increase secretion in the neigh- 
bourhood of an inflamed part, and we can alter the general tension of the 
vascular system. We can also modify the local vascular condition to 
a slight extent by dilating vessels in parts adjacent by means of phar- 
macological agents. In two other ways, also, it is possible by drugs 
indirectly to influence inflammatory processes in parts subjacent to 
cutaneous surfaces. There is evidence that cutaneous irritation has 
a distinct effect on the vascular supply and the nutrition in adjacent 
parts, and clinically it appears in some cases to limit inflammation. The 
other method is to give drugs which exercise a sedative influence on 
the mechanical conditions affecting the part inflamed. It is thus that 
opium is used in peritonitis. 
The products of ordinary inflammation which interfere with the 
functions of tissues may possibly, when consisting of cell growths, be 
broken up and absorbed under the influence of mercury and iodide 
of potassium, as the products of syphilitic inflammation certainly are. 
We have as yet no strong proof of this, though analogy has led to an 
extensive use of both substances for the removal of the various forms 
of inflammation; and the disappearance of deposit has so frequently 
followed the use of these drugs that we can hardly doubt that some use- 
ful effect is produced. There is reason to believe also that we can cause 
the absorption of inflammatory deposits by stimulating the nerve endings 
in adjacent areas. As a rule, for this purpose, preparations containing 
mercury or iodine are employed, often with friction. It is a moot point 
whether the dissipation of inflammatory deposits which certainly appears PRINCIPLES OF DRUG THERAPEUTICS 
to take place under these applications is due directly to the absorption 
of these substances, or indirectly to their stimulating action on the cuta- 
neous surface. Though mercury will pass through the skin, we have no 
proof that either iodide of potassium or iodide of lead do so: neverthe- 
less they are manifestly of service at times. On the other hand, the 
irritation they cause is so slight that we can hardly attribute to this 
agency the absorptive influence these applications seem to possess. 
Concerning the removal of other cell growths which interfere with 
the functions of tissues we have but little information. In all ailments 
which have any resemblance to the granulation tissues of syphilitic 
deposits we use mercury and iodine, and not unfrequently we see absorp- 
tion take place ; but we do not at present know the natural history of 
such ailments sufficiently well to feel assured that the disappearance is 
due to the drug. Arsenic can be shown to have a very decided effect 
on the nutrition of the skin, and it sometimes distinctly influences inflam- 
matory deposits therein. It is supposed also to exert some influence on 
sarcomatous and cancerous tissues, but here again more exact observa- 
tion is required. 
Drugs such as chloral, belladonna, physostigma, and nux vomica, 
act on the tissues of certain parts of the brain and spinal cord, and 
thereby increase or decrease the functions of those parts. We can 
depress the functions of the motor nerve endings with conine, and the 
sensory nerve endings with aconite. We can paralyse the involuntary 
muscle fibres directly with the nitrites, or indirectly by chloral hydrate, 
which depresses the functions of the vaso-motor centre. We can 
stimulate *or depress the functions of the cardiac muscle. The tissues 
of the various glands may likewise be stimulated or depressed. We can 
improve the nutrition, and therefore the function of almost all the tissues, 
by iron, cod liver oil and lime ; and indirectly we can produce the same 
effect by the gastric tonics and digestives which promote the taking and 
absorption of food. 
Our knowledge of the method in which drugs influence tissues in 
health and disease is largely, of course, the outcome of observations made 
on the effects of drugs on the functions which they modify; we must 
discriminate, however, between the action of drugs on an organ as a 
whole, and the changes in function which arise from drug influence 
on one of its tissues or on one of its parts. In restoring the function 
of an organ we have then to consider the influence of the drug 
on the various tissues and parts of which it is composed. In dealing 
with the cerebral functions, for example, the effect of the remedy 
on vessels as well as on cerebral tissues has to be remembered; and 
in the restoration of the cardiac functions the effect of agents on 
various portions of the nervous system as well as on the muscle should 
be borne in mind. The influence, too, of changes in one organ on the 
functions of another are very considerable, and it is often by acting on a 
healthy organ by stimulating or depressing its functions that we are able 
to restore another from a pathological to the normal condition. 
239 240 
SYSTEM OF MEDICINE 
In a case of cerebral haemorrhage, for example, in which the brain is 
the main seat of pathological change, we know of no drugs which by 
directly influencing its tissues will bring about its return to a normal 
state. We are able, however, to act upon it indirectly by purgatives 
which tend to lower blood pressure, and after a while by giving drugs 
which improve the general nutrition. In valvular affections of the heart 
we cannot remove the chief pathological condition, but by acting on the 
cardiac muscle and its ganglia we can so strengthen and moderate the 
beat as practically to restore its normal function. 
In phthisis we have hardly any power to influence lung tissue directly: 
but, by substances such as cod liver oil and lime which improve the gen- 
eral nutrition of the body, we can indirectly, perhaps indeed to some ex- 
tent directly, help to restore the lung tissue and function. In bronchitis 
we can act directly on the tissue of the mucous membrane, and pro- 
mote its normal secretions; but in pneumonia we probably cannot 
influence the affected tissues directly, although we employ salines 
with a vague idea that we may do so. Here we are limited in our 
action to sustaining the functions of other parts, in which the patho- 
logical change is much less marked, until such time as resolution may 
take place. It is possible, indeed, that expectorants sometimes influence 
the lung changes favourably by promoting secretion from the bronchial 
mucous membrane adjacent to the inflamed tissue; but it is unlikely 
that they act on this tissue itself. In pleurisy we are quite as helpless 
so far as direct drug treatment is concerned; we know no drug which has 
any direct effect in reducing pleural inflammation, and we are limited for 
the most part to the exhibition of agents for the relief of pain. 'Yet even 
here, when the acute stage has passed, we may promote the restoration 
of the pleura to a normal state by iron and nutrients. 
Though we have no more power over peritoneal inflammation than 
we have over that occurring in the lungs or pleura we are able in peri- 
tonitis to give some aid by limiting the movements of the inflamed part. 
Opium probably influences the nerves supplying the intestinal muscles, 
and thus decreases peristaltic action. It also fulfils the next indication, 
the relief of pain. Here again, as in many other instances, in the efforts 
we make to restore parts pathologically affected we act on other and more 
or less normal structures. We have no reason to believe that the chief 
effect of opium, either in relieving pain or in checking peristalsis, is due 
to any large extent to its action on the nerve endings in the affected part. 
In a few cases we attempt to restore the normal functions of an organ 
by the addition of certain materials which are lacking in its secretion. 
Thus, for example, in dyspepsia we administer pepsin; or we may aid 
duodenal digestion by a remedy derived from the pancreas; or we may 
give bile where we think this secretion defective. In all these cases, 
however, our immediate objects are 'in the first place to relieve discom- 
fort, and in the second to restore the normal functions of the gastro- 
intestinal tract which are interfered with by the abnormal state of their 
contents due to the absence of pepsin, trypsin, and bile. PRINCIPLES OF DRUG THERAPEUTICS 
241 
Sometimes we appear to apply pharmacological substances to influ- 
ence a symptom rather than a pathological state, as when we use an 
antipyretic in fever. Here, however, we are really attempting to act on 
the pathological conditions causing high temperature; but not knowing 
what these are, we have to use a remedy in ignorance of the exact 
nature of its action. 
In administering drugs to restore tissues and organs to a normal 
state we usually act on the supposition that an organ thus restored will 
maintain its improved condition even when the drug is withdrawn. 
When digitalis, for example, is given in cardiac dilatation and irregular 
action it is assumed, and for the most part rightly so, that if we can 
restore or partially restore the heart to a normal state it will so remain 
when the medicine is withheld. We do the same in bronchitis when 
we administer expectorants; in fact we apply a generalisation in this 
matter, as in many others, founded on a weak induction which must be 
referred to one or more inductions of wider scope. The reason that a 
tissue or organ restored to its normal state by a drug does not revert to 
its abnormal condition on the loss of the drug, depends partly upon the 
fact that every altered condition of an organ reacts on the surrounding 
tissues and organs; and partly on the tendency to revert towards the 
normal when perturbations have ceased to act. 
(d) Relief of Pain and Suffering. - This indication has to be followed 
not only from considerations of humanity, but because pain and suffer- 
ing, by their influence on nutritional processes, tend directly to prevent 
the return of tissues and organs to their normal state. The relief of 
pain may be accomplished by drugs which depress the functions of the 
sensory nerve endings, or act on certain parts of the central nervous 
system. The nerve endings may be affected through the circulation or 
directly. It is probable that most of those substances which depress 
the tissues of the central nervous system, those especially which are in 
relation to its higher functions, have also some influence on the nerve 
endings, though by no means in like proportion. On the other hand 
substances, such as cocaine, which very distinctly paralyse the sensory 
nerve endings, have comparatively little effect in preventing the percep- 
tion of pain in the cerebrum. The influence of substances which act 
directly on nerve endings is practically much affected by the relations 
between themselves and the epidermis. The epidermic covering is 
probably a complete bar to the action of cocaine on the nerve endings; 
proof has not yet been given that, even by combining it with substances 
such as chloroform and lanolin which are said to aid the passages of 
drugs through the epidermis or its ducts, any effective influence is 
exerted on the tissues beneath. The epidermis likewise almost entirely 
resists the passage of morphia: hence opiate applications are far less 
frequently of benefit than is popularly supposed. On the other hand 
atropia, although not a powerful depressant of the functions of the 
nerve endings, passes readily through the epidermis; so too does aconi- 
tine, which has, however, in addition to its ansesthetic effects on the 
VOL. I 
R 242 
SYSTEM OF MEDICINE 
nerve endings, an irritant effect on other tissues. Conium, like cocaine,, 
has no action when applied to a surface covered with epidermis. 
The exact part influenced by analgesics acting on the central nervous 
system is not known. 
Substances which depress the higher cerebral functions such as 
anaesthetics, chloral, bromide of potassium, are undoubtedly analgesics; 
but opium, which stands first and foremost of all drugs in the relief of 
pain, may act as an analgesic without exerting the slightest recognisable 
influence on the higher centres. We have no evidence that its influence 
is largely due to its local action on the nerve endings; morphia will 
indeed relieve pain applied locally, but this may be due to its absorp- 
tion into the blood. It certainly has no such depressing effects on the 
nerve endings as cocaine; if injected subcutaneously the place of injec- 
tion is a matter of indifference. Possibly it influences the gray matter 
in the cord along which painful sensations are conveyed, and the con- 
tinuation of the gray matter into the brain; or it may affect the centre 
for the reception of pain. 
The exact point, then, on which morphia exerts its effect in produc- 
ing analgesia is still unknown. Such too is the case with the newer 
analgesics - antipyrine, antifebrin, and phenacetin. They likewise in- 
fluence painful sensations in a manner for which neither their local 
action nor their influence on the cerebrum can account. 
In choosing an analgesic the pharmacological influences of the drug, 
other than those which effect the relief of pain, are not to be forgotten; 
these secondary actions often limit their use. 
Not only must we relieve pain where possible, but all forms of suf- 
fering also; and next to pain insomnia is perhaps the most distressing 
of these forms. There is reason to believe the presence of certain ele- 
ments and radicals in drugs gives them a power of depressing the tissues 
of the higher centres of the brain, and thus causing sleep. Almost all 
soporifics are derived from the fatty series, and many of them contain the 
elements chlorine and bromine. It seems probable that these elements^ 
and also the fatty radicals, directly depress the function of the nerve cells 
in the cortex. The structure of hypnotics which do not belong to the 
fatty series, of which opium is the only one of importance, is not suf- 
ficiently known to enable us to ascertain to which of its constituent 
groups of molecules its effects are due. As in the case of analgesics the 
use of soporifics is limited by the extent of their other pharmacological 
effects; chloral depresses the cardiac and respiratory centres, the former 
to a dangerous extent when administered in large doses. In the newer 
compound chloralamide this effect is in part avoided by the presence of 
a molecule of formamide, which contains a group N.H2 capable of stimu- 
lating the centres in the medulla. It still remains to be seen whether 
this is sufficient to neutralise entirely the depressing action of chloral. 
Paraldehyde produces few special effects other than those procuring 
sleep, but its taste and the odour it gives to the breath are very objection- 
able ; it is moreover much less certain in its effects than chloral. Sul- PRINCIPLES OF DRUG THERAPEUTICS 
phonal is also less certain than chloral; it is devoid of the unpleasant- 
ness of paraldehyde, but it seems at times to disturb muscular co-ordina- 
tion, and it is said to lead to the presence of haematoporphorin in the urine. 
243 
III. Principles of Administration 
In the administration of drugs the chief point for consideration is 
the method by which they can best be brought, in the requisite quantity, 
in contact with the tissues to be influenced. 
Methods.-Drugs may be introduced into the body in many ways, 
which may thus be shortly enumerated. 
1. By the Skin. - The skin presents two pathways for the absorption 
of drugs, viz., through the epidermis or through the cutaneous glands. 
Whether drugs actually penetrate the epidermis is very doubtful, and it 
is found that the more effectual ways of securing absorption through 
the skin are those which appear most apt to carry the drug into the 
interior of the cutaneous glands, such as the inunction of a mercurial 
ointment, the exposure of the skin to the hot moist vapour of a calomel 
fumigation, or the solution of the drug in chloroform as a liniment. By 
this mode of administration we avoid any disturbing influence of the 
drug on the digestive organs, and young children can thus easily be put 
under treatment. The disadvantages consist in uncertainty as to the 
quantity of drug absorbed, and in the unpleasantness of greasy and 
sometimes dirty applications to a large surface of skin. 
The following means are usually adopted for securing cutaneous 
absorption: - 
Fumigations ..... 
Inunction of ointments or liniments 
Endermic applications to surfaces denuded of epidermis 
Effectual. 
Plasters continually applied 
Baths .... 
Medicated poultices and fomentations 
Of doubtful value. 
2. By the Alimentary Canal. 
(a) By the stomach. The disadvantages of stomach administrations 
are - 
(a) The drugs may be variously changed and decomposed by the 
digestive juice. 
(/?) They may disturb the digestive functions. 
(y) There is often delay in action, the rate of absorption being influ- 
enced by the solubility of the drug and the condition of the 
stomach mucous membrane; hence certain substances, such as 
sulphonal, are very uncertain in the time of their action. 
(&) By the rectum in the form of enema and suppository. Absorp- 
tion is slow from the rectum in the case of most drugs, and the dose 244 
SYSTEM OF MEDICINE 
needed is larger than when given by the stomach. Strychnine and 
tobacco are exceptions to this rule. 
3. By the Respiratory Mucous Membrane. - This is probably the most 
rapid means of entrance for drugs, owing to the large absorbent surface 
of the lung, and to the fact that the blood into which the drug has 
passed goes directly to the heart. Hence the extremely rapid action of 
amyl-nitrite. This method of administration is limited, for the most 
part, in its application to drugs volatile at the temperatures of the body, 
but injections into the trachea have been made; atomisation and in- 
sufflation of powders are commonly employed in local medication of the 
respiratory mucous membrane. 
4. By the Genital Mucous Membrane. - Absorption through this chan- 
nel is slow and uncertain. Usually the injections, pessaries, bougies, 
etc., used in this form of medication are employed for their local effect 
only. 
5. By Hypodermic Injection. - This has the advantage of directly in- 
troducing the drug into the lymph stream without any decomposition. 
The influence is rapid, and the dose of the drug can be accurately 
graduated. The use is limited to drugs which are not irritating, and, 
for the most part, to those of which the dose is small. 
6. By Intravenous Injection. - This is practically only used for the 
introduction of large quantities of saline fluid, though ammonia has thus 
been given. 
7. By Intraserous Injection. - This has been employed in exceptional 
cases, but, so far as drug treatment is concerned, is of no value. The 
rapidity, however, with which absorption from serous cavities takes place 
is of importance in other relations. 
Dosage. - The dose of a drug is not a fixed quantity, but must be 
determined according to the purpose for which the drug is used, and the 
conditions under which it is used. The conditions which chiefly influence 
dosage are age, sex, size and weight, and disease. 
Age. - The usual rule is to take the adult dose as 1 year, and make 
a fraction, which has the age of the child for a numerator, and this age 
plus 12 for a denominator: this gives the fraction of the adult dose which 
is suitable for the child. Thus, for a child of six the dose would be j-. 
or one-third of the adult doses. This is, of course, a mere approxima- 
tion ; moreover, each drug has to be considered separately in this respect. 
Children, for example, bear much larger relative doses of belladonna and 
arsenic than adults; but of opium, on the other hand, smaller doses. 
Sex. - Women differ considerably from men in their reaction to 
medicine; the dose for a woman is usually considered to be four-fifths 
of that for a man. 
Size and Weight seem to have less influence than would be generally 
supposed. It is only in exceptional cases - that is, where the size and 
weight are very small - that these factors need be taken into con- 
sideration. PRINCIPLES OF DRUG THERAPEUTICS 
The Present Disease. - This has often an important bearing on the 
dose. Any ailment which interferes with the functional activity of 
eliminating organs may seriously modify drug action. Hence, in kidney 
diseases, for example, opium has at times an exaggerated action. 
As the dose of a drug has to be adapted to the changes in the tissues 
and organs it is meant to affect, and as the tissues of similar kind in 
different individuals are not influenced by the same amount of a drug, 
the dose which will effect its purpose has often to be arrived at by 
experiment - that is to say, by gradually raising it until a definite 
result is obtained. 
Circumstances modifying the Influence of Drugs. - Idiosyncrasy. - 
One or more of the tissues may be unduly susceptible or insusceptible 
to the action of a drug. It is well known that the smallest quantity of 
calomel will salivate some persons, and a very minute dose of quinine 
will cause a rash in others. The explanation of this is quite unknown, 
but evgn the simplest tissues vary in their reaction to drugs; the excised 
muscles of one frog, for example, may differ considerably in their ordi- 
nary reactions from those of a series of other frogs without any other 
ascertainable differences in the experiment. [ Vide art. " Temperament."] 
Toleration. - When, on taking a drug continuously, the first effects 
decrease until they are no longer noticed, toleration is said to be estab- 
lished. In some cases this may be due to conditions causing increased 
elimination, or to the initiation of new chemical changes by which the 
drug becomes altered and even rendered inert. It may, however, also 
be due to some modification in the reacting tissue, caused by the con- 
tinuous contact of the drug. It would appear as if toleration can be 
established more readily with some drugs than others; with opium, for 
example, it is easily established. For arsenic the toleration is not so 
readily established, unless indeed we accept the stories of the Styrian 
peasants. For chloral hydrate tolerance seems to become only partially 
established; patients can become habituated to larger doses, yet at times 
toleration seems temporarily to disappear, and a large habitual dose may 
at last have a fatal effect. 
The duration of action of a drug is likewise dependent on the rapidity 
of its excretion and its adhesion to the tissues. The difference between 
drugs in this matter is enormous. Such substances as ammonia, ether, 
the nitrites and alcohol, produce their effects on the tissues quickly, and 
their effect as quickly passes away. An ordinary dose of ammonia or 
ether acts within a second or two; its effects do not last more than half 
an hour or an hour. Two grains of nitrite of sodium begins to act in 
two or three minutes, and its influence cannot be detected after three 
hours. Digitalis, on the other hand, does not show any signs of affect- 
ing the system for a long time, but its effect is long continued. It is 
manifest that this difference in the duration of the action of medicines 
should be considered in our combinations of them. It seems probable, 
for example, that if ammonia and digitalis are given in combination the 
ammonia will have ceased to act before the digitalis begins. 
245 246 
SYSTEM OF MEDICINE 
Cumulative Action. - Some drugs are quickly excreted, others are 
stored up in the body, and may not exert their characteristic effect 
until a certain amount has accumulated. This is the case with digi- 
talis, for example. When this drug is taken in small doses, its special 
effects are not seen, as a rule, for two or three days. Cumulative action 
of a drug is usually due in part to difficulty of excretion, but also to the 
stronger adhesion of its molecules to the tissues. Digitalis, as a matter 
of experiment, is washed out of tissues with much greater difficulty than 
many other substances. The reverse is the case with curare, which is so 
slowly absorbed from the stomach and so quickly removed from the tis- 
sues and excreted that, if the drug be taken by the mouth, a sufficient 
quantity does not abide in them to produce its characteristic effect. 
Hence it must be given subcutaneously. 
Sources of Fallacy in Therapeutics. - Some of the fallacies arising 
from defective observation and other causes have already been pointed 
out incidentally. 
One is the assumption of pharmacological knowledge which does not 
exist. Some knowledge of the action of drugs on various parts of the 
body has been obtained, but concerning the effects of a large number 
definite information is wanting. Unfortunately, when knowledge is 
wanting, suppositions founded not on experiment but on fancy or on 
imperfect observation usually take their place. The reputed action of 
many drugs as cholagogues, diaphoretics, diuretics, etc., is founded on 
the most slender basis; yet it is constantly alleged as if it were founded 
on real knowledge. Of the alleged diaphoretic action of such substances 
as sassafras, and serpentary, nothing certain is ascertained. Again, under 
what conditions the so-called " expectorants " produce their effects we do 
not know, and so forth; indeed the action of most drugs on the tissues 
and organs is guessed at rather than known. Yet in therapeutic reason- 
ing these hazy apprehensions are usually accepted as a basis for treatment. 
A second source of fallacy is the persistence of old and baseless 
theories. The opinions of Hippocrates and of Sydenham; those of Willis, 
concerning the aiding of nature with regard to fermentation; of Boer- 
haave, on obstruction of the vessels; of Brown on asthenia, still colour 
our therapeutic reasoning, and lingering like the nomenclature of their 
inventors, like it they influence thought. 
Limits of the Utility of Drugs.-Drugs only act beneficially when 
they can exercise such influence on the morbid changes in tissues and 
organs as to restore the parts to a state compatible with systemic life. 
But in a large proportion of cases such restoration is impossible. Unfor- 
tunately for the reputation of drugs it is considered necessary to give 
them in all cases, even where it is manifest that the case is beyond the 
limits of drug treatment. The prevalent want of belief in drugs is largely 
due to the fact that they are expected to achieve the impossible. 
D. J. Leech. CLIMATE IN THE TREATMENT OF DISEASE 
247 
BIBLIOGRAPHY 
1. Daremberg. La m^decine, histoire et doctrines. Paris, 1865.-2. Haeser. 
Geschichte der Medicin. Jena, 1875.-3. Hirschel. Geschichte der Medicin. Wien, 
1862. - 4. Renouard. History of Medicine (Transl. by Comegys). Lond. 1856.- 
5. Withlngton. Medical History from the Earliest Times. Lond. 1894. - 6. 
Thomson, John. Life of William Cullen, vol. i. Edin. 1859. - 7. Brown, John. 
Elements of Medicine, with a Biographical Preface by Thomas Beddoes. Lond. 1795. 
- 8. Broussais. Examen des doctrines medicales et des systemes modernes de nosolo- 
gie. Paris, 1816.-9. Willis. Pharmaceutice rationalis. Geneva, 1676-77.-10. 
Magendie. Journal de physiologie experimentale. Paris, 1821.-11. Bernard, Cl. 
Introduction a Vetude de la medecine experimentale. Paris, 1865. -12. Chambers, 
T. K. True Art of Healing. Lond. 1866. -13. Headland. "Advance in the 
Science of Medicine in Modern Times," Lancet, Lond. 1858, vol. i. pp. 27-79. -14. 
Crum-Brown and Fraser. " On the Connection between Chemical Constitution and 
Physiological Action," Trans. Roy. Soc. of Edinburgh, vol. xxv. -15. Blake. "On 
the Action of certain Inorganic Compounds when introduced directly into the Blood," 
Proc. Roy. Soc. vol. iv. Jan. 28, 1841. -16. Forbes. Nature and Art in the Cure of 
Disease. Lond. 1858.-17. Brunton. Pharmacology and Therapeutics; or, Medicine 
Past and Present. Lond. 1880.-18. Schmiedeberg. Elements of Pharmacology 
(Transl.). Edin. 1887. -19. Ringer, S. Articles in Journal of Physiology. Lond. 
1878 and following years.-20. Brunton and Cash. Phil. Trans. Pt. i. 1884. - 21. 
Monro. "The Scientific Basis of Medicine," Glasgow Med. Journal, 1885.-22. 
Plugge. Die wichtigsten Heilmittel in ihrer wechselnden chemischen Zusammen- 
setzung und pharmakodynamischen Wirkung. Jena, 1886.-23. Boehm. " Einige 
Beobachtungen uber die Nervenendwirkung des Curarin," Arch. f. exp. Path. u. 
Pharm. B. mv. H. 1. 
D. J. L. 
CLIMATE IN THE TREATMENT OF DISEASE 
The Climate of a region or site is the combined effect of the 
atmosphere and of the nature of the surface in their relation to man. 
Of these the atmosphere, which is the product of many more or less 
varying agents, is the chief. The most important qualities of the atmos- 
phere are: - 
1. The chemical composition. 2. The organic and inorganic substances floating 
in it. 3. The temperature and its variations. 4. The degree of humidity. 5. The 
■diathermancy. 6. The transparency and the quality of light. 7. The density and 
pressure. 8. The electrical conditions. 9. The circulation of the air - the direc- 
tions and the force of the winds. 
The climatic character of a locality depends chiefly: - 
1. On the distance from the equator. 2. The elevation above the sea. 3. The 
relation of its position to adjacent seas or large inland lakes, or deserts, or marshes. 
4. The predominating winds. 5. The nature of the soil: whether rock or dry por- 
ous ground, such as sand, allowing rapid percolation of moisture, and enclosing 
between the solid particles a large amount of air; or stiff, more or less impermeable 
ground, such as clay, peat, or marsh. 6. Configuration of surface: the amount of 
shelter, the position on a slope, terrace, or plateau, or in a valley ; the aspect towards 
the sun, and possible amount of sunshine. 7. The mode of the cultivation of soil, SYSTEM OF MEDICINE 
248 
whether arable fields or pastures ; the planting and clearing of forests ; the density 
of population ; the establishment of manufactures; the amount of drainage of the 
rural and the urban districts. 
This article will be divided into three sections, as follows: - 
First Section: Remarks on some of the principal elements of climate. 
Second Section: Principal climatic regions and health resorts. 
Third Section: Use of climate in the treatment and prevention of 
disease, with a sub-section on the use of " home " from a hygienic and 
therapeutic point of view. 
First Section. - Remarks on some of the Principal Elements of 
Climate 
1. Composition of the Air. - At one time it was generally maintained 
that the composition of the air was the same in all parts of the earth 
- at the tops of the mountains, on the sea, in rural and in town districts; 
but the researches of Tyndall, Frankland, R. Angus Smith, and others 
have shown that there are slight differences from the usually assumed 
composition, viz. - 
Oxygen . . 20-96 
Nitrogen . . 79-00 
Carbonic acid . . 0-04 
in 100-00 volumes of air. 
Although the differences in the proportion of oxygen rarely exceed 
Jq volume, such a plus or minus is of great importance if we consider 
the large quantity of air which we inhale, and if we may assume that 
any deficit is generally associated with the presence or the increase of 
more or less injurious substances. 
R. Angus Smith found even in the same town considerable differences 
in the proportion of oxygen, e.g. in a northern suburb of London 
(Belsize Park) 21-01 per cent, in the middle of Hyde Park 21-005, in 
the Eastern district 20-86, in the tunnel of the Metropolitan Railway 
20-70. In an open yard before a house more oxygen was found than 
within the rooms of the house. At the same spot he found differences 
under the influence of weather - more oxygen during and after rain 
than in dry and foggy weather. 
Carbonic acid was first found by De Saussure as a regular constituent 
of the air in the proportion of 3-6 to 6 parts in 10,000; but its percentage 
varies considerably. Thus Angus Smith found in crowded law courts 
as much as 20, and in theatres even 32 in 10,000; and Pettenkofer found 
20 to 58 in 10,000 in crowded schools at Munich. It is probable that air 
rich in carbonic acid is also rich in other impurities and in bacteria. 
The air contains other gaseous substances, such as ozone, antozone, 
ammonia, on which we cannot enter here; and the vapour of water, 
which we shall discuss under humidity. 
Very important are the solid substances floating in the air, the nature CLIMA TE IN THE TREA TMENT OF DISEASE 
249 
of which varies considerably at different localities and under different 
conditions. They are partly inorganic, such as salty particles, silica, 
chalk, iron, etc.; partly organic, such as pollen, algse, bacteria, fragments 
of hair, vegetable fibre, and insects. Some of these substances are inno- 
cent, or nearly so; others are injurious. Ehrenberg, Schwann and others 
directed attention to this matter long ago; but to Pasteur and Tyndall 
our debt is greatest. Pasteur has shown the absence of organic impurity 
on glaciers, and its presence in large quantities in villages not far distant. 
The recognition by Lister of the influence of these suspended matters 
on wounds, and the adoption of successful means to exclude them, mark 
an epoch in the history of Medicine; and their presence in the air of 
different localities deserves attention in the appreciation of climates. 
On this depends the septic or aseptic character of the atmosphere; and 
the predominant feature of the localities most beneficial in the treat- 
ment of tubercular phthisis is the aseptic character of the atmosphere. 
2. Temperature is a most powerful modifier of climates. We dis- 
tinguish between radiant or sun heat, and shade or air heat. The rays 
of the sun have great power of heating the human body and other solid 
substances on which they fall, but heat only slightly the air through 
which they pass. The air would, in fact, allow the heat to pass through 
it entirely - it would be, to use a scientific term, quite diathermic - 
were it not for the watery vapour it contains. On the amount of this 
vapour depends the degree of the diathermancy of the air, which is a 
very important factor of different climates. The more vapour the air 
contains the less powerful is the direct or radiant sun heat. 
The shade temperature is due mainly to the warmth imparted to the 
air from the ground - water as well as land - previously warmed by the 
sun's rays. The shade temperature may, however, be greatly influenced 
by currents of air from distant regions, viz., warm or cold winds. 
Melloni and Tyndall discovered that the water vapour is much less 
diathermic to the invisible waves of heat radiated back from the earth 
than to the direct luminous rays of the sun. To this is due the pro- 
tecting influence of the vapour on the ground, especially during the 
night - without it the greater part of the heat absorbed during the day 
would be rapidly radiated into space, which indeed does occur when the 
air is very dry and the sky cloudless. 
The nature of the surface of the ground exercises great influence 
on the amount of heat which is absorbed and reflected. We can only 
briefly allude to Frankland's instructive experiments on this subject. 
The nearer the colour of the ground approaches to white (snow, chalk 
cliffs, white walls, etc.) the more the direct sun heat is reflected by it, 
the less heat is absorbed; the darker the ground (grass, green leaves) the 
less heat is reflected, the more is absorbed. The ground which absorbs 
more heat from the direct rays of the sun can give out more heat dur- 
ing the night and vice versa. The influence thus exercised on the cli- 
mate of a place is evident, and the white snow fields of the Alps in 
winter form a well-known illustration. 250 
SYSTEM OF MEDICINE 
We cannot enter on the distribution of temperature in the atmos- 
phere on the surface of the earth, or on the great differences existing 
between the distances from the equator and the isothermal lines (with 
the same annual temperatures), and the isochimenal lines (with the 
same winter temperatures), and the isotheral lines (with the same 
summer temperatures). We must refer to Humboldt, Dove, Carpenter, 
Haughton, Scott, and others, for accounts of the warming influences 
of the equatorial currents of the sea, and of the chilling action of the 
Arctic and Antarctic streams. This and other factors of climate are 
very clearly described in the Lumleian lectures on " Aero-therapeutics " 
(1894) by Dr. C. T. Williams. 
The temperature of the sea-coasts, however, is influenced not only 
by great sea currents; the nearness of oceans acts powerfully on the 
temperature of large tracts of continents - the range of temperature, 
as a rule, increasing from the coasts towards the interior. The Pacific, 
the Atlantic and other oceans diminish the annual range of tempera- 
ture on adjacent shores to 20° F. and less; while in the interior of large 
continents - as in the centre and north of Asia - the range may be 
60°, 80°, and even 100° F. 
Mountains and high elevations above the sea act likewise to some 
degree as equalisers of temperature by lowering the annual range. In 
addition to this high mountain ranges act as shelters to the leeward 
regions; they condense the moisture on the side towards the sea, and 
render the air currents on the leeward side drier. We see this, for 
instance, by comparing the dry climates of Tibet and Cashmere with 
those of the windward side of the Himalayas, and those of the eastern 
side of the Rocky Mountains with those to the west of them. 
Our knowledge of the influence of different degrees of temperature on 
the human body is still imperfect. Experiments have shown that cold 
acts as a stimulant and increases the amount of carbonic acid exhaled; but 
Pfliiger has found a similar increase from heat, and Marcet came to the 
same result from his observations on the island of Teneriffe: we must 
infer, then, that heat, up to a certain limit, acts likewise as a stimulant. 
Our general views on the influence of temperature are based partly on 
the effects of different seasons on the health of individuals; partly on 
the effects of moving during winter to warmer climates, and vice versa; 
partly on the consideration of the physical and mental constitution of 
peoples dwelling in different regions: but the coexistence of other 
climatic factors -• such as moisture, light, rarefaction, or condensation of 
air - render inferences difficult, a difficulty further increased by differ- 
ences in the manner of life. 
It is necessary to distinguish between radiated or sun heat and 
shade heat. We do not yet know how great a degree of sun heat can be 
borne. It is certain that sunstroke is very rare in great sun heat in the 
pure and comparatively dry air of high elevations; and this seems also 
to be the case on the ocean. High shade temperature is, however, 
much less easily borne, and persons who can do hard work in a sun heat CLIMATE IN THE TREATMENT OF DISEASE 
251 
of 120° become rapidly exhausted in a shade heat of 90°. Here again 
we must bear in mind that we cannot distinguish the effects of tempera- 
ture from those of moisture, electrical condition, and movement of air. 
Different individuals bear heat very differently; and many Europeans 
living in hot climates injure themselves by continuing to take the same 
kind and amount of food and stimulants as they do at home (Ranald 
Martin, Parkes, Fayrer, and others). However, as Parkes says, great 
heat in shade exerts " a depressing influence, lessening the great func- 
tions of digestion, respiration, sanguification, and, directly or indirectly, 
the formation and destruction of tissues."1 
At climatic health resorts, however, we have not to deal with high, 
but with moderate degrees of heat, such as we find in summer in temperate, 
and in winter in hot climates, namely, between 55° and 70° F. In such 
temperatures the organism loses less heat than at lower degrees. In 
strong persons, after long exposure to such temperatures, we often find 
a certain degree of lassitude, diminution of appetite, and impairment 
of the functions of digestion, respiration, circulation, and metabolism. 
Weak persons, on the other hand, often exhibit greater energy of 
all the functions of the mind and body, gain in weight, and are less 
liable to disease. Hence the value of such climates to permanently 
delicate persons, or to those temporarily weakened by disease, and to the 
elderly. 
The effects of low temperature are likewise rarely observed alone; 
but it is certain that the body loses more heat and has to supply this 
loss. Increase of appetite, improvement of digestion, circulation, sangui- 
fication, and metabolism are in vigorous persons generally the results of 
moderate degrees of cold. The opposite is often the case with delicate 
persons, and especially so when cold is combined with damp and wind. 
It is especially amongst old persons that the combination of cold with 
damp and high winds and absence of sun acts injuriously. The reports 
of the Registrar-General give ample proof of this. Thus in the last 
quarter of 1878, including two very cold months, the mortality of people 
above sixty was 24 per cent higher than in 1877, when the same period 
was characterised by mild weather. The rate of increase amongst people 
below sixty was only 8 per cent. However, by dryness of the air, light, 
sunshine, and absence of wind, moderate degrees of cold are rendered 
beneficial even to many delicate persons. 
The fact that cold is disagreeable to many persons induces them to 
regard it as injurious. That this, however, is not the case, is proved by 
the fact that the mortality decreases as we proceed from the tropics 
towards the pole. We quote Michel Levy's table in his Hygiene: - 
From 0 to 20 degrees latitude, 1 death in 25 inhabitants. 
,, 20 ,, 40 ,, ,, 1 „ ,, 35-5 ,, 
„ 40 „ 60 „ „ 1 „ „ 43-2 
,, 60 ,, 80 ,, ,, 1 ,, ,, 55 ,, 
1 Manual of Practical Hygiene, 1878, p. 436. 252 
SYSTEM OF MEDICINE 
It was formerly assumed that great equability of temperature is a 
necessary element of a climate useful in the treatment of chest complaints 
and vice versa; but this again is not correct. There may be great dif- 
ferences between sun heat and shade temperature, and still greater dif- 
ferences between day and night temperatures - as in Alpine climates 
in winter - and yet such climates exercise the most beneficial effects, 
provided the invalid can take sufficient shelter. 
3. The humidity of the air is almost as important a factor of climate 
as the temperature. Watery vapour is always contained in the air, but 
its amount is constantly changing by the ceaseless processes of evapora- 
tion and condensation. The degree of absolute humidity varies with the 
seasons, and at different hours of the day; it is generally greater with 
higher temperatures and vice versa. The variations of relative humidity 
follow to some degree an opposite course: the relative humidity is, in 
general, lower in summer than in winter, and lower during the warmer 
parts of the day than during the colder; lowest, in fact, during the first 
hours of the afternoon and highest about sunrise. The variations are 
greater in summer than in winter, greater in inland than in marine 
climates; they are influenced by predominant winds. 
Saturation of the air leads to mists and clouds, and the periods and 
frequency of their occurrence are of great importance in the appreciation 
of climates. Mists are more rare at considerable elevations above the 
sea; clouds are more frequent at certain medium elevations, changing 
with the seasons. 
The rainfall varies considerably in different regions, from 0 in the 
desert of Sahara, and at some parts of the coast of Peru, to several 
hundred inches on the south-east slopes of the Himalayas, which are 
exposed to the moisture-laden monsoons. The amount of rain is not 
proportionate to the moisture of the air, for a region may be rainless, as 
Lima on the coast of Peru, in spite of a very humid atmosphere; and 
localities with considerable rainfall, like Genoa, may have tolerable dry- 
ness of soil and air. The number of rainy days does not correspond to 
the amount of rainfall. It may even be said, with some exceptions, that 
the number of rainy days increases with the distance from the equator, 
while the amount of rainfall decreases. The number of rainy days, the 
season when it rains oftenest, and the hours of the day on which the 
rain falls, are important matters to the invalid. 
It is generally assumed that considerable rainfall is an injurious 
condition, but this is not always correct. Provided time enough be left 
for the invalid to take exercise and sit in the open air, rain is to some 
degree useful, as it has a purifying influence on the atmosphere. We 
must remember that Angus Smith found an increased amount of oxygen 
during and after rain, and cool and rainy summers in England mostly 
show smaller mortality than hot and dry ones. The notion that snow 
is injurious is even more incorrect. It is true that frequent melting of 
snow is apt to produce catarrh, but if the snow remain on the ground 
without melting for periods of several months, it is to many invalids a CLIMATE IN THE TREATMENT OF DISEASE 
253 
source of benefit, for (a) it keeps the air free from the impurities rising 
from the soil, and from dust; (&) it increases the amount of radiant or 
sun heat by reflection; (c) it diminishes local currents of air by prevent- 
ing the heating of the ground. 
We have spoken of the moisture of the atmosphere as a great regu- 
lator of the distribution of warmth on the surface of the globe, and 
that it is as essential to man as to vegetation; but it is difficult to define 
accurately the effects on man of different degrees of moisture, because 
the factor of moisture cannot be separated from other factors, especially 
temperature, light, atmospheric pressure, wind. In dry air the evapora- 
tion from the skin and from the lungs is promoted, and this effect is 
increased if, at the same time, the sunshine be powerful, as in elevated 
regions. In moist air both are diminished. In moist and warm air the 
appetite and the vital energies become diminished, and there is often a 
tendency to diarrhoea and to affections of the abdominal organs. The 
development of low organisms is favoured in such climates, and this 
probably is the reason why in some such, as at Lima, tuberculosis is 
frequent and runs a most rapid course. In moist and cold air the evap- 
oration from the skin is checked, the surface loses much warmth, and 
rheumatic and catarrhal complaints are common. Climates with a moder- 
ate amount of moisture are more equable by day and night, and in sun 
and shade; the evaporation also is slight; in dry climates, as we have 
already said, the opposite holds good. Climates with much moisture, 
especially with low temperatures, often have a very dull sky, which may 
shut out the light and heat of the sun for many days and weeks; such 
climates are not exhilarating, but with proper hygienic management 
may allow perfect maintenance of health and vigour. 
4. Our knowledge of the effects of slight changes in the atmospheric 
pressure is not well defined; the effects of the great diminution of press- 
ure at high elevations will be discussed under Alpine climates. 
5. Light is of primary importance. As we all know, light is neces- 
sary for the development of chlorophyll in plants; and we meet per- 
sons frequently who after some dull days with absence of sun become 
depressed, disinclined to work, and dyspeptic, and who regain their 
energy with the return of the sun. We also often see home-sickness 
in natives of foreign and more sunny countries after some sunless weeks 
in London, which disappears after a few weeks of sunny weather; but 
though we may suppose that absence of sunshine is the principal cause 
of such mental and bodily disturbance, it is difficult to say how much 
is due to concomitant circumstances, such as excessive moisture and 
to low temperature. W. F. Edwards showed long ago that light is 
necessary for the development of the perfect form of the Batrachia. 
Moleschott, Pfluger, von Platen, Tubini, and others have found in- 
creased absorption of oxygen and excretion of carbonic acid under 
the influence of light in Batrachia and in some warm-blooded animals. 
H. Quincke's experiments prove that the oxidation of animal cells (of 
blood and pus) is increased under the influence of light. Many of the 254 
SYSTEM OF MEDICINE 
effects of light on the animal organism are, no doubt, due to its action 
on the centripetal nerves, and especially on those of the retina; but 
the result of Quincke's researches, and also of those of other observers,, 
show that light acts also directly on the cells and tissues without the 
influence of nerve centres. 
The human body is influenced indirectly by the action of light on 
certain microbic parasites. Downes and Blunt, Arloing and Roux, had 
already shown that sunlight can kill bacteria, when Koch stated to the 
International Medical Congress at Berlin (1890) that it kills the tubercle 
bacillus within a very short time - varying from a few minutes to a few 
hours; and that even diffuse daylight does so, but requires from five to 
seven days. According to P. A. Komelevsky, solar light destroys the 
vitality of the Staphylococcus pyogenes aureus and albus, etc., in about 
six hours. He found that all portions of the spectrum powerfully affect 
the microbes, excepting the red and infra-red rays. Professor Marshall 
Ward showed by experiments that the blue rays of the spectrum have 
the greatest power in destroying bacteria; while the red, orange, yellow, 
and ultra-violet rays do not affect them; our present experience seems 
to him, however, not conclusive with regard to all varieties of microbes. 
Dr. Arthur Ransome communicated to the Royal Society in 1890 ex- 
periments on the action of soil, air, and light on the tubercle bacillus; 
and again Drs. Ransome and Delepine infer " (1) that finely-divided 
tuberculous matter - such as pure cultures of the bacillus, or 'tuber- 
culous dust,' in daylight and in free currents of air - is rapidly 
deprived of virulence; (2) that even in the dark, although the action 
is retarded, fresh air has still some disinfecting influence; and (3) that 
in the absence of air, or in confined air, the bacillus retains its power 
for long periods of time." These experiences seem of great importance 
in the explanation of the aseptic nature of the air in the high Alps, on 
the Riviera, in the desert, etc. It may further be mentioned that 
Buchner has shown that direct as well as diffused sunlight very rapidly 
kills bacteria suspended in water. 
There is yet a third kind of influence of light on the human body, 
namely, on the skin. John of Gaddesden, a court physician in the reigns 
of the Edwards (" Rosa Anglica"), in treating a royal prince, a son of 
Edward I., for small-pox, prevented scars by having the bed-curtains 
and all surroundings made of red colour. The same treatment has been 
pursued by N. Finsen1 and Svensden,2 with the result of preventing the 
suppurative stage and the pitting. This, if confirmed, may be explained 
by the exclusion of the chemical rays by the red curtains. On the irritat- 
ing influence of these rays interesting experiments have been made by 
Drs. Bowles, Unna, Hammer, Finsen, and others. Dr. Bowles in his re- 
searches in the Alps on the effects of sunlight on the human body, was 
led to the conclusion that it is not heat, but those rays of shorter vibra- 
tion at the violet end of the spectrum, which give rise to the phenomena 
1 Hospitalstidende, 1893. 
2 Den ledste Koppeepidemi i Bergen, Medecinsk Revue, October 1893. CLIMATE IN THE TREATMENT OF DISEASE 
255 
of sunburn, and that rays reflected from snow are far more potent than 
rays direct from the sun, or those reflected from rocks. He found that 
various colours applied to the skin prevented the harmful rays from 
reaching the delicate nerves and vessels beneath the epidermis, and 
quotes a singular case of an Indian officer, who, having had repeated 
attacks of sunstroke, thinks that he has prevented the recurrence of the 
attacks by wearing an orange coloured lining to his clothes. 
6. Of Winds - a large subject - we can only speak briefly. They are 
necessary as purifiers of the air, though they may under special circum- 
stances carry malarial and other poisons. They often produce great and 
sudden changes in temperature, moisture, light, and atmospheric press- 
ure ; and bring with them, so to speak, the climates of distant regions. 
Before selecting a health resort the winds prevailing at different seasons, 
at different parts of the day, and their character, must be ascertained. 
7. Mountain chains act as barriers to cold and to hot winds, and thus 
cause in the former case higher annual temperatures in the leeward 
localities, in the latter case lower. Their effects vary with their height, 
extension, abruptness, quality, and amount of vegetation; and with 
presence or absence of snow and glaciers. They exercise also a great 
influence on the quality of the atmosphere carried by the wind; they 
deprive, for instance, the moisture-laden, warm winds of a great part of 
their moisture, so that the climates to leeward of the chain are rendered 
drier and less equable. 
8. Buchan (12 and 13) gives interesting facts on the effect of drainage 
on the temperature of the soil. The mean temperature of arable land is 
raised 0-80° F. by drainage; cold penetrates undrained more quickly than 
drained land; the temperature of drained land is more equable than that 
of undrained; in summer the temperature of drained land is occasionally 
raised 1-8° to 3° F. above that of undrained land. These facts may 
throw some light on the discoveries of Bowditch and Buchanan with 
regard to the diminution of phthisis mortality by drainage. 
9. The presence or absence of vegetation exercises a marked influence 
in all climates. Bare surfaces differ according to the conducting power 
of the ground. The covering of the surface by vegetation prevents 
more or less completely the direct fall of the sun's rays on the ground 
itself, and thus prevents it from being heated to the same degree as bare 
rock or dry sand; and the plants themselves are never heated quite so 
much as bare ground on account of the constant process of evaporation. 
We have found the temperature above grass-land, and likewise clover, 
more than twenty degrees lower than above bare ground under great 
sun heat. The character of the vegetable covering, however, makes a 
considerable difference. 
The influence of forests has been carefully studied by Buchan and 
Ebermayer (25). They found the temperature of the ground on which 
a forest stands to be several degrees lower than that of the neighbour- 
hood. The difference is greater in summer than in winter, but the air 
within the forest has a lower annual mean. In summer the cooling SYSTEM OF MEDICINE 
256 
influence is specially marked during sunshine. The changes of 
ture in forests are narrower and less sudden; the days are cooler, the 
nights warmer; the climate more equable. Trees acquire their max- 
imum temperature in summer at about 9 p.m., while that of the air 
occurs between 2 and 3 p.m. " Hence trees may be regarded as reser- 
voirs in which the heat of the day is closed up against the cold of the 
night." The relative humidity in forests is higher; in July about 10°, 
in January about 3-7°; forests lead also to increased rainfall; the air 
in forests being cooler and more saturated, the vapour of a moist wind 
on reaching a forest is condensed into mist and rain. There is less 
movement of air in forests, and they protect the adjacent land on the 
leeward side from winds and cold currents. 
Second Section. - Principal Climatic Regions and Health Resorts 
There are insurmountable difficulties in the classification of climates; 
the same degrees of latitude, for example, containing the most different 
climates. Many French writers, especially Levy, Pochard, Fonssangrives 
and Lacassagne take the mean annual temperature with various modifica- 
tions ; but the mean annual temperature is an imperfect guide in the 
treatment of disease, for localities with the same annual mean often differ 
very widely in range at the same season or at different seasons. Thus 
Torquay, Paris, and Odessa have approximate annual means, but the 
following table shows how different are their seasonal ranges: - 
Annual Temperature. 
Winter. 
Spring. 
Summer. 
Autumn. 
Torquay about 52° Fahr. 
44-0° 
50-1° 
61-3° 
53-1° 
Paris about 51 *5° ,, 
38-4° 
50-4° 
64-5° 
52-0° 
Odessa about 50-4° ,, 
27-5° 
45-8° 
70-0° 
50-7° 
Thus the difference between summer and winter is for Torquay only 
17°, for Paris 26°, for Odessa 42-5°. 
A division according to the temperature of the seasons would be 
more useful, but places with the same winter temperatures may differ 
widely as to equability, sunshine, and humidity. 
Several authors, English and foreign, adopt relative humidity as the 
main principle of classification (Vivenot, Walshe, Rohden, P. Niemeyer, 
Thomas), and this arrangement has its advantages; but other climatic 
factors may vary widely where the relative humidity is almost the same. 
All such classifications appear to us so constrained that we should 
prefer to describe the several localities alphabetically; but this would 
lead to much repetition and require more space. 
We therefore propose to follow, with some modifications, the plan CLIMATE IN THE TREATMENT OF DISEASE 
which has been adopted in previous treatises on this subject,1 although 
we acknowledge its imperfections. 
The sea exercises so powerful an influence on the climate of the 
localities adjacent to it that we will consider these under one great head 
- Marine Climates (in distinction from Inland Climates'). 
A. Marine Climates. -As fully marine climates can only be enjoyed 
on the ocean itself, we will begin with a short account of the ocean and 
such sea-voyages as are best adapted to invalids, and then consider the 
climates of small islands and the sea-coasts. 
I. The Ocean and Sea-Voyages. - The climate of the ocean is char- 
acterised by warmth, equability, and considerable atmospheric moisture. 
Its physiological effects are sedative to the nervous system, while at the 
same time appetite and digestion are much improved. The aseptic 
character of the air, moreover, acts beneficially both upon the air pas- 
sages and the system at large. The advantages which it offers are 
absolute repose and facilities for an open-air life. Its drawbacks are 
the confined sleeping space, the discomforts of cabin life in bad weather, 
and in some cases the monotonous character of the food. 
The voyages most suitable to the invalid are practically four: - 
(1) the steamship voyage to the Cape of Good Hope; (2) the sailing 
voyage to Australia; (3) the steamship voyage to Australia; (4) the 
steamship voyage to New Zealand round the Cape. 
The voyage to the Cape occupies about twenty days, and is thus too 
short for much benefit in serious cases; but it has great value as a 
remedy for overwork or tardy convalescence. The heat in the tropics is 
rarely injurious, and there is no sudden transition to cold. 
The voyage to Australia on a sailing ship gives the full benefit of the 
marine climate. Two or three clipper ships, with special accommodation 
for invalids, sail in September or October. The outward voyage takes 
ninety to a hundred days. The log of one of these ships shows the 
highest temperature to have been 85° F., the lowest 49° F., while the 
difference between one day and another never amounted to more than 
7°F. (109). Except in a long calm in the equatorial belt the heat is not 
severely felt. To obtain the benefit of the change the patient should 
be moderate in his diet and take sufficient daily exercise. With such 
precautions selected cases will derive the greatest benefit from the life. 
The drawbacks to the voyage are the monotony of the life and the 
lack of fresh food. The return voyage might be made in a sailing 
ship round the Cape, or by steamer. A return by Cape Horn is always 
unsuitable. The steamship voyage offers more frequent places of call, 
and more frequent supply of fresh meat and vegetables. On the other 
hand greater heat is experienced (in the Red Sea), and the greater speed 
of the vessel makes the changes of climate more sudden. The transition 
from the Suez Canal to the Mediterranean is a considerable danger on the 
257 
1 " Klimato-Therapie " in Ziemssen's Handbuch der allgemeinen Therapie, vol. ii. 
part 1, 1880, English translation by Dr. Port: Smith, Elder and Co., 1885. And in " Cli- 
mate and Health Resorts " in the Book of Health. Cassel and Co., London, 1883. 
VOL. I 
8 SYSTEM OF MEDICINE 
258 
return journey. In modern ships the smoke from the engines is no longer 
a real drawback. The times of departure and return must be carefully 
chosen in order to avoid the hot months in the Red Sea and the mon- 
soon in the Indian Ocean; it is wiser to return by San Francisco than 
to pass through the Red Sea in the hot months. 
In the steamship voyage to New Zealand the weather encountered 
is very similar to that met with in the sailing voyage, but is shorter, 
and the food more varied. 
We may add that in exceptional cases of hardy invalids summer 
voyages with whalers to the northern seas have been tried with fairly 
good results. 
In the summer months yachting around the coasts of England,. 
Sweden, Norway, and the north of France offers a good chance for en- 
joying the advantages of marine climates without much risk. 
A combination of yachting with residence on land may occasionally 
be carried out with great advantage in the Mediterranean during the 
colder months. 
II. Coast Climates, including small Islands. - These climates, greatly 
though they differ amongst themselves, have some points in common: 
(1) The air is comparatively free from organic dust; (2) it contains a 
larger amount of moisture owing to the constant evaporation from the 
surface of the sea, and the amount of moisture does not vary much; 
(3) there is a constant renewal of the atmosphere by the air currents; 
(4) there is greater equability of temperature, not only between differ- 
ent seasons, but also between the different parts of day and night, 
when compared with inland climates. 
A striking instance of this equability of a climate almost entirely 
marine is given by A. Buchan (in his suggestive article on " Climate " in 
the Encyclopaedia Britannica') in the island of Monach, situated about 
seven miles westward from the Hebrides, between 57° and 58° N. " in 
the full sweep of the westerly winds of the Atlantic which there prevail. 
The mean January temperature is 43-4°, being 1-8° higher than the 
mean of January at Ventnor, Isle of Wight (nearly seven degrees farther 
south), 0-8° higher than that of Jersey and Guernsey." On the other 
hand, the mean temperature of July is 55-0° at Monach and 62-4° at 
Ventnor. Monach has therefore warmer winters and cooler summers 
than an ordinary coast climate farther south. 
The effects of the sea-side, although varying considerably according 
to constitutions and localities, may be said to improve the appetite, the 
mental and bodily energy, the condition of the skin, the sleep, and 
metabolism of tissues. Such changes are very useful in many cases of 
weakness without actual disease, during convalescence from disease, in 
climacteric conditions, and in people who are said to be " run down " from 
work or social exertions and worry. These climates are invaluable in 
the physical training of children disposed to scrofulous diseases and allied 
conditions. They require, however, a certain degree of resistance, and, in 
many persons, special attention to the action of the bowels. They are CLIMATE IN THE TREATMENT OF DISEASE 
mostly unsuitable for chronic affections of the heart with great dilata- 
tion, for some kinds of asthma, and for skin diseases. Although the 
numerous varieties in the climatic conditions of different marine regions 
render subdivision necessary, yet different localities in the same region 
and very near to one another may present varieties of climatic elements, 
such as aspect, elevation, degree of shelter, and so forth. 
As the degree of humidity of the air exercises great influence on the 
equability of climates and on the functions of the body, we will adopt it 
with C. T. Williams, Thomas, and others, as the principle of the greater 
subdivisions, and use the differences of temperature for the formation 
of sub-classes. 
If we adopt as subdivisions: 1. Humid marine climates; 2. Marine 
climates with moderate or slight humidity, we must confess that no 
thorough lines of demarcation can be drawn, and that some of the 
localities placed in sub. 1 might claim a place in sub. 2. 
1. Humid Marine Climates. - There are great differences in this sub- 
division according to the temperature. We are, however, principally 
concerned with the warmer climates, of which Madeira may be taken as 
a type. The opinions on the climato-therapeutic value of Madeira have 
varied considerably. In former years it was considered by many authors 
as the best climate for consumption, while at present many regard it as 
the worst. We will endeavour to give a short description, and refer for 
further information to the works of Renton, Clark, Mittermaier, Lund, 
Grabham, Goldschmidt, Langerhans, and others. The Madeira Islands 
are situated between 32° and 34° N. and between 16° and 17° W. The 
climate of Funchal, the principal town, is remarkably equable; the mean 
moisture varies between 70° and 74°, but is subject to variations from 
air currents. The number of rainy days is mostly above fifty. The 
mean annual temperature is 65° F. - winter about 61°, spring 62°, 
summer 69-5°, autumn 67°. Lowest night temperature rarely below 
43°; highest day rarely above 86°. Mean differences between night 
and day about 9°, from one day to another about 1-1°. Funchal is not 
exempt from winds, but the air is usually calm from 7 to 9 a.m., at 
which hour sea-breezes blow till 3 p.m. ; land winds set in later at 
night. The air is free from dust and rich in ozone; the character of the 
climate is sedative, to some people relaxing. It has great power to allay 
coughs in chronic catarrh with irritability of the mucous membrane; 
but many people after some weeks feel depressed, lose appetite, and 
have a tendency to diarrhoea. A disadvantage of Funchal is the steep- 
ness of the hillside on which it lies, and the consequent difficulty of 
getting above the houses on foot. 
As to the effect on tubercular consumption, the result of the experi- 
ment made by the authorities of the Brompton Hospital on twenty 
selected cases of consumption has not been satisfactory, and we know 
ourselves of a rather large proportion of unfavourable cases; but, on the 
other hand, we have seen better effects than at most other places in 
elderly persons with much loss of lung and emphysema, in complica- 
259 260 
SYSTEM OF MEDICINE 
tions with albuminuria, and in weak and irritable people with rapid 
pulse (the erethic type). The beauty of the vegetation, the scenery, and 
the easy life of Madeira exercise on some persons so great a charm that 
it is impossible to dissuade them from going thither, even if they are 
told that they could do better elsewhere. More than once, especially 
in former years, patients would tell us they would rather die in the 
enjoyment of the sub-tropical beauty of Funchal than fight for life 
in the "ice-bound Alps," or at the'"dusty Riviera," or in "sunless 
England." And such mental conditions have a claim on our sympathy. 
This climate is more generally beneficial in cases of chronic bronchial 
and laryngeal catarrh, and in emphysema with scanty expectoration than 
in pulmonary tuberculosis; but in cases with copious discharges from 
the mucous membranes, atonic dyspepsia, and tendency to diarrhoea, 
Madeira and allied climates are to be avoided. 
Similar remarks may be applied to the Azores, which are little used 
as climatic resorts. 
The Canaries, with Teneriffe and the Grand Canary, have in common 
with Madeira the equability of the climate, but have a slightly higher 
temperature and are decidedly drier, so that they might claim a place in 
the subdivision of moderate humidity. They are mentioned here princi- 
pally on account of their situation near Madeira. The heat of the day 
is tempered and the coolness of the night is diminished on Teneriffe by a 
layer of mist between 3000 and 5000 feet above the sea-level. On the Peak, 
above this layer of mist, Dr. Marcet found the climatic conditions very dif- 
ferent, viz., hot days, cold nights, and great dryness of air. The Canaries 
have a greater claim as health resorts than Madeira, and offer good accom- 
modation, but are much wanting in means of amusement (53, 35, 60). 
Of Mogador, on the north-west coast of Africa, we owe a written 
account, based on personal experience, to the late Dr. Leared, who 
describes it as one of the most equable climates. Mean annual tem- 
perature 67° F., mean winter 61°, mean summer 72°, mean hottest 
month 80°, mean coolest 59°, relative humidity 78°. Number of rainy 
days 44, of clear days 270. It is under the influence of the Atlantic; 
is sheltered from the desert winds by the Atlas chain. Accommodation 
is as yet limited. 
Cadiz, on the island of Leon, on the south-west coast of Spain, may 
be placed in this group. It partakes of the character of the Atlantic as 
well as of the Mediterranean, has about one hundred rainy days in the 
year, and an average relative humidity of 76°; the mean winter and 
spring temperatures are about 59° F.; the average daily range is only 
10-5° F. We have seen some satisfactory results from this resort in 
early cases of consumption in weakly and irritable persons, but the 
hotels are situated in the midst of the town, and are scarcely suitable to 
invalids. Only persons, therefore, who have to earn their livelihood at 
the place ought to be sent there. San Lucar, in the same region, with 
a similar but somewhat drier climate, is recommended by Spanish phy- 
sicians at the commencement of tubercular phthisis. CLIMATE IN THE TREATMENT OF DISEASE 
261 
In the southern hemisphere, where the sea predominates more than in 
the northern, there are several islands with moist and warm climates,, 
which under especial circumstances may be used as health resorts, 
especially Tahiti, in the Society Islands, the Tristan d'Acunha group, the 
Feejee (Fidji, Fiji, or Viti), the Friendly or Tonga Islands; but the ac- 
commodation and hygienic conditions are as yet defective. 
The groups of islands situated to the east of Central America, and 
comprised under the collective name of the West Indies (from 10° to 27° 
N.L.) find a place among the warm and humid marine climates. They 
possess rather uniform high temperatures, varying in the different islands 
between about 68° F. and 83° F. Their action is rather sedative and 
relaxing. Diseases of the digestive organs are prevalent; and only in 
exceptional cases can they be recommended to invalids suffering from 
irritable catarrhs of the respiratory mucous membranes. Dr. C. T. 
Williams (105) reports a favourable result in a consumptive young 
physician at Jamaica; R. H. Bakewell (Practitioner, 1878) has a rather 
high opinion of Barbados; and we have ourselves seen some fairly satis- 
factory results in emphysema with chronic pulmonary catarrh, and in two 
cases of phthisis - one at Jamaica, the other at Barbados; but unfavour- 
able results have prevailed in our experience, especially through failure 
of the digestive system with loss of appetite and chronic diarrhoea, so 
that we can scarcely recommend these localities excepting in cases where 
the choice of climate is limited by other circumstances. 
The climate of the peninsula of Florida, extending from 24° to 31° N., 
resembles that of the West Indies, but is less relaxing. In July, August, 
and September fevers are prevalent, but they are rare during the re- 
mainder of the year. Florida enjoys some reputation in North America 
as a mild winter resort for delicate persons suffering from emphysema, 
chronic bronchial catarrh, and early phthisis. The adjacent coasts of 
Georgia and South Carolina have somewhat similar climates, but they 
are more under the influence of the continent, and have lower average 
temperature and humidity. 
Humid and cool marine climates are rarely used in climatic treatment, 
but they are very interesting on account of their great equability of tem- 
perature. The best known localities belonging to Europe are the Hebrides, 
the Orkneys,the Shetland Islands,the Faroe Islands and Iceland; and 
in the southern hemisphere the Auckland and Falkland Islands. 
2. Marine Climates with Moderate or Slight Humidity. - Amongst 
the warmer localities of this sub-section those of the Mediterranean coasts 
are of the greatest interest to us. They are all under the powerful 
influence of this remarkable inland sea, which differs from the Atlantic 
and Pacific in its freedom from polar currents, and in its temperature 
which down to its greatest depths (1500 to 2000 fathoms) is 54° to 56°; 
while in the Atlantic, outside the Straits of Gibraltar, the temperature 
at the same depth is only 35-6° to 37°. The Strait of Gibraltar is so 
shallow that it does not admit the polar stream of the Atlantic. 
Although all the localities on the shores of the Mediterranean have 262 
SYSTEM OF MEDICINE 
some points in common, yet the several tracts offer considerable differ- 
ences. The Riviera has the first claim on our attention. 
The Riviera stretches from Toulon to Genoa. The region consists for 
the most part of a plain from two to four miles in width, extending from 
the sea to the lower spurs of the mountains which everywhere guard 
the coast. From these lower slopes the mountains rise rather steeply to 
a height of from 2000 to 3000 feet, affording everywhere a shelter from 
the north, and generally from the north-east and north-west. The coast 
consists of a series of headlands, between which stretch gently-curved 
bays, on whose shores the main resorts are situated. The character- 
istics of the climate are as follows : - 
(a) Warmth. - Greater than that of other localities in the same lati- 
tude. This greater warmth is due to three causes: (1) The complete 
shelter from northerly winds ; (2) Radiation from the mountains during 
the colder parts of the day and year; (3) The presence of the Mediter- 
ranean Sea, which is some 5° warmer than the atmosphere. The mean 
temperature for the six winter months varies from 50-8° to 51-5°; for the 
months of December, January, and February, it varies from 47° to 49° F. 
(6) Dryness.-Unlike most of the marine climates, the Riviera is 
distinguished for its dryness, the mean relative humidity being about 
■65° to 70° during the winter months. 
(c) Abundant Sunshine. - During the six months of winter generally 
from 100 to 120 days are fine. 
(d) Small Rainfall. - With few rainy days, the rainfall varies from 
28 to 31 inches, and a great part of this falls between the end of Sep- 
tember and the beginning of November. In such a climate some hours 
of almost every day can be passed out of doors. 
There are, however, several very distinct drawbacks to the climate: 
(a) The great frequency of high winds, principally in the spring, mainly 
from the north-east and north-west. (/3) The great difference between 
sun and shade temperature, thus increasing the danger of chill, (y) The 
rapid fall of temperature at sunset, which compels the invalid to return 
home before that hour. 
The physiological effects of the climate are exerted for the most part 
on the nervous system; the climate is, with a good deal of truth, 
described as exciting. Sleeplessness is a common complaint on first 
reaching the coast, but in most cases soon passes off. Neuralgia, on the 
other hand, is often aggravated, and any hysterical or melancholic 
tendency is frequently made worse. Most persons, however, feel 
invigorated both in mind and body. Considerable care is necessary to 
avoid catching a chill. Exposure to sudden changes of temperature does 
not so frequently lead to a cold in the head, or tracheo-bronchitis, as at 
home, but more often causes an attack of diarrhoea or even of colitis. 
The several resorts to be considered are: - 
(i.) Hy^res, situated about three miles from the sea. The mean winter 
temperature is 50-6° F. (Biden). Relative humidity 73°. It is not, 
however, very well protected from the north, and is much exposed to the CLIMATE IN THE TREATMENT OF DISEASE 
263 
north-west, whence the mistral blows in the spring. In other respects, 
being somewhat more distant from the sea, it is not so exciting as are 
the other resorts; patients sleep better, and hysterical women suffer no 
aggravation of their symptoms. 
(ii.) Costa Belle, nearer the sea, is much better protected from winds, 
is more wooded, and not quite so dry. 
(iii.) St. Raphael and Valescure, near Frejus. The former is near 
the sea-shore, the latter some short distance inland. They are not very 
well protected by mountains, but are surrounded by pine woods. The 
mean temperature is somewhat lower than that of the other resorts. 
They are better suited, perhaps, to a more vigorous class of case, and 
are not so exciting as the more easterly resorts. Some forms of asthma, 
neuralgia, and irritability of the skin do better there than at the more 
eastern places of the Riviera di Ponente. 
(iv.) Cannes has a mean temperature of 50'85° for six winter months, 
and a mean relative humidity of 73° (53); it is the largest of the mere 
health resort towns along the coast. To the north the protection is not 
by any means complete; the higher ridges of the Alps are too far re- 
moved. from the sea to afford adequate shelter from this quarter. It is 
well protected, however, on the east and west. The mistral blows fre- 
quently in February and March. The majority of the patients find the 
climate bracing to the body and exhilarating to the mind, but it pos- 
sesses to a marked degree the quality of an excitant to the nervous sys- 
tem. Invalids requiring much shelter can do better elsewhere than at 
Cannes; on the other hand, patients who require a bracing and yet warm 
climate will fare better at Cannes. Cannes enjoys the advantage of offer- 
ing several residential localities with distinct varieties of climate. There 
is a warmer district near the sea, while more bracing and less exciting 
situations inland can be found on the Californie and in the district of 
Cannet. Patients who find the sea-shore too exciting often benefit by a 
removal to the latter. 
(v.) Grasse, situated behind Cannes at an elevation of 1000 feet, 
possesses a cooler climate, and forms a useful intermediate station dur- 
ing April and May for patients who find the heat in those months 
already too oppressive at Cannes. 
(vi.) Antibes, situated on the headland of that name, now possesses 
an excellent hotel. It is perhaps not sufficiently sheltered for serious 
invalids, but hardier ones find it a pleasant climate and the centre of 
beautiful excursions. 
(vii.) Nice, the largest town upon the coast, was formerly also its 
principal health resort. Latterly, however, it has somewhat fallen into 
disfavour on account of the piercing winds which visit it in winter and 
the irritating dust of the roads. The suburbs, however, of Carabacel, 
Cimiez, and Mont Boron present many attractions; they are moderately 
sheltered and possess one advantage, namely, distance from the sea. 
Some persons when residing near the sea always suffer from constipa- 
tion or other digestive disturbance, or are troubled by insomnia. Such 264 
SYSTEM OF MEDICINE 
symptoms are often entirely removed by a change to a residence a mile 
or two inland. 
(viii.) Villefranche and Beaulieu lie between Nice and Monaco; both 
possess considerable advantages as to shelter and temperature. 
(ix.) Monte Carlo is certainly one of the most sheltered situations 
on the coast. The presence of the gaming tables, however, offers an 
insuperable objection to its being seriously considered as a health resort. 
(x.) Mentone. - Mean temperature for winter months 51-5°, mean 
relative humidity 72-8°.1 This place, owing to the advocacy of the late 
Henry Bennet, has perhaps obtained the greatest celebrity as a health 
resort. The town proper is situated on a tongue of land, which sepa- 
rates the bay into an eastern and western portion. The eastern bay of 
Mentone is admirably sheltered, the mountains rising on all sides sharply 
from the sea. It possesses the warmest temperature for the winter 
months of any resort on the Riviera. For cases requiring absolute 
shelter and warmth it is superior to any locality on the coast. Many 
persons, however, find it relaxing, while the steep rise of the mountains 
compels a residence close to the sea, with the ill effects which such a 
position exerts upon some temperaments. On the whole, however, in 
those qualities by virtue of which the Riviera climate is most to be 
esteemed it may be considered rich. The western bay, on the other 
hand, is less sheltered and more bracing, and, owing to the larger space 
away from the sea, is adapted to a larger number of cases, though not so 
peculiarly suitable for a few. Cap Martin, in the vicinity, must also be 
mentioned. 
(xi.) Bordigliera is well protected from the north-east and the west,, 
but through the valleys in the north-west the wind finds access. The 
chief hotels and villas, however, are not situated by the sea-shore, and 
by the intervention of a spur of the mountains obtain adequate protec- 
tion from that quarter. The temperature is for the winter months- 
somewhat lower than at Mentone, but the climate is more bracing. 
The exciting effects of the Riviera climate are also not so marked as at 
places farther westward. 
(xii.) San Remo has a mean temperature for six months of 50•55°' 
(36); a mean relative humidity of 68°. It lies eight miles from Bordi- 
ghera, and well sheltered from the north and north-west, the mistral 
occurring but once or twice in the winter months. On the other hand 
the east wind is prevalent. The exciting effects of the climate are not 
so marked, but to some cases it will not be found so well adapted as- 
the east bay of Mentone. 
(xiii.) Alassio, twenty-eight miles east of San Remo, is well sheltered 
from the north and north-west and west; it is, however, exposed to the 
east and north-east. The lower spurs of the mountains are admirably 
sheltered from this quarter, but unfortunately all the hotels are situated 
on the sea-shore, and are consequently exposed. 
(xiv.) Pegli, six miles from Genoa, the last of the resorts on the 
1 Andrew, quoted by Marcet. CLIMATE IN THE TREATMENT OF DISEASE 
265 
Western Riviera, is sheltered on the north, north-west, and west, but 
exposed to the east. It is, however, not sufficiently organised for the 
reception of other than the hardier class of invalids. The climate is more 
humid and less exciting than the westerly resorts. 
By the end of October the weather will be cool enough to render any 
of these resorts suitable for invalids. It is rarely prudent to prolong 
the stay beyond the end of April, and never to spend the summer on 
the coast. 
Eastern Riviera. - The continuation of the coast-line from Genoa to 
Pisa, usually called the Riviera di Levante, is less dry than that between 
Cannes and San Remo, and somewhat less protected from cold winds, 
the mountain chain being low and broken; otherwise there is some 
similarity between them. Nervi, near Genoa, has the principal claim as 
a health resort. It is fairly well protected from cold winds, and is less 
exciting than the majority of localities on the Western Riviera. The 
mountains come so near to the coast that the excursions for the invalid 
are limited; but those requiring repose find it helpful, the more so as 
there is not much temptation to social dissipation. Other localities 
picturesquely situated, but not so well protected, are Spezia, Chiavari, 
Rapallo, and Santa Margherita. A rising health resort, for bathing in 
summer and shelter in winter, is Viareggio, about twelve miles north of 
Pisa. The shelter is principally due to the large pine forests in the 
neighbourhood. 
Pisa, although six miles from the sea, may likewise be mentioned 
here, since the climate partakes both of marine and of inland characters. 
It is rather humid, and not well protected; the sky is often dull, but 
it is comparatively free from mists. The winter temperature is about 
2° to 2|° lower than at the Western Riviera. It is now less frequented 
than in former years. 
Genoa and Leghorn are too much, exposed to be regarded as health 
resorts. 
Southern Italy is rich in charms of nature and historical associations. 
The accommodation at the principal places is good, and the hygienic 
arrangements are improving; the climate is sunny, but by no means free 
from cold northerly and north-westerly winds, especially in spring. 
Naples has considerably gained of late by a good water supply. Castella- 
mare, Sorrento, and Amalfi have good autumn climates, and Amalfi is also 
well sheltered in spring. The islands of Capri and Ischia have many 
attractions, but are not sufficiently sheltered from cold winds, nor are 
they, as yet, thoroughly hygienic. 
The island of Sicily is not much recommended by English physicians, 
nor can careful medical supervision be had there ; but the great beauty 
of the country, and the many historical and archaeological points of inter- 
est, have their favourable influence, and, combined with light and sun, 
have led to recovery or great improvement in many cases of overwork, 
of invalidism allied to the neurasthenic type, of rheumatism, slighter 
degrees of glycosuria, and tendency to premature senile decay in its 266 
SYSTEM OF MEDICINE 
various forms. The sirocco is occasionally irritating and depressing. 
Rain rarely falls in summer, but abundantly in late autumn and winter. 
The mean humidity is moderate - rather higher at Palermo and the north 
coast than on the east coast. Good accommodation, with fair sanitary 
arrangements, is to be found at Palermo, Taormina, Acireale, Catania, and 
Syracuse. The Hotel des Temples at Girgenti is now open again. 
On the south-west of the Mediterranean, Tangiers in Morocco is under 
the combined influence of the Atlantic and the Mediterranean, and, owing 
to the former, approaches more the humid than the dry class of marine 
climates. The winter temperature lies between 57° and 62°; the prin- 
cipal rains in November and December. The late Dr. Leared and most 
of those who have resided there describe the winter and spring as 
delightful. The absence of carriage roads and the want of public security 
are for the present great drawbacks to its usefulness. 
Gibraltar may be mentioned in this group, but it can scarcely be 
called a health resort. 
Valencia has often been recommended on account of its mild and 
equable climate, but the effects of the irrigation of adjacent rice fields are 
injurious to most invalids. Barcelona is rathered sheltered by a range of 
hills from northerly winds, has good accommodation and fine walks. 
Alicante, like the whole coast of Murcia, is rather more dry. Malaga is 
described by Dr. Francis, who has studied the climates of Spain, as the 
mildest place in Europe; it has a dry soil, a south-eastern aspect, and 
is surrounded by a semicircle of mountains, but it is not sufficiently 
sheltered from the cold north-west winds. The temperature in winter is 
about 55° F., in spring 62°; the daily range scarcely 5°. The number 
of rainy days is about 40. 
Algiers consists of the old Moorish town and the French settlement, of 
which the slope of Mustapha Superieur and the road thence to El Biar are 
the most satisfactory localities for residence. The mean temperature 
during the invalid season, from the end of October to the end of April, 
is about 57° to 52° F., and the average number of rainy days is between 
45 and 65. The soil is so porous that the rain seldom keeps an invalid 
at home the whole day. Rain usually falls heavily; there is rarely 
a drizzle. The sirocco is rare during the invalid season, but it blows 
occasionally, and exerts on some persons a relaxing effect, being hot, 
sultry, and dry. At few places is the difference of winters so great 
as at Algiers; two seasons are rarely alike. As a rule, however, No- 
vember, April, and part of May are like a fine summer in England; 
December to March like autumn, but with a greater share of sunshine. 
The air of Algiers is much less dry than at the Western Riviera; the 
hills are covered with evergreen shrubs and woods. The neighbourhood 
of Mustapha is rich in beautiful walks, and good carriage roads extend 
in every direction. 
People who stay the winter in Algiers may spend part of their time 
at Hammam Meskouttin or Hamman R'Irha, with their well-known hot 
springs; or at Biskra. CLIMA TE IN THE TREA TMENT OF DISEASE 
267 
Biskra, a place of growing importance, is a union of several villages 
or urban quarters, lying among plantations of date-palms and evergreen 
trees, N. lat. 34° 51', on the outskirts of the Algerian Sahara, at an 
elevation of about 360 feet above sea-level. It thus partakes of the 
characters of desert climates, excepting when northern winds prevail; 
and enjoys during the six colder months of the year many climatic 
advantages. It is much drier and sunnier than the neighbourhood 
of Algiers itself; but it is subject to violent winds which for days 
together may prevent outdoor exercise. Another disadvantage is that 
the water contains too much salt for drinking and some cooking pur- 
poses. There is good hotel accommodation, and the place is likely to 
become a satisfactory health resort for fairly hardy invalids requiring 
warm and dry air. The railway journey occupies at present from Al- 
giers two days, from Constantine one. There are hot springs a few miles 
from Biskra, at "Fontaine chaude," Hammam Salahin ("Bath of the 
Saints") but the arrangements are not yet suited even for moderately 
fastidious people. 
The Slopes of the Lebanon offer an excellent climate, only varying with 
the height above sea-level - the higher, of course, the colder. The view 
of the hills and of the sea below is glorious. In the summer months 
grapes, figs, and other fruits abound. The hotels are said to be good, 
especially at Alai, three hours' drive above Beyrout (or two hours by the 
new railway). The cost of board and lodging is usually about seven 
shillings a day per head. Dr. Canney, of Luxor, tells us that Brumana, 
on a fir-clad crest near Beyrout, is a pleasant health resort, and probably 
a little better than Alai. 
Ajaccio in Corsica has a mean annual temperature of 62-5° F. - 
autumn 66-7°, winter 52°, spring 60-3°, summer 76-7°. The number of 
clear sunny days is great; the humidity is greater than on the Riviera. 
It is almost completely protected from cold winds. The accommodation 
is good. The climate is less exciting than that of the Riviera, and some 
invalids, who suffer from sleeplessness and neuralgia at the Riviera, feel 
better at Ajaccio. The best time is from the beginning of November to 
the middle of April. Summer stations can be found on the mountains 
for those who are not fastidious. 
The Sanguinaires, small rocky islands near Ajaccio, have a still more 
decided marine climate, but the accommodation is as yet poor. 
The climates of the shores and islands of the Adriatic Sea are very 
different from those on the western side of Italy. The predominant 
defects are the prevalence of the dry and cold wind from the north, the 
bora or tramontana-a land wind; and the moist and warm sirocco - 
a sea-wind. The change between these two winds is accompanied by 
great variations in the temperature and in the relative humidity of the 
air, which are not well borne in irritable states of the nervous system 
or by pulmonary invalids. 
Venice, the best known of these localities, enjoyed in former years a 
great reputation in the treatment of consumption, and has the advantage 268 
SYSTEM OF MEDICINE 
of being free from dust and having good accommodation and artistic 
attractions. Goerz, near the north-west corner of the Adriatic, and Vo- 
losca and Abbazia near the north-east shore, possess some shelter and 
beautiful positions, but cannot compete for English invalids with the 
Riviera di Ponente. Amongst the islands only Lesina and Lissa need 
be mentioned; they possess rather more equable climates than the 
shores, and some accommodation. 
In the Ionian Islands the only place which has some pretension to be 
a health resort is Corfu. The beauty of the position of the town of Corfu 
is great, and the whole island is beautiful; but it is too much exposed 
to wind, and the temperature and humidity of air vary considerably. 
The south-west coast of France possesses a few localities which deserve 
to be mentioned. 
Biarritz is fully exposed to the influence of the Atlantic; it is bright, 
and exercises on most people a bracing influence in spite of a rather high 
degree of humidity and frequent rains. It is not suitable to persons 
requiring shelter; but many old Indians with their complicated cachexias 
derive much benefit from this climate, which also offers a useful change 
to invalids wintering at Pau and Arcachon. St. Jean de Luz, a little to 
the south of Biarritz, has a similar climate. 
A different kind of climate is that of Arcachon, which is situated on 
the shores of a large basin of salt water connected with the actual sea by 
a narrow channel. The influence of the sea is, therefore, considerably 
modified. The houses of Arcachon lie within a large pine forest, which 
is spread over the extensive dunes of the Atlantic. It is thus protected 
from the violence of the Atlantic winds, and the inland winds, too, are 
greatly mitigated by the trees. The climate is rather humid, equable, 
and unirritating, and the air in the " ville d'hiver " is impregnated with 
emanations from the pine-trees. 
The western portion of Southern California presents several localities 
suitable for invalid residence. The country consists of a wide, fertile 
plain intersected by the lower spurs of the Sierra Madre and the coast 
range. The climate is warm and dry, with a large proportion of sunshine 
and small rainfall. The daily range is considerable, the prevalent 
westerly wind causing a fall of temperature in the afternoon. The 
damp, chilling sea-fogs, rolling in from the Pacific, are a drawback. On 
the other hand, the variety of elevation within a comparatively small 
compass fits it admirably for an all the year round residence. According 
to Dr. Davidson (16) a few hours' ride enables one to escape from the 
heat of summer to a cool and bracing atmosphere. Presenting some 
resemblance in climate to the Riviera, it shares some of its draw- 
backs, treachery amongst them. Very good results, however, are 
reported in cases of phthisis, while its fruit-growing industries offer a 
means of livelihood and permanent occupation. Dr. Davidson cautions 
the invalid against staying near the coast; the best residences are 
sheltered spots in the foot-hills or at the base of the mountains. 
The chief resorts where good accommodation can be had are: - CLIMATE IN THE TREATMENT OF DISEASE 
269 
Los Angeles, with a mean annual temperature of 61° and relative 
humidity of 69°; its suburb. Pasadena, at an elevation of 830 feet, may 
also be mentioned. San Diego has a temperature of 54° in January 
and 69° in August; Santa Barbara, on the coast plain, a temperature 
of 50° to 55° in winter and 65° to 70° in summer. 
The coast climates of Great Britain and Ireland may be placed among 
the cooler marine climates with moderate humidity. Some localities 
might more justly find a place amongst the humid climates, but for the 
sake of brevity we will consider them together. Between the coasts of 
these islands there are considerable differences, especially between the 
resorts on the east coast and those on the west; but certain features 
more or less common to all give them a special character. The 
mean temperature is much higher than is due to latitude. This is 
strikingly illustrated by A. Buchan. " If no more heat were re- 
ceived than is due to the position on the globe in respect to latitude, 
the mean winter temperature of Shetland would be only 3°, and that of 
London 17°. But chiefly owing to the heat given out by the Gulf 
Stream during winter, and carried to the places by the winds, their 
winter temperatures are respectively 39° and 38° - Shetland being 
benefited 36° and London 21° from their proximity to the warm waters 
of the Atlantic." Part of this increase of temperature is due to the 
actual contact with the warmer sea. 
Mild winters and cool summers, comparative absence of extremes, and 
a rather humid air, with many rainy days and comparatively many rainy 
hours, are the effects of these influences. The air, rich in water vapour, is 
less transcalent and translucent than in drier regions; hence direct sun- 
heat and sunlight are less than on the Alps (Waters and Frankland) and 
on the Riviera (Marcet). On the other hand, the water vapour checks 
radiation at night and equalises the temperature of night and day. The 
chill at sunset is less than on the brighter and drier Riviera. The 
climatic characteristics are, therefore, comparatively high annual tem- 
perature, a fairly high degree of humidity, great equability as regards 
seasons and periods of the day, dulness of atmosphere with but a small 
amount of direct sunlight and sunheat, and more than average windi- 
ness. The combined effect produces health-giving and tonic, though 
not uniformly agreeable and exhilarating climates, which require some 
vigour of constitution to bear them. Speaking roughly, we may desig- 
nate the west coast as warm and moist, the east as dry and cold; the 
western part of the south coast, as far as Sidmouth, as moist and spe- 
cially warm; the line from Bournemouth to Hastings, including the Isle 
of Wight, as fairly dry and warm ; the south-eastern part, with Folke- 
stone and Dover, as approaching the characters of the east coast. 
During the early part of the winter the temperature on the west and 
south-west coasts of England is between 2° and 6° higher than on the east 
coasts; it gradually rises from the south-east to the south-west coasts. 
Towards summer this difference gradually disappears, and then some- 
times the east coasts are warmer than the west. 270 
SYSTEM OF MEDICINE 
We may roughly divide the sea-side resorts into (a) summer and (6) 
winter resorts - adding, however, that some of the latter can occasionally 
be beneficially employed in summer, and vice versa. 
(a) Summer liesorts. - There is no other country which is so well 
provided with good summer sea-side places. The majority of them are 
situated on the east coast, and are decidedly bracing. Going from north 
to south we have Nairn, St. Andrews, Portobello, North Berwick, Redcar, 
Saltburn, Whitby, Scarborough, Filey, Bridlington, Hunstanton, Cromer, 
Yarmouth, Lowestoft, Aidborough, Felixstowe, Walton, Westgate, Mar- 
gate, Broadstairs, Ramsgate, St. Lawrence, Deal, Walmer and St. Marga- 
ret's. On the south-east and south coasts, Dover, Folkestone, Sandgate, 
Hythe, Eastbourne, Seaford, Brighton, Worthing and Littlehampton, 
Bognor, Southsea. In the Isle of Wight, Sea View, Cowes, Ryde, Alum 
Bay, Freshwater, Sandown and Shanklin; farther west, Swanage, Wey- 
mouth, Lyme Regis, Seaton, Exmouth ; the Channel Islands; New Quay 
and Bude, Ilfracombe and Lynton on the north coasts of Cornwall and 
Devon; Minehead, Weston-super-Mare, Clevedon and Portishead on 
the Bristol Channel; Tenby, Aberystwith, Barmouth, Beaumaris, Pen- 
maenmawr, Llandudno, in Wales ; Southport and Grange-over-Sands in 
Lancashire; Douglas and Ramsay on the Isle of Man have almost 
thoroughly marine climates. Silloth in Cumberland, and Ardrossan, 
Oban, and Rothesay on Bute in Scotland have cool and rather humid 
summers, the last has mild autumns and winters. 
The coasts of Ireland possess a mild, equable and rather humid 
climate; Bray, Howth, Kingstown, Dundrum, Holywood, Queenstown 
and Glengariff are good representatives ; Bundoran and Kilkee are under 
the full influence of the Atlantic; Port Rush and Port Stewart in the 
north are somewhat more bracing; Rostrevor and Warrenpoint are not 
quite exposed to the sea, and offer the advantages of beautiful inland 
country, protection from wind, and modified influence of the sea-air. 
(b) Winter Resorts. -If we proceed from east to west we begin with 
Hastings and St. Leonard's, which are less warm and somewhat more 
bracing than the localities farther west and south-west, and would be 
similar to the other places on the south-east coast were it not for the 
greater shelter which the Downs afford from north-west, north, and 
north-east winds. Those requiring a warm, humid and equable atmos- 
phere are better farther west and south-west, but cases of atonic catarrh 
of the mucous membranes are mostly benefited in the autumn and 
winter, up to the end of February when the east winds begin. 
The Undercliff on the Isle of Wight, and the fair results obtained at 
the National Hospital for Consumption at Ventnor, are well known. 
This is also the case with Bournemouth and Boscombe, which offer 
abundant accommodation at the hotels and in numerous villas scattered 
about on the cliffs and in the pine woods ; these unfortunately are 
suffering from the rapid increase of the buildings. 
Salcombe, Sidmouth, Budleigh-Salterton, Exmouth, Dawlish and 
Teignmouth have all fairly warm and equable winters, and in their CLIMATE IN THE TREATMENT OF DISEASE 
271 
climatic characters resemble Torquay, which, however, by its situation 
in a large bay surrounded by three hills, offers opportunities for extensive 
exercise on level as well as on rising ground, with ever varying beautiful 
views. In spring the east wind sweeps round the protecting rocks and 
promontories, but is felt less severely than on the eastern part of the 
coast. Farther west Falmouth in Cornwall claims our attention by 
similar qualities, and Penzance, which has less shelter from wind, but 
fair equability of temperature. On the coast of Wales, Pwllheli on the 
Cardigan Bay deserves our appreciation by its sheltered situation from 
north and east winds; and Llandudno, although principally a summer 
resort, offers also some advantages in winter. Grange on Morecambe 
Bay has good shelter. More northward the coast and the islands on the 
west of Scotland have a remarkably mild and equable, but at the same 
time humid winter climate; Rothesay, on the island of Bute, offers the 
best accommodation. Glengariff and Queenstown in Ireland, among the 
humid climates, have good claims to be regarded as winter resorts. 
The climate of the north and still more of the north-west coast of 
France has, owing to the Gulf Stream, some analogy to that of the south 
and south-west coast of England, especially in summer. There is very 
little shelter in winter, but the climate in summer is rather more dry and 
stimulating than on the opposite coast of England. Dinard, Cabourg, 
Houlgate, Villers-sur-Mer, Trouville, Deauville, Etretat, Fecamp, Dieppe, 
St. Valery en Caux, Treport and Boulogne offer satisfactory accommoda- 
tion and good sands for bathing. The same may be said of Ostend, Blank- 
enberghe and Hey st in Belgium, and Scheveningen on the Dutch coast. 
More bracing still are the sea-side and island resorts on the north 
coast of Germany, exposed to the German Ocean; Borkum, Norderney, 
Baltrum, Langeroog, Spikeroog, Wangeroog, Wyk on Fbhr and Wester- 
land on Sylt, but the accommodation at them is often primitive. The 
island of Heligoland has a much more decided marine climate. 
The shores of the Baltic are less stimulating, but have beautiful 
forests. 
B. Inland Climates. - We must be satisfied with the subdivision of 
the great variety of these climates into, I. Elevated or Mountain climates, 
and II. Lowland or Plain climates. 
I. Elevated or Mountain Climates. - Great as is the difference be- 
tween the various resorts belonging to this subdivision, elevation above 
the surrounding regions produces modifications in the climatic character 
which are common to them all. It is impossible by the mere elevation 
above the sea to define the limits which entitle a place to be called a 
mountain health resort. Latitude and the features of the surrounding 
country exercise great influence in this respect, which manifests itself 
quite as much in the nature of the vegetation as in the meteorological 
character; and from both combined we may draw some inferences as to 
the probable physiological and therapeutic effects on the human constitu- 
tion. In the low parts of Northern Europe, for instance, we find at an 
elevation of about 1200 to 1600 feet the vegetation peculiar to much 272 
SYSTEM OF MEDICINE 
higher elevations in Southern Europe, unless the nearness of the sea or 
surrounding higher mountains exercise modifying influences. In lati- 
tudes nearer the equator a much higher elevation is required to produce 
analogous effects. Thus J. M. Toner says, " On Chimborazo the palms, 
bananas, and oranges grow at 5000 feet; at 10,000 feet, Indian corn and 
wheat; and at 15,000, barley and the more hardy grasses." In a rough 
way we may assume that in Northern Europe (above 50° lat.) an elevar- 
tion of 1000 to 1500 feet produces a mountain climate, unless nearness 
of the sea or of higher mountains interfere; while in the centre of 
Europe (between 48° and 50° lat.), 1400 to 2500 feet are required; 
between 47° and 48°, 2400 to 3500 feet; and in the tropics 6000 to 
9000 feet. The upper limits of elevation for health resorts likewise 
vary according to latitude and local circumstances. 
We will begin our description with the Swiss Alps. 
The general characteristics of the climate of the Swiss Alps in 
winter are: - 
1. Low barometric pressure due to the altitude. 2. Great diather- 
mancy of the atmosphere. 3. Low temperature. 4. Absence of fog and 
comparative rarity of cloud. 5. Low absolute and relative humidity. 
6. Rareness of wind. 
The patient is thus placed in an atmosphere of dry, still, cold, and 
rarefied air, and exposed to very powerful sunlight and sunheat. 
What then are the effects of this climate upon the body? On 
arriving at one of the Alpine resorts the patient first experiences a 
certain amount of difficulty in breathing; any exertion causes him to 
pant; frequently he cannot sleep; sometimes there is headache; the 
bowels are often constipated, and there is a general feeling of listlessness; 
thirst and dryness of the throat are prominent symptoms. On examina- 
tion the respirations are found to be quicker and the pulse accelerated. 
Marcet (54) has shown that the amount of carbonic acid and water 
exhaled by the lungs is increased. Acclimatisation may take from three 
or four days to as many weeks; when this is established the pulse will 
have fallen to its normal condition, the respiration will be fuller and 
deeper than on the plain (94), the bow'els regular, sleeplessness gone, 
and appetite improved. 
These effects are merely those of altitude, as they may be observed 
in the summer to the same degree, and quite as frequently as in the 
winter. In the winter we have further to consider the bracing effect of 
the dry, cold air. The influence which the cold air produces is probably 
seen chiefly in increasing appetite and digestion ; at the same time an 
increased amount of water is exhaled by the lungs, and the exhalation 
of carbonic acid is promoted by the cold air of the Alps (Marcet). 
Taken altogether, it appears that altitude and cold combined produce a 
more rapid interchange in the tissues, and that in consequence of this 
greater activity the tissues acquire an increased resistance to the action 
of micro-organisms. The paramount constitutional benefit of climate in 
phthisis must lie in the increase of this resistance of the tissues, and such CLIMATE IN THE TREATMENT OF DISEASE 
is the unanimous opinion of all who have had much experience of the 
climates of high altitudes, and for these reasons: - 
(ct) Signs of constitutional improvement; gain in weight, and increase 
of appetite frequently precede any local improvement discernible by 
auscultation. 
(b) Many patients, who have improved in the high altitudes, on going 
down to a lower level where the atmosphere may be equally pure and 
dry, begin to lose weight; while the disease shows signs of fresh activity. 
This increased resistance seems to be brought about by the following 
factors:- 
1. The large amount of time which is passed in the open air in 
a still atmosphere. 2. The tonic action of the dry cold air. 3. The 
purity of the atmosphere. 4. The large amount of sunlight. 5. Per- 
haps a general tonic influence exerted by rarefied air upon the metab- 
olism of the body. 
In past years much more importance was attached to the extreme 
rarity of phthisis among the natives of the high Alpine valleys. This 
rarity is rather to be explained by the outdoor life of the people, and 
the smallness of the communities; the absence or rarity of microbes is, 
however, well established. 
The alleged fact that phthisis is unknown amongst the inhabitants 
of the steppes indicates that altitude may not be the only factor in con- 
ferring immunity; an outdoor life is at least as habitual to these people 
also. 
Increased resistance is brought about not only by increased appetite, 
but also by improved digestion and assimilation. The patient finds, 
to his surprise, that he can eat a heavy meal without any subsequent 
lassitude and torpor. Viault and Egger have shown that there is a 
somewhat rapid increase in red corpuscles in patients taken to a high 
altitude. Further, Bert's experiments in Peru (9) prove that the blood 
at high altitudes takes in a much greater percentage of its volume of 
oxygen. 
Besides the constitutional effects of the dry, cold, thin air, there are 
certain purely physical effects produced upon the lungs themselves. 
Owing to the rarefied atmosphere each breath taken must, to supply the 
due measure of oxygen, be deeper than on the plain. The effect of this 
is to enlarge the circumference of the chest; Williams (108) gives this 
enlargement at from one to three inches; other observers are inclined 
to put it at somewhat less, though all are agreed that it does occur [yide 
art. on "Artificial Aerotherapeutics"]. A further result of this deeper 
manner of breathing is thoroughly to open up all the air vesicles, and 
thus to prevent any accumulation of secretions in them. After a more 
prolonged residence at high altitudes a state is reached which has been 
termed "hypertrophy of the lung." The chest is enlarged to some 
extent and is hyper-resonant; the breath-sounds, instead of being weak, 
are puerile or exaggerated, but expiration is not prolonged. Whether 
this be merely a form of emphysema, or an actual increase in the 
273 
VOL. I 
T 274 
SYSTEM OF MEDICINE 
respiratory area of the lungs, we cannot say; but after considerable 
experience, both of the natives of the high Alpine valleys and of con- 
sumptive patients, we can assert that this condition is very rarely 
associated with the ordinary symptoms of emphysema. 
The principal resorts are: - 
Davos (5200 feet). Is less windy than the other resorts, but receives 
less sun during the day. It is adapted to a greater variety of cases, and 
the accommodation and nursing arrangements are excellent. It is con- 
nected with Zurich by rail. 
Moritz (6000 feet). Is more windy than Davos, but has a slight 
advantage in the matter of sun. It is admirably suited to more vigorous 
cases, but severe cases are better at Davos. The accommodation is good. 
Ley sin (4712 feet). Above Aigle. Is well protected and receives a 
large share of sunlight. An admirably-conducted sanatorium has been 
established there, and thorough supervision of the patients is carried 
out. 
Wiesen (4771 feet). Chiefly used as a halting-place to and from 
Davos. 
Arosa (6100 feet). Admirably sheltered, and at the Kulm receives a 
fair share of sunlight. 
Les Avants, above Montreux (3500 feet), may be of use where the 
higher elevations are ill borne. An equally sheltered and sunny estab- 
lishment at an elevation of over 5000 is being built. 
The elevated resorts of the Rocky Mountains have, of late years, come 
into repute, and, thanks to the admirable accounts given by Dr. C. T. 
Williams (107), and the earlier ones by Denison, their main features 
are becoming well known. These resorts are situated in the State of 
Colorado, on the eastern slopes of the chain as it traverses that terri- 
tory, at altitudes of from 5000 to 7000 feet. Meteorological observa- 
tions tend to show that the climate is somewhat drier than that of the 
Swiss Alps, and has a very distinct advantage in the matter of sunshine; 
at Colorado Springs during the winter the sun shines during the greater 
part of the day for 165 days out of 182 (77), and the mean temperature 
is higher than in the Swiss Alps, the snow only lying for a few days at 
most during the winter. On the other hand, there is very much more 
wind and much more dust than in Alpine resorts. Electrical manifesta- 
tions are a prominent feature of the climate, but as to whether these 
influence the body for good or ill, we know, scientifically speaking, 
nothing. Their advantages are: - 
1. Altitude, the effects of which we have already discussed. 2. Dry- 
ness. 3. Abundant sunshine. 
The climate, although not possessing some of the advantages of the 
Swiss Alps, is better adapted on the whole for an all the year round 
residence; there is no snow-melting time, and the summer, although 
hotter, is more constant than in the Alps. Colorado, moreover, offers 
better facilities for employment, sport and exercise, than any other 
resort. Subjects of constitutional erethism will probably fare even CLIMATE IN THE TREATMENT OF DISEASE 
worse in Colorado than in the Swiss Alps. The accommodation is good, 
though, owing to the American fashion of meals, the food may not be so 
acceptable to the invalids as that of the Swiss hotels. It must be remem- 
bered also that the living expenses are heavier than in Europe. 
The principal resorts are: - 
Denver (5000 feet). A town of 150,000 inhabitants covering about 
five square miles. The mean annual temperature is 50°, the month of 
January showing a mean of 27-2°, and August 72-8°. Rainfall 14-17 
inches (107). The accommodation is good, and the place presents all the 
advantages of a large town, though this can hardly be regarded as an 
unmixed benefit. 
Colorado Springs (6022 feet). Seventy-five miles south of Denver; a 
town of 15,000 inhabitants. The mean temperature is 46-4°. Colorado 
Springs possesses an advantage over Denver in being almost exclusively 
a health resort, while the latter is a large commercial town. 
Glenwood, (5000 feet), on the Pacific slope, may also be mentioned; 
it possesses a most admirably-conducted hotel. The climate is, however, 
damper than that of the other slope. 
New Mexico seems to possess a valuable winter climate, but is practi- 
cally unavailable, owing to the absence of suitable accommodation which, 
even at El Paso, is far from good. 
The Andes. - Another class of mountain climates, which may with 
advantage be touched on here, contains those of the Andes, since it was 
by experience gained in them that Archibald Smith was first enabled to 
draw attention to the benefit in the treatment of phthisis likely to be 
obtained by residence in elevated regions. 
The main resorts are situated on the Pacific slope of the Andes - in 
Peru, and New Granada, at elevations varying from 8000 to 12,000 feet. 
The chief characteristics of these climates are : - 
1. Moderate warmth even in the highest resorts, owing to their prox- 
imity to the equator. 2. Remarkable equability of temperature. At 
Jauja, according to Archibald Smith, during a whole year the tempera- 
ture never rose above 60°, or fell below 50°. 3. Considerable atmos- 
pheric dryness. 4. Abundant sunshine. 
We have thus a temperate and extremely equable climate, with the 
additional advantage of rarefaction of the atmosphere. The admirable 
results obtained there among the consumptive natives of the plain prove 
the curative properties of the climate. Unfortunately, however, at none 
of the resorts is the accommodation good enough for invalids. For 
English patients, also, the length of the journey is prohibitive, except 
in the case of vigorous men with limited disease. For such as these, 
and for arrested cases, who wish to have a settled home in a good cli- 
mate, and who are willing to build their own houses, these resorts offer 
decided advantages. Dr. Smith points out that patients, as a rule, 
do better at an elevation of 8000 to 10,000 feet than at the higher 
levels. 
The principal resorts are : - 
275 276 
SYSTEM OF MEDICINE 
Huancayo (10,000 feet), in Peru; the temperature of the whole year 
ranges between 51° and 63° (Williams). 
Jauja, 10,000 feet, also in Peru, with a temperature ranging between 
50° and 60° for the whole year round. 
Quito, in Ecuador; a town of 80,000 inhabitants, situated at an 
altitude of 9500 feet, and with an all the year round temperature of 
about 60°. 
Santa Fe de Bogota, in New Granada, at an elevation of 8648 
feet. The temperature is 59°, and is fairly constant all the season 
through. 
In India there are several hill-stations, situated in the Himalayas and 
Nilgiris; but, except for those who cannot leave India, they possess no 
particular advantages. The atmosphere is said to be very damp in the 
summer, owing to the heavy rainfall. The chief resorts are Simla (8000 
feet) and Darjeeling (8000) in the Himalayas, with Ootacamund (7361) 
and Wellington (5840) in the Nilgiris. In considering the hill-stations 
of India we must bear in mind the nearness to the equator, by which the 
influences of altitude are considerably modified; and further, that the 
peninsula is surrounded, excepting at its broad base, by large masses of 
warm water. The periodical moisture-laden winds coming from these 
seas must, on reaching the colder mountain ranges, necessarily deposit 
a large portion of their humidity, rendering the soil damp, and the air 
emanating from it moist and impure. 
Very different are the mountain climates on the north and north-west 
of the Himalayas, for the atmosphere on reaching them has lost a great 
part of its moisture on the southern slopes. Hence Tibet to the north, 
at 9000 to 11,000 feet, and Cashmere on the north-western chain, at 5000 
to 6000 feet, possess healthy climates, and offer sites for most useful 
health resorts. 
A class of resorts of moderate altitude (about 1700 feet), presenting 
peculiarities worthy of notice, are Cbrb ersdorf in Silesia, Falkenstein in the 
Taunus, Reiboldsgriln (2250 feet) in the Erzgebirge, and Hohenhonnef in 
Rhenish Prussia. These resorts base their efficacy not so much upon 
their climate as upon the manner in which, by careful management and 
artificial shelters, an open-air life is rendered possible to the consumptive, 
even in a somewhat inferior climate. Further, the patients reside in 
sanatoria, in which every, even the smallest, detail of their daily life is 
under the immediate control of the physician, while obedience to his 
orders is a condition of residence. This system of treatment was inau- 
gurated by Dr. Brehmer at Gorbersdorf some forty years ago; his main 
contention being that the essential point in the cure of phthisis was 
supervision of the minutest particulars of the patient's life, aided by 
drugs and hydrotherapy when necessary. The soundness of his views 
has been abundantly proved by the high percentage of cures amongst 
his cases, while to his teaching is due the sytematisation of the mode 
of life at Davos and other health resorts. We cannot help remarking 
here that Brehmer's results, obtained in an inferior climate, are better CLIMATE IN THE TREATMENT OF DISEASE 
than most of those obtained in far more suitable localities, where the old 
haphazard traditions of treatment still reign. The difficulties of establish- 
ing such a system amongst English patients are great; but some modi- 
fied form of Brehmer's system could easily be brought into vogue by a 
determined effort on the part of the medical profession. We have yet 
much to learn from the German physicians as to the best possible method 
of utilising each climate. Brehmer's system is carried out at the estab- 
lishment which he founded at Gorbersdorf, situated in a pine-clad valley 
in Silesia, at an elevation of 1700 feet. Dr. Dettweiler, one of Brehmer's 
assistants, and Dr. Hess now direct the establishment of Falkenstein, 
situated in a sheltered valley of the Taunus, at an elevation of 1500 
feet; to this is now attached a sanatorium of 100 beds for patients of 
small means. Dr. Meissen, another former assistant of Dr. Dettweiler, 
directs yet another sanatorium at Hohenhonnef, about 1600 feet high. 
Dr. Trudeau, again, carries out a system similar to Brehmer's at his 
sanatorium in the Adirondacks, in the United States of America; here 
the patients lie during the greater part of the day in open verandahs, 
even in a temperature of 10° below zero. 
The large number of excellent hotels in the mountainous part of 
Switzerland, Italy, and France, at elevations of about 5000 to 6000 feet, 
may be ascertained from the current guidebooks. 
277 
The Eastern Alps, with the Dolomites and the Tyrol, contain many 
beautiful localities which are gradually being provided with hotels 
suitable for delicate persons. In the Dolomites we may specially men- 
tion Campiglio (Madonna di San Campiglio), San Martino di Castrozza, 
Schluderbach, Landro or Hohlenthal, and Cortina d'Ampezzo. In the 
Tyrol, St. Gertrud, in the Sulden Valley, is above 6000 feet, all the 
others are below 5000, and the majority below 4000, descending to about 
2000: the Mendelhof, near Botzen; the hotels on the Semmering Pass; 
Gossenap, near the Brenner Pass ; Innigen, Niederdorf, Toblach, and Neu 
Toblach, in the Puster Valley; Kreuth and the Achensee; Oberstdorf; 
Berchtesgaden, with Steinhaus and Vordereck ; Zell am See; Parten- 
kirchen and Kainzenbad; Aussee and Altaussee; Innsbruck, with Igls. 
There are, besides, many even less elevated localities, which, owing to 
the beauty of the situation and the comfort of the hotels, may be selected 
for shorter or longer stays, such as Beichenhall, Salzburg, Ischl, Gmunden. 
Italian Mountain Stations. - The mountain ranges of Italy, excepting 
the southern valleys of the Alps, included in the Alpine resorts (Macug- 
naga, Gresoney, Alagna), do not yet offer many localities which have 
adequate accommodation. Ceresola Reale in Piedmont, 5100 feet high, 
and Abetone and Serrabassa in the Apennines, at an elevation of about 
5000 feet, deserve to be mentioned; and at lesser elevations, St. Martin 
Lantosque and the Certosa di Vai Pesio, in the Maritime Alps. Perugia 
and Siena are scarcely elevated enough to be regarded as hill stations, 
but they are delightful in spring and autumn. 278 
SYSTEM OF MEDICINE 
In the Pyrenees we have the different spas, which can also be used 
as climatic health resorts - Bareges, Cauterez, Bagn^res de Luchon, Bag- 
n^res de Bigorre, Eaux Bonnes, etc., but they are less bracing than many 
of the Alpine localities. 
In the mountains of the Auvergne Mont Dore has a claim to be re- 
garded as a mountain health resort, but widely useful accommodation in 
this district might be provided on the Puy-de-Dome, near Royat. 
The health resorts of the Black Forest are of lesser elevation than 
those of Switzerland, but exercise, nevertheless, a moderately bracing 
though less stimulating influence. In addition to elevation, most of these 
localities have in their neighbourhood large pine forests, which exercise 
a purifying and equalising action. Hochenschwand and Schonwald are 
the only places worth mentioning above 3000 feet; the other available 
localities are between 3000 and 1400 - Schluchsee, Titissee, St. Blasien, 
Triberg, Freudenstadt, Allerheiligen, Rippoldsau, Griesbach, Badenweiler. 
Rather similar in character are some localities in the Vosges Moun- 
tains, of which Hohwald, Dreiaehren, and Odilienberg are the best known. 
Besides Gorbersdorf and Reiboldsgrun, Falkenstein, and Hohenhonnef, 
already mentioned as sanatoria for the treatment of consumption, the 
eastern mountain ranges of Germany are rich in well-wooded health 
resorts of local fame, ranging from 1500 to 2500 feet. 
The Harz Mountains in the north of Germany offer many useful 
summer resorts between 1400 and nearly 3000, especially Clausthal, 
Andreasberg, Alexisbad, and Harzburg; the two first are already in use 
as sanatoria for phthisis all the year round. 
The mountains and elevated places of Great Britain differ in climatic 
characters from those on the Continent. The atmosphere is more humid, 
less transparent and transcalent, the sun heat is less high, the tempera- 
ture is more equable. There are scarcely any health resorts higher than 
1000 feet, but the climate at such and at lower elevations is much more 
bracing than at similar elevations on the Continent. This is owing partly 
to the greater coolness of the summer, partly to the absence of high 
mountains around them, preventing free access of air. There are no 
elevated winter resorts. The air on the Scotch and Yorkshire moors is 
thoroughly invigorating, but, unfortunately, the owners do not as yet 
tolerate hotels or sanatoria on them. There is, however, a considerable 
choice of localities, with good climates and fair accommodation. In 
Scotland-Braemar, Ballater, Grantoicn, Forres, Strathpeffer, Blair Athole, 
Pitlochrie, Inversnaid, the Trossachs, Crieff, and Moffat. In England - 
Buxton, Harrogate, Rkley, Gilsland, Malvern, Tunbridge Wells, and Front. 
In Wales, Llanberis and Llandrindod are best suited for those who want 
some comfort with mountain air. It is much to be regretted that there 
are no good inns higher up on the mountains. In the south of England 
Hind Head and Black Down have the advantage of good villas, but not 
of hotels; and the same is the case with the chain of Leith Hill. On 
Dartmoor moderate accommodation is to be found at Princetown, about 
1400 feet high. CLIMA TE IN THE TREA TMENT OF DISEASE 
279 
South Africa. - The district of South Africa which offers several 
localities possessing a climate suitable to invalids, is the Karroo, a rolling 
heath-like country, varying in elevation from 2500 feet to 6000 feet. 
It is divided by the Nieuweld Mountains into two districts, Central and 
Upper Karroo. Of these the former slopes gradually southward, while 
the latter stretches northward as far as the Orange River. The climate 
is characterised by extreme dryness of the atmosphere, great heat in the 
summer, and small rainfall. The winter nights are cold, but, according 
to Dr. Saunders, the days are bright and sunny. The advantages of 
this climate are its altitude and the abundant opportunities it offers 
for outdoor life, without danger of taking cold; its drawbacks are the 
large amount of dust and the extreme heat of summer, though, owing to 
the dryness, the latter is not severely felt. The climate is bracing, but 
too exciting for persons of a nervous temperament. In timing the 
arrival of patients it must always be remembered that the seasons are 
the reverse of our own. The simple character of the accommodation, 
moreover, should deter the fastidious and any invalid not possessed of 
a fair amount of constitutional vigour. 
Of the resorts whose capabilities have been so admirably summarised 
by Dr. Symes Thompson (89), we may mention - 
1. In the Great Karroo: Craddock (2855 feet) and Beaufort West 
(2792 feet). 
2. In the Upper Karroo: Burgersdorp (4552 feet) and Tarkastad 
(4280), at which good results have been obtained in the treatment of 
phthisis; also the flourishing townships of Aliwal North (4348), 
Kimberley (4012), and Bloemfontein (4500). Pretoria in the South 
African Republic is also rising into favour as a health resort. Ceres 
(1493), with its sanatorium, and Grahamstown (1800), form excellent 
intermediate stations between the coast and higher altitude sanatoria. 
Australia. - The regions of Australia, possessing climates suitable 
to invalids, are the inland plains, certain localities in the Blue Moun- 
tains and the Australian Alps. The climate of the coast region, in 
which all the chief towns are situated, is too variable, owing to the cold 
southerly winds and the hot winds which blow from the central desert. 
The mountains, which fringe the coast from the South Australian 
border to Queensland have in the main a temperate, dry and bracing 
climate. Although amongst the varieties of their climates there are 
probably some which would be of great value, yet the want of accom- 
modation, except at two or three places, materially lessens their utility. 
The available resorts are confined to those on Mount Macedon in Vic- 
toria, with Catoomba and Mount Victoria in New South Wales. The 
former, situated 44 miles from Melbourne, consists of Upper (3000 feet) 
and Lower Macedon (1660 feet), with the excellent sanatorium, Braemar 
Wood End (2500 feet). The mean annual temperature of Macedon is 
53° F. The locality forms a good place of sojourn for those spending 
a short time in the colony (8). 
Mount Victoria (3490 feet), 77 miles from Sydney, mean annual 280 
SYSTEM OF MEDICINE 
temperature 53° F., provides an excellent change from the climate of the 
inland plains. 
Catoomba (3349 feet) is slightly more humid than the last named. 
The chief characteristics of the Inland Plains are extreme dryness of 
the atmosphere, abundant sunshine, and small rainfall. All these con- 
ditions mean ample opportunities for outdoor life. The drawbacks to 
the climate are the large amount of dust, the occasional occurrence of a 
hot north wind, and the possibility of a drought. The climate is un- 
doubtedly bracing, the danger of chills is slight, and there are no 
marked ill effects upon the nervous system, such as sleeplessness, etc. 
The Inland Plains divide themselves into two districts: the Riverina 
in Victoria, lying to the north of the Murray River, and the Darling 
Downs in Queensland, an upland plateau (2000 feet) lying to the east of 
the former. 
According to Dr. Lindsay (47) the heat in summer in the Riverina 
is considerable, though easily borne. In winter there are slight frosts, 
but the days are warm. The Darling Downs are somewhat cooler and 
less exposed to the hot wind. In both districts the accommodation is 
rough, and the climate is best enjoyed by residence on a station. 
For some cases of phthisis the climate is admirably suited; the 
patient, however, must possess a good share of constitutional vigour, and 
must be ready and willing to content himself with the monotonous fare 
of a station or up-country township. Accommodation can be obtained 
at Deniliguin in the Riverina, and Warwick and Towoomba in the 
Darling Downs. 
II. The Lowland Climates. - After having considered so many 
regions under the heads of Marine and of Mountain Climates, we can 
throw but a rapid glance at some of lower regions not included in the 
former. Our foremost attention is claimed by Egypt. 
Egypt owes its virtue as a climate chiefly to its being composed 
mainly of desert, so much so that the fertile spots included in the 
wastes share, on the whole, the characteristics of the desert air. The 
main characteristics of the climate are: - 
1. Warmth, the mean temperature at Cairo for the winter months 
being 58-3°. 2. Large Daily Range, the difference between day and 
night temperatures varying from 35° to 19°. 3. IjOw Relative Humidity. 
4. Abundant Sunshine. - Blue sky was chronicled on all but fifteen days 
during five months at Assouan, in the winter of 1892-93 (Longmore). 
5. Small Rainfall. - Six rainy days only in five months were chronicled 
at Assouan in 1892-93. 6. The extremely aseptic character of the air, 
which is constantly refreshed by a breeze blowing over hundreds of miles 
of desert whence no emanations rise. 
Most of the observations have been taken in localities situated on 
the cultivated land. Dr. Canney's observations, however (supported 
by Dr. Longmore's personal communications), taken in the desert at 
Luxor, and in other situations in Egypt, tend to show that the 
climate in the desert itself has a smaller daily range (17° in Luxor CLIMATE IN THE TREATMENT OF DISEASE 
281 
desert as against 32° in Luxor) and a lower relative humidity (54° 
in Luxor desert as against 69° in Luxor). The advantages of the 
climate are dry, warm, sunny days with cool nights, and a marvellously 
pure atmosphere. The drawbacks to the climate are the not infrequent 
presence of cold winds (though not to the same extent as on the Riviera), 
and the occasional occurrence of hot winds laden with dust; these are 
not only constitutionally most depressing, but intensely irritating to the 
lungs. 
The physiological effects of the climate may be described as bracing 
to the organism as a whole, and sedative to the nervous system. Dr. 
Sandwith (70) gives records of 105 cases of phthisis; improvement took 
place in 72. 
In Egypt the invalid can spend the greater part of the day in a warm 
climate, while at the same time sleep is encouraged rather than interfered 
with, and the nervous system is soothed. The danger of chill at sunset 
is, however, always present, and has to be guarded against as carefully 
as on the Riviera. The length of the journey and the great expenses 
of living necessarily exclude a certain number of invalids. 
The chief individual resorts to be considered are : - 
Cairo. - This should be avoided, as it is a crowded town, offering too 
many social temptations. Although the sanitation and water-supply of 
the hotels are good, the town itself is far from being in a sanitary condition. 
Helouan. - About 15 miles from Cairo, standing in an oasis in the 
desert. There is more wind than at some other resorts; the accommoda- 
tion is excellent. As it is a little above the level of the Delta Helouan 
can be utilised also from November to January. 
Mena House.-Near the pyramids, an admirably kept hotel. The 
climate in the late winter and early spring is much the same as that of 
Helouan. Owing to its proximity to the Delta the best season to visit 
Mena House is from the middle of February onwards; before that date 
there is too much moisture in the air, owing to the drying up of the 
inundated plain. 
The Nile Voyage. - This may be made in two ways: (a) by steam- 
boat, (5) by dahabeyah. (a) The steamboat voyage is shorter, but less 
repose is obtained than on the dahabeyah. There is, moreover, far too 
much wind for serious invalids, and often a difference of 10° between 
different parts of the boat, and much more between sun and shade. 
Patients suffering from the throat often catch cold and become feverish. 
Here, too, the belief prevails that climate must do everything, and that 
the doctor need not be consulted. The long and hurried excursions to 
tombs and temples afford another source of danger to many invalids. 
Dr. Longmore, as the result of his experience, is inclined to regard the 
voyage during the months of January and February as unsuitable to the 
pulmonary invalid, particularly so far as lower Egypt is concerned. 
(5) The dahabeyah, on the other hand, affords perfect leisure, while 
the contrasts of temperature are not so great. It is, however, costly, 
and the patient, unless he can afford a travelling physician, will be 282 
SKSZ'AJZ OF MEDICINE 
away from medical supervision; even in promising cases this is rarely 
advisable. During the months of January and February the dahabeyah 
should be kept south of Luxor (Longmore). 
Luxor, situated on the Nile, 450 miles south of Cairo, possesses a 
milder climate than lower Egypt, being warmer and not so subject to 
cold winds. Luxor is admirably suited as a residence for the invalid 
from the end of November to the middle of March. Moreover, the 
invalid can travel by train within a day's boat journey of Luxor; this is 
a great boon to those arriving late in the season, for whom the boat 
voyage is unsuitable. 
There is an admirable site for a sanatorium south of the hills above 
the tombs of the kings. Here, owing to the conformation of the country, 
the full advantage of desert air could be enjoyed to a greater degree 
than in any of the present resorts. 
Assouan stands at the first cataract; it is somewhat more bracing, 
drier, and warmer, but, on the whole, a little more windy than Luxor. 
The accommodation is fair in the new hotel, but there are few arrange- 
ments for sitting in the open air without exposure to draughts and dust. 
This, however, we hear is to be remedied, and with judicious manage- 
ment Assouan can be made an excellent resort for sufferers from 
rheumatism, early phthisis, and the like. 
On the whole the great advantages of desert air are not yet suffi- 
ciently available. We may say, however, that our experience of treat- 
ment by continued residence during several entire years in the Nubian 
Desert, under tents shifted from one place to another, has, in several 
advanced cases of consumption, given results which are altogether 
superior to any obtained from any health resort or from any other treat- 
ment. Yet if, at the site indicated near Luxor, a hotel were constructed 
on an improved plan as regards ventilation, air spaces for the night, food, 
and so forth, the conditions, to judge from the medical and scientific ob- 
servations that have been made on the climate, would be nearly perfect. 
Pau, in the south-west of France, about 630 feet above sea-level, 
owes the peculiarities of its climate to its situation north of the Pyrenees, 
not far removed from the Atlantic, and to its being surrounded by a 
wide circle of hills. Thus it enjoys considerable calmness of atmosphere 
with the exception of occasional storms. The air is less dry, and the 
number of rainy days is greater than at the Riviera. The mean temper- 
ature from November to April is about 48-5° F. which is nearly 5° F. 
less than at the Western Riviera resorts, but it is rather more equable. 
There is less sunshine and sun heat; the difference between sun and 
shade, and between day and night is less. On the whole the climate 
may be called sedative, and is therefore more suitable to cases with an 
irritable mucous membrane and an irritable nervous system than the 
Riviera (85). 
Dax, in the south-west of France, has a somewhat similar climate, 
but is less sheltered and more under the influence of the Atlantic. 
Arcachon, which has been mentioned under the marine climates, but CLIMATE IN THE TREATMENT OF DISEASE 
283 
has almost equal right to a place here, has some points in common 
with Pau. 
The interior of Italy is rich in delightful localities, which may tem- 
porarily serve as residences to invalids, but few of them can be regarded 
as health resorts. 
Rome will always claim the attention of physicians called upon to 
advise on climates, although it has long lost its great reputation in the 
cure of phthisis. November is often rainy; December, January, and 
February are frequently cold; but March, April, and part of May 
are mostly pleasant, and may be useful in cases of arrested phthisis, 
cases with chronic bronchial catarrh, chronic rheumatism, gout, and 
mental depression, provided due care be taken to avoid over-fatigue 
in sight-seeing, and changes from the hot sun into cold galleries and 
churches. The climate of Rome should not be called relaxing, it may be 
said to take an intermediate place between Pau and the Riviera. Dr. 
Charles and other physicians residing in Rome describe the hygienic con- 
dition as much improved, especially in consequence of the excellent water- 
supply. 
In the north of Italy the Lake district offers some climatic advantages, 
especially the Lago Maggiore, the lakes of Como, Varese, and Lugano, 
and the Lago di Garda. The climates of the different localities on these 
lakes are by no means the same, but all have in common the position to 
the south of the sheltering Alps, and the influence of the large sheets of 
water near which they are situated. They offer less warmth, less shelter, 
and less sun than the Riviera, and have more rain; but, compared with 
England, the number of clear days is greater and the relative humidity 
is smaller. The late Dr. Scharrenbroich, in a carefully-written work on 
Pallanza, gives the relative humidity as 67-6° F., the number of bright 
days during the colder seasons 185, of rainy 61. Pallanza, which is open 
throughout the year, has a mean winter temperature of only 39-1° F., 
which is scarcely more than the inland localities in the south of England, 
but in spring 54-4°, in summer 71-4°, in autumn 55-65°. The climate 
may be regarded as moderately dry and stimulating. That of Locarno, 
likewise open in winter, is somewhat similar. Stresa and Baveno are 
rather less sheltered, and are suitable only for spring, summer, and 
early autumn. On the Lake of Como, the Villa d'Este, Menaggio, 
Cadenabbia, and Bellagio are favourite resorts in spring and autumn. 
Lugano in winter and spring, according to Dr. Thomas, is slightly cooler 
than Pallanza. Varese, on the lake of the same name, deserves likewise 
to be mentioned; it lies higher (1250 feet) than the localities on the four 
other lakes, which lie between 600 and 1000 feet. The accommodation 
at Orta, with its beautiful little lake, is not yet quite so good as at the 
other places mentioned. 
The Lago di Garda, south-east of the Lake district mentioned, at the 
foot of a precipitous mountain range, possesses a much more sheltered 
tract of shore than any of the other Italian lakes. It offers a very 
remarkable instance of the power of configuration, by which a limited 284 
SYSTEM OF MEDICINE 
Riviera-like climate is produced: here many delicate plants grow in the 
open air, and even lemon-trees on steep terraces. At a village, called 
Gardone-Riviera, a winter resort has sprung up which offers many 
advantages to those requiring much shelter. 
Arco, which has fair, though not the same amount of shelter, lies very 
near to the Lago di Garda, in an easterly direction; it has for many 
years been used as a winter resort. All these localities are less dry, less 
warm, and less stimulating than the Italian Riviera, but less sedative 
than Pau. 
We may here allude to two other localities, which have in former 
years enjoyed a wide reputation, especially in the treatment of phthisis, 
viz., Meran with Obermais, and Botzen with Gries, both at the southern 
slopes of the Tyrolese Alps. They have bright, sunny climates, with a 
certain amount of shelter and moderate relative humidity. 
Third Section. - Utilisation of Climates 
We cannot regard climatic treatment in the narrow sense of treat- 
ment by the mere physical elements of climate, but we must include in 
it and avail ourselves of all the agencies associated or associable with 
the change of climate. Some of these agencies act principally on the 
bodily functions, while others bear directly on the mental functions, and 
through them on the organs and tissues. 
Physicians who are consulted about the choice of a climate often 
meet with misconceptions on the part of the patients. The latter not 
rarely think that it is sufficient to know that they have "gout," or 
" dyspepsia," or " rheumatism," to enable the physician to recommend 
the " best climates " for those complaints: they do not consider that 
" gout " is often complicated with other affections, and differs so widely 
in different persons and constitutions, as to need widely different treat- 
ment ; and that the same is the case with " dyspepsia," with " rheuma- 
tism," and with almost all other complaints. The patient, moreover, 
frequently regards the " climate of a place " as a fixed agent, comparable 
to a fixed dose of a particular drug, - say a grain of calomel, or three grains 
of quinine, or five of iodide of potassium, - while in reality the climate 
of a place during a certain season, say winter or spring, is an unstable 
agent, varying with the weather. Some physicians are in the habit of 
saying that all climates are uncertain with the exception of Egypt, but 
after the personal experience of a winter in Egypt we cannot allow even 
this exception. 
To answer a question frequently asked, What is a good, climate V 
our answer is: A good climate is that in which all the organs and 
tissues of the body are kept evenly at work in alternation with rest. 
A climate with constant moderate variations in its principal factors is the 
best for the maintenance of health. It calls forth the energy of the 
different organs and functions, their power of adaptation and resistance, 
and keeps them in working condition. Such are the climates of England CLIMATE IN THE TREATMENT OF DISEASE 
285 
all the year round, and they belong to the most health-giving in the world. 
They produce the finest trees, the finest animals, the finest men, and are 
most conducive to longevity. They are, it is true, not the most agree- 
able or exhilarating climates; but the brightest and most exhilarating 
climates - such as those of Egypt, Spain, Italy, Greece, Asia Minor - 
are not the best for health and longevity; they are in many respects 
very inferior to those of England. 
The best climates, however, for healthful development and for 
maintenance of health need not be the best, may even be injurious to 
delicate or diseased persons whose organs and tissues have, temporarily 
or permanently, lost their energy and their power of resistance and 
adaptation. We must, therefore, endeavour to find climates for invalids. 
And here we must say at once there are no perfect climates for invalids. 
Relatively good climates for a given case are those in which the influences 
injurious to this case are either absent, or prevail only in a much less 
degree ; and where at the same time other influences exist which, when 
properly utilised, effect a general improvement of the whole constitu- 
tion, and thus facilitate the recovery of the diseased or weakened organs 
and tissues, as far as possible. Pure air and water, the possibility of 
spending a great part of the day in the open air, good hygienic and 
dietetic arrangements, and the presence of a good local physician con- 
versant with the peculiarities of the climate and of the entire locality, 
are the most necessary conditions. 
The physician is, indeed, a very important part of a health resort and 
of a climatic cure, although the invalid is often disinclined to see this. 
Many lives are needlessly lost by trusting to the climate alone. The 
exhilarating influences of a climate, the many interesting objects of a 
place and its neighbourhood, and the social entertainments, are sources 
of temptation, lead often to undo exposure, to over-exertion, or to chills, 
and may destroy the chances of recovery for ever; on the other hand, 
with the help of a judicious physician, not only may the dangers result- 
ing from the defects of a place be escaped, but these very circum- 
stances may also be employed to the benefit of the invalid. 
The invalid must begin by studying, with the guidance of his 
physician, the following essential points: - 
(1) The selection and arrangement of his rooms for air and sun, and 
other hygienic influences. (2) The arrangement of his meals as to 
quality, quantity and time. (3) How to be as much as possible in the 
open air. (4) What kind and amount of exercise to take, and at what 
times of the day, and when to rest. (5) How to clothe himself at dif- 
ferent times of the day and of the season. (6) How to manage the skin. 
(7) How to occupy the mind. 
Without due attention to these points many cases, even at the best 
resorts, are not benefited; with it, good results can be obtained even at 
inferior localities. 
In former times climatic treatment was almost limited to diseases of 
the respiratory organs, but at present we know that the treatment of SYSTEM OF MEDICINE 
286 
almost every chronic deviation from health may be assisted by judicious 
change of climate. Our survey of the principal conditions in which cli- 
matic treatment is usually resorted to must, however, be a summary one. 
The Treatment of Phthisis by Climate. - The utilisation of climate 
for the alleviation or arrest of phthisis is perhaps the most important 
office which change of air can fulfil. From its very nature it is only 
within the reach of the richer of the victims of this malady. Too often, 
moreover, the change, either owing to the relentless march of the disease, 
the unsuitable locality selected, or indeed, and more commonly, the 
imprudence of the patient himself, ends in disappointed hopes. The 
selection of a locality is often one of the most difficult problems with 
which the physician is confronted. Accumulated clinical experience, it 
is true, has given us a series of fairly definite indications to guide us in 
the choice; more frequently than not, however, we have to be governed 
in our selection by the poverty of the patient; and, instead of the best 
possible climate, have rather to consider where he may find an oppor- 
tunity of earning a livelihood. 
The cases which will receive most benefit from a stay in the Swiss 
Alps require somewhat careful selection. Early cases of either unilateral 
or bilateral phthisis in young and fairly vigorous persons, in which the 
disease is of a limited character and the pyrexia moderate, should be 
sent to the Swiss Alps in preference to any other resort. In young per- 
sons a sojourn of one or two years in the Alps will probably not only 
arrest the disease, but so establish the constitution that the patient may 
cautiously resume his ordinary occupation at home. It has been urged 
that these cases will do well anywhere; but not only do statistics show 
that more first stage cases are arrested in the Swiss Alps than elsewhere, 
but the experience of all those who have compared cases coming from 
various resorts testifies in favour of the greater quickness and certainty 
of the cure in the Swiss Alps. 
In the early days of high altitude treatment a history of haemoptysis 
was looked upon as a bar to the employment of the climate ; the reasons 
for this belief were mainly theoretical, and a more extended experience 
has shown that the very reverse is the fact, and that the haemorrhagic 
cases do particularly well there. 
When a case has passed on to the stage of excavation, although the 
ultimate outlook may be, on the whole, less hopeful, clinical experience 
warrants us in saying that a greater benefit may be anticipated from a 
prolonged or indeed an indefinite sojourn in the Alps than from any other 
form of climatic treatment. The presence even of considerable pyrexia, 
so long as we can be sure that it arises rather from septic absorption than 
from active tuberculosis, forms no bar to sending the patient away. In 
the bronchiectatic form of phthisis progress is certain to be extremely 
slow. Since, however, the majority of these cases arise directly from a 
pleuritic effusion, we should take early advantage of the very definite in- 
fluence for good which the rarefied air is likely to exert upon collapsed 
lung; at the same time we shall put the whole constitution in a better CLIMATE IN THE TREATMENT OF DISEASE 
287 
condition to withstand the inevitable strain which following years will 
bring. In this form of disease a constantly high bodily temperature, oi* 
occasional rushes of temperature up to a great height, form no impedi- 
ment to sending the case to the Alps. 
A further class of cases which should, except in the face of obvious 
contra-indications, be so treated, is that in which the phthisis supervenes 
after a pleuritic effusion in a young subject. From the climate of the 
Alps, in such cases, we may almost always anticipate the happiest results 
due not only to the expansion of the compressed lung, but to the strength- 
ening of a constitution of whose proneness to tubercle the effusion was 
but a manifestation. 
What are then the symptoms or conditions which contra-indicate the 
High Alps in cases of phthisis ? We will consider first the more dis- 
tinct and absolute of these. 
The presence of albuminuria forms an absolute contra-indication. 
Any affection of the kidneys bars the employment of the climate of the 
Alps; such cases are invariably aggravated. 
Cases in which there is valvular disease of the heart or degeneration 
of the arteries should never, except under very exceptional circumstances, 
seek the climate of the Alps; indeed this rule is absolute as regards 
the condition of the arteries. In those rare cases of affection of the 
mitral valve in which the compensation is thoroughly good the patient 
may be sent without much hesitation. In disease of the aortic valves the 
experiment is a more hazardous one, and we should be very well assured 
that compensation is perfect before sending the case to high elevations. 
The next complication which would contra-indicate the Alpine cli- 
mate is the presence of diarrhoea due to tubercular ulceration; diarrhoea 
of a merely catarrhal nature may, however, derive benefit from the cli- 
mate. As regards laryngeal complications when, as is commonly the 
case, there is slight hoarseness with the laryngoscopic appearances of 
laryngeal catarrh, even though the appearances are such that tubercle 
cannot be definitely excluded, the patient may be sent. Where there 
is a tubercular ulcer on one vocal cord, provided that the arytenoids 
are free, he may also seek the Alpine air, appropriate treatment being 
at the same time applied to the throat. When, however, the arytenoids 
are involved, or when perichondritis is present, the case should on no 
account be sent thither. 
When there is high fever due to the rapid extension of the tubercular 
process in the lungs the Alps must be forbidden; but if the fever yield 
to treatment and the inflammatory process lessen in intensity, the ques- 
tion may be reconsidered. In cases where the disease is far advanced, 
and the amount of diseased lung large, the Alpine air should not be tried; 
the respiratory area will probably be insufficient to meet the added 
strain, and the fatal event will be hastened. The subjects of constitu- 
tional erethism - persons, that is, with habitually quick pulse, subject 
to feverish attacks, and with an irritable condition of the nervous system 
- almost invariably get worse rather than better in the rarefied air. 288 
SYSTEM OF MEDICINE 
There are, besides, a certain number of persons who cannot bear cold; 
elderly persons especially, in spite of the hot sun, are injuriously affected 
by the cold air of the Alps. The exclusion of such cases from the Al- 
pine treatment is often a matter of difficulty. It is rarely safe to place 
much faith in the patient's statement that he cannot bear cold; but such 
a statement should ensure a careful estimate of his constitutional vigour. 
The length of residence in the High Alps which is likely to secure 
restoration to health must necessarily vary with the progress of the case. 
We should never, however, lead the patient to expect thorough restora- 
tion to health from a residence of less than two winters. This term has 
often to be cut down for pecuniary reasons, but it should never be short- 
ened in deference to the wishes of the patient. If the case progress 
favourably the patient will probably have got most of the benefit he is 
likely to obtain from the treatment at the end of two years. There are 
always a certain number of persons, however, who relapse if long away 
from the high altitudes. For these there is nothing for it but to settle 
for the winter, at all events, at one of the Alpine health resorts. A late 
distinguished man of letters was a remarkable instance of a life so 
spent, and literature is the richer for his courage and prudence. 
A point upon which the local physicians justly lay great stress, is that 
the residence should be continuous; that is, two winters and one summer 
at least should be spent in the High Alps. It has been the custom for 
invalids to go down to a lower level during the snow-melting time in the 
spring. Latterly, however, the physicians only allow patients who are 
doing well to do this, and rather to provide a change of scene than for 
other reasons. A critical case is likely to lose more by the journey to 
and fro than by remaining during the few damp days. The places most 
usually resorted to in the spring are Ragatz and Thusis. Sometimes a 
descent to the Italian lakes or Montreux is permissible in the autumn. 
The Alpine sanatoria, Davos and St. Moritz particularly, owe not a 
little of their success to the very thorough and efficient manner in which 
every detail of the patient's life is supervised by the local physicians, 
as contrasted with the somewhat haphazard method only too much in 
vogue at other health resorts. The opportunities for over-indulgence 
in violent outdoor sports which these places offer, and the temptations 
in large hotels to an irregular way of living, are in most cases controlled 
by the physicians. 
The time of year at which the patients should be sent is a matter 
of some importance: the end of September is the best time, since the 
patient then becomes acclimatised before the winter sets in. Often, 
however, the patient falls ill later in the year. It is a sound rule not 
in any case to send a patient after the end of January; he will then 
get but little benefit before the snow begins to melt, and it would prob- 
ably be better to wait until June. In a doubtful case it is better to 
make the ascent gradually, stopping a few days at a moderate elevation. 
During the summer in the Alps the invalid can find change of scene 
at a like elevation at Pontresina, Maloja, and other localities. CLIMATE IN THE TREATMENT OF DISEASE 
289 
The special utility of the Colorado resorts lies in the fact that profit- 
able occupation, or at least a livelihood, can be obtained in a climate 
little if at all inferior to that of the Swiss Alps. The expanse of 
country possessing, with very minor modifications, a uniform climate is 
large; while one of the resorts, Denver, is a great city with flourish- 
ing industries. In the selection of cases for treatment in Colorado the 
same contra-indications hold as in the case of the Swiss Alps; we should, 
however, be more rigorous in excluding doubtful cases, seeing that the 
experiment entails long journeys by sea and land. 
Some persons, indeed, with a limited area of damaged lung, who find 
the Alpine climate too cold, may seek the equally elevated yet warmer 
climate of Colorado, with better prospects of recovery than would be 
given by a descent to a lower level. Moreover, Colorado presents advan- 
tages to that class of cases to which we have before referred - those 
cases, namely, which remain quiescent in the mountains, but relapse in 
the plains. Young subjects, the children of phthisical parents, not 
themselves tubercular, but for whom a change of climate is thought 
advisable as a prophylactic measure, - as, for instance, after a pleural 
effusion, - will do better in Colorado than elsewhere. 
The cases which are likely to receive benefit from Australia are: - 
1. Cases of early consolidation, in which there is no fever. 2. Quiescent 
cavity cases. 
In every case there must be a sufficient amount of constitutional 
vigour to support an outdoor life, and all the more serious complications 
- laryngitis, intestinal ulceration, or high fever - are absolute contra- 
indications. With regard to employment, we must point out that a 
sedentary occupation followed in one of the coast towns holds out no 
prospect of cure; for such cases the highland townships of South Africa 
or Colorado would offer greater advantages. 
With regard to South Africa, the same rules as to choice of cases hold 
good. Practically, unless the patient have plenty of vigour, and there 
seems solid ground to hope for early subsidence of the disease, he had 
much better seek some climate nearer home. Haemoptysis occurring 
early in the course of the disease is no bar; late haemoptysis proceeding 
from a cavity is an absolute bar. 
The advantage of the Egyptian climate in the treatment of phthisis 
lies in the warm, sunny days, the dryness of the atmosphere, and the 
aseptic character of the air. Its drawbacks are: the short time of year 
during which it is available, and the danger of contracting chills, chiefly 
abdominal. The cases of phthisis most likely to derive benefit from it 
are: - (a) Cases complicated by bronchitis in which emphysema is also 
present. (&) Cases of bronchiectatic phthisis, for which a winter or two 
in the Alps have already been prescribed, will often derive great benefit 
from Egypt, (c) Cases for which the Riviera is too cold, or in which 
chills often recur, (d) Cases of early consolidation in which, either 
owing to susceptibility to cold or some other reason, the Alps are contra- 
indicated. (e) Cases with albuminuria in which the destruction of lungs 
VOL. I 
u SYSTEM OF MEDICINE 
290 
is not very great. (/) Cases in which insomnia and nervous irritability 
form prominent symptoms. 
On the other hand we are not justified in sending cases presenting 
the following complications: - 
1. Intestinal Ulceration, or indeed any tendency to diarrhoea what- 
ever. This is sure to be aggravated. 2. Laryngeal Ulceration. The 
dryness of the air always aggravates the symptoms. 3. Cases beginning 
with acute pneumonic symptoms. These should not be sent on account 
of the length of the journey and the short time during which the climate 
is available. 
The main virtues of the Riviera climate are that it permits the patient 
to pass several hours of most days in a fairly warm and dry atmosphere 
which, owing to the vicinity of the sea and mountains, is comparatively 
free from impurities. Its drawbacks are the winds which materially 
curtail the amount of open-air life, and the danger of chills from the 
contrast of sun and shade temperature. Early cases, as a rule, will do 
better in the Alps, but there always remains a residuum for whom the 
Riviera will be the most appropriate climate. Patients for whom the 
Alps are too cold will generally do very well on the Riviera without going 
so far afield as Egypt, while the more bracing climate will increase the 
resistance of the body more than will that of Madeira. Some persons, after 
one or two winters passed in the Alps, find that they do not stand the 
cold so well as at first; such persons will generally continue to improve on 
the Riviera. A continuous residence in the Alps sometimes also impairs 
the appetite; this symptom will generally be removed, and the general 
condition of the patient ameliorated, by a change to the Mediterranean. 
When the time of the year at which the disease manifests itself is too 
late to admit of the possibility of Alpine treatment, the spring may with 
advantage be passed on the Riviera. 
Phthisical patients, in whom the disease is characterised by a great 
deal of irritation, as evidenced by signs of catarrhal pneumonia, probably 
do better on the Mediterranean coast than elsewhere. This form of 
phthisis frequently follows influenza, and such cases generally do well. 
When the bronchitic element is marked the Riviera will often be found 
practically as efficacious as Egypt, and is nearer and less expensive. 
Cases of laryngeal phthisis often improve under appropriate treat- 
ment at Mentone and San Remo. Even in the more advanced cases 
patients may be sent, if willing to take the risk; for though there may 
be but slight hope of recovery, yet their life will, on the whole, be easier 
than in England. They must, however, be pecuniarily in a position to 
afford every possible comfort. 
Amongst the serious drawbacks of the Riviera must be mentioned 
the numerous social temptations. The Riviera has become the favourite 
resort of healthy and wealthy people who crave for excitement and 
amusement, the charms of which are irresistible to their invalid friends, 
who not rarely lose through them the last chance of recovery. The 
danger is much aggravated by the mischievous habit amongst patients CLIMATE IN THE TREATMENT OF DISEASE 
291 
at the Riviera, not to place themselves under the entire guidance of a 
physician, not to consult him at the beginning and during the whole 
stay about the manner of living, - hygienic, dietetic and social, - but to 
act as it pleases themselves and their healthy friends, and to fly to the 
doctor only when acutely ill. The climate itself would offer very good 
chances to a great many consumptive patients if they were placed in 
well-arranged sanatoria, or at all events under strict medical guidance; 
but the present fashions render this almost impossible. 
Madeira is often more useful in consumptive cases with much irrita- 
bility of constitution, and especially of the mucous membranes, accom- 
panied by a dry cough; and in cases complicated with emphysema. It 
deserves a trial also in patients with laryngeal irritation. Patients with 
much expectoration, or with a weak intestinal mucous membrane, ought 
not to be sent to Madeira. 
The Canaries have a wider range of usefulness than Madeira; they 
are less humid, and the principal localities offer more chance for exercise 
on level or gently-rising ground. Life there is, unfortunately, very 
monotonous. 
Pau and Arcachon are suitable in senile cases, and in complications 
with dry cough and constitutional irritability, where shelter from wind 
is important. 
Ajaccio has much analogy with the Riviera, but is better for patients 
with great irritability of the system. The same is the case with Algiers: 
on the other hand, cases with much expectoration and with albuminuria 
generally do better in Egypt and on the Riviera. 
The Ocean. - The patients most likely to derive benefit from the 
sea-voyage are: - 
1. Those in whom symptoms of phthisis form only part of a general 
breakdown from overwork. 2. Cases of limited consolidation without 
fever. (But it must be borne in mind that the percentage of cures 
amongst such cases is higher in the Alps.) 3. Quiescent cavity cases 
often seem to do better at sea than elsewhere; the constitutional and 
local improvement is most striking. 
The contra-indications to a sea-voyage may be enumerated as : - 
1. The graver Complications, laryngeal and intestinal. 2. Debility. 
3. Fever. 
It must be remembered that serious illness at sea is a greater 
misery than on shore. Early haemoptysis seems not to be aggravated, 
but cases of haemoptysis from cavities should on no account be sent to 
sea, owing to the difficulty of carrying out efficient treatment. The 
victims of phthisis suffer but little from sea-sickness ; the discomforts of 
sea-life, however, tell so much more on women than on men as prac- 
tically to exclude the former. Old people, also, the subjects of heart- 
disease and arterial degeneration, are injuriously affected by the sea. 
The treatment of phthisis by climate in the British Isles may be 
regarded in two main divisions : - 
1. The provision of a summer residence for those who winter abroad. 292 
SYSTEM OF MEDICINE 
2. The, choice of a tuinter resort for those whose condition or cir- 
cumstances forbid their going farther afield. 
The climate of England, although changeable, is, during the summer, 
bracing and sedative to the nervous system; in this respect it provides 
a most useful change to those who have wintered in the more exciting 
climates of the south. The choice will have to be made between the dry 
and bracing east coast towns, and the moister, more sedative, and 
warmer resorts of the south and west. For more vigorous patients, and 
particularly for those coming from the Riviera, the east coast resorts - 
Hunstanton, Cromer, Yarmouth, Lowestoft, Felixstowe, Ramsgate and 
Margate - are suitable during summer. These are often more benefi- 
cial to the Riviera patient than the Swiss resorts. The less vigorous, 
markedly catarrhal, and febrile cases will generally be more benefited 
by the resorts of the south coast - Bournemouth, Hastings, and Vent- 
nor, or, in the west, Ilfracombe, Torquay, and Falmouth. Ilkley, 
Malvern, and Tunbridge Wells, again, are excellent resorts for those who 
are injuriously affected by sea-air. Unfortunately, the English winter 
climate, owing to its changeableness and number of rainy days, precludes 
a great deal of that outdoor life so necessary to the well-being of the 
consumptive. Were the existing opportunities for outdoor life, however, 
more fully utilised - by sun galleries, etc. - as at Folkestone and still 
better at Falkenstein, far better results would be obtained. 
Dr. Williams' statistics (105) show a slightly smaller proportion of 
cures from winters at health resorts in England than on the Riviera, and 
distinctly less than those reported from the Swiss Alps. Although, 
therefore, the chances of cure are somewhat less than in the foreign 
resorts, yet the risks are smaller. Early cases, in which the course of 
the disease requires to be watched before deciding upon the trial of a 
foreign climate, may have the benefits of one of the home resorts. For 
cases of early consolidation, without fever, or for partially arrested 
cases, England is a safe abode all the year round. There remain be- 
sides, as Dr. Wilson Fox (31) pointed out, a certain number of patients 
who, after trying foreign resorts without benefit, improve even in the 
most unlikely situations in England. But we have no indications to 
guide us to their recognition. Cases of laryngeal phthisis should seek 
the milder resorts on the south coast if there be any doubt as to the 
advisability of their going abroad. More severe and advanced cases 
will find opportunities for a fair amount of outdoor life without the 
discomforts of a probably fruitless journey abroad. 
The choice of a locality rests between Bournemouth, Ventnor, Torquay, 
Queenstown and Hastings. Hastings is not adapted for other than the 
hardier cases; Torquay and Queenstown are relaxing, but well suited to 
patients with little constitutional vigour. Bournemouth and Ventnor 
are more suitable for earlier cases in the first and second stages. 
In conclusion, it must be borne in mind that though we have some 
few clinical rules which may help us in the selection of a climate, yet the 
issue of the selection lies mainly in the patient's own hands. Those CLIMA TE IN THE TREA TMENT OF DISEASE 
patients do best who bear in mind that climatic change is the smallest 
factor in the treatment which is to restore them to health, and setting 
before themselves the recovery of health as their single aim, submit 
to a regulated manner of life. Nor can we ignore in this respect the 
sanatorium method of treatment against which such unfortunate preju- 
dice exists, but which has undoubtedly yielded admirable results. 
Bronchitis, or Chronic Bronchial Catarrh, in young people is in gen- 
eral better influenced by mountain climate than by the sea-side; but in 
old persons the mountains are often injurious, and amongst the localities 
abroad the warm sea-side places of the Riviera or the climate of Egypt, 
of Algeria, of the south-west of France or of the Canaries, are beneficial; 
or Hastings, Bournemouth, Ventnor, Falmouth, Penzance in England. 
Whenever there is much expectoration the drier climates are better than 
the more humid ; but if there be irritable cough without expectoration, 
the latter are preferable, such as Madeira, Algiers, Pau, Arcachon, 
Torquay, Queenstown. In albuminuria, however slight, the mountain 
climates are to be avoided, while Egypt and the Riviera are often bene- 
ficial ; the same is mostly the case with gouty bronchitis. 
Emphysema with much expectoration is favourably influenced by dry 
and warm inland and coast climates; if it be attended with dry cough, 
the more humid climates of Madeira, Pau, Algiers and Torquay are 
preferable. High elevations are not suitable, but moderate elevations 
are so in summer. 
Asthma often does not allow a decided opinion without a trial. Of two 
apparently similar cases one may bear a certain place well, the other not. 
In general we can say that younger subjects are more benefited by long 
residence in the Alps than by any other climate or place. If possible 
their education should be conducted at high elevations. Senile patients 
with much expectoration ought to try Egypt or the Riviera; with little 
expectoration and irritating cough, Pau, Arcachon, Algiers, Ajaccio, or 
South Devon and Cornwall in England, or Queenstown in Ireland. Many 
asthmatic persons are better in London than elsewhere. In nervous 
asthma a cautious trial is required to find the most suitable localities. 
Scrofula in its various forms requires improvement of nutrition, and 
mostly acceleration of tissue change. Residence at the sea-side is 
most useful. Scrofulous children ought to be educated at the sea-side. 
The sea-coasts of England are pre-eminently adapted to this treatment; 
but in delicate children, with little reactive power, the winters ought 
to be spent at warmer coasts, such as the Mediterranean, or Ajaccio, or 
Algiers, or Biarritz, or Arcachon. Sea-voyages are likewise very useful. 
Alpine climates, too, offer advantages, but in the majority of cases the 
sea is to be preferred. 
Gouty and rheumatic affections are aggravated by damp cold and 
winds. They require dry soil and warm and dry inland climates, such 
as the desert of Egypt or Algeria, and southern slopes of mountains, or 
fairly warm sea-shores. 
Affections of the heart include so many varieties that each class of 
293 294 
SYSTEM OF MEDICINE 
case requires special management. On the whole high elevation ought to 
be avoided, excepting in mitral cases with good compensation. Moderate 
elevations from 500 to 2500 feet with level walks are mostly preferable 
to the sea-shore. The winter should be spent in warm inland climates. 
In diseases of the kidneys and chronic catarrh of the bladder warm 
and dry climates act beneficially, by rendering the skin more active, 
and thus relieving the work of the kidneys. Good milk ought to be 
obtainable at the resorts for these complaints. Elevated regions are 
mostly unsuitable. 
The diseases of the organs of digestion are so multiform that one 
cannot lay down general rules. In convalescence from chronic catarrh 
of the colon and dysentery of malarious origin, dry elevated regions are 
useful. The same is the case with chronic flatulent dyspepsia, which 
often disappears rapidly on ascending, for instance, from Italy to the 
Engadine. Dry and w'arm inland climates may likewise be recommended, 
especially where high elevations and sea-voyages are not suitable. 
Localities which offer inducement to open-air exercise deserve special 
attention. If, as frequently is the case, these complaints are only symp- 
toms of nerve affections, the latter demand the principal consideration. 
Malarious affections in general are benefited by high elevations with 
dry and sunny air, and in summer especially by the air of glaciers. 
Cases of anaemia and chlorosis require climates where the invalids 
can sit or lie the whole day in the open air without fatigue - such as 
sunny moderate elevations, and the cooler marine resorts in summer and 
the warmer in winter. Sea-voyages and yachting are useful for good 
sailors. Only a moderate amount of exercise is to be permitted, with 
easy and genial mental and social occupation, and inducement to take 
a proper amount of food. 
In the treatment of affections of the nervous system, especially in 
those called functional, climate can take a fair share. In mental depression, 
and also in different forms of hypochondriasis, travelling, sea-voyages, 
frequent change of residence to places of historical interest, which afford 
at the same time social attractions and facilities for open-air life and 
exercise, are often attended with excellent results. Rome, Florence, 
Naples, Sicily, Egypt, Athens and Greece, Palestine and Asia Minor, 
have in our experience often assisted recovery, and enabled the sufferer 
to return to home life and active mental occupation. 
In cerebral exhaustion from overwork, or from ill-regulated and 
unsuccessful work, and in the numerous forms of nerve failure in men as 
well as women (Weir Mitchell's Wear and Tear), often comprised under 
the much-abused term of " neurasthenia," change of climate and surround- 
ings is often an essential help; but the nature of the change must depend 
on the degree of exhaustion and on the mental and physical constitu- 
tion of the invalid. In cases not too advanced occurring in fairly robust 
persons, prolonged residence near glaciers, or at all events in the Alps, 
in winter as well as in summer, with graduated exercise and in cheerful 
company, has often proved most beneficial; while in cases of greater CLIMATE IN THE TREATMENT OF DISEASE 
295 
exhaustion or of low resisting power, better remedies will be found in 
yachting in warmer regions; and in wintering in the Riviera, in Algiers, 
in Sicily, in Rome, in Naples, or in Egypt, where under such circum- 
stances the Nile journeys on a dahabeyah are more restful and mostly 
preferable to those on steamboats. Time, however, is necessary, varying 
from some months to some years. 
Neuralgia is to be treated according to its nature. If it be of gouty 
or rheumatic or dyspeptic origin, it falls under these several heads; if, 
as is often the case, it is one of the earlier symptoms of nervous exhaus- 
tion, the suggestions given above are applicable to it. 
Diabetes, if acute, requires strict treatment at home; but in persons 
affected with chronic diabetes, or with different degrees of glycosuria 
(which are of widely varying nature), climatic treatment can be rendered 
more or less beneficial according to the nature of the case. In gouty con- 
stitutions, for instance, where corpulence is not rare, and where glucose 
in the urine often alternates with excess of uric acid, the indications are 
similar to those in gouty and corpulent persons. In invalids, where gly- 
cosuria is one of the manifestations of nerve failure, we may recommend, 
according to the degree of strength and resisting power, long residence at 
high elevations, or sunny inland and sea-shore localities. In addition to 
the considerations mentioned under the head of affections of the ner- 
vous system, we have in glycosuric cases to bear dietetics in mind, and 
see that the plan of diet recommended can be carried out. 
Polyuria or diabetes insipidus is mostly a symptom, sometimes one 
of the earliest, of disorder of a nerve centre. As valerianate of zinc and 
similar remedies have a beneficial action, so have Alpine climates com- 
bined with open-air life, but without fatigue. 
In the state of convalescence from acute disease climatic treatment is 
often very useful, especially in tardy convalescence. We have to bear 
in mind that the whole system is weakened, and that there is increased 
liability to disease of different organs from over-fatigue in travelling, 
injudicious exercise or food, cold winds, damp, etc. It is, therefore, often 
advisable to begin with change to a good place within easy reach, and to 
proceed later to more distant localities. Great heat and cold are equally 
to be avoided, and much patience is often required. Important though 
this subject be, in a climatic point of view, we must restrict ourselves to 
these cursory remarks, and leave more detailed suggestions to the authors 
on the several diseases. 
Climacteric changes, in the wider sense of the term, frequently need cli- 
matic treatment. The deviations connected with the so-called "change 
of life " in women are well recognised; but in both sexes the quick rise 
to a higher stage of development, as well as the rapid descent to a lower 
stage, and also the delay of development, are often attended by a vari- 
ety of disorders of the nervous system which manifest themselves in 
physical and mental disorders of most varied nature. The development 
and the cessation of the sexual functions are the most perceptible signs 
of climacteric periods; but other important functions undergo like 296 
SYSTEM OF MEDICINE 
changes, and the harmony or equilibrium of the whole organism be- 
comes sometimes disturbed for shorter or longer periods. The more 
invigorating climates are mostly preferable, but diversion of the mind 
greatly assists the adaptation of the altered functions to the system at 
large. We have to bear in mind that there is increased " vulnerability," 
and that over-exertion and other risks are to be avoided; otherwise the 
physical climatic elements of places need not be so carefully selected, 
while localities offering change, exhilaration and mental recreation 
deserve special recommendation, such as Florence, Rome, the Gulf of 
Naples, Sicily, Greece, Spain, Asia Minor, Egypt, Algeria, the United 
States of America, the artistic centres of France, Germany, Holland and 
Belgium, and so forth, according to the nature of the individual cases. 
Senile decay, whether simply natural, or premature, is to be regarded 
as one of the climacteric changes; but in these cases we have to meet 
permanently diminished vital powers; hence the necessity of looking 
for localities where the demands on the weakened organism are more 
moderate than at home, and the mental faculties are at the same time 
gently stimulated. The first Lord Brougham showed his wisdom in 
spending the winters of his advanced life at Cannes. 
We could go on almost indefinitely to enumerate morbid conditions 
which can be benefited by judicious use of climatic changes, but for a 
mere survey we have probably said enough. We must content our- 
selves with a mere allusion to the prophylactic value of climates. As 
we have alluded under the head of scrofula to the advisability of 
educating children with scrofrdous tendencies at the sea-side, so we may 
say that in hereditary or acquired tendency to tubercular phthisis 
education at well-selected elevated localities is much to be recom- 
mended, for instance at St. Moritz, Davos, or " les Avants." 
Moreover, we constantly meet with persons who have no measur- 
able disease, but are in a state of health, physical or mental, in which 
slight injurious influences may do mischief. In such states a judi- 
ciously arranged climatic change will often lead to the recovery of 
health and energy. 
Utilisation of Home and Home Climates. -We will restrict ourselves 
in this chapter to the life of the invalid in English climates and in his 
own house. We must consider the disadvantages as well as the advan- 
tages. We cannot help acknowledging that there is some truth in the 
description which that sympathetic observer, the elder Dumas, puts into 
the mouth of D'Artagnan in Vingt Ans Apr^s, the " pays ou il fait froid 
toujours, ou le beau temps est du brouillard, le brouillard de la pluie, la 
pluie du deluge; oil le soleil resemble a la lune, et la lune a un from- 
age a la crSme." Nor can we forget that we frequently meet with cases 
similar to that of a singer from Spain whom we often found on her sick- 
bed humming words from Geibel's " Spanish Gipsy Boy in the North."1 
1 She was a consumptive patient who was unable or disinclined to eat, and whom we 
could only induce to do so by the constant promise to send her to Malaga, where she 
ultimately recovered. CLIMATE IN THE TREATMENT OF DISEASE 
297 
Dieser 2\ebel driickt mich nieder 
Der die Sonne mir entfernt 
Und die alten lust'gen Lieder 
Hab' ich alle fast verlernt. 
Immer in die Melodien 
Schleicht der Eine Klang sich ein ; 
In die Heiinath mocht' ich ziehen, 
In das Land vol! Sonnenschein! 
We must acknowledge that the climates of England are rather moist, 
that the air is often dull and sunless, that rain falls on comparatively 
many days, and is distributed over many hours, that the wind is often 
high and chilling, and that the shelter is limited. On the other hand, 
the hygienic conditions are better than anywhere else, the food is good, 
and the separation from the family is less. The climates of England 
belong, as we have said, to the most health-giving climates for the fairly 
vigorous, but are less good for the delicate invalid. If, however, a 
delicate person is obliged to stay at home or near home, it is often 
possible for him by judicious management to obtain great benefit by 
availing himself of all the advantages, and defending himself from the 
injurious influences of the home climates. 
It is doubly necessary for him to attend under medical guidance 
to the seven points which we formulated on page 285. If we carefully 
examine the good results obtained at foreign climatic health resorts, we 
often find that they are not so much due to the climatic advantages of 
those localities as to the hygienic and dietetic management and the 
whole manner of living. We see, for instance, that the results obtained 
at Gbrbersdorf, at Falkenstein, and at Hohenhonnef are at least as good 
as those gained at Davos, at St. Moritz, and Colorado; and yet in the 
prominent climatic conditions - namely, the elevation, the number of 
sunny hours, the diathermancy of the atmosphere - the three former 
localities are decidedly inferior to the three latter; but in these the 
hygienic and dietetic arrangements, and especially the open-air treatment 
and the limits of exercise, are under careful supervision. We could give 
many instances from which we ought to gain hope that in our home 
climates, inferior as they are for the management of many delicate 
persons, satisfactory results may be obtained. A great source of difficulty 
is that at home the invalid is not inclined to devote the whole day to 
health matters, to walking or lying in the open air, to taking the neces- 
sary numerous meals ; but if it be once recognised that life depends on 
it, the majority of invalids will endeavour to obey. 
Most important points for an invalid at home are the selection of a 
residence and the arrangement of the rooms he lives in. If it be possible 
for him to choose his house, let it be on a dry soil or rock, on a southern 
slope, and not at the bottom of a valley; let it be in the neighbourhood 
of woods, pine woods by preference, and let the woods be between the 298 
SYSTEM OF MEDICINE 
prevalent cold winds and the house. An abundant supply of good water 
is likewise necessary. The house ought to have a sunny verandah with 
movable glass walls. All the rooms inhabited by the invalid should be 
towards the sun, and ventilated by day and by night. Couches for lying 
out of doors or in open verandahs or galleries, and seats with shelter, 
movable against the wind, ought to be provided. Such arrangements 
are expensive for single persons; but it ought not to be difficult to found 
establishments for a number of cases, with diminution of expense and 
increase of convenience, with well-arranged walks, with large screens 
against the cold winds; such establishments ought to be under constant 
medical guidance. There is, we know, a certain amount of prejudice in 
England against strict medical supervision, but if it were once realised 
that many lives can be saved in such establishments and under such 
judicious guidance, which, even at the best climatic health resorts, are 
otherwise lost, the opinion of the profession and the public would gradu- 
ally become favourable to them. 
It is a matter of great importance that the invalid who remains at 
his home or in his own country should feel that he is not doomed to die, 
that he should retain his energy and his firm will to regain his health. 
Every one of us has many pleasant memories of patients whose cases did 
not look promising at first, but who, by their firm will and their judicious 
and dutiful perseverance, entirely recovered under indifferent external 
circumstances. The qualities of energy, perseverance, and hope cannot 
be over-estimated in the treatment of chronic disease by climate. 
Hermann Weber. 
Michael G. Foster. 
REFERENCES 
1. Allbutt, T. Clifford. "The Climate of Davos," Lancet, 1877-78-79.-2. 
Bakewell, R. H. " On Climate of Barbados," Practitioner, 1878. - 3. Bennett, J. H. 
Winter and Spring on the Shores of the Mediterranean, 5th ed. 1875. - 4. Bennett, 
J. H. On the Treatment of Pulmonary Consumption, 1866. - 5. Bentley, A. J. M. 
Wintering in Egypt, 1894.-6. Bentley, A. J. M. The Maintenance of Health in 
Egypt, 1894. - 7. Bird, S. Dougau. On Australian Climates, 1863.-8. Bruck, L. 
Guide to the Health Resorts of Australia, Tasmania, and New Zealand, 1888.-9. 
Bert, P. La Pression BaromAtrique, 1870. -10. Bowles, R. L. Sunburn on the 
Alps, 1890; " Observations on the Influence of Solar Rays on the Skin," British Medical 
Journal, 29th September 1894. -11. Brehmer, H. Die chron. Lungenschwindsucht, 
2nd ed. 1869. -12. Buchan, A. Handbook of Meteorology, 1871. -13. Buchan, A. 
"Climate" in Encyclopaedia Britannica, vol. vi. 1887. -14. Buchner, H. " Einfluss 
des Lichts auf Bacterien," Centralbl. f. Bacteriologie, xi. 781. 1892. -15. Canney, 
H. E. L. "Influence of the Climate of Egypt upon Diseases," Lancet, 1894.-16. 
Davidson, J. "Notes on Health Resorts of Southern California," Brit. Med. Journ., 
January 1893. -17. De la Harpe, E. "Le climat d'altitude, ses facteurs, son action 
sur 1'homme," Revue Med. Suisse Roman de 1893. -18. Denison. Rocky Mountain 
Health Resorts, 2nd ed. 1881.-19. Dettweiler, P. Therapie der Phthisis, 1887. 
20. Dettweiler, P. Bericht liber 72 seit 3-9 Jahren geheitter Faile von Lungenschwind- 
sucht. Frankfurt a/M., 1886.-21. Dixey. "Sea Voyages for Health," Lancet, 1892, 
II.-22. Downes, A. H. "Researches on the Effect of Light upon Bacteria," Proc. 
Roy. Soc. 1887.-23. Downes, A. H. "The Action of Sunlight and Diffused Light on 
Micro-organisms," Ibid. 1886. - 24. Downes and Blunt. "Influence of Light upon 
Protoplasm," Ibid. 1878. - 25. Ebermeyer. Diephysicalische Einwirkung des Waldes CLIMATE IN THE TREATMENT OF DISEASE 
299 
auf Luft und Boden, 1873.-26. Egger. "Ueber Veranderungen des Bluts im Hoch- 
gebirge," Verhandl. d. Congr. f. innere Med. Wiesbaden, 1893. - 27. Engelmann, 
Th. W. " Ueber Liebtsinn und Einfluss d. Lichtes auf die Bewegungen niederer Organ- 
ismen," Pflilger's Archiv, vol. xxx. - 28. Faber. " On the Influence of Sea-Voyages on 
the Human Body," Practitioner, March 1876. - 29. Fonsangrives, J. H. Hygiene et 
assainissement des villes, 1774.-30. Foster, Michael G. " Alassio as a Winter 
Resort," B. M. J. 1891. - 31. Fox, Wilson. Treatise on Diseases of the Lungs, edited 
by Dr. Coupland, 1891. - 32. Geissler, Th. " Zur Frage uber die Wirkung des Lichts 
auf Bacterien," Centralblatt. f. Bacteriologie, 1892. - 33. Gilchrist, E. The Use of 
Sea-Voyages in Medicine, 1771. - Goldschmidt, see Mittermaier.-34. Grabham, 
M. C. The Climate and Resources of Madeira, 1870. - 35. Hart, Ernest. Winter Trip 
to the Fortunate Islands. - 36. Hassall, A. H. San Remo and the Western Riviera, 
1879. - 37. Hudson, L. " Sea-Voyages for the Surgical Convalescent," Lancet, October 
1893. - 38. Huggard, W. R. Davos Platz, 1886. - 39. Jaccoud, S. The Curability and 
Treatment of Pulmonary Phthisis, translated by Montagu Lubbock. - 40. Klomelev- 
sky, P. S. "Inaug. Diss., St. Petersburg, 1893," in Epit. B. Med. Journal, May 5, 
1894. - 41. Lacassagne, A. Precis d'Hygiene privee et sociale, 1876.-42. Lang, 
Melchior. Ajaccio, 1894.- 43. Leach, Harry. "Climatic Treatment of Pul- 
monary and Other Diseases in South Africa," Practitioner, 1878. - 44. Leech, D. J. 
"Les Avants as Winter Health Resort," Med. Chron. 1890. - 45. Leech, D. J. 
" Sierre as a Health Resort," Practitioner, 1890. - 46. Levy, M. Traite d'Hygiene 
publique et privee, 5th ed. 1869. -47. Lindsay, J. A. Climatic Treatment of Consump- 
tion, 1887.-48. Lombard, H. C. Le Climat de Montagnes, 3rd ed. 1873. - 49. Lom- 
bard, H. C. Traite de Climatologie medicale, 1877-80. - 50. Lorenz und Rothe. 
Lehrbuch der Climatologie, 1894.-51. Ludwig, I. M. Das Oberengadin in seinem 
Einfluss auf Gesundheit und Leben, 1877. - 52. Marcet, W. On the Meteorology of 
Cannes, 1877. - 53. Marcet, W. The Principal Southern and Swiss Health Resorts, 
1883.-54. Marcet, W. "A Chemical Enquiry into the Phenomena of Human 
Respiration," Phil. Trans., vol. clxxxi.-55. Mittermaier, K., und Goldschmidt. 
Madeira, 2nd ed. 1885. -56. Otter, R. H. Winters Abroad, 1882. -57. Penzoldt, F. 
Behandlung d. Lungentuberculose, 1894. - 58. Pepper, W. Climatological Study of 
Phthisis in Pennsylvania, 1886. - 59. Peters, H. Die physikalische Therapie der 
Phthise. Leipzig, 1893. - 60. Perez, E. V. Oratava as a Health Resort.-61. 
Powell, Douglas. Diseases of the Lungs and Pleura including Consumption, 3rd ed. 
1893. -62. Proust, A. Traite d'Hygiene, 1877. - 63. Quincke, H. "Einfluss des 
Lichts auf den Thierkorper," Pfliiger's Archiv, 1894.-64. Ransome, A. " On Certain 
Conditions that Modify the Virulence of the Bacillus of Tubercle," Proc. Roy. Soc. 
vol. xlix. 1890.-65. Ransome, A., and Delepine, S. "On the Influence of Certain 
Natural Agents on the Virulence of the Tubercle Bacillus," Proc. Roy. Soc., vol. Ivi. 
1894. - 66. Reimer, H. Klimato-therapie, 1889.-67. Richter, M. Ocean Currents 
Contiguous to the Coast of California, 1887. - 68. Sanderson, J. Burdon. " Egypt as 
a Winter Health Resort," Practitioner, liv. 1890. - 69. Sandwith, F. M. Egypt as a 
Winter Resort, 1889. - 70. Sandwith, F. M. "Four Hundred Cases of Phthisis," 
Lancet, 1892. - 71. Saunders, H. W., M.D. The Voyage to South Africa. - 72. 
Secretan. " The Winter Climatology of Leysin," 1891. Revue Med. Linzse. Rowand. 
- 73. Siordet, J. L. Mentone in its Med. Aspect, 1865. - 74. Smith, Archibald. "In- 
fluences of the Climate of Peru on Pulmonary Consumption," Brit, and For. Med. Chir. 
Rev. 1856.-75. Smith, Archibald. " Climate of the Swiss Alps and Peruvian Andes 
Compared," Dublin Quarterly Journal, 1866.-76. Smith, R. Angus. Air and Rain, 
1872. - 77. Solly. Facts Med. and otherwise about Colorado Springs. - 78. Sparks. 
The Riviera, 1878.-79. Spengler, A. Die Landschaft Davos als Kurort gegen Lun- 
genschwindsucht, 1869.-80. Spengler, A. Indicationen fur und gegen Davos. -81. 
Spengler, Lucius. " Zur Phthisio-therapie im Hochgebirge," Fortschritte der 
Krankenpflege, 1893. - 82. Spengler, Carl. Chirurg. u. klimatische Behandlung d. 
Lungenschwindsucht, 1891.-83. Spengler, Carl. "Ueber Lungentuberculose und 
bei ihr vorkommende Mischaffectionen," Zeitschrift f. Hygiene, 1894. - 84. Symonds, 
J. A. Winter at Davos and Our Life in the Swiss Highlands, 1892. - 85. Taylor, 
Sir A. The Preventive and Curative Influence of the Climate of Pau, 1856. - 86. 
Taylor, H. Coupland. in Search of Health, 1890. - 87. Thompson, E. 
Symes. " On the Elevated Health Resorts of the Southern Hemisphere," Med. Chir. 
Trans. 1873.-88. Thompson, E. Symes. "Winter Alpine Health Resorts," Med. 
Press and Circ. 1883. - 89. Thompson, E. Symes. Proceedings Colonial Institute.- 
90. Thorne, W. Bezly. Open-Air Treatment of Phthisis at Falkenstein, 1894.-91. 300 
SYSTEM OF MEDICINE 
Toner, J. M. Dictionary of Elevations and Climatic Register of the United States, 
1874.-92. Trudeau, E. L. The Open-air Treatment of Phthisis at the Adirondack 
Sanatorium. - 93. De Valcourt. Sketch of Cannes and its Climate, 1881. - 94. Vera- 
guth. St. Moritz, 2nd ed. 1894. - 95. Viault. "Action physiologique des Climats de 
Montagne," Compt. Rend. Acad. d. Sc. cxiv. Paris, 1892.-96. Walshe, W. H. 
Diseases of the Lungs, 4th ed. 1871.-97. Ward, Marshall. Address, Royal Institu- 
tion, April 1894. - 98. Waters, A. W. Winter im Hochgebirge, 1871. - 99. Waters, 
A. W. Some Meteorolog. Conditions of Davos, 1890. -100. Weber, Hermann. "Notes 
on the Climate of the Swiss Alps," Dublin Quarterly Journal, 1864. -101. Weber, 
Hermann. "Influence of Alpine Climates on Pulmonary Consumption," Brit. Med. 
Journ. 1867. -102. Weber, Hermann. "Treatment of Phthisis by Prolonged Resi- 
dence in Elevated Regions," Med. Chir. Trans. 1869. -103. Weber, Hermann. 
Hygienic and Climatic Treatment of Consumption, Croonian Lectures, 1885. -104. 
Williams, C. Theodore. Climate of the South of France, 2nd ed. 1869. -105. 
Williams, C. Theodore. Lettsomian Lectures on the Influence of Climate in the Treat- 
ment of Pulmonary Consumption, 1887. -106. Williams, C. Theodore. " Treatment 
of Phthisis by Residence at High Altitudes," Med. Chir. Trans, vol. Ixxi. -107. 
Williams, C. Theodore. Aero-therapeutics, 1894. -108. Williams, C. Theodore. 
Transactions Internal. Med. Congress, 1881.- 109. Wilson, W. S. The Ocean as a 
Health Resort, 1880. -110. Wise, A. T. Tucker. Alpine Winter in its Medical 
Aspects, 5th ed. 1892. - 111. Yeo, J. Burney. Climate and Health Resorts, 1893. -112. 
Climate and Baths of Great Britain. Rep. of Committee of Roy. Med. and Chir. Soc. 
1895. 
H. W. 
M. G. F. 
ARTIFICAL AERO-THERAPEUTICS 
By artificial aero-therapeutics we mean the treatment of disease by 
atmospheres artificially prepared, and differing from the normal either in 
composition, pressure, or temperature. This will serve as a rough defini- 
tion of our subject, but it must not be considered as exhaustive, for 
nature herself supplies exceptions to the normal standard in the varieties 
of atmosphere caused by the emission of gases in volcanic districts, in 
the density of air in mines, and in its rarefaction on mountains. 
The subject may naturally be divided into two portions - 
A. Artificial atmospheres produced by variations in the relative pro- 
portions of the gaseous components of air, or those produced by admix- 
ture with gases or elements other than those of the atmosphere. 
B. Artificial atmospheres produced by variation in the barometric 
pressure. 
Of artificial atmospheres we have a familiar example in the air of 
great cities which contains impurities, varying with the materials used for 
heating, lighting, and manufactures. In foggy states of the air, such as 
occasionally prevail in London and other towns, sulphuretted hydrogen 
and carburetted hydrogen have been detected in the atmosphere; the 
former arises from sewer gas, and can easily be demonstrated by the 
blacking of white lead paint on the exterior of buildings; the carburetted 
hydrogen, the result of the escape of coal gas, may be detected by its 
odour, unless it have passed through some thickness of earth. In addi- ARTIFICIAL AERO-THERAPEUTICS 
301 
tion to excess of carbonic dioxide and aqueous vapour, carbonic monoxide, 
sulphurous acid and ammonia, and organic matter are present; and if 
there be factories, unless the Smoke Abatement Act be rigidly observed, 
their products mingle with the atmosphere, making it deviate still more 
from the normal. Thirty years ago the air of Manchester contained so 
much sulphurous acid that the late Dr. Angus Smith was in the habit of 
saying that when it rained in Manchester it did not rain water, but 
dilute sulphuric acid from the condensation of the sulphurous acid fumes 
in water. 
We must, however, confine ourselves to those modifications of atmos- 
phere which can be applied to the treatment of disease, and we must 
likewise extend our observations to the application of gases of different 
kinds to therapeutic uses. 
A. Medicated Atmospheres. - Inhalation is the most common form of 
applying medicated atmospheres to the human body, the lungs being the 
medium of communication. The best instances of inhalation are certain 
gases, such as oxygen, nitrous oxide and carbonic acid, which have been 
used for therapeutic purposes; and again the vapour of certain medicines 
volatile at low temperatures, such as ether, chloroform, nitrite of amyl, 
tetrachloride of carbon, iodide of ethyl and the like. 
There is no method of artificial aero-therapeutics so successful as this; 
in most cases the full physiological effects of the drug are produced very 
speedily, as is seen in chloroform inhalation, where a few seconds or 
minutes suffice to render the patient unconscious : as the gaseous nature 
of the agent renders it easy of absorption by the lungs, it passes speedily 
by the circulation to the brain and spinal cord, producing characteristic 
effects. 
The methods of inhalation principally in use are as follows: - 
I. Inhalation of gases, such as oxygen and nitrous oxide. II. Inhala- 
tion of vapours of certain medicines volatile at low temperatures, such as 
ether and chloroform. III. Vapours of substances requiring heat for 
volatilisation, such as mercury and sulphur. IV. Moist warm inhala- 
tions. V. Cold medicated sprays. 
I. Of the first class the inhalation of oxygen has lately come into 
extensive use to relieve dyspnoea and cyanosis in pneumonia, capillary 
bronchitis, and like states. It would appear that oxygen combines with the 
haemoglobin of the red corpuscles of the blood, and that the quantity 
absorbed depends upon the pressure of the atmosphere and the amount 
of haemoglobin present in the blood. Paul Bert took blood which, under 
the ordinary atmospheric pressure, absorbed 14 per cent by volume of 
oxygen, and shook it up with oxygen under increased atmospheric 
pressure; he found under 6 atmospheres it contained 19'2 per cent by 
volume of oxygen, under 12 atmospheres 26 per cent, and under 18 
atmospheres 31-1 per cent, thus absorbing the element in accordance 
with Dalton's w'ell-known law of gases. The highest limit of absorption 
reachedin animals inhaling an atmosphere containing oxygen of increased 
density was 28 to 30 per cent by volume of oxygen in arterial blood. SYSTEM OF MEDICINE 
302 
Pure oxygen under a pressure of 3-5 atmospheres was fatal to animals, 
inducing first slight trembling of the extremities, followed by stronger 
convulsions repeated at regular intervals, but becoming weaker and 
weaker till death supervened. For therapeutic purposes oxygen is sup- 
plied under high pressure in iron cylinders; the gas is admitted into 
an intermediate india-rubber bag whence it flows through a mouthpiece 
or tube into the mouth, or in some cases through a pipe inserted into 
the nostrils. 
This means has been tried in apparently desperate cases of pneu- 
monia and of capillary bronchitis where cyanosis and unconsciousness 
have been the striking features. In almost all these patients improve- 
ment has followed; the colour has brightened, consciousness has re- 
turned, and respiration and pulse rates have fallen; but in many of 
them the improvement was but temporary, though the rally might 
be repeated more than once before death, which was usually sudden. 
Such is my general experience; but in one case it certainly bridged 
over the crisis, and permanently relieved the dyspnoea and cyanosis. 
In all the successful cases of oxygen administration in pneumonia 
the improvement and ultimate recovery seem to have depended on 
the continuous use of the remedy; it is therefore better to administer 
oxygen in smaller quantity for hours, possibly for days, than in a 
large quantity for a short time. It is possible that the sudden deaths 
recorded may be due to over-stimulation and exhaustion of the respira- 
tory or cardiac centre by the oxygen. This inhalation has been used in 
the cyanosis of advanced emphysema and in asthma, but only with 
temporary benefit in either. During their balloon ascents the French 
aeronauts Croce-Spinelli and Sivel succeeded in alleviating and even 
dispelling the symptoms of giddiness, nausea, faintness, and the 
increased respiration and pulse rate by inhaling a mixture of oxygen 
and nitrogen containing from 40 to 70 per cent of the latter; this they 
began to use at an elevation of 5000 metres. 
Nitrous oxide, or laughing gas, on account of its harmlessness, is 
largely used as an anaesthetic, especially by dentists. It is also 
employed during surgical operations, but seldom alone, as its effect 
is not sufficiently lasting. 
Carbonic acid in small quantities has been inhaled for phthisis and 
other lung affections, and is reported to have a sedative effect on the 
cough. It is far too dangerous a gas to use as a therapeutic agent,1 though 
we often witness its influence on man in atmospheres rendered impure 
by human exhalations: here, however, the percentage of carbonic acid 
is still small, and possibly some of the evil effects may be due to other 
1 Carbonic acid, mixed with sulphuretted hydrogen, has been used by Dr. Bergeon of 
Lyons, as a gaseous injection per rectum. Claude Bernard showed that certain gases, toxic 
when inhaled, might be absorbed by the colon in large quantities without any bad effects, 
and thence passing into the portal system, and reaching the heart and pulmonary circula- 
tion, be eliminated from the system through the lungs. Dr. Bergeon professed to cure 
lung tuberculosis in this way, but the treatment failed after a fair trial at the hands of 
myself and others. A A' TIFICIAL A ER O- TH ERAPE UTICS 
303 
impurities, such as tne organic matters mingled with it. The symptoms 
of excess of carbonic acid in the air are headache, drowsiness, vertigo, 
and, in time, increasing feebleness of the heart's action with slowness 
of pulse, the respirations being quickened even to gasping. I have 
often thought that the relief which suddenly comes to asthmatics at the 
height of a paroxysm, when lividity and feebleness of pulse proclaim the 
accumulation of the products of respiration in the blood, may be due to 
the lowering of the sensibility of the nerve centres by the carbonic acid. 
I remember a female asthmatic in whom, during a severe spasm, there 
was complete cyanosis, the nails and lips turning quite blue. The 
respirations became fearfully laboured, the pulse slow and irregular, 
and at last apparently stopped altogether. She fell back in the bed, and 
my assistant thought she was dead; but at the next moment the colour 
returned to her lips and face, the pulse beat again, she heaved a deep 
sigh, and her breathing once more became easy. I could not account for 
these phenomena in any other way than that the accumulation of the 
gases of respiration, and principally the carbonic acid, acted as an 
anaesthetic to the medulla and the pulmonary and cardiac plexus. 
Chlorine was largely used by the late Dr. A. T. Thomson, who con- 
sidered it " the best topical expectorant and the most salutary excitant 
to the mucous membrane that had yet been inhaled "; other authorities, 
like Laennec and Dr. Stokes, found chlorine too irritating for inhalation. 
It was at one time largely used for disinfecting purposes, and is very 
effective, but its strong, pungent smell is offensive. A useful and less 
pungent form of inhalation is chloride of ammonium vapour: this is 
made by mixing the vapours of liquid ammonia and fuming hydro- 
chloric acid, the chloride of ammonium fumes are then purified from any 
excess of hydrochloric acid by passing them through water. Thence 
they are drawn through a tube into the pharynx, larynx, and nasal 
passages, and prove beneficial in pharyngeal and nasal catarrh. 
Iodine was employed for inhalation by Laennec, Berton, Murray and 
Scudamore for the treatment of phthisis; the patients either inhaling 
the vapour itself for a short period, or being surrounded by an atmos- 
phere strongly impregnated with iodine. All these authors speak very 
favourably of the results obtained. My personal experience of the 
iodine vapour is favourable, but I have never seen it arrest tuberculosis. 
Iodine is a strong antiseptic, and probably exercises a bactericidal action 
on surfaces immediately exposed to its influence, but that it has any 
effect on the progress of tuberculisation in the lung itself I much 
doubt. Iodine vapour has been administered with advantage in 
laryngeal diseases. 
II. In the second method certain liquids are used which are volatile 
at low temperatures, such as ether, chloroform, bichloride of methylene, 
tetrachloride of carbon and the like. These are almost entirely em- 
ployed as anaesthetic inhalations, either in a pure condition or occasion- 
ally, as in the case of chloroform, mixed with a certain percentage of 
air; their uses as anaesthetics, however, will not be considered here. 304 
SYSTEM OF MEDICINE 
III. The chief substances requiring heat for volatilisation which are 
used in aero-therapeutics are Mercury and Sulphur. In the so-called 
mercurial and sulphur baths the patient, covered up with a sheet, sits on 
a chair, with a spirit-lamp or gas-jet underneath by which the drug is 
heated to vaporisation; the vapour envelops the patient, and is absorbed 
to a large extent by the skin. If the evaporation of steam accom- 
pany this process the skin is better prepared for the reception of the 
drug. From time immemorial, mercurial vapour has been used in India 
and Arabia for exciting salivation in certain diseases, and it was employed 
later in the south of Europe. In England the practice was resuscitated 
by Jackson, and more completely by Mr. Henry Lee, who introduced 
mercurial baths largely into the treatment of syphilis. Mr. Lee used 
calomel, and, in order to get rid of the possible excess of hydrochloric 
acid, baked the calomel before each bath.: in this method the powder is 
laid on a circular plate, surrounded by a trough containing water which the 
flame soon converts into steam; at the same time the calomel is vaporised. 
The patient is enveloped in a cloak which, fastened round the neck, pre- 
vents the calomel vapour from escaping; this is occasionally unfastened 
during the fumigation to allow of a short period of inhalation also. Another 
method of mercurial fumigation is by Trousseau's cigarettes, which con- 
sist of blotting-paper soaked in a solution of nitrate of mercury and 
nitric acid. These were recommended by Trousseau for chronic laryn- 
gitis, as well as for syphilitic pharyngitis and laryngitis. The sulphur 
baths are prepared and conducted in the same way as the mercurial; and 
have been employed for scabies and other parasitic affections of the skin. 
IV. For moist, warm inhalations, where steam, or rearm water vapour 
is the medium for applying medicinal agents to the lungs, the apparatus 
vary greatly. The simplest form is a wide-mouthed jug or gallipot 
filled with boiling water into which a drug is thrown; the patient, 
taking deep respirations, draws the vapour into his mouth and nostrils 
through a napkin arranged in the form of a tube. More compli- 
cated are the steam spray apparatus of Siegle, Oertel, Robert Lee, 
Codman and Shurtleff, and others. In some hospitals, as in the Brompton, 
steam and sprays are fitted up in separate rooms, so that the patients can 
inhale without admission of the moist air into the ward. This class of in- 
halations beneficially affects the bronchial tubes, specially in inflamma- 
tory or catarrhal conditions, by promoting secretion; but it is doubtful 
whether they penetrate deeply, or go beyond the primary and secondary 
bronchi. Steam sprays saturate the atmosphere with moisture, which is 
not always desirable in lung diseases; moreover, they cause excessive skin 
perspiration. The spray, whether it be a steam or handball apparatus, 
is produced by a strong transverse current passing over a perpendicular 
tube; as the air in the upper part of that tube is thus rarefied, 
any liquid in which the tube may be immersed ascends, and, as it 
meets the current, is broken into spray. Boyle's well-known ventilating 
extractors act in the same manner. The apparatus introduced by Sales- 
Giron, Matthieu and Bergson consisted of two pointed tubes at right ARTIFICIAL AERO-THERAPEUTICS 
305 
angles, placed with their extremities together, and so joined that the 
extremity of the perpendicular tube should stand in front of the axis of 
the horizontal tube. As the stream of air or steam passes along the 
horizontal tube the medicated fluid rises in the vertical tube, and, on 
meeting the air current, is broken into fine spray. 
Fig. 15. - Oertel's Steam Nebuliser. 
The method is the same, whether air be used, as in the well-known 
handball spray apparatus, or steam, as in Siegle or Oertel's " steam 
nebulisers." 
The handball sprays are used at ordinary temperatures, and as a rule 
are not so grateful to the patient as warm vapours. They are very use- 
ful for the medication of the mouth, the pharynx, and even the larynx; 
and solutions of quinine, chlorine, or carbolic acid can be well applied 
through them. They seldom penetrate beyond the larynx and larger 
bronchi, and generally condense into liquid on the fauces and pharynx. 
The sprays of mineral water in use at Aix les Bains, Pirrefonds, Mont 
Dore, Cauterets, etc., belong to this category, and are of use in laryngeal 
and bronchial affections, but seldom in lung diseases. The free applica- 
tion of antiseptic sprays for purifying the atmosphere of sick chambers 
and of hospital wards is excellent - carbolic acid (1 in 50), thymol, 
eucalyptol, or chlorine being adapted to the purpose. 
Artificial atmospheres for invalids may be made by respirators which 
VOL. I 
X 306 
SYSTEM OF MEDICINE 
cover the mouth, or, still better, the nose and mouth. These generally 
consist of metal or celluloid, with two layers of wire gauze or perforated 
iron plates containing between them cotton wool, tow or sponge on which 
are sprinkled a few drops of carbolic acid, creosote, terebene, eucalyptol, 
or other disinfectant. Thus the patient with each respiration breathes 
an impregnated air, and may do so for any length of time desired. The 
advantages of these respirators are - 1st, that they admit of the use of 
certain drugs for long periods; 2nd, that in cases of foul breath, as in 
bronchiectasis and abscess of the lung, the wearing of an antiseptic respi- 
rator purifies the patient's exhalations, to the advantage of his friends 
and attendants. The patterns are very numerous, such as Roberts', 
Coghill's, Curschmann's, Hunter Mackenzie's, and Wordsworth's. The 
most comfortable is Curschmann's : it consists of half a globe of metal, 
enclosing the mouth, nose, and a portion of the face, from which a short 
tubes passes for the admission of air. This contains the antiseptic 
sprinkled on wool or tow between two folds of wire gauze; a strap 
behind holds the instrument on, and any uncomfortable pressure of the 
metal against the face is prevented by a layer of air cushion next the 
skin. The great objection to all respirators is that they interfere with 
free respiratory movement. 
On the efficacy of inhalations as a method of artificial aero-thera- 
peutics, some experiments made by myself in 1888 throw great doubt; 
these show that inhalations of iodine, supplied by steam or handball 
sprays, even when given for a considerable period, produce no trace of 
iodine in the urine; whereas iodine can be detected in the urine after 
a few doses by the mouth. Turpentine inhalations, on the other hand, 
produced the characteristic odour in the urine, but not to so marked a 
degree as when the medicine was administered by the mouth. 
The late Dr. Hassall, from careful experiments, came to the con- 
clusion that the greater part of the substances inhaled remained in the 
inhaler; and that, in the case of the ordinary ori-nasal respirators, four- 
fifths of the carbolic acid, creosote and other drugs were recoverable 
from them after the inhalations. 
B. Artificial Atmospheres varying in Barometric Pressure must now 
be considered as therapeutic agents - atmospheres, that is, denser or 
more rarefied than at sea-level. 
The average barometric pressure at sea-level is 29 to 30 inches, at 
Davos (5200 feet) it is 25 inches; on the summit of Pike's Peak, Colo- 
rado (14,147 feet), it is 17-54 inches; and during the famous balloon 
ascent of Glaisher and Coxwell, at a height of 29,000 feet, a pressure 
of 9| inches was registered; indeed, so low a pressure as 7 inches was 
seen afterwards by Coxwell, though he could not record it. On the 
other hand, the air is far denser in the deepest mines than at sea-level; 
and it has been calculated that if a shaft could be sunk forty-five miles 
into the earth, the air at the bottom of it would be as dense as quick- 
silver. 
Junod was one of the first to apply air at diminished barometric AR TI FI CI AL AER 0- THER APE UTICS 
307 
pressure to the human body : in 
1835 he contrived a hollow 
copper ball, 1| metre in diam- 
eter, capable of containing an 
adult man, and by an exhaust- 
ing apparatus he reduced the 
barometric pressure one-third, 
producing distension of the 
membrana tympani, dyspnoea, 
chiefly in the form of short, 
quick respirations; turgescence 
of the superficial vessels of the 
body, as seen in the eyelids 
and lips; and diminution of the 
salivary, renal, and other glan- 
dular secretions. Junod did 
not continue his experiments on 
the general influence of rarefied 
air on the human body, but 
turned his attention to the 
local effects, which were also 
being studied by Neil Arnott, 
Murray, and Clanny, and in- 
vented the Junod boot and the 
cupping-glasses, which are still 
in use. The Junod boot and 
Sir James Murray's instrument 
are apparatus for enclosing a 
limb, or a part of a limb, in an 
air-tight vessel, and exhausting 
the atmosphere by an air-pump; 
the atmospheric pressure being 
thus removed from the surface 
of the limb, blood is drawn to 
the part, the vessels become 
gorged, and blood is derived 
from the internal organs. The 
action of cupping-glasses is, of 
course, the same in principle. 
Dry cupping is useful in 
congestion of certain internal 
organs, such as the lungs, kid- 
neys or brain. From the ease 
and readiness of its application 
it is of value in cases where 
blood is to be drawn rapidly 
from an organ, and especially 
Fig. 16. -Waldenburg's Apparatus. 308 
SYSTEM OF MEDICINE 
in haemoptysis. I have witnessed some of the most profuse haemorrhages 
from the lung suddenly brought to a termination by the use of dry cup- 
ping to the chest-wall; and I have often observed that so long as the 
cupping-glasses are kept on the haemorrhage has been controlled, and 
that on their removal it may return. Hence the great advantage of 
cupping-glasses with exhausters attached by which a partial vacuum 
can be maintained. 
This treatment, if carefully applied, leaves no mark, and it is to be 
preferred to blistering or strong poulticing in cases of gouty disposition 
or where the patient has a very irritable skin. 
The Artificial Application of Air at a Varying Pressure to the Lungs 
is carried out by various apparatus, most of which are constructed both 
for rarefaction and for condensation. 
It is possible to apply air to the lungs in four different ways: - 
1. Inspiration of rarefied air. 2. Expiration into rarefied air. 3. In- 
spiration of compressed air. 4. Expiration into compressed air. 
Of these varieties the only ones found generally useful are the 
second and third; though in the pneumatic cabinet, to be presently 
described, the other changes can also be carried out. 
The earliest instrument for condensing and rarefying the air was 
constructed by Hauke, of which Waldenburg's well-known apparatus is 
a modification (Fig. 16). This last consists of a hollow metal cylinder or 
bell, containing a certain volume of air, which is plunged into a second 
and inverted cylinder containing water. By means of pulleys and weights 
an equilibrium is established, and a pipe is passed from the air cylinder 
through a drying-box to a mask 
fitting the patient's mouth; through 
this he respires the air, which can be 
rarefied or condensed by raising or 
lowering the cylinder in the water. 
This is done in the first instance by 
drawing off water, in the second by 
placing weights on the cylinder. 
Some apparatus, like Cube's and 
Schitzler's second form, are double, 
and consist of two cylinders, one for 
condensing and the other for rarefying 
the air; thus, by changing the tube 
connections, expiration into a rarefied 
atmosphere can be followed by the 
inspiration of condensed air. Others, 
as Biedert's and Fraenkel's, contain 
a kind of leathern bellows to compress 
or rarefy the air as required. Fraen- 
kel's ingenious instrument resembles 
a concertina with a tube and mouthpiece; it is simple and cheap, and 
can be worked by the patient himself. The obvious objections to it are 
Fig. 17.-Fraenkel's Apparatus. A RTI FI CI AL A ER 0- THERAPE UTICS 
309 
the contracted attitude of the patient, and the impossibility of regulating 
the pressure. 
Lastly, the principle of the centrifugal pump is adopted in Giegel 
and Mayer's machine, which seems the most complete apparatus of all; 
in it air, compressed or rarefied by the action of water, is stored up in 
a central reservoir. 
" By the simultaneous use of two apparatuses placed in communica- 
tion with the mouth of the patient by means of two flexible tubes and 
a double respiratory valve, and by maintaining the constancy and con- 
tinuity, a simultaneous rarefaction and condensation of the air can be 
established, which enables the patient to inspire compressed air and to 
expire into rarefied by one and the same expiratory act." For further 
particulars of this apparatus the reader is referred to Oertel's article 
on "Respiratory Therapeutics," in the 3rd vol. of Ziemssen's Handbook 
of General Therapeutics. 
One of the newest portable instruments for using air at various press- 
ures is the pneumatic cabinet of Mr. Ketchum of the United States. A 
rhomboidal cupboard on wheels, large enough 
to hold a man in a sitting position, is con- 
structed of steel with a plate-glass window in 
front; at the back is an air-tight door, which 
forms the whole side. Above this cabinet is 
a bellows, worked by a lever, with one set of 
valves opening into the cabinet, and a sec- 
ond set communicating with the external air: 
these valves can be reversed, so that by the 
bellows the air of the cabinet may be con- 
densed or rarefied at will. An artificial wooden 
glottis regulates the air-stream into the pa- 
tient's lungs, passes through an aperture in 
the glass plate, and is connected by india- 
rubber tubing with the patient's mouth. The 
pressure within the cabinet is increased by working the lever, or de- 
creased by turning a tap communicating with the external air. In this 
machine a pressure of two inches can be obtained. 
Various modifications of the respiratory act are possible with this 
machine. When the artificial glottis is closed, the bellows worked for 
rarefaction, and the patient makes deep expirations - 1. Residxtal air- 
expansion results. If he put a nose clip on and adjust his mouth to 
the glottis tube, which is opened gradually, air from the outside is 
admitted. 2. Forced inspiration results, and a larger volume than usual 
enters the lungs. The alternation of these two movements, viz., residual 
air-expansion and forced inspiration, constitutes, 3. Respiratory differen- 
tiation, an exercise for the purpose of expanding the lungs. 4. Forced 
expiration takes place when the air of the cabinet is condensed, and the 
patient, having taken a deep breath, expires through the artificial glottis. 
The pneumatic cabinet is used for lung gymnastics of different kinds. 
Fig. 18. - The Pneumatic Cabinet. 310 
SYSTEM OF MEDICINE 
A committee of the Brompton Hospital, appointed to investigate its 
capabilities, showed that its use caused (a) increase of chest circumfer- 
ence, (b) increase of spirometric capacity, and (c), in many cases of con- 
solidation, diminution in the area of dulness. The cabinet was found 
less successful as a vehicle for medicinal agents, and the remedial effect 
of medicated sprays in this machine was not greater than at normal press- 
ures. Great caution is necessary in the selection of appropriate cases, 
and the cabinet must not be used in cases of vascular weakness or of 
pyrexia-haemoptysis has followed its use in the former and increased 
temperature in the latter class of patients. 
Many of the described methods of aero-therapeutics depend for suc- 
cess on the exact adjustment of mouthpieces or masks, which are often 
exceedingly irksome and induce headache and faintness. Another diffi- 
culty in many of the instruments is that of supplying sufficient fresh 
air at the proper pressure; the consequence is that patients have to 
inhale rebreathed air. To meet this objection the compressed air bath 
was invented, in which patients are surrounded with an atmosphere in 
which they can respire air at any desired degree of pressure for hours 
at a time, and in some cases, as in the St. Petersburg establishment, for 
days together. Different forms of the bath have been devised, and the 
size varies according to the number of occupants. The essential elements 
appear to be (a) an air-tight oval chamber of sufficient strength to resist 
the variations of atmospheric pressure, and (b) an efficient compressing 
apparatus. The chamber may be constructed of masonry or of iron, but 
more generally it is of wrought iron -yL inch thick, in an irregular or 
ovoid form, and, if possible, with a domed roof to resist pressure, the 
whole being strengthened by girders and ribs of iron. The compressing 
apparatus generally consists of a steam-engine, but in some places, as in 
M. Fontaine's establishment at Paris, hydraulic power is used which has 
the advantage of compressing the air, without materially increasing its 
temperature, and any smell arising from contact with boilers is also 
avoided. The advantage of steam is the rapidity with which pressure 
can be increased and steadily maintained. 
The annexed woodcut of the compressed air bath in use at the 
Brompton Hospital will give some notion of the details of the appara- 
tus. The drawing is supplied by Mr. Blake, the manager of Messrs. 
Haden & Sons of Trowbridge, the constructors of the bath. 
The bath consists of three parts : the engine (A), the receiver (B), 
and the air-chamber (C). A includes a steam-engine D, which, by means 
of a flywheel and crank, works a second engine E in another and sepa- 
rate compartment F. E is the air-compressing engine, with a cylinder 
containing an inlet hole and an outlet hole, and in this cylinder works 
the piston H, the plate of which is perforated by diaphragm valves, 
not here shown, which close during the descent of the piston and open 
during its ascent. The air from outside enters the compartment F 
through the inlet G, and follows the course indicated by the arrows. 
Entering the air-cylinder it is driven forward by the piston through the AR TIFI CI AL AER O- THERA PE UTICS 
pipe I into the receiver B, containing layers of cotton wool W, into the 
air-chamber. Both I and J contain valves to prevent a return current. 
311 
Fig. 19.-Compressed air bath. 
The air leaves the bath by an outlet pipe in the roof, which is always 
open, the strength of the current through it depending on the rate at 
which the engine works. M is a safety valve which opens wide and blows 312 
SYSTEM OF MEDICINE 
a whistle when the full pressure of 10 lbs. is reached. L is a glass spy- 
hole through which the inmates can be watched. N is an air-tight 
cupboard, fitted with double bolts to adjust the pressure, by which food 
and messages, and, if necessary, medicines, may be passed in. Appara- 
tus to regulate the escape of air (K), which can be worked both from 
within or outside the bath, complete the chamber, which is lit from with- 
out by stout plate-glass windows, and fitted with a strong iron door. 
The air can be changed about five times in two hours, and must be sup- 
plied from a pure source, such as a garden or open space, away from 
machinery and drainage; and in cities it must be filtered through cotton 
wool in the receiver B. The air rises in temperature during compression, 
and in summer it is often necessary, for cooling purposes, to pass it over 
ice before it enters the bath. The extra pressure used for medical pur- 
poses varies from to atmospheres, pressures very different from 
those which produce the well-known caisson disease, and amount to 
more than 4 atmospheres. For most diseases, and certainly for lung 
affections, the added pressure does not exceed 10 lbs. (| of an atmos- 
phere) ; and 9 lbs. above the mean atmospheric pressure is usually suf- 
ficient for aero-therapeutic purposes. 
The bath or sitting lasts two hours; half an hour is spent in increas- 
ing pressure, which is maintained for one hour at the maximum, and 
half an hour in reducing pressure to the normal. In some obstinate cases 
of asthma it might be well to maintain the pressure for long periods, and 
thus enable the patient to live in a compressed air atmosphere for days 
together. This would be quite possible by means of the air-tight cup- 
board, through which supplies could be passed. The rate of increase or 
decrease of pressure should be about 1 lb. in three minutes. 
As during compression there is increase of temperature, so during 
reduction there is a slight fall, accompanied by deposition of moisture 
in the interior of the chamber. In the management of the bath the 
chief points to be borne in mind are four: - 1. To increase and reduce 
the pressure as gradually as possible. 2. To keep the temperature below 
65° F. 3. While increasing or maintaining the pressure, to provide for 
the escape of the used-up or contaminated air. The air should be 
pumped through the chamber, not merely into it; and, as the stream is 
always flowing, accumulation should only be the result of the outlets 
being somewhat smaller than the inlets. 4. In case of bad symptoms 
arising from increase or decrease of pressure, to reverse the process at 
once. 
A healthy person taking a compressed air bath first experiences, as the 
pressure increases, an unpleasant sensation in the throat, referred to the 
pharynx immediately behind the tonsil; this is relieved by swallowing 
saliva or drinking water. Pain is also felt in the membrana tympani, 
which is due to the different calibres of the external auditory meatus and 
the Eustachian tube. The latter being much smaller than the former, the 
column of air, during increase of pressure, penetrates with difficulty to the 
internal surface of the membrana tympani, and changes of pressure are AR TIFICIAL A ER O- TH ERA PE UTICS 
slowly communicated; whereas through the meatus air passes freely, and 
causes under these circumstances a convexity inwards of the auditory 
membrane. The opposite change takes place when pressure is dimin- 
ished. Hence the pain and discomfort in the membrane are at the 
beginning and end of the bath. The voice becomes shriller, and I have 
known singers gain a note or two above their average while in the bath. 
The arch of the abdominal wall is flattened, which has been ascribed 
by Panum to compression of the intestinal gas. 
Experiments made by myself and others in healthy individuals show 
the following results from compressed air: - 
Respiration. - The patient breathes slower, deeper and with greater 
ease. The respiration rate falls from 16 or 15 to 14 or 12 a minute. 
Von Vivenot records its falling to 5 or even 4 a minute. Inspiration 
becomes easy, but expiration less so, and the relation between the two 
becomes changed; whereas at normal pressure the ratio between them 
is as 4 to 3, it becomes in compressed air as 4 to 6 or 4 to 8. Von Vive- 
not tells of one case where it was as 4 to 11. 
313 
Fig. 20. 
The annexed diagram from Von Vivenot shows this as well as the 
depth of the respiration in compressed air (dotted line) compared with 
that of ordinary breath (unbroken line). 
Spirometric observations show a marked augmentation of lung 
capacity and chest measurements, a slow but considerable increase in 
circumference. It would appear that breathing compressed air in- 
creases lung capacity, probably by opening up alveoli not previously 
in use; and the amplitude of each respiration makes up for the smaller 
number. 
Circulation. - The influence of compressed air on the circulation is 
that the pulse becomes slower and reduced in volume; but the arterial 
pressure is raised, the superficial capillaries are smaller, and the veins 
less full of blood. Von Vivenot's white rabbit, when placed in the com- 
pressed air bath, admirably exhibited the effect on the circulation. 
Under normal pressure, the rabbit being quiet and at liberty, the ears 
were full of blood, the conjunctival vessels injected, and the iris tinted 
deep red; when pressure was increased, the conjunctival vessels became 
finer and paler, and in one experiment they visibly filled and emptied. 
When pressure was maintained at the maximum, the iris and pupils 
became discoloured, and the ears, seen by transmitted light, showed 
empty vessels; even the larger vessels were scarcely visible. 
In man the pulse rate diminishes four to twenty beats a minute; but 314 
SYSTEM OF MEDICINE 
this depends very much on the temperature of the bath; for, though a 
prolonged sitting generally causes a fall in the pulse rate, a hot atmos- 
phere will make the pulse rise at first. Sphygmographic tracings show 
a lowering in the height of the tidal and dicrotic waves, but this change 
is only maintained during the bath; after it the pulse tracing returns 
to its former standard. To the finger the pulse appears small and 
Fig. 21. - Before bath, ordinary pressure. 
Fig. 22. - Pressure, 3 lbs. 
Fig. 23. - Pressure, 6 lbs. 
Fig. 24. - Pressure, 9 lbs. 
Fig. 25.-After bath, ordinary pressure. 
hard. All observations indicate that compressed air exercises an in- 
tropulsive influence, affecting naturally the surfaces most exposed to it, 
such as the skin and lungs, and drives the blood into the organs pro- 
tected from air pressure, such as the brain, heart, liver, spleen and 
kidneys. The pressure is exerted more in the capillaries and superfi- 
cial veins and arteries; and its tendency must be to reduce pressure on 
the right side of the heart and to increase it on the left. A proof of the 
fulness of the arterial system is to be found (1) in the sphygmographic 
tracings, and (2) in the fact that when haemorrhage occurs in the bath 
the blood is invariably bright red (arterial). The slower pulse rate, 
according to Professor Burdon-Sanderson, is the effect of the diminished 
pressure in the venous system, which retards the filling of the ventricles 
during the period of relaxation, and consequently lengthens the diastolic 
period; thus the pulse frequency is diminished. 
Again, the introduction of a larger amount of oxygen causes greater 
absorption of this gas by the lungs, and increased oxidation and tissue 
change; this is proved by the increase in the amount of carbonic acid 
exhaled from the lungs, and in that of urea from the kidneys. Appetite 
is improved and weight is generally gained. Muscular power is stated 
by Lange to be increased; he found men could carry weights better after 
the bath than before it. 
The internal temperature of the body is slightly raised, sometimes ARTIFICIAL AERO-THERAPEUTICS 
315 
half a degree in the mouth, that in the axilla being diminished; the 
rectum temperature (Stembo) rises, as might be expected, from the 
intropulsive action of the bath on circulation. 
From the preceding observations it will be understood that, on 
account of this intropulsive action on the circulation, the use of the 
compressed air bath is contra-indicated in congestion, or inflammation, or 
haemorrhage of any of the organs which are wholly or partially protected 
from air pressure by bony cavities, such as the brain, spinal cord, heart, 
liver, spleen, kidneys, uterus and ovaries. Again fever, in which there 
is congestion of internal organs, is increased by it. 
The intropulsive action is sometimes serviceable, as, for example, in 
long-standing amenorrhoea; for by its effect on the ovaries the bath will 
often restore the menstrual flow. Anaemia, too, is greatly relieved by 
compressed air baths, probably on account of the large amount of 
oxygen supplied. Certain it is that under their use pallor gives way to 
the blush of health, anaemic murmurs disappear, and the number of red 
corpuscles, as noted by the haemocytometer, largely increases. This has 
been my experience in all the cases of anaemia I have treated in this 
way. 
The diseases in which compressed air baths have been found to do 
most good are bronchial asthma, chronic bronchitis, and emphysema. 
Emphysema. - In the tense or large-lunged form, which accom- 
panies bronchitis and asthma, and has been so well described by Dr. 
C. J. B. Williams and Sir William Jenner, a course of these baths effects 
a wonderful change. The patient finds he can breathe more freely, and 
can ascend steps and hills with greater ease. His cough and expectoration 
are reduced. His respirations are slower and deeper, and the pulse is 
slower and firmer. Physical examination shows the thoracic distension 
to be diminished. The line of hepatic dulness, long absent, reappears and 
rises to the old level, the area of cardiac dulness can again be detected, 
and the impulse is felt, not in the epigastrium, but in the normal posi- 
tion between the fifth and sixth ribs, slightly to the right of the nipple. 
Hyper-resonance of the thorax gives place to something more like 
the normal note; and although there may be prolonged expiration with 
occasional wheezing sounds, the air is heard to penetrate into blocked 
portions of the lung in which breath sounds were previously absent. 
Cyrtometric measurements show a reduction in the chest circumference 
at different levels of from | to 11 inches; and the spirometric observa- 
tions yield evidence of "increased vital capacity." 
These changes appear to be due to the removal of some of the causes 
of the emphysema, such as bronchial catarrh and bronchial spasm, thus 
allowing the escape of some of the distending air from portions of the 
lung in which the emphysema was perhaps temporary. 
Bronchial Catarrh and Bronchitis. - The effect on this class of diseases 
is excellent; cough is diminished, expectoration first becomes easier and 
then lessened in amount, breathing is freer, and any accompanying 
emphysema is reduced considerably. I have used the compressed air 316 
SYSTEM OF MEDICINE 
bath in a large number of cases of bronchitis and emphysema, and in 
every case there has been relief, though it has not always proved per- 
manent. Oertel considers the improvement to be due to the increased 
pressure on the larger tubes, causing diminution of the blood in the bron- 
chial system, and consequently less exudation of serum into the coats of 
the bronchi, and less pressure on the lymphatic system. 
Bronchial Asthma. - The principal effect of the treatment on asthma 
seems to be sedative to the pulmonary plexuses and to the pneumo- 
gastric nerves. The attacks are rendered less severe, and after a course 
of twenty or thirty baths the intervals between the attacks become 
much longer and the spasms finally cease. I have several times placed 
a patient in the bath during an asthmatic attack, and always with relief 
to the spasms. In addition to the soothing influence on the nerve- 
storm, the baths reduce the accompanying emphysema, and more so 
than in the emphysema of bronchitis, probably because the bronchial 
obstructions are of a more transitory character. The patient is able 
to breathe more freely and to take deeper inspirations, the chest dis- 
tension, as shown by the measurements, diminishes, and the spirometric 
records increase in amount. Thus an improvement in their general 
condition ensues. Exercise can be more freely taken, digestion and 
assimilation are carried on with greater ease and comfort, and strength 
and colour are gained. 
Phthisis. - I have tried the treatment in a large number of cases of 
phthisis, generally those of limited lung tuberculosis; and beyond the 
facts that cough and expectoration slightly diminish, and that some 
portions of the lung become more expanded, I could see no good result. 
In several of the cases hsemoptysis came on either in the bath or after 
the treatment, and this constitutes a fresh danger. In some of the 
patients there was improvement of appetite and gain of weight, but it 
cannot be said that any lasting benefit resulted. 
I tried the treatment in cases of chronic pneumonia and chronic lung 
infiltration, and also in commencing pleuritic effusion -in the latter case, 
with the view of inflating the lungs and thus opposing the increasing 
fluid pressure; but in none of these instances did the bath do any good, 
and the progress of the disease was unchecked. 
The number of compressed air baths sufficient to produce a thera- 
peutic effect varies greatly, but in asthma or bronchitis about thirty are 
necessary; in chronic emphysema a larger number, sixty to seventy, are 
often required. 
It is a remarkable fact that, while there are numerous establish- 
ments for compressed air baths on the Continent and elsewhere, in 
England there are scarcely any: those best known are the one at Ben 
Rhydding in Yorkshire, and the admirable one of the Brompton 
Hospital, which is largely used, and is now made available for private 
patients. 
Respiratory Gymnastics.-Dr. Marcet (8) dwells with great force 
on the advantage of training the respiration, not only for physiological ARTIFICIAL AERO-THERAPEUTICS 
317 
exercise, but as an important aid in the treatment of such diseases as 
asthma. He showed that after forced breathing more than double the 
weight could be lifted than after ordinary breathing; and he instances 
the well-known fact of the asthmatic spasm being sometimes momen- 
tarily suspended by a forced inspiration, as a proof that a deficient 
supply of oxygen to the respiratory centres bears a definite relation to 
the causation of asthma. 
Dr. Marcet advocates, as a method of therapeutics for asthma, the 
practice of the respiratory movements required to carry the air through 
the lungs in order to oxidise the blood and exhaust the carbonic acid; 
this practice, at the same time, brings the circulation into better co- 
operation with the respiratory function. A good form of exercise, 
according to this author, is "cycling, which increases the depth of 
breathing, and this without fatigue, the inspiratory movements being 
automatic; at the same time, it accustoms the rider instinctively to 
take in at each respiration the volume of air required to aerate the 
blood, and to eliminate a certain proportion of carbonic acid, leaving in 
the circulation that amount which is compatible with health." 
C. Theodore Williams. 
REFERENCES 
1. Bert, Paul. La pression baromttrique, 1878. - 2. Cohen, J. Solis. Inhala- 
tion in the Treatment of Disease, 1876. - 3. Hassall, A. Hill. The Inhalation 
Treatment of Diseases of the Organs of Respiration, including Consumption, 1885. - 
4. Junod, Theodore. Recherches sur les effets Physiologiques et Therapeutiques de la 
compression de I'air, 1835. - 5. Lange, J. On Compressed Air, its Physiological 
Effects and their Therapeutic Importance, 1864. - 6. Lee, Henry. "Calomel Baths," 
Lancet, August 21,1875. - 7. Liebig, G. von. " The Exchange of Gases in the Lungs 
under Increase of Air Pressure in the Pneumatic Chamber," Bayer, Aerztlich-Intelligenz 
Blatt, 1874.-8. Marcet. " Contribution to the History of the Respiration in Man," 
Croonian Lectures. Brit. Med. Journal, July 1895. - 9. Oertel, M. J. Handbuch 
der respiratorischen Therapie. English translation, 1885. -10. Panum, P. L. Fysiologiske 
Undersbgelser over dem i de pneumatiske Helbredel-sesaanstalter, 1866. -11. Bergeon. 
fttudes erperimentales et cliniques sur la tuberculose, 1887. -12. Sanderson, J. Burdon. 
" The Compressed Air Baths of Reichenhall," Practitioner, October 1868. -13. Simon- 
off. " On the Effects of Condensed Air on the Respiratory Organs," Petersburg, 
Medicin. Zeitschrift, 1873. -14. Stembo. Contributions to the Physiological Influ- 
ence of Compressed Air, 1877. -15. Tabarif. Emile. "Recherches Physico-physi- 
ologiques," Compt. Rendus, 1838. -16. Vivenot, Von. Therapeutic uses of Compressed 
Air, 1868. -17. Williams, C. Theodore. " On the Value of Inhalations in the Treat- 
ment of Disease," Brit. Med. Journal, 1888; " Lectures on the Compressed Air Bath," 
Brit. Med. Journal, 1885; Aero-therapeutics, 1894. 
C. T. W. 318 
SYSTEM OF MEDICINE 
BALNEOLOGY AND HYDROTHERAPEUTICS 
A. - Balneo-Therapeutics ; or, Treatment by the Internal and 
External Use of Mineral Waters 
Definition. - The name Mineral Waters is applied to those waters 
which are used in the treatment of disease, either internally or in the 
form of baths, on account of the saline or gaseous substances which 
they contain, or on account of their elevated temperature. 
The science of the origin of these waters, and of the causes to which 
they owe their chemical composition and their temperature, is usually 
called Balneology, or in a wider sense Hydrology ; and may be regarded 
as a part of Geology and Physical Geography: the art of using them 
in the treatment of disease is Balneotherapy, and mineral waters are a 
part of Materia Medica. 
Our article is not intended as a regular treatise on Balneotherapy, 
but only as a survey of the uses of mineral waters in the treatment of 
disease. The external applications of mineral waters in the form of baths 
and douches, as practised at most of the spas, are, with few exceptions, 
similar in their effects to those of ordinary water at more or less elevated 
temperatures. We refer, therefore, for their appreciation to section B 
on Hydrotherapeutics; but we may mention here that at some of the spas 
various earthy matters are added to the water, such as peat earth or 
moor earth, and are also used in the shape of local baths or cataplasms. 
We will divide the present section into two parts: - 
1. Description of mineral waters and their effects. 
2. Therapeutic employment of mineral waters. 
I. Description of Mineral Waters 
The principal constituents of mineral waters are: Water, sodium, 
magnesium, calcium, and iron; combined with hydrochloric, sulphuric, 
carbonic, and hydrosulphuric acid. Other substances often present are : 
Arsenic, lithium, potassium, manganese, bromine, iodine, alum, silica, 
argon, various organic matters, and other substances in minute quan- 
tities. The principal gases are: Oxygen, nitrogen, carbonic, and 
hydrosulphuric acids. 
These substances are derived partly from the surface soil, partly 
from the rocky strata through which the water deposited from the 
atmosphere has passed. The differences between the different mineral 
waters are due to the differences in the superficial soil and the rocks 
through which the water has passed. 
The mineral waters may be divided into groups for more easy 
survey; for instance, according to their temperatures, or their chemical 
ingredients, or their physiological or their therapeutical effects. Every BA/.NEOLOGY AND HYDROTHERAPEUTICS 
319 
classification is more or less imperfect, and an alphabetical arrange- 
ment would be the most easy; but this would entail frequent repetition 
and thus require more space. We therefore attempt a somewhat mixed 
arrangement, based principally on the chemical constituents of the 
springs. It will, however, be evident that some springs contain so 
large an amount of several ingredients that they can claim a place in 
different groups; and that others ard named not after the substance 
which they contain in the largest amount, but after that which is held 
to be most potent. Those thermal waters which are almost devoid of 
solid substances are placed in a separate group. Thus we may form 
eight groups: - 
1. Simple Thermal Waters. 
2. Common Salt or Muriated Saline 
Waters. 
3. Alkaline Waters. 
4. Sulphated Saline Waters. 
5. Iron or Chalybeate Waters. 
6. Arsenic Waters. 
7. Sulphur Waters. 
8. Earthy or Calcareous 
Waters.1 
1. Simple Thermal Waters. -(Syn.: Wildbader, indifferent thermal 
waters.) The waters of this group have a higher temperature than 
ordinary springs, varying between 80° F. and 150° F. or more; they 
are transparent, very soft, almost tasteless, of low specific gravity, very 
poor in solid and also in gaseous substances; some contain a little 
more nitrogen than ordinary water; others claim a little more oxygen. 
It has been stated that the electrical conditions of these waters are 
peculiar, but, so far as we know, there is no proof of this. 
Matlock, in Derbyshire, deserves to be mentioned in this place, 
although the temperature of its waters is only 68° F. It lies in a beauti- 
ful valley, but the climate of Matlock itself cannot be called bracing. 
Many other slightly mineralised warm waters, whose principal action 
is to be attributed to the temperature of the water, might be mentioned 
under this head, such as Acqui in Italy and the hot sulphur waters of 
the Pyrenees; while some of the spas mentioned in the preceding 
table, such as Leuk, Bormio, Bagneres de Bigorre, Badenweiler, Bath, 
and Aix-les-Bains, may claim a place in other groups. 
The very hot Algerian baths near Biskra, the "Fontaine chaud," 
(Hammam Salahin, Bath of the Saints) of a temperature of about 
112° F.; Mammam Meskoutin, with waters of 170° F.; Hammam R'Irha, 
158° F.; and others, may be regarded as belonging to this group. 
The United States of America are rich in simple thermal springs 
which are partly in use, partly in course of development. Some of 
the most important are-the "Hot Springs" in Virginia, the "Hot 
Springs" in Arkansas, the "Calistoga Hot Springs," the "Geysers," 
the "PassRobles Hot Springs" in California, the " Idaho Hot Springs" 
in Colorado, the "Warm Springs" in North Carolina, the "Warm 
Springs " in Georgia, the " Lebanon Springs " in Columbia County, the 
1 For all English Spas, see The Climates and Baths of Great Britain, by the Com- 
mittee of the Roy. Med. and Chir. Society. London, Macmillan, 1895. SYSTEM OF MEDICINE 
320 
"Warm Springs" and the "Healing Springs" in Bath County. We 
refer for the mineral waters of the United States to Dr. Walton's 
work (New York, 1883). 
Here we ought to mention the large cave of Monsummano in Italy, 
in which hot vapour is disengaged from numerous surfaces of hot 
water. The patient walks about in it as in a spacious steam-bath. The 
benefit derived by Garibaldi has brought new fame to Monsummano. 
Smaller, partly artificial excavations in the rocks of Battaglia, in the 
Euganean Hills of Upper Italy, are used in a similar way. 
Enumeration.-We can mention some of the best-known waters of 
this group in the form of a table showing at a glance the two most 
important points, viz., the elevation above sea-level and the temperature 
of the springs. 
Name of Spa. 
Country. 
Approximative 
elevation above 
Sea in feet. 
Temperature of 
Springs in Fahrenheit. 
Panticosa 
Spain (Pyrenees) 
5000 
77° to 92° 
Leuk (L65che-les-Bains) 
Switzerland 
4600 
102° to 122° 
Bormio 
Italy . 
4300 
90° to 104° 
Wildbad Gastein . 
Eastern Alps 
3300 
95° to 104-8° 
Pfseffers 
Switzerland 
2115 
100° 
Johannisbad 
Bohemia 
2000 
86° 
Bagneres de Bigorre . 
French Pyrenees. 
1850 
90° to 95° 
Ragatz 
Switzerland 
1700 
96° to 98° 
Badenweiler 
Baden. 
1425 
86° to 90-5° 
Landeck 
Prussian Silesia . 
1400 
66° to 84-2° 
Wildbad 
Wurtemberg 
1323 
95° to 98-6° 
Plombibres . 
France 
1300 
65° to 156° 
Luxeuil 
France 
1300 
65° to 163° 
Neuhaus 
Styria . 
1200 
95° 
Liebenzell . 
Wurtemberg 
1113 
72° to 82° 
Warmbrunn 
Prussian Silesia . 
1100 
97° to 104° 
Tobelbad 
Styria . 
1090 
77° to 82° 
Aix-les-Bains 
Savoy . 
1060 
86° to 120° 
Buxton 
England 
1000 
82° 
Schlangenbad 
Nassau 
900 
81-5° to 86° 
Rdmerbad and Tuffer . 
Styria 
700-800 
81-5° to 86° 
Nbris .... 
France 
800 
114° to 125° 
Teplitz 
Bohemia 
650 
95° to 120° 
Lucca .... 
Italy . 
500 
100° to 120° 
Dax .... 
France 
130 
88° to 140° 
Bath .... 
England 
100 
100° to 120° 
Action. - The water of such springs, when taken internally, acts 
probably like any other pure, not hard, ordinary warm water of the same 
temperature. We may refer for this use to the article on 4*'Hydrothera- 
peutics," restricting ourselves to the remark that warm water is more 
rapidly absorbed by the stomach, and makes less demand on the body by 
saving the expenditure of heat. We are occasionally told by some patients, 
whose words are in our note-books, that a single tumblerful of the water 
of Gastein, or Wildbad, or Buxton, or Teplitz, or Bath, has given rise to 
striking symptoms, such as the most severe headache, giddiness, inability BALNEOLOGY AND HYDROTHERAPEUTICS 
to walk, sleeplessness, etc., and, on the other side, to rapid removal of 
long-standing neuralgia, headache, sleeplessness, mental depression, 
anorexia, optic disturbances, etc. It is not impossible that these 
extraordinary effects, good as well as bad, which are quite out of pro- 
portion to the quality and quantity of the remedial agent, were due to 
imagination or suggestion. 
Uses. - Drinking courses of these waters are useful in irritable con- 
ditions of the mucous membranes of the digestive and respiratory organs, 
in gastralgia and in some forms of gout and rheumatism. 
Bathing courses often act beneficially in allaying great sensitiveness 
and excitability of the nervous system in its various spheres, and are 
therefore often resorted to in cases of neuralgia, hypersesthesia, and 
hysteria. Their reputation in painful cicatrices and rheumatism in the 
neighbourhood of old injuries is historical. In chronic rheumatism, in 
sciatica, and allied affections, in some forms of gout and their remnants, 
these waters often assist and complete the cure, especially, when com- 
bined with Swedish gymnastics and massage. 
In the choice of the most suitable spa for individual cases the situa- 
tion and climate of the spa, the elevation above sea-level, the quality of 
the bathing arrangements, and the accommodation, are to be considered; 
and not less so the skill of the medical guidance, and of the persons 
applying massage and Swedish gymnastics. 
2. Common Salt or Muriated Saline Waters. - Although common 
salt forms the principal ingredient of these waters, many of them 
contain iron, carbonates of sodium, lithium, magnesium, and calcium, 
and other chlorides; some also sulphates of sodium, magnesia, and 
lime, others sulphides and sulphuretted hydrogen, and again others 
traces of bromine and iodine and other substances. In some of these 
waters the action is no doubt modified by these admixtures, but as the 
effect of the chloride of sodium seems to predominate, they have been 
placed in this group. The difference of different springs is great, not 
only by the amount of common salt and other solid ingredients which 
they contain, but also by the presence of free carbonic acid in greater or 
smaller amount in some of them; and further by the temperature, as 
some are more or less hot, while the majority are cold. In a larger work 
it would perhaps be advantageous to make several subdivisions accord- 
ing to strength, according to temperature, according to the presence or 
absence of carbonic acid, and according to that of other solid constituents; 
but in this survey we will only mention the more important common salt 
waters, dividing them according to their situation in different countries. 
Enumeration. - The number of common salt waters in various 
countries is very great. England has the most concentrated salt waters 
or brines at Droitwich, Nantwich, Middlewich, and Ashby-de-la-Zouche. 
Droitwich, which has satisfactory arrangements and accommodation, is 
one of the best places for brine-baths. Moderate amounts of salt are 
contained in the waters of Woodhall, where they are combined with 
bromine and iodine in small quantities. Harrogate, situated in a bracing 
321 
Y 
VOL. I 322 
SYSTEM OF MEDICINE 
district of Yorkshire, the most flourishing of spas in England for drink- 
ing, and to some degree also for bathing courses, has springs of varying 
strength in common salt, combined with sulphuretted hydrogen and 
sulphide of sodium. Llandrindrod (Wales) possesses similar springs, 
rather weaker, but still useful. At Bridge of Allan, in Scotland, situated 
in a sheltered position, we have a large admixture of chloride of lime 
and sulphate of lime. Melksham (Wilts) deserves a place as well here 
as amongst the sulphated waters. At Leamington and Cheltenham the 
common salt is combined with so great a proportion of sulphates that 
these springs may be placed in the group of sulphated waters. England 
has no thermal saline waters. 
In Germany and Austro-Hungary we may mention - Kissingen, 
Homburg, Soden (on Taunus), Nauheim, Rehme-Oeynhausen, Kreuznach, 
Wiesbaden, Baden-Baden, Reichenhall, Ischl, Hall in the Tyrol, Hall in 
Wurtemberg, Hall in Austria, Kreuth, Durkheim, Niederbronn (Alsace), 
Krankenheil, Salzungen, Cannstatt, Cronthal, Aix-la-Chapelle (with sul- 
phur), to which many others could be added. Germany does not possess 
any brine-baths so concentrated as Droitwich and Nantwich, but it has 
the advantage of several waters rich in carbonic acid, as Kissingen, Hom- 
burg, Soden, Nauheim, and Rehme; and again some with elevated tem- 
peratures, as Wiesbaden, Baden-Baden, Aix-la-Chapelle, Nauheim and 
Rehme. 
Erance is rich in salt springs of elevated temperature and strong to 
medium mineralisation: Bourbonne (Haute-Marne), Balaruc (Herult), 
Bourbon 1'Archambault (Allier), Bourbon-Laney (Sabne-et-Loire), La- 
motte (Jura); Uriage (Isere), and St. Gervais (Savoie), with sulphur; 
Chatel-Guyon (Puy-de-D6me), with iron. Amongst the cold salt springs 
of France, Salins (Jura) and Brides les Bains deserve to be mentioned. 
Switzerland possesses strong salt waters at Bex and Rheinfelden. In 
Italy one of the most popular salt spas is Monte Cattini in Tuscany; 
Castro Caro likewise in Tuscany, is comparatively rich in iodine. Ischia 
and Castellamare were used in ancient times. 
Spain has in Caldas-de-Montbuy, in the province of Barcelona, a 
strong thermal salt water of great local reputation, and a weaker one in 
Caldas-de-Malavella in the province of Girone, remarkable for the large 
proportion of chloride of calcium and magnesium. 
Caldas de Rainha, in Portugal, in a beautiful situation, is a most useful 
weak thermal salt spring, impregnated with sulphuretted hydrogen. 
North America possesses St. Catherine's Wells, Michigan Congress 
Spring, Spring Lake Well, Fruit Port Well, Ballston Spa, and the much 
frequented Saratoga Springs. 
Action. - Common salt is an important constituent of all our organs 
and tissues; it is an essential part of food, and cannot be dispensed with 
for any length of time. It plays a great part in the nutrition and me- 
tabolism of our body. Owing to its easy diffusibility, a large portion 
of the salt taken in natural waters is absorbed at once in the stomach, 
while another part passes into the intestines. It stimulates the secreting BALNEOLOGY AND HYDROTHERAPEUTICS 
apparatus of the stomach and. intestines, the peristaltic action of the 
bowels, and. the circulation in the portal vein. It seems to act specially 
on the mucous membranes, and to render their secretions less viscid. 
According to Voit it increases the solubility and diffusibility of albumin, 
and his experiments corroborate those of Bischoff and Kaupp, showing 
that an increased supply of chloride of sodium causes an increase in the 
excretion of nitrogen through the urine. As many persons take at their 
meals a considerable quantity of salt in addition to that contained in the 
food itself, the extra amount taken in salt waters, say 100 to 300 grains 
at the outside, may seem unimportant; but if we take into account that 
this extra, dissolved in water, is taken on an empty stomach during half 
an hour or an hour, and that the absorption and diffusion is mostly aided 
by gentle exercise, it cannot be regarded as insignificant. 
Carbonic acid in these waters, as in other mineral waters impregnated 
with it, seems to alleviate irritation of the sensitive nerves of the stom- 
ach, and, by stimulating the minute capillaries and the secretion and 
peristaltic action of the stomach and intestines, to accelerate the pas- 
sage of the waters from the stomach into the intestines, and to promote 
action of the bowels. 
In the form of baths chloride of sodium and the other chlorides act as 
stimulants on the nerves and blood-vessels of the skin, and this stimulus 
seems to be transmitted to the nerve centres and thus to influence the 
function of internal organs. A feeling of warmth is produced by a warm 
salt bath greater than is due to the actual elevation of temperature. 
The presence of carbonic acid in the water appears to heighten these 
effects. Actual absorption of chlorides does not occur, or, at all events, 
the quantity absorbed is so small that it may be left out of consideration. 
Uses. - The common salt waters are much used in sluggish action 
of the bowels and stagnation in the branches of the portal vein, with 
the resulting troubles of dyspepsia, of congestion of the pelvic argans 
and hsemorrhoidal vessels and enlargement of the liver. They deserve 
in such conditions to be preferred to " bitter waters " (and also to the 
alkaline sulphated waters) in spare persons where emaciation is to be 
avoided. They are also useful in catarrh of the stomach and intestines, 
and also in catarrhs of the respiratory organs, where they render the 
secretion less viscid and promote expectoration. In chronic bronchitis 
their beneficial effect is, no doubt, largely due to the indirect action on 
the right ventricle and to the improvement in the contraction of the 
whole heart. Their use (especially that of the hot springs) in chronic 
rheumatism, in sciatica, and some forms of peripheric neuritis, is well 
known. Some of them have also long standing reputation in scrofula, 
as Creuznach, Krankenheil, Woodhall, and in the removal of chronic 
enlargement of the womb and remains of perimetritis. Many judicious 
gynaecologists maintain the good effects of these spas in uterine fibroids, 
although this is not generally admitted. 
3. Alkaline Waters.-Waters of this class contain carbonate of 
sodium as a prominent constituent, and, besides, a varying amount of 
323 324 
SYSTEM OF MEDICINE 
free carbonic acid; but many of the waters contain chloride of sodium, 
and others sulphate of soda in so large a proportion that we are obliged 
to make three subdivisions: - (a) Simple Alkaline Waters; Qj) Muri- 
ated Alkaline Waters; (c) Sulphated Alkaline Waters. 
Enumeration of the principal spas: - (a) Simple Akaline Waters are 
partly hot, partly cold; the hot springs are Vichy (France), Neuenahr 
(Germany), Mont Dore, Chaudes Aigues, and Neris, in France; the three 
last are feebly mineralised. Mont Dore has an appreciable amount of 
arsenic, on account of which it will again claim a place in a later class. 
The cold waters are Rohitsch in Styria, Vals (Depart. Ardeche), Obersalz- 
brunn (Silesia), Le Boulou (Pyrenees), Evian (Savoy), the Helenenquelle 
at Wildungen, Bilin (Bohemia), and a number of feebly mineralised 
waters which are used as table waters (Apollinaris, Gerolstein, Fachingen, 
Geilnau, Giesshuebel, Soulzmatt, Wilhelmsquelle, Taunusquelle). 
(ft) Muriated Akaline Waters. - The principal hot springs are Ems 
(Nassau), Roy at (Auvergne), with some lithium and arsenic; La Bour- 
boule (Auvergne), with arsenic; Chatel-Guyon (Puy-de-D6me), Szczaw- 
nicza (Galicia). The cold springs are Luhatschowitz (Bohemia), Elster 
(Saxony), Gleichenberg (Styria), Weilbach (Nassau), Toennisstein 
(Rhine) and the table waters of Roisdorf and Selters. In North Amer- 
ica the Congress Springs in California and the St. Louis Spring in Michi- 
gan belong to this class. The California Seltzer Springs contain a large 
amount of carbonate of magnesium. 
(c) Sulphated Akaline Waters. - The different springs of Carlsbad 
(Bohemia) are all more or less hot; the weak springs of Bertrich (Rhen- 
ish Prussia) are lukewarm (87° F.); Marienbad (Bohemia), Franzensbad 
(Bohemia), Elster (Saxony), and Tarasp (Switzerland) are cold, as also 
Rohitsch (Styria) and a weak spring at Fuered (Hungary). 
Action. - Like chloride of sodium, so also is carbonate of sodium an 
important constituent of the human body, and plays a part in its metab- 
olism. Liebig surmised that it acted as vehicle for the carbonic acid 
from the blood to the lungs. It has a great share in the secretion of 
saliva, bile, pancreatic juice, and the digestive processes. Introduced 
into the stomach, carbonate of soda neutralises the acidity of the gastric 
secretion, and acts as an antacid; it increases the flow of bile and renders 
it more fluid; it also renders the intestinal mucus less viscid, and acts as 
a diuretic. In large doses it is apt to cause emaciation; in small doses 
it rarely has this effect. The combination with common salt in the 
muriated alkaline waters further counteracts the emaciating and weaken- 
ing tendency of the pure alkaline waters, besides which some of the action 
of common salt mentioned under that head is brought about. A greatly 
modified effect is exercised by the combination with sulphate of soda 
in the sulphated alkaline waters. The laxative effect of this salt is 
predominant; it may be due to stimulation of the nerve ends in the 
mucous membrane, or to increased exosmosis, or both combined. The 
increased movement in the intestinal walls leads to more rapid flow of 
blood in the branches of the portal vein and in the liver itself, and BALNEOLOGY AND HYDROTHERAPEUTLCS 
325 
further assists in the fluidifying effects of the alkalies on the bile and 
intestinal mucus. By easing the portal circulation the contractions of a 
dilated heart are improved, and chronic pulmonary catarrh is relieved. 
Uses. - Alkaline waters are serviceable in certain forms of dyspepsia 
where there is a tendency to excessive formation of acid in the stomach, 
and especially in those cases where this tendency is combined with 
catarrh of the stomach and intestines; but they are injurious in catarrhal 
conditions of the digestive organs with deficiency of acidity, as often 
occurs in anaemia, chlorosis, and convalescence from acute disease. The 
muriated alkaline waters act beneficially in chronic catarrh of the respira- 
tory organs. The sulphated alkaline waters are often very helpful in 
atonic constipation, with all its injurious effects on the blood, on the 
circulation of the portal vein, and consequent passive congestion of the 
liver; also in tendency to gall-stones, and to uric acid gravel; in some 
forms of gout, and in the glycosuria of gouty and corpulent persons. 
4. Sulphated Waters, or Bitter Waters. - We will apply this name 
to the waters containing as their active constituent the sulphates of mag- 
nesium and sodium. Some of them contain sufficient amounts of chloride 
of sodium to produce an alteration in their effects. The majority of 
these waters are used at home, not by residence at the spas. 
Enumeration. - Franz Joseph, Hunyadi Janos, .Bsculap, and other 
"Hungarian Bitter Waters"; Rubinat (Spain), Birmensdorf (Switzer- 
land), Pullna (Bohemia), Sedlitz (Bohemia), Saidschutz (Bohemia), Mont- 
mirail (Dep. Vaucluse), Friedrich shall (Saxe-Meiningen), Mergentheim 
(Wurtemberg), Melksham (Wilts), these three with a large proportion 
of chloride of sodium; the Victoria Spa (near Stratford-on-Avon), Purton 
Spa (Wilts), Cherry Rock (Gloucester), Scarborough (Yorkshire), Leam- 
ington and Cheltenham (yide Common Salt Waters). 
In this class we may mention Brides-les-Bains in Savoy, with hot 
mixed sulphated saline springs, containing the sulphates of sodium and 
calcium and chloride of sodium. These are the only waters of this class 
which are principally taken not at a distance, but at the place itself 
which is situated in a beautiful valley, south of the Mont Blanc chain. 
Action. - In moderate doses these waters stimulate the mucous mem- 
brane of the digestive tract, and increase at the same time the peristaltic 
actions. In larger doses they cause watery motions. Their action is similar 
to that of the sulphated alkaline waters described in the preceding class. 
Uses. - They are used in habitual constipation, with sluggish circula- 
tion in the portal vein and its branches, in passive congestion of the liver, 
and in excessive corpulency. They have the reputation of removing the 
latter by an accelerating influence on the retrogressive tissue change of 
proteinaceous substances. Whether this be so or not, no doubt they 
remove the alimentary substances from the intestines before all the 
nutrient has been absorbed; they act therefore as abstractors, and, 
unless an increased amount of food is taken, the weight must decrease. 
We often hear that bitter waters are quite mild, certain, and easy 
aperients; this is the rule with many persons, but the exceptions to this 326 
SYSTEM OF MEDICINE 
rule are rather frequent. They act injuriously in most cases of chronic 
peritonitis and of the resulting adhesions, in ulcers of the stomach and 
intestines, and in cancerous affections of these organs. 
We have sometimes heard that it is more simple to prescribe a certain 
amount of sulphates in substance and administer them dissolved in hot or 
cold water; but in our trials of this plan we have frequently found that 
a much larger dose of the salts thus prescribed was required in order to 
produce the same aperient effect as a dose of mineral water containing a 
smaller quantity of bitter salts. We have noticed this especially in 
using the more composite waters such as Friedrichshall, or Franz Joseph, 
or Hunyadi, or the sulphated alkaline waters of the preceding class: 
in like manner a larger quantity of the dried natural salts (say of 
Carlsbad salts) seem to be required than would correspond to the active 
quantity of the mineral waters at say one of the Carlsbad springs. It is 
probable that not all the substances contained in the mineral water are 
contained in the same conditions and combinations in the salts obtained 
from it; one point is evident, viz., that the free carbonic acid is lost in 
the salts. The latter defect may often be corrected by taking the salts 
in one of the natural acidulated table waters, or in a salutaris " or soda 
water. Possibly, also, the preparation of these so-called " natural salts " 
is not always accurate, and indeed may be in some much employed salts 
intentionally modified, so as to furnish transparent crystallised instead 
of opaque amorphous salts. 
5. Iron or Chalybeate Waters. - This term is applied to those springs 
in which the proportion of iron to the other ingredients is large enough 
to produce a therapeutic effect. A great many of the mineral waters 
enumerated in other classes contain iron; but the amount of other con- 
stituents is considered to predominate over the iron. The iron is mostly 
contained in them as a bicarbonate, with free carbonic acid, and the 
quantity rarely exceeds four-tenths to six-tenths of a grain in sixteen 
ounces of water. There are some springs with sulphate of iron in rather 
larger quantity, but they are rarely used therapeutically. We may 
divide the iron springs into - (a) pure iron waters containing only a few 
grains of other substances in sixteen ounces of water; and (&) mixed 
iron waters which contain, besides the iron, a larger but still a small 
amount of other substances, enough to alter somewhat the character 
without removing the predominant effect of iron. There is, however, 
no strict line of division between these groups. 
Enumeration. - (a) Pure or comparatively pure iron waters. - Schwal- 
bach (Nassau), Spa (Belgium), Ceresole Reale in Piedmont, Koenigswarth 
(Bohemia), Orezza (Corsica), Schandau (Saxony), Alexisbad (Harz Moun- 
tains), Briickenau (Bavaria), Flitwick«(Beds), Tunbridge Wells (Kent), 
Charbonnieres (Rhone, France). (&) Mixed iron waters contain, in addi- 
tion to bicarbonate of iron, bicarbonates of sodium, magnesium or calcium, 
as Arapatak (Transylvania), Griesbach (Baden), Liebenstein (Thuringen), 
with bicarbonate of lime; St. Moritz (Oberengadin), Santa Catarina 
(Northern Italy), Pyrmont (Waldeck), Recoaro (Northern Italy), Reinerz BALNEOLOGY AND HYDROTHERAPEUTICS 
327 
(Silesia), Sternberg (Bohemia), G-odesberg (Rhenish Prussia), Booklet 
(Bavaria), Imnau (Wiirtemberg), Cudowa (Silesia), Kohlgrub (Bavarian 
Tyrol), Cambray Chalybeate (Cheltenham). 
Some possess an appreciable amount of sulphate of soda, as Rippold- 
sau (Baden) and Driburg (Westphalia), the " Stahlquelle" and " Kalte 
Sprudel " at Pranzensbad (Bohemia), Elster (Saxony). 
France possesses two thermal iron springs in Rennes-les-Bains 
(Aude), and Sylvanes (Aveyron). 
A strong iron water is that of Muskau (Silesia), which contains both 
carbonate and sulphate of iron. 
The arsenic waters of Roncegno and Levico, in the Austrian part 
of the Italian Tyrol, contain large proportions of sulphate of iron. 
Action. -The points accepted by the majority of medical men as to 
the effects of iron waters are: - Increased formation of blood globules ; 
improved contractility of the circulating apparatus, including the heart; 
better oxidation and heat production; improvement in appetite and 
general nutrition. A small quantity only of iron is absorbed by the 
stomach, and none by the skin. The baths of the pure iron springs 
seem to act like ordinary water-baths impregnated with carbonic acid. 
Uses. - Iron waters are, in the minds of most people, the best remedy 
for aneemia; but their use in this respect is perhaps overrated. There 
are many cases of ansemia which are not improved, but aggravated, not 
only by pharmaceutical preparations of iron, but also by iron waters. 
Anaemia and chlorosis are often caused by constipation and poisoning 
by ptomaines. In these cases pure iron waters are mostly injurious, 
while some of the common salt waters and sulphated waters, with or 
without small proportions of iron, are useful. Many other morbid 
conditions complicated with anaemia - for instance, malarial cachexia 
and some chronic skin diseases - are likewise rarely cured by pure iron 
waters, and this reminds one forcibly of the prescriptions of some very 
successful practitioners who combine good doses of sulphate of soda or 
sulphate of magnesia with iron whenever they prescribed the latter. 
There are, however, some cases of pure anaemia and some complications 
of neuralgia, sterility, impotency, and general debility complicated with 
anaemia, which are benefited by iron waters in drinking as well as bathing 
courses. In some cases of this kind the compound iron and arsenic 
waters are indicated. 
We have mentioned under the head of simple thermal waters that the 
degree of elevation above sea-level must be regarded as an important 
point in the effects produced on the invalid. These remarks are 
applicable to all the different spas, but especially to the chalybeate class. 
A course of waters, say of a month, at St. Moritz, or Ceresole Reale, or 
Santa Catarina, between 5000 and 6000 feet above sea-level, has a 
different effect on the constitution from that of similarly constituted 
waters at elevations below 1000 feet. 
6. Arsenic Waters. - There are no pure arsenic waters, but the waters 
containing arsenic in appreciable amounts contain also either iron or 328 
SYSTEM OF MEDICINE 
saline substances. Arsenic is, however, so powerful a substance that we 
venture to place these waters together in a small separate group, in order 
to direct more attention to them. The group will perhaps be enlarged 
by further discoveries. 
The strongest arsenic waters used at present are those of Roncegno 
and Levico, which possess sulphate of iron combined with arsenic; they 
are both situated in the Southern Tyrol, not far from Trento. They are 
both so strong that the doses required are small, and that they are advan- 
tageously diluted with warm water, or with one of the acidulous table 
waters, or with wine, and taken at or after meals in doses of one or two 
teaspoonfuls, increasing gradually to two tablespoonfuls. It is advis- 
able to commence with small doses, and carefully to watch the effect, as 
in some persons they occasionally cause digestive derangements, such 
as diarrhoea; and in others constipation. 
There are now fair hotels both at Levico and Roncegno, but the 
waters are more used away from the spas themselves. 
At Vai Senistra, in the Lower Engadine, are springs containing 
arsenic in smaller quantity (one-fifth of the strength of Roncegno and 
Levico), combined with carbonate of iron and carbonate of soda. 
Ceresole Reale, in Piedmont, has, in addition to bicarbonate of iron, 
small quantities of arsenic; it is situated in a beautiful and bracing 
locality, and has good accommodation. 
Uses. - These arsenical chalybeate waters are applicable to the same 
ailments as are the pure and mixed iron waters, but specially deserve 
a trial in chronic skin affections with anaemia, and in lymphatic and 
glandular diseases, and in malarial cachexia. 
La Bourboule, which we have mentioned already amongst the warm 
muriated alkaline waters, has so appreciable an amount of arsenic that 
it demands a preference over other muriated alkaline waters in chronic 
skin diseases, and may also assist in the treatment of chronic phthisis. 
Mont Dore, with a smaller amount of arsenic and alkaline substance 
than La Bourboule, has a much greater reputation in the treatment of 
asthma. This is probably due in part to its higher elevation, and in 
part to the very energetic use of inhalations; which, however, require 
careful management in delicate persons. 
7. Sulphur Waters. - They contain either sulphide of sodium, cal- 
cium, potassium, or magnesium, or sulphuretted hydrogen in an appreci- 
able and fairly constant proportion. 
In some of the springs, as at Aix-les-Bains and Landeck, the quantity 
of sulphur is so small that they may be placed amongst the simple 
thermal waters. 
In other sulphur waters the amount of chloride of sodium and other 
solid substances is so large that they find a place in other classes; such, 
for instance, is the case with Harrogate, Llandrindod, Uriage, Aix-la- 
Chapelle, Caldas de Rainha, Mehadia, the Columbia Springs, and the 
Louisville Artesian Well in the U. S. A. Many of these springs are 
thermal, but some are cold. BALNEOLOGY AND HYDROTHERAPEUTLCS 
Enumeration. - The best thermal sulphur waters are those of the 
French Pyrenees - Eaux Bonnes, Eaux Chanties, Cauterets, Bareges, St. 
Sauveur, Bagneres de Luchon, Le Vernet, Amelie-les-Bains- which all 
contain the sulphur as sulphide of sodium, and are situated at fair 
elevations. 
Other hot sulphur wraters of great reputation are - Baden, Lavey, and 
Schinznach in Switzerland; Aix-les-Bains andUriagein France; Aix-la 
Chapelle and Burtscheicl in Germany; Landeck in Silesia; Baden in 
Austria; Mehadia and Pystjan and others in Hungary; Battaglia and 
Acqui in Piedmont; Abano in the Euganean Mountains of Northern 
Italy ; Panticosa in the Spanish Pyrenees; Trillo near Madrid; Caldas 
de Rainha in Portugal; Helouan in the Arabian desert near Cairo. 
Amongst the cold springs Harrogate is best known in England, Llan- 
drindod and Builth in Wales, Strathpeffer and Moffat in Scotland, 
Lisdoonvarna in Ireland; Chalies, Enghien, and two springs at Ba- 
gneres-de-Bigorre in France ; Eilsen, Nenndorf, Weilbach, Meinberg in 
Germany; Alveneu, Gurnigel, Stachelberg, and Heustrich in Switzerland. 
Action. - Sulphuretted hydrogen is absorbed by the skin and by the 
stomach, and we know that larger quantities are poisonous by depressing 
the action of the heart, and by decomposing the blood globules. It is, 
however, difficult to account for the alleged action of such small 
quantities as are taken up by the system during drinking and bathing 
courses. They are said to act as cholagogues, but this is not clearly 
demonstrated by experiments. 
Uses. - They are used in chronic rheumatism and gout, but hot baths 
and hot water drinking are likewise beneficial, and it is not certain that 
the presence of small quantities of sulphur adds much to the effect of 
hot water; the same may be said with regard to some chronic skin 
diseases. Chronic bronchial, laryngeal and pharyngeal catarrh are 
benefited; and often also hsemorrhoidal conditions. We have occasion- 
ally seen good effects in conditions of great irritability of the heart with 
palpitation. The ancient reputation of their good effects in poisoning 
with mercury or lead has become doubtful. Much has been written about 
the action of these waters in syphilis, but we must not forget that the 
successful physicians at these spas make most energetic use of mercury. 
8. Earthy or Calcareous Waters.-Carbonate and sulphate of lime 
and carbonate of magnesia are the principal constituents. 
Enumeration. - Contrexeville, Vittel, Bagneres-de-Bigorre, Pougues, 
St. Arnaud, Cransac (contains also manganese and alum) in France; Wil- 
dungen, Lippspringe and Inselbad, in Germany ; Alzola and Fitero, 
the latter with hot springs, in Spain; Chianciano, with hot- springs, in 
Central Italy; Weissenburg in Switzerland. In North America the best- 
known earthy springs are - the Butterworth Springs, Eaton Rapid 
Wells, and Leslie Well in Michigan; the Gettysburg Spring in Penn- 
sylvania, the Sweet Springs in West Virginia, and the Alleghany Springs 
in Virginia. The table waters, St. Galmier, Couzan and Taunus, may be 
placed in this class. Many of the waters mentioned in other classes con- 
329 SYSTEM OF MEDICINE 
330 
tain much calcareous matter, as Bath, Loeche, Bormio, Lucca and Fiired, 
classed amongst the simple thermal waters; and Baden in Austria, Baden 
in Switzerland, Schinznach, Battaglia and Abano amongst the sulphur 
waters. 
Action. - Internally taken these waters exercise, through the car- 
bonate of calcium, an antacid and also soothing effect on the mucous 
membranes, and are at the same time slightly astringent and constipat- 
ing, especially when they contain much sulphate of lime. In bathing 
courses their action is nearly the same as that of simple hot water. 
Uses. - They are useful in dyspepsia, with irritability of the mucous 
membrane, acidity, and diarrhoea. Some of these waters possess a great 
reputation in proclivity to gravel and stone, and to chronic catarrh of the 
bladder. They are used also in biliary concretions, and in gouty condi- 
tions. Their good effects are probably due in a great degree to the cir- 
cumstance that these waters can be taken in large quantities, and thus 
exercise a washing-out effect. In cases of actual stone in the bladder, or 
in the kidney, the use of these waters is of doubtful value; the concre- 
tions may be actually increased by fresh deposits around them. 
A speciality at some springs, especially at Loeche in Switzerland, is 
the treatment of chronic eczema, psoriasis, and other chronic skin diseases, 
by hot baths prolonged over several hours, and this treatment is not rarely 
successful, at all events for a certain time; but relapses are rather com- 
mon. 
II. Therapeutic Employment of Mineral Waters 
There is perhaps no section of medicine about which the ideas of the 
educated classes, including many members of our own profession, are 
so vague as about the effects of courses of mineral waters and baths, 
especially at foreign spas. On the one side we hear very often that the 
good effects produced by spa treatment abroad are due not to the waters 
and baths, but only to the concomitant influences, such as change of 
locality and habits of living; on the other, we hear that the waters 
alone are the curing agents, and that they have, or ought to have, the 
same effect when taken at home. Both views are, however, defective, 
and based on imperfect observation. The error of the former assertion 
is due to inferences from cases where the aberrations from health are 
not great, and are caused only by faults of home life, such as indul- 
gence in food, irregular hours, social or business worry, excessive or 
unsuccessful work, acute or chronic mental shocks, want of exercise, and 
unhygienic arrangements. It is not quite so easy to show the error of 
the latter view, but it is equally real with regard to the majority of 
invalids. It is a great tax on the system to digest compound mineral 
waters. There are, it is true, strong persons with imperfect portal cir- 
culation, dyspepsia, hsemorrhoidal congestion, and inactive liver, who are 
able to right themselves by good purgative waters; and can take with 
advantage even courses of Carlsbad or Kissingen waters while continu- 
ing their usual diet and their daily work; but the majority of invalids, 2?/?ZA7?0Z<9(7y AND HYDROTHERAPEUTICS 
331 
especially those with a delicate constitution, or with a weak heart, do not 
possess the amount of vital force sufficient for the digestion of these 
waters, if at the same time their brain or their mind is taxed, if they 
have to go into society, and take long or large meals in close rooms. 
They often break down utterly if they attempt to do so. Even at 
country houses many people cannot disengage their minds to such a 
degree as to be able to bear these waters; and at the spas themselves it 
often happens that success is entirely spoilt by attention to letters from 
home, especially about business or family worries. 
On the other hand, we have to deal with the opposite error, viz., the 
belief of many persons that the power of foreign waters is so great that 
they think they can remove large tumours, fatty or bony, or carcino- 
matous ; that they can unbend contracted limbs; that they can restore 
the muscles wasted from infantile paralysis, or the functions lost from 
senile decay. Incredible as this may appear to the educated medical 
man, such ideas persist in the high places of society. It is, therefore, 
very desirable that our profession should devote more attention to this 
important branch of treatment, and should diffuse general knowledge on 
the subject amongst the public. For this purpose a few lectures ought 
to be given regularly at our medical schools on balneo-therapeutics, and 
also on climato-therapeutics, as a part of the course of Materia Medica. 
We ought not to be deterred from such a course by the great difficulties 
which beset the subject, to which we can but briefly allude. While 
in our pharmaceutical remedies we have to deal with more or less fixed 
and simple substances, most of the mineral waters are compound; and, 
even if we know to some degree the action of the constituents severally, 
we often cannot accurately calculate the share which each of these sub- 
stances plays in combination with the others, or their mutual interaction 
- points to which we have already alluded in the description of 
the different classes of mineral waters. We may call to mind some- 
thing analogous in our ordinary treatment when we prescribe compound 
aperient pills, or compound sedative draughts. Another point of some 
uncertainty is that we prescribe the waters according to their most 
prominent ingredients, but we cannot be perfectly sure that the sub- 
stances present in small quantities do not play a more important part 
in the action of the whole water than we generally concede to them. 
We must acknowledge that we have, as yet, no scientific basis for 
balneo-therapeutics. Our position is still entirely empirical, based on 
the observation and experience of physicians and patients as to the 
effects of certain waters and cures, either at home or at the spas; but 
with all the admissions as to our exactness of knowledge, we are 
obliged to grant that special bathing and drinking cures are most 
efficacious in many chronic morbid conditions, and cannot be replaced 
by any other modes of treatment (32). 
We will now endeavour to give a short sketch of the main points 
which are to be considered by the practitioner who is asked about 
mineral waters and baths. We must begin in every case with the 332 
SYSTEM OF MEDICINE 
question, whether balneo-therapeutic treatment offers advantages over 
the ordinary medical treatment; and then consider whether this treat- 
ment ought to be carried out at home or abroad, and whether it is to 
be preceded or followed by pharmaceutical or other treatment, or com- 
bined with it. When the question is decided in favour of balneo- 
therapeutic treatment, we have to regard not only the name and nature 
of disease, but have to study all the conditions and habits of the 
individual before us, pecuniary, physical, and psychical; his constitution 
in general; his power of reaction; whether the different organs are 
healthy or not; whether they can take up increased work in order to 
relieve the diseased part; whether they are able or unable to respond to 
any unusual demand. Thus we shall learn whether stronger thera- 
peutic action is permitted; whether rougher journeys and accommoda- 
tion, colder climates and seasons can be borne; or whether gentle 
treatment is necessary, with easy journeys, warm seasons, mountain 
climates of moderate elevation, sheltered and sunny habitations, and 
delicate food. 
The chemical constitution of the waters alone is not sufficient for 
our selection of the place; we must know the accustomed methods of 
treatment at certain localities, the accommodation, the quality of food 
and the cooking, the climate, the social elements likely to be found, and 
above all the qualities of the local physician to be selected for the 
treatment of the case. 
It must be evident from these remarks that the same morbid con- 
dition may in different persons require different localities and even 
different classes of mineral waters; and, further, that diseases of different 
nature may be benefited at the same spa, by adapting the various 
bathing procedures, the doses and temperature of water to be drunk to 
the individual case, and by selecting, when there are different springs 
at the same place, the most suitable one. Often the treatment must be 
at first of a tentative nature, requiring the most careful watching by the 
local physician, and perhaps frequent alterations. In many cases it is 
impossible to attack the principal complaint, and our efforts must be 
directed towards improving the general condition, by which means very 
often the diseased portion of the organism is drawn into the stream of 
general improvement. 
Taking the different points just alluded to into consideration, every 
one will see how much depends on the local physician ; and that it is not 
in the interest of the patient to prescribe the course of treatment, either 
directly or indirectly: though it is often advisable for the home practi- 
tioner to make suggestions based on previous experience. 
We will now sketch the applicability of waters to some morbid con- 
ditions, but must limit ourselves for want of space to a few states only. 
1. Tardy or imperfect convalescence is the condition of many 
persons inquiring about waters, and the nature of these cases varies con- 
siderably. All have this in common, that they are in a state of insta- 
bility ; their balance is easily upset. Any increased demand on their BALNEOLOGY AND HYDROTHERAPEUTLCS 
nerve power, or on their digestive functions, may lead to illness; the 
nerves and blood-vessels of the skin are weak; and comparatively slight 
exposure leads to chill and to more or less grave results. In advising 
we must therefore be careful to warn against fatiguing journeys, 
irregular or heavy meals', long cold drives, and so forth. The majority 
do not require spa treatment; when they do, spas not too distant, 
with gentle treatment and good accommodation, in sheltered positions 
at medium elevations, are to be recommended; or change of air alone 
without spa treatment at the beginning. Later, iron waters or common 
salt waters are often useful. If there be still remains of disease, each 
such case will require special consideration. 
In the exudations of perimetritis, for instance, after miscarriage or 
confinement, the common salt waters, such as Kreuznach, Kissingen, 
Woodhall are useful. 
If after rheumatic fever the skin remains weak, the joints painful, 
the heart dilated, with or without some valvular complication, the 
thermal gaseous saline waters of Nauheim and Rehme are of great 
value, sometimes assisted by Schott's movements with resistance. 
If tendency to diarrhoea be a prominent symptom, Plombieres is 
often useful; if much neuralgia without organic cause, Schlangenbad; 
if chronic bronchial catarrh, the muriated or muriated alkaline waters 
of Soden, of Gleichenberg, of La Bourboule, or of Baden-Baden. 
2. Abdominal venosity is a prominent feature of many chronic 
ailments, not only of the abdominal, but also of the circulatory and 
respiratory organs - of obesity, of drowsiness, of aneemia, of glycosuria, 
etc. The term used by the old German authors, Abdominal plethora, 
is very significant. It is often the cause of piles, of the enlargement 
of the liver, of chronic pulmonary catarrh, and so on; and is generally 
part of a weak organic fibre in the whole system, of the heart and all 
the blood-vessels, especially of the capillaries and veins, but also of the 
intestines and of the mucous membranes. Dietetic and hygienic man- 
agement, the various forms of active and passive exercise, are pre- 
eminently useful, but these are greatly assisted and must sometimes be 
preceded by waters: here the alkaline sulphated, the " bitter waters," 
the common salt waters are most useful, for an account of which we 
refer to the first part of this contribution. 
3. Diseases of the Respiratory Organs. - Climato-therapeutic treat- 
ment is, in the majority of cases, more important than waters, but the 
latter in many conditions may be a great help, and in others deserve the 
first place. 
In chronic catarrh of the bronchial tubes the alkaline and muriatic 
alkaline waters and the sulphur waters are beneficial; and when it owes 
its origin to abdominal venosity, the recommendations of the previous 
section find a place. When the dilatation of the heart is the prominent 
feature, the waters and baths of Nauheim, assisted by the movements 
with resistance, are required. 
Emphysema comes more or less under the same head. Climatically 
333 334 
SYSTEM OF MEDICINE 
the saps of G-leichenberg in Styria and of the Pyrenees are well adapted 
to these cases, and so is Ems in the earlier or later summer. 
Chronic naso-pharyngitis, if it be not connected with adenoid 
growths, requires likewise alkaline muriated or sulphur waters, or the 
arsenical waters of Mont Dore with inhalations. 
Imperfect resolution of pneumonia needs climatic and careful hygienic 
management, and sulphur and alkaline muriated waters, but with careful 
avoidance of exposure to the raw morning air while taking the early 
draughts. 
Asthma depends on various causes, and accordingly requires various 
modes of treatment by drugs and water and climate, or is not amenable 
to any. The catarrhal form in fairly robust persons is often greatly 
relieved by the treatment at Mont Dore. 
4. Diseases of the Heart. - We restrict ourselves to a few remarks. 
Many cases are not suited to long journeys and treatment by waters. 
Fatty hearts or weak hearts in fat persons are mostly benefited by 
diet, combined with active and passive exercise and with sulphated 
alkaline and bitter waters. For dilated hearts associated with abdominal 
venosity, see sub-section 2. 
In valvular affections with great anaemia iron waters are often useful; 
but in many cases aperient waters or pharmaceutical preparations, and 
Swedish gymnastics, must be combined with chalybeate waters. 
In weak and moderately dilated hearts graduated exercise (Oertl) 
is better than baths; but if the dilatation be great, whether with or 
without valvular disease, the cautious use of the baths of Nauheim, 
assisted by movements with resistance, must precede the voluntary move- 
ment with climbing. In some cases treatment at home on the Nauheim 
plan must precede the journey abroad; and sometimes we must not be 
deterred from such measures by seemingly advanced symptoms. 
Recent valvular affections resulting from rheumatic fever we have 
already mentioned in sub-section 1. 
5. In Anaemia we have to consider whether it is caused- (a) by direct 
loss of blood or albuminous and mucous discharges; (b) by constipation 
and impeded abdominal circulation; (c) by inability to take food, sleep- 
lessness, mental shocks and worry, neuralgia, etc.; (d) by diseases of the 
lymphatic glands; or (e) by malarious affections and consequent affec- 
tion of the spleen and liver. The more a case belongs to (a) the more 
likely is the effect of iron to be beneficial; and the physician has to 
decide whether chalybeate spa treatment offers advantages over pharma- 
ceutical preparations. In the group (6) chloride of sodium waters are 
mostly preferable at first to pure steel waters; and a course of the latter, 
or of climatic treatment, or of both combined, may in many cases follow 
with advantage. In (c) climatic change alone is often more important 
than waters. In (d) the use of muriated saline and of arsenic waters 
may be tried; but they often fail, and ought at all events to be followed 
by long sea-side residence or sea-voyages. In (e) the muriated or sul- 
phated saline waters at mountain localities ought to be combined with BALNEOLOGY AND HYDROTHERAPEUTLCS 
335 
iron or arsenic, and followed by long residence at high elevations or 
occasionally sea-side places. 
6. Gravel and Stone. - In the uric acid varieties the alkaline waters 
are generally prescribed, but great care is necessary not to allow the 
urine to become too alkaline, since this may lead to deposition of phos- 
phates around a small uric acid stone. A better plan, in general, is to 
order the sulphated alkaline waters, especially the hot waters of Carls- 
bad, in the numerous cases where a certain amount of abdominal venosity 
and sluggish circulation of the liver are among the causes of gravel. 
We have already mentioned that it is difficult to explain the great 
reputation of earthy waters in gravel, and that their effect is probably 
due to the administration of such waters in large quantities, so as to pro- 
duce a washing out effect, which probably would be obtained quite as 
well by the systematic drinking of large amounts of hot water on an 
empty stomach. 
7. Gout occurs in widely-differing constitutions, varies widely in de- 
gree, and may or may not be complicated with many other morbid affec- 
tions. If we have to deal with persons of so-called " full habit " - with 
portal venosity, sluggish liver, and a urine of rather high specific grav- 
ity, loaded with urates and uric acid-the sulphated alkaline or mild 
bitter waters are indicated, especially Carlsbad, Marienbad, Tarasp, 
Franzensbad, Elster, Brides-les-Bains. All courses of the stronger waters 
ought to be followed by a long rest with careful diet in good air before 
returning to the daily life; and this is pre-eminently the case with the 
courses just mentioned. If such a long rest be impossible, a less search- 
ing course ought to be recommended, such as, according to the nature of 
the case, Homburg, Kissingen, Harrogate, Leamington, Royat, Contrexe- 
ville, La Bourboule, Wiesbaden, Baden-Baden, Aix-la-Chapelle, Uriage, 
Aix-les-Bains, Bagneres de Luchon. A shorter rest is usually sufficient 
after these waters. In many delicate persons, especially if time be lim- 
ited, the simple thermal waters are preferable - Buxton, Bath, Wildbad, 
Ragatz, Schlangenbad, Teplitz, Gastein. Numerous cases of gout, how- 
ever, are not suitable for mineral water treatment, and will be found 
more amenable to pharmaceutical remedies, diet, and climate. 
8. Chronic Rheumatism. - In cases associated with exudation round 
the joints, the hot thermal treatment is very useful; and it must 
frequently be combined with various forms of massage and Swedish 
gymnastics. The simple thermal waters, the hot sulphur waters, the 
muriated saline waters, can be employed with success. Chronic mus- 
cular rheumatism is amenable to similar treatment. In cases com- 
bined with affection of the heart, especially with dilatation, the tepid 
gaseous saline waters of Nauheim are preferable, associated with Schott's 
modification of Ling's system. Many cases are well suited to simple 
hydrotherapeutic treatment. 
9. Diabetes and Glycosuria. - It is not long since some alkaline and 
sulphated alkaline waters, especially Vichy, Carlsbad, and Neuenahr, were 
thought to exercise a specific influence on these complaints ; but reason 336 
SYSTEM OF MEDICINE 
and experience have proved this view to be erroneous. It is quite 
true that in the milder forms of glycosuria courses of treatment at these 
spas improve the general health, and greatly diminish or temporarily 
remove the sugar from the urine. This, however, is due in the first 
place to the arrangement of diet, in the second to improvement of the 
digestive organs and functions by the use of the waters, and, thirdly, to 
the removal of the patients from the worries of life at home. In the 
frequent cases of chronic glycosuria in fat and gouty persons, sulphated 
alkaline waters are beneficial, and the more bracing the climate the 
better. 
10. Diseases of the Nervous System. - Spa treatment is, as a rule, 
not applicable to mental diseases, although milder forms of hypochondri- 
asis and melancholia, if they depend on chronic constipation or abdominal 
venosity, may be favourably influenced by the waters mentioned under 
that head. Epilepsy is likewise to be excluded, and also locomotor at- 
axy, unless they depend on syphilis, which will be presently discussed. 
Nerve exhaustion and neurasthenia in their various forms and degree 
may, according to the nature of the cases, be treated at chalybeate, 
or thermal muriated saline, or simple tepid spas; but such treatment 
can only take a small share in the judicious general management, which 
must be pursued during a long period of time. 
Neuralgic affections are often relieved by spa treatment, if they can 
be referred to gout, to anaemia, or to nerve exhaustion; and the selec- 
tion of the spa must depend on these considerations. 
11. Affections of the Female Sexual Organs are frequently treated 
at spas, although such treatment is not always required. Chronic con- 
gestion of the womb, especially in consequence of confinements and 
miscarriages, can be greatly benefited by the muriated saline, by the 
alkaline, and also by the simple and the sulphurous thermal waters. The 
deposits round the pelvic organs from perimetritis are often removed by 
the careful use of the muriated saline waters. Many gynaecologists, both 
in this country and abroad, have great faith in the effect of these waters 
(especially those of Creuznach) in fibrous tumours of the uterus. 
12. Syphilis is regarded by many persons as one of the diseases 
which can be cured by the use of mineral waters; but all that can be 
said is that the use of other remedies may be assisted by them. It often 
happens that the energetic use of hydrargyrum cannot be carried out 
under the usual circumstances of home life, and that it is facilitated by 
the methodic employment of hot baths and vapour baths, and the careful 
management of the manner of living, so as to avoid chills, and other injuri- 
ous influences. Thus certain spas, like Aix-la-Chapelle, have acquired a 
great reputation in the treatment of syphilitic affections, especially those 
of secondary and tertiary phases. In this way many cases of affections 
of the skin, of the mucous membranes, of the muscles and organs of 
circulation, of the brain and spinal marrow, epilepsy and locomotor ataxy, 
on a syphilitic basis, are cured or benefited more or less permanently, or 
again it may be but transitorily, by treatment at spas; but generally BALNEOLOGY AND HYDROTHERAPEUTLCS 
337 
not by mere spa treatment. This applies as well to acquired as to 
inherited syphilitic affections. As in home treatment, so also at spas, it 
is often found that serious affections on a syphilitic basis are no longer 
amenable to anti-syphilitic treatment, and that the latter does more harm 
than good. In such cases the means for the improvement of the general 
health are all that remain to us, and herein climate and spas may take 
again their humble share according to the nature of the cases. 
We might mention a number of other morbid conditions which can 
be relieved by spa treatment, but for a mere survey the preceding classes 
of affections are probably sufficient. We can also dispense with sugges- 
tions about diet and manner of living, as each individual case ought to 
be considered in itself by the local physician, whose assistance, as we 
have already urged, is indispensable. 
Seasons for Spa Treatment. - A few words as to the times of the 
year to be selected are perhaps not out of place. Climate and weather 
are important agents in spa treatment. Most delicate persons are better 
in summer than in winter; spa treatment has, therefore, a greater chance 
of doing good in summer. Extreme heat, however, is to be avoided in 
most cases, and spas which are very hot in the middle of summer, such 
as Wiesbaden, Ems, Aix-les-Bains, Vichy, Baden-Baden, Bath, ought 
therefore, as a rule, not to be visited in July and the beginning of August, 
but in the earlier and later parts of the summer. On the other hand, 
spas at high elevations, such as St. Moritz and Tarasp, ought to be 
recommended only between the middle of June and September. Few 
resorts are open earlier than May or later than September; but some 
of the hot springs, as Bath, Aix-la-Chapelle, Wiesbaden, Baden-Baden, 
Amelie-les-Bains, and Dax, are available during the whole of the year. 
It must be borne in mind, however, that much greater care is required 
in the hot baths during the colder months, and that the exhilarating 
influence of fine weather is mostly wanting. 
Duration of Courses of Spa Treatment. -Formerly it was the custom 
to have fixed periods for the treatment at different spas, say three, four, 
or five weeks; but in the light of increased knowledge, we have learnt 
that it is in many instances impossible to fix at the outset the length 
of the course - just as it is often impossible to say, on prescribing iron 
■or arsenic, that it is to be continued for two or three weeks and not longer. 
Much must depend on the effect which a course of spa treatment has on 
the individual case, and the local physician must decide not only on the 
doses, but also on the duration of the course. There are cases in which 
it is wise to give small doses for a long period of time, and others in 
which it is more advantageous to give large doses for short periods only. 
In some instances two courses are required in the same year, with a 
longer or shorter rest between them. Again it frequently occurs that 
two courses of different waters ought to follow one another; for instance, 
in a case of anaemia with a sluggish portal system and passive congestion 
of the liver, it may be necessary to begin by a course of saline waters to 
unload the portal system, and afterwards to use chalybeate waters. 
z 
VOL. I 338 
SYSTEM OF MEDICINE 
After-management. - The success of courses of mineral waters often 
depends entirely on the way in which the first three or six weeks follow- 
ing the treatment are employed. In almost all cases it is necessary to 
spend some time away from home at a good climatic resort, with careful 
diet and with open-air life, but without mental or bodily fatigue. It 
seems difficult for many people to see this, but we cannot too strongly 
advise our professional brethren to insist upon it. Some waters, like 
the simple thermal or thermal-sulphur waters, especially when taken 
at bracing localities, require a shorter after-treatment than the more 
complicated and searching waters of Carlsbad, Marienbad or Tarasp. 
Every one who is acquainted with the "Weir Mitchell treatment" 
will admit that its author is correct in demanding after the termination 
of the treatment proper a further absence of six or eight weeks from 
the excitement and worry of home life; and some of us must have found 
that the neglect of this demand often destroys the good effect of the 
previous treatment. Similarly, after a serious course of waters the whole 
system is in many persons in an abnormal state of sensitiveness or 
unstableness, especially as regards the organs of digestion, circulation,, 
and, not least, the nervous system. Injurious influences, however slight, 
such as a chill, mental or bodily fatigue or excitement, a mistake in diet, 
are apt to cause a new break down. We ought not to be influenced in 
our directions by the fact that some strong persons can do everything, 
even at or after Carlsbad, with impunity. Such cases form rare excep- 
tions, not the rule. 
Hermann Weber. 
1. Althaus. The Spas of Europe, 1882. - 2. Basch and Dietl. "Untersuch. 
fiber die phys. Wirkung Kohlensauersalt," Boeder. Oest. Med. Jahrl. 1870. - 3. 
Baumann. " Wildbaeder (Akratothermee)," Valentiner's Handbuch d. Balneotherapie, 
1876. - 4. Beneke. Ueber Nauheim's Soolthermen, 185$.-5. Beneke. Zur Therapie 
d. Gelenkrheumatism, 1872.-6. Blanc, L£on. Aix-les-Bains and Marlioz. London, 
1893.-7. Bottentuit. Plombi'eres, 1882.-8. Bracket. Aix-les-Bains. London, 
1884.-9. Brandt. Roy at, 1883. -10. Braun, J. Lehrbuch d. Balneotherapie, 5th ed. 
1887. -11. Braun, J. Curative Effects of Baths and Waters, English edition, 1875.- 
12. Broadbent, J. F. H. " Chronic Heart Disease by the Methods of Dr. Schott at 
Nauheim," Pract. 1895, i. p. 385.-13. Broadbent, W. " On the Mode of Action of the 
Treatment and its Indications," Ibid. p. 394.-14. Cuffe, R. "Cases treated by 
Bromo-Iodine Waters and its Salts," Brit. Med. Journ. 1873. -15. Cormack, C. E. 
The Mineral Waters of Vichy, 1887. -16. Diruf, O., Sen. Kissingen, its Baths and 
Mineral Springs, 1887. -17. Debout-d'Estrees. A Lecture on Contrexeville, 1891.- 
18. Deetz, W. Homburg v. d. H. und seine Heilfactorem, 2nd ed. 1888.-19. Durand- 
Fardel and Le Bret. Dictionn des Eaux Minerales, 1862. - 20. Durand-Fardel. 
Traite des Eaux Minerales, 1862.-21. Eardley-Wilmot, R. On the Natural Mineral 
Waters of Leamington, 1890.-22. Emond, E. Le Mont-Dore et ses Eaux Minerales, 
1893.-23. Fox, R. F. Strathpeffer Spa, its Climate and Waters, 1889. - 24. Freeman, 
H. W. The Thermal Baths of Bath.-25. Garelli, G. Acque Minerali d'Italia, 1864. 
- 26. Geisse, N. The Springs of Ems, 1892.-27. Grossmann. "Diealkal. Quellen " 
in Valentiner's Handbuch, 1876. - 28. Guttmann. "Ueber d. therapeut. Werth d. 
Carlsbaden Miihlbrunnens bei Diabetes Mellitus," Berl. klin. Wochensch. 1880.-29. 
Helfft. Handbuch d. Balneotherapie, 9th ed. 1882. - 30. Jacob. Grundzilge d. 
Balneotherapie, 1870. - 31. Lane, H. General Hints on the Use of the Baths at Bath, 
1892.-32. Leichtenstern. General Hydrotherapeutics, in von Ziemssen's Handbook 
of General Therapeutics. London, 1885. - 33. Lersch, B. M. Hydro-Chemie, 1864. -34.. 
REFERENCES BALNEOLOGY AND HYDROTHERAPEUTICS 
339 
Lersch, B. M. Die phys. u. therapeut. Fundamente der pract. Balneologie, 1868. - 35, 
Macpherson, J. The Baths and Wells of Europe, 3rd ed. 1888.-36. Macpherson, J. 
The Mineral Waters of the British Islands, 1871.-37. Mering. "Stoffwechsel beim 
Gebrauch des Friedrichshaller Bitterwassers," Berlin klin. Wochenschr. 1880.-38. 
Myrtle, A. S. and A. Pract. Observ. on Harrogate Mineral Waters, 1892.-39. 
Oliver, G. The Harrogate Waters, 1881.-40. Petit, C. A. Guide Medical a Royat, 
8me ed. 1893.-41. Quincke, H. Balneol. Tafeln, 1872.-42. Reimer, H. Klimato- 
therapie und Balneotherapie, 1889.-43. Reumont. "Sulphur Wells" in Valentiner's 
Handbuch, 1876. - 44. Riess. "Ueber den Einfluss des Carlsbader Wassers auf 
die Zuckerausscheidung," Berl. klin. Wochensch. 1877.-45. Robertson, W. H. "The 
Medical Value of the Nitrogenous Tepid Water of Buxton," Lancet, 1872 and 1874.-46. 
Schetelig, A. Homburg-Spa, 1893. - 47. Schott, A. "Die Bedentung d. Gym- 
nastik f. d. Diagnose, Prognose u. Therapie d. Herzkrankheiten," Zeits. f. Therap., 
1885. - 48. Schott, Th. "Die Behandlung d. chron. Herzkrankheiten," Deutsche 
Med. Zeitung, 1887.-49. Schott, Th. "The Treatment of Chron. Diseases of the 
Heart by Means of Baths and Gymnastics," Lancet, 1890.-50. Schott, Th. The 
Nauheim Min. Waters, their Actions, Uses, and Effects. Eyre and Spottiswood, 1894. 
- 51. Seegen, J. Handbuch d. allgemeinen und speciellen Heilquellenlehre, 2nd ed. 
1862.-52. Seegen, J. "Ueber den Einfluss des Glaubersalzes auf den Stoffwechsel," 
Virchow's Arch. 29, 1864. - 53. Thorne, W. Bezley. The Treatment of Chronic 
Diseases of the Heart by Baths and Exercises according to the Method of Dr. Schott. 
Churchill, 1894. - 54. Valentiner. Handbuch d. allgemeinen und spec. Balneothera- 
pie. Berlin, 1876. -55. Voit. Ueber den Einfluss des Kocksalzes auf den Stoffwechsel. 
Miinchen, 1860. - 56. Voit. " Ueber den Einfluss des Glaubersalzes auf den Stoffwech- 
sel," Zeitsch. f. Biologie, 1865, p. 196. - 57. Climates and Baths of Great Britain. 
Report of a committee of the Roy. Med. and Chir. Soc. 1895. 
H. W. 
B. - Hydrotherapeutics 
Under the term "Hydrotherapeutics" the therapeutic use of water 
is considered, especially in its external application to the body. The 
internal and external uses of natural mineral waters are dealt with in 
the article on " Balneo-therapeutics." 
History. - Hydrotherapeutics was known to the ancient Greeks and 
Romans, and regular bathing of the body and keeping of the skin in a 
healthy condition were, like the athletic training of the body, held by 
them in high esteem. It is possible that a reaction from the excessive 
luxury of later Rome partly helped to bring baths into the neglect into 
which they fell amongst the early ascetic Christians. 
In Italy and France hydrotherapeutics made a start in the fifteenth 
and early sixteenth centuries, and were even applied in mental diseases, 
as narrated in one of Poggio's tales. In the seventeenth century 
Floyer and T. Smith wrote on hydrotherapeutics in England, and in 
the early eighteenth century F. Hoffmann wrote on the subject in Ger- 
many. About the middle of the eighteenth century J. G. and J. S. 
Hahn treated febrile diseases with cold sponging, and one of them, when 
attacked with typhoid fever, had himself treated by this method, modifi- 
cations of which have been so widely adopted in modern times. In the 
latter part of the eighteenth century, in spite of the results by W. 
Wright, James Currie and W. Jackson, and in Germany by Reuss, 
Frohlich, Brandis and Horn, hydrotherapeutical treatment was again 
falling into disuse, when, soon after 1820, Vincent Priessnitz, originally 
a small farmer of Graefenberg in Silesia, began to treat every kind of SYS7EM OF MEDICINE 
340 
ailment, chronic as well as acute, by hydrotherapeutic means. He 
added to the external applications the abundant internal use of water, and 
with this treatment he combined active exercise, and a very simple diet, 
and prohibited tea, coffee and all alcoholic beverages.' Priessnitz at 
different periods made considerable alterations in his hydrotherapeutic 
measures. Originally he packed patients for several hours in dry woollen 
blankets, covered with feather beds, before applying cold affusions; later 
he substituted packing in wet linen sheets for several hours, followed 
by a full bath or a douche; still later he frequently employed a cold wet 
pack of fifteen or twenty minutes' duration, repeated several times in 
the same day. He introduced the method of rubbing the whole body 
with a cold wet sheet instead of the full bath; and made extensive use of 
partial baths for the hips, the hands, the arms, or the feet, of wet abdomi- 
nal belts, and of wet applications on different parts of the body. The 
success of his measures, combined as they were with a simple diet and 
exercise in a healthy, mountainous country, was in many cases consider- 
able ; but the indiscriminate, too energetic, and protracted use of his 
methods often led to unfavourable results. The system was beginning 
to be regarded as a sort of quackery, when, about the year 1850, estab- 
lishments were placed under the superintendence of regularly-educated 
physicians, who studied the physiological effects of the different methods, 
and modified them according to the requirements of individual cases: 
they also added pharmaceutical remedies when required. To the more 
modern works, by Winternitz, Hayem, Scheuer, etc., the writers of the 
present article are largely indebted. 
Although England has taken such a prominent position in the use of 
baths in health, especially the daily morning " tub," it is remarkable that, 
as compared with French and German hospitals, the London hospitals 
are still very badly furnished with douches, and other means of hydro- 
therapeutic treatment. 
Modes of Application. - Amongst these are the ordinary full bath 
at different temperatures, hip-baths, shower or rain baths, wrapping in 
wet towels, affusions, douches of various kinds, and many forms of local 
applications. The temperature may sometimes be varied during the 
application (alternating douche, Scotch douche). Among the many 
forms of medicated baths only a few can be mentioned here. Brine- 
baths, to imitate sea-baths, can be made by adding about 10 lb. of sea 
salt to thirty gallons of water. Alkaline baths of thirty gallons contain 
about six ounces of carbonate of sodium or three ounces of carbonate of 
potassium. Acid baths can be made by adding about twelve ounces of 
diluted nitro-muriatic acid to thirty gallons of water. The common bran 
and mustard baths need not be described. Aromatic and pine baths are 
made by adding a decoction of aromatic plants, such as lavender or fresh 
pine leaflets, or an extract or essence of pine leaflets to warm water. 
Mercurial baths belong to the treatment of syphilis, and electrical baths 
will be described under " Electro-therapeutics." Baths can also be made 
to imitate those of natural mineral waters. BALNEOLOGY AND HYDROTHERAPEUTICS 
341 
The varieties of hydrotherapeutic application are very numerous, but 
most ends which can be attained in the present state of our knowledge can 
be arrived at by the judicious use of a very small number of appliances. 
The internal use of plain water as a therapeutic agent, much 
employed in the old " water cure," is now generally but an adjuvant to 
other methods of treatment. Vapour and hot air baths may conveniently 
be classed with hydrotherapeutic appliances. In the Turkish and 
Russian baths the patient is placed in a chamber heated with watery 
vapour; but a vapour-bath may be taken in a box not including the 
head. In the Roman bath the hottest chamber, the " Calidarium " or 
" Sudatorium," is heated by dry air to a temperature of 133° to 140° F., 
and perspiration is more free than in vapour baths. These baths may 
be followed by soaping, rubbing, douching, and a plunge into cold water. 
Treatment by hydrotherapeutic means depends chiefly on the reaction 
of the organism to cold and heat; but a mechanical stimulation is added 
to the purely hydrotherapeutic effect by the impetus of the water in 
douches, and to some extent by the bubbles of carbon dioxide in the waters 
of Schwalbach, Nauheim, etc.; the addition of a little mustard has a 
chemically stimulating effect, and a bran-bath diminishes the irritability 
of the skin; stimulation of the skin may also be increased by friction 
and massage. Care must, however, be taken that stimulation does not 
exceed the powers of the organism, and supervision by a medical man is 
necessary for the proper regulation of the treatment in every case. Each 
case must be individually considered, and hydrotherapeutic treatment 
may be associated, according to requirements, with change in diet, air, 
and the surroundings of the patient; or with a course of mineral waters 
or internal medication. 
Action and Physiological Effects. - What has been called the " hydro- 
therapeutic reaction " is the natural reaction of the organism to cold or 
heat; the organism thus endeavours to defend itself against the action 
of these agents. In human beings, the skin of the body, unprotected 
by any natural covering, reacts the more readily to cold and heat; in 
most races this sensitiveness is increased by the habitual use of clothes: 
the clothes form a sort of zone around the body, in which the temperature 
stands, with tolerable regularity (according to Winternitz) at about 90° F. 
In order, therefore, to obtain the "hydrotherapeutic reaction" it is 
necessary that the water should have a temperature some degrees above 
or below 90° F. It is obvious, also, that on account of its greater 
specific heat and greater coefficient of heat conductivity, water is much 
more active than air of the same temperature in inducing the reaction. 
On the proper bringing about of this reaction the result of hydrothera- 
peutic treatment largely depends. 
Cold Water Treatment. - When a healthy man jumps into a cold 
bath, or has a cold douche applied over the whole or a considerable area 
of his body, he receives an impression of cold, shivers, and, after 
an almost involuntary pause in breathing, takes a very deep inspira- 
tion. The skin is pale, and owing to the contraction of the unstriped SYSTEM OF MEDICINE 
342 
muscle fibres, presents the appearance called " goose skin." When the 
man gets out of the bath, or sometimes even whilst he still remains in it, 
these first effects give place to the phenomena of the " reaction." The 
skin then becomes slightly reddened, and an agreeable subjective sensa- 
tion of warmth is experienced. He breathes more easily, and has a 
general feeling of comfort and capability for exertion. This is the 
" hydrotherapeutic reaction " to cold; it depends in degree and rapidity 
on the temperature of the water, the length of the application, and, in 
the case of a douche, on the force with which it is applied. The reac- 
tion is assisted by voluntary movements and friction of the skin, and 
varies much with the health and strength of the individual and with his 
previous habits in respect of cold bathing. To those already accustomed 
to cold baths the initial shock is not unpleasant, and the reaction sets 
in much more easily. 
Many physiological experiments have been made to explain scientifi- 
cally what takes place when the whole body is exposed to cold. The 
pallor of the skin during the initial shock is due to the contraction of 
the superficial blood-vessels, which sets up a corresponding dilatation of 
the internal vessels of the body. As the blood is the great distributor 
of heat in the body, the central temperature, measured b^ a thermometer 
in the rectum, may rise slightly at first. The contraction of the super- 
ficial blood-vessels of the body must prevent excessive loss of heat 
until heat production is increased. Owing to this contraction of the 
superficial blood-vessels the general blood pressure rises and the heart's 
action is increased. 
When the reaction sets in, the superficial vessels dilate, the flow of 
blood through the skin is much increased, and affects the sensory nerve 
terminations so as to give rise to a sense of warmth in the skin. Ac- 
companying the reaction a thermometer in the rectum shows a slight 
lowering of the central temperature, which then gradually regains its 
initial level or slightly surpasses it. 
The vascular phenomena consequent on the hydrotherapeutic appli- 
cation are clearly proved to be due mainly, if not entirely, to nervous 
vaso-motor action; for, although the muscular walls of the arterioles, 
like other unstriped muscle, can certainly react to direct stimuli, the 
phenomena follow a stimulus too fleeting to act directly on the muscle 
fibres (Hayem). The phenomena are not, to any considerable extent at 
least, due to the peripheral nervous mechanism, but to a reflex mechanism 
including the central nervous system: in animals they are absent from 
parts in which the nerves have been experimentally cut; and in the case 
of men the phenomena may be diminished or absent in paralysed and 
anaesthetic limbs. An attempt to trace out the " reflex arcs " concerned 
in the hydrotherapeutic reaction would take us too far away from 
practical medicine. 
The respiratory phenomena observed after the application of cold 
water to the skin are also due to a nervous (reflex) action; they have 
been produced in animals rendered insensible by chloral (Roehrig). BALNEOLOGY AND HYDROTHERAPEUTLCS 
343 
These phenomena consist in increased amplitude of the respiratory 
movements, with increased liberation of carbon dioxide and absorp- 
tion of oxygen by the blood circulating through the pulmonary capil- 
laries. 
Increased combustion in the tissues is due to the need for increased 
heat production to compensate the heat given up to the cold water. 
Shivering must be regarded as part of the means whereby nature causes 
increased heat production. As is the case during muscular exercise, this 
increased combustion is shown by the increase of carbon dioxide given 
off by the lungs. Increase of urea and diminution of uric acid are some- 
times observed in the urine of patients under hydrotherapeutic treat- 
ment ; and, when observed, show that the nitrogenous catabolism in the 
body is more extensive. When, owing to the continued application of 
■cold, the muscular layer of the body becomes cooled catabolism is 
diminished, but it is again increased when the reaction takes place 
after the application. 
The flow of urine is increased and the action of the bowels promoted, 
the latter probably being due partly to increased peristaltic action, 
partly to increased intestinal secretion. The appetite is stimulated, the 
digestion of food aided, and the tpnic effects on the nervous and mus- 
cular systems increase the desire for physical exertion and make work 
feel lighter. 
If the cold application (douche or bath) instead of being general, be 
local, and especially if it be limited to an extremity, the general effects 
are less marked. Local applications have been shown, however, to cause 
certain distant reactions. Thus, when iced water is applied to one 
hand both become colder, and both show a diminution in volume as 
measured by the plethysmograph. These phenomena are doubtless due 
to the diminution in the amount of their blood, caused by contraction 
of their blood-vessels. Inverse phenomena are observed to take place 
at a level of the body remote to that affected by the cold application; 
thus, during the application of a cold hip-bath, Winternitz has found 
that an augmentation in the volume of the arm takes place. These dis- 
tant reactions following on local applications form an additional argu- 
ment in favour of the reflex nature of the general "hydrotherapeutic 
reaction." If an antiphlogistic action be desired, it is important that 
the local application of cold be continuous: Leiter's tubes are less 
easily displaced than icebags. 
Warm Water Treatment. -Whereas the chief ultimate effect of cold 
stimuli to the skin is tonic, that of warm stimuli is sedative. The effect 
of the warm treatment is not, however, exactly the opposite of that of 
the cold; indeed, all cutaneous stimuli whether mechanical (by friction 
or massage), electrical (by faradic shocks), chemical (by counter-irri- 
tants), or thermic (cold or hot), show certain points of analogy. 
Like cold applications hot ones probably produce an initial vaso- 
contraction; this, however, passes off quickly and gives place to vaso- 
dilatation, which lasts during the rest of the application, and then slowly SYSTEM OF MEDICINE 
344 
passes off. This dilatation of the superficial vessels, with the subjective 
feeling of warmth, is the characteristic effect of hot applications. The 
superficial vaso-dilatation is associated with increase in the secretion of 
sweat and in the frequency of the respiratory movements. The whole 
constitutes the reaction of the body to heat, and thus the animal mech- 
anism increases the loss of heat to counteract the heating effects of the 
application. Owing to superficial vaso-dilatation more heat radiates 
from the body; by increased sweating the loss of heat by evaporation 
is augmented; and by increased respiratory movements more heat is 
given off in the air and watery vapour expired. 
In addition to the local sedative action of hot applications on the 
sensory nerves, as seen in the application of poultices and hot fomenta- 
tions, there is a general sedative action exercised by heat, when the 
application is general and sufficiently prolonged. This general sedative 
action is shown by diminished desire for exertion, and is probably ex- 
plained by the partial emptying of the deeper blood-vessels and slowing 
of the blood-streams which accompany the dilatation of the superficial 
vessels, and cause a certain anaemia of the viscera and brain. 
If the loss of heat be partly prevented by immersing the whole body 
in a bath of hot water, the central temperature, as measured by a ther- 
mometer in the rectum, rises somewhat; but doubtless in such cases 
diminution of the heat production in the body assists the loss of heat by 
respiration to prevent undue rise of the body's temperature. 
Hot applications tend to constipation. This may, perhaps, be due to 
diminished peristalsis, perhaps to a diminution in the intestinal secretion 
on the increased excretion of sweat. 
The local applications of hot water, like local cold applications but 
to a lesser degree, have been found to cause certain distant reactions. 
Thus when one lower limb was heated, vaso-dilatation, increase in 
volume, and sweating were observed in the other lower limb. 
Hot air and vapour baths differ from hot water baths chiefly in their 
action on the skin; the greatest amount of perspiration is obtained by 
hot air baths. 
The Internal Use of Water.-Plentiful drinking of water leads to 
increase in the watery secretions; besides the urine, the bile, saliva, 
pancreatic juice and sweat appear to be increased; though if increased 
secretion of sweat be desired, it is generally stimulated by heat or bodily 
exercise. This increase in the watery constituents of the secretions is 
accompanied, for a time at least, by increased excretion of the waste pro- 
ducts of tissue metabolism, which are " washed out " from the tissues 
and the blood itself. The effects of plain water taken internally form 
a considerable part of the results obtained from courses of mineral 
waters (see article on " Balneo-therapeutics "), and the treatment may 
exercise a good influence in some cases of gout, urinary gravel, imper- 
fect secretion of bile, and constipation from sluggish peristaltic action. 
Excessive water-drinking, on Priessnitz's original plan, may however 
lead to dyspepsia. BALNEOLOGY AND HYDROTHERAPEUTICS 
345 
Diseases and Morbid Conditions Suitable for Hydrotherapeutic Treatment 
Digestive Derangements. - Habitual constipation from atony of the 
bowels, often associated with a tendency to haemorrhoids and "abdominal 
venosity," may sometimes be treated with cold baths and other stimulat- 
ing methods, which increase the general nutrition of the tissues and the 
physical and psychical energy of the nervous system. In cases of 
chronic dyspepsia with catarrh of the stomach the common salt waters 
and alkaline sulphated waters (as at Carlsbad) are more frequently used 
and often preferable; but hydrotherapeutic treatment may be employed 
for the tonic after-treatment, or it may be employed with due care from 
the beginning as an adjuvant to the other treatment. 
Muscular Pains and "Muscular Rheumatism."-Some of these cases 
may be treated with cold, some with hot baths, or with hot air or vapour 
baths, according to the patient's power of reaction; they are often treated 
by warm or hot baths followed by a cold shower bath. The diaphoretic 
methods by packing with woollen blankets or wet sheets are often found 
to be useful, but they sometimes fail. In this class of cases the original 
supporters of hydrotherapeutic treatment considered their methods in- 
fallible, but this is by no means the case. Invalids of this class should 
not be exposed to all weathers during the cure, and the access of cold air 
to the wet body should not be risked. The course of treatment should 
not be too prolonged at one time, but may be repeated again after an 
interval of some months: the interval may advantageously be spent at 
sheltered sea-side localities, at moderate elevations, or at one of the 
gaseous thermal saline spas. 
Sciatica and Neuralgias. - Some patients may be treated by hot 
baths, but they are more often sent to natural thermal spas, such as 
Schlangenbad, Wildbad, etc. 
Hepatic and Nephritic Colics, etc. - Hot baths may be of great 
service in hepatic and nephritic colics, probably by the relaxing action 
on unstriped muscle, and in helping the action of opiates. They may 
sometimes be of service in severe flatulent colic, in tenesmus, in reten- 
tion of urine, etc. 
Rheumatism and Gout. - In chronic rheumatic joint affections the 
patient is often too enfeebled for cold hydrotherapeutic treatment, but a 
hot bath (with the help, if necessary, of a chair to lower the patient into 
the bath), may be useful in the treatment of such cases. Mild cases of 
gout may derive benefit from the usual hydrotherapeutic treatment, in 
so far as it aims at invigorating the nervous system, and producing more 
complete oxidation of the downward products of tissue metabolism; the 
treatment should be associated with moderation in the amount of food, 
and especially in the use of stimulants. Local packing may cause fits of 
gout, and indeed the hot mustard foot-bath has been used for this purpose 
in supposed cases of " suppressed gout." The more severe forms of gout 346 
SYSTEM OF MEDICINE 
are too much complicated with general constitutional defects to encour- 
age us in recommending cold water treatment. 
Catarrhal Attacks.-Weakness or over-sensitiveness of the skin, or 
nerve terminations in the skin, may be the cause of frequently recurring 
attacks of diarrhoea, or of tendency to catarrh of the respiratory mucous 
membrane; at all events, when this over-sensitiveness is present, cold 
is more likely to induce such attacks. Hydrotherapeutic methods, 
mildly stimulating at first, with gradually increasing energy, are here 
useful; unless, as in impeded convalescence, the reactive power is so 
reduced that gaseous thermal salt baths and mountain air are prefer- 
able. In some cases sea-air and sea-baths are most useful. 
Chronic Affections of the Skin. - In local perspirations, some cases of 
prurigo, and chronic affections of the skin, hydrotherapeutic treatment 
in a modified form may be useful; it may also be used as an adjuvant in 
the treatment of syphilis. In some affections of the skin alkaline baths 
are of service, and bran-baths are used to allay cutaneous irritability. 
Psoriasis has been successfully treated by prolonged cold baths. 
Chronic Metallic Poisoning. - In some cases of this sort, if there is 
sufficient reactive power, cold water treatment may be of as much good 
as the thermal sulphur treatment. The treatment will be aided by the 
abundant internal use of water, and if necessary by the administration of 
iodide of potassium, which is commonly supposed to assist in the removal 
of the poison from the tissues. 
Hysteria, etc. - Cold water treatment, pine-baths, and aromatic-baths 
may sometimes be found useful in the treatment of hysteria and 
functional nervous affections, and in some cases of " diabetes insipidus." 
In organic nervous diseases they are not to be recommended, unless it 
be to relieve the lightning pains of tabes. 
Catamenial Irregularities. - These are frequently treated at hydro- 
therapeutic establishments. Profuse menstruation may often be checked 
by the regular use of the cold hip-bath for three to five minutes. In 
cases where the menses are insufficient, warm hip-baths of ten to fifteen 
minutes' duration, combined in some cases with wrapping in a wet sheet, 
may often be found useful; dysmenorrhoea is likewise occasionally treated 
with advantage by the partial wet sheet or hot baths. 
Anaemia. - Scheuer recommends the treatment of some anaemic con- 
ditions by hydrotherapeutic measures. Under general cold applications 
an increase in the haemoglobin and number of the red blood corpuscles 
has been observed. Of course special care must be observed in the 
treatment by cold water of anaemic and feeble persons. According to 
Scheuer the loss of heat can be counteracted by rest in bed, by wrapping 
up after the application of cold, by preliminary moderate exercise, or by 
previously over-heating the body in the hot air chamber, or by hot water, 
as in the Scotch douche. 
Rickets. - In some rickety, scrofulous, and other ill-nourished chil- 
dren regular bathing in rather cold salt or sea water may form a part of 
the treatment, provided that great care be taken to avoid a chill. BALNEOLOGY AND HYDROTHERAPEUTLCS 
Infantile Convulsions, etc.-Hot baths of short duration, with or 
without the addition of mustard, are often employed for the immediate 
treatment of laryngismus stridulus and general convulsions in children. 
Hot baths also are sometimes used for adults in cases of puerperal 
eclampsia and uraemic convulsions, but in these cases some benefit is 
expected from their diaphoretic action as well as from their sedative 
influence on the cerebrum. Cold douches, or the continuous application 
of cold (by some form of " cap "), to the head are often of the utmost 
value in acute delirium; as for example in the course of the infectious 
fevers. Delirium and screaming are sometimes arrested almost at once 
by holding the patient's head over a pail at the bedside and pouring 
cold water over the head, beginning near it and slowly raising the can 
higher and higher. 
Nephritis and Uraemia. - The wet pack, hot water, hot air, or vapour 
baths are sometimes of service by producing diaphoresis. When the 
patient has to remain in bed the application of the two latter baths 
requires especial care. 
Enteric Fever and other Acute Infectious Diseases. - Of acute 
febrile diseases enteric fever is the one in which cold baths have been 
most practised. Brand's direction for the use of the cold bath is in gen- 
eral to take the rectal temperature every three hours; if it be 102-2° F. 
or more, the patient is to be placed in a cold bath of 64-4° F. to 68° F., 
and to be kept there until a slight shivering is observed, probably 
about a quarter of an hour. There are, however, many varieties of this 
treatment; English physicians, following von Ziemssen, prefer to place 
the patient in water at about 90° F., and to cool the bath gradually by 
the addition of cold water until the fever is reduced to about 101° F. 
Von Ziemssen's method is within fifteen minutes to cool the bath down 
from about 95° to 68° F.; the skin is lightly rubbed, and in 20-30 
minutes, or when shivering commences, the patient should be put back 
to bed. His temperature usually falls one or two more degrees after 
removal to bed, which should be warm and contain a hot bottle for the 
feet. Cold affusions, cold sponging, the application of ice to the body, 
or the suspension of ice in vessels in a " cradle " within the bedclothes, 
have been used in milder cases for a similar purpose. Persistent fever 
in children may be conveniently reduced by filling wide-mouthed pickle- 
bottles with ice, wrapping each in flannel, and placing more or fewer 
of them about the patient - in the axillae, against the flanks, or between 
the legs. Bottles may be added or removed from time to time as the 
thermometer may indicate. The temperature should not only be taken 
soon after the bath, but also after an interval of fifteen minutes; the 
temperature then indicates whether the bath was sufficiently cold; this 
indication is of use in regulating the next bath. A little alcohol may 
be administered before or whilst the patient is in the bath, and friction 
may be applied to prevent the too sudden contraction of the cutaneous 
vessels. The use of cold baths in enteric fever was introduced by 
F. Glenard in 1871 from Germany into France, and was adopted 
347 348 
SYSTEM OF MEDICINE 
especially in Lyons. Dr. Osler, in the report on typhoid fever (Johns 
Hopkins Hospital Reports, vol. iv. 1894), speaks in favour of the bath 
method of treatment, which indeed has been widely practised in most 
countries, and is very efficacious, not only as regards the pyrexia, but in 
low delirium, subsultus tendinum, tympanites and like "typhoid" states. 
Similar methods have been used for acute infectious diseases other than 
enteric - in the typhoid symptoms sometimes occurring during the course 
of pneumonia, small-pox, erysipelas, scarlatina, etc. On account of the 
tonic and diuretic action of the baths, it is said that they may be em- 
ployed also with advantage in some cases of infectious fevers, where, 
although the temperature is not much more than 100° F., a condition 
of prostration and tendency to stupor is found. Further details will be 
found in the elaborate account by Dr. H. Faure-Miller (Les Bains Froids 
dans les Formes Typhoides des Maladies Infectieuses, 1893). 
Hyperpyrexia. - In cases of hyperpyrexia, occurring in the course of 
acute rheumatism and other acute diseases, the advantage of the cold 
water treatment over the internal use of antipyretic drugs is now gen- 
erally admitted, and the methods of its use are well understood. 
Burns, Phlegmons, etc. - The use of baths for these cases comes 
under the head of surgery. 
Contra-Indications. - For the successful results of cold water treat- 
ment it is essential that the organism be able to stand a certain amount 
of abstraction of heat; that it be capable of more or less energetic 
reaction, and that the digestive and assimilative organs be able to take 
up a fair amount of nourishing material to compensate increased catabo- 
lism. In cases of great debility after illness special care must be observed, 
and cold water treatment is still more hazardous when, to the debility 
of illness, the weakness of childhood or old age is added. When cold 
water treatment causes diarrhoea, urticaria, or haemoglobinuria, it must 
be discontinued; and in chronic nephritis and any great degree of 
arterio-sclerosis it is contra-indicated; so also is it certainly in cases of 
aneurysm, in those who have had one attack of cerebral haemorrhage, or 
appear threatened with cerebral haemorrhage, and in all cases of heart 
disease, except in slight and well-compensated mitral valvular affections. 
The abundant use of liquids internally is injurious to patients with old 
valvular heart disease and a tendency to loss of compensation; it is to 
be avoided likewise by many obese persons with weakly acting hearts. 
Hermann Weber. 
F. Parkes Weber. 
REFERENCES 
1. Beni-Barde. Manuel medical d'Hydroth#rapie, 2me edition. Paris, 1883. - 2. 
Bottey, F. Trait# d' Hy dr other apie. Paris, 1895.- 3. Brand, Ernst. Die Wasser- 
behandlung der typhbsen Fieber, 2nd edition. Tubingen, 1877.-4. Delmas, P. 
Physiologic nouvelle de l'hydroth#rapie, d'apres des recherches rtcentes sur faction 
du froid et de la chaleur sur I'organisme. Paris, 1880. - 5. Faure-Miller, H. 
Les Bains Froids dans les formes typho'ides des Maladies Infectieuses. Paris, 1893. - THE MEDICAL APPLICATIONS OF ELECTRICITY 
349 
6. Fleury, L. Traite therapeutique et clinique d'hydrotherapie. Paris, 1875. - 7. 
Hayem, G. Leqons de Therapeutique. Les Agents Physiques et Naturels. Paris, 1894. 
- 8. Hoppe, F. " Ueber d. Einfluss des Warmeverlustes auf die Eigentemperat. warm- 
bliit. Thiere," Virch. Arch. 1857, xi. - 9. Jurgensen, Theodor. "Zur Lehre von 
der Behandlung fieberhafter Krankheiten mittelst des kalten Wassers," Deut. Arch.f. 
klin. Med. 1868, vol. iv. pp. 110 et seq. -10. Labadie-Lagrave. Du Froid en Thera- 
peutique. Paris, 1878. -11. Lehmann, L. "Ueber die Wirkung kalter Sitzbader," 
Archiv fiir wissensch. Heilkunde, 1854. -12. Lepine, R. and Flavard. " Note relative 
a Faction du bain a temperature excessivement basse, sur la composition de Purine," 
Societe de Biologic, Comptes Rendus, 1880, p. 80.-13. Liebermeister. " Phys. Unters. 
iiber die quantit. Veranderung d. Warmeproduct," Reichert und Du Bois Reymond's 
Arch. 1860, 1861. -14. Liebermeister and Hagenbach. Beobachtungen und Vesuche 
iiber Anwendung des kalten Wassers bei fieberhaften Krankheiten, 1868. -15. Lieber- 
meister and Gildemeister. Ueber die Kohlensaurereproduction bei Anwendung v. 
kalten Bad. Bale, 1870. -16. Liebig, G. von. " Ueber d. Vera-nder. d. Puls, im lauen 
Bade," Centralblatt fiir d. med. Wissensch. 1878, 49. -17. Mosler. " Untersuch. iiber 
d. Einfl. v. Trinkwasser auf d. Stoffwechsel," Arch. f. wiss. Heilkunde, 1857, iii. 3. - 
18. Paalzow. " Ueber d. Einfl. d. Hautreiz., auf d. Stoffwechsel," Pfliiger's Arch. vol. 
iv. 1871. -19. Petri. " Hydrotherapie." Valentiner's Handb. d. Balneotherapie, 1873. 
- 20. Richter. Das Wasserbuch, etc. Berlin, 1856.-21. Riegel, Franz. "Ueber d. 
Beziehung d. Gefassnerv. z. Kbrpertemp," Pfliiger's Arch. v. 1872. -22. Riegel, Franz. 
44 Ueber Hydrotherapie und locale Warmeentzieh ungen," Deut. Arch.f. klin. Med. 1872, 
x. 6.-23. Roehrig. Die Physiologie der Haut experimented und kritisch bearbeitet. 
Berlin, 1876. - 24. Rosenthal. 44 Die Physiologie der thierischen Warme," in Her- 
mann's Handb. der Physiologie. Leipzig, 1882. -25. Runge, F. 44 Ueber die Bedeutung 
der Wasserkuren in chronischen Krankheiten," Deut. Arch, f iir klin. Med., vol. xii. 
1873-1874, pp. 207-232. - 26. Scheuer, V. Essai sur I'action physiologique et thera- 
peutique de I' Hydrotherapie. Paris, 1888. - 27. Senator. 44 Unters. iiber d. Warmebild. 
und d. Stoffwechsel," Reichert und Du Bois Reymond's Arch. 1871.-28. Stolnikow. 
44 Ueber d. Verand. d. Hautsensibilitat dutch kalte und warme Bader," Petersburg med. 
Wochenschr. 1878, 25, 26. - 29. Thermes. De I'influence immediate et mediate de 
I'hydrotherapie sur le nombre des globules rouge du sang. Paris, 1878. - 30. Virchow. 
44 Ueber d. Baden," Virchow's Arch. 1859, xv. Heft 1 and 2. - 31. Virchow. " Wirkung, 
d. kalten Bades, und Warmeregulirung," Virchow's Arch. 1872, ii. 133. - 32. Weber, 
Hermann. Article on Hydrotherapeutics in Quain's Dictionary of Medicine, 2nd ed. 
London, 1894. - 33. Winternitz, W. "Hydrotherapie," in H. v. Ziemssen's Hand- 
buch der allgemeinen Therapie. Leipzig, 1881. This contains a long bibliography up 
to 1880, including Winternitz's earlier works on the subject. English translation by 
F. W. Elsner, London, 1886. - 34. Wundt. "Ueber d. Einfl. hydrotherap. Einwickl. 
auf d. Stoffwechsel," Arch, des Vereins fur gemeins. Arbeit, iii. 1856. - 35. Ziemssen, H. 
44 Die zweckmassigste Methode der Kaltwasser behandlung des Typhus " in Cent, fiir die 
med. Wissenschaften, 1866, p. 642. - 36. Ziemssen and Immermann. Die Kaltioasser 
behandlung des Typhus abdominalis. Leipzig, 1870. 
H. W. 
F. P. W. 
THE MEDICAL APPLICATIONS OF ELECTRICITY 
Although a large number of books have been written upon medical 
electricity its use makes slow progress among medical men. The appar- 
ent reasons for this are that the apparatus is expensive, its management 
troublesome, and the time required to carry out the treatment more 
than a busy practitioner can spare; these objections would probably 
vanish quickly if the fact could once be grasped that electrical treat- 
ment is of real value in a considerable variety of cases. The true 350 
SYSTEM OF MEDICINE 
reason for the slow advance of medical electricity is that the medical 
profession have not yet become fully aware of its advantages. 
There is no manner of doubt that electrical currents produce definite 
physiological effects; from a consideration of these it is possible to arrive 
at an estimate of the value of electricity in the treatment of disease, 
and medical electricity may be defined as the application of our knowl- 
edge of these physiological actions to the study and treatment of disease. 
The most obvious physiological action of electricity is its power of 
stimulating living tissues. This is apparent enough when the current is 
applied to nerves or muscles, for it can be felt and seen: but the stimulat- 
ing effect is not confined to nerves and muscles; it can also be observed 
in unicellular organisms, and its results noted in several ways in man 
and animals. The metabolic activity of the tissues can be considerably 
increased by electricity, as Gautier and Larat have shown in their 
experiments upon the elimination of carbonic acid gas and urea under 
electrical treatment, when it was found that an increase of 40 or 50 per 
cent could be produced by general electrification. This trophic action 
of electricity has valuable applications in medical treatment. It is 
surprising to see the great improvement in general health shown by 
children during a course of electrical treatment for infantile paralysis; 
and in rickety children the most encouraging results have been obtained. 
The same beneficial trophic effects are commonly seen in adults; and 
the most suitable methods of treatment will be considered below under 
the head of general electrification. In addition to the other methods 
of improving nutrition - such as change of air, exercise and gym- 
nastics, massage, or the administration of cod liver oil and certain 
other drugs - we have in electricity a most direct and useful means to 
the same end, and one which sometimes offers advantages over all the 
others. 
When the question is one of localisation of the stimulating effect, 
then the advantages of electricity are conspicuous, as is clearly shown 
by the almost exclusive use of electrical methods by physiologists when 
local stimulation is required for purposes of experiment. The power 
of exercising and of stimulating to contraction any paralysed muscle or 
group of muscles is a most valuable one. 
The electrotonic effects of currents can also be applied to purposes 
of treatment. By electrotonus is meant the changed condition of a 
nerve during the passage of a steady current through it; that is, an 
increase of irritability in the region of the negative pole, and a decrease 
round the positive pole. Physiological principles suggest the use of the 
anode (or positive pole) for conditions of exalted irritability, such as 
neuralgia or spasm; and the use of the kathode for paralytic or paretic 
states: thus we are often enabled to obtain favourable results. In 
patients with injuries to nerves and impaired cutaneous sensibility the 
electrotonic effects of the current are often plain enough; the application 
of the anode to the affected region with a moderate current may be able 
to abolish all sensibility for the time, while the use of the kathode will THE MEDICAL APPLICATIONS OF ELECTRICITY 
restore it in an increased degree. So too it is common for a trigeminal 
neuralgia to fade away completely during the application of the anode 
over the affected region, and it often happens that a neuralgic pain thus 
dissipated does not return. 
Another effect of the current is electrolysis, which is made use of in 
surgery when destructive effects are desired; as, for example, in the 
treatment of naevus. In medical treatment these destructive electro- 
lytic effects at the surface of the electrodes have to be remembered 
in order to be avoided; but the electrolytic process implies not 
merely the dissociation of chemical compounds at the poles, but also 
a rearrangement of the molecules composing the electrolyte which lies 
between the poles - i.e. in the case of the body, the juices and tissues: 
and it is not impossible that some of the results of electrical treatment 
may be due to interpolar electrolytic actions in the tissues traversed 
by the current. It is difficult at present to estimate the exact impor- 
tance of these molecular changes, but they may be considered for the 
present as " alterative " effects. 
Sometimes it is possible to make use of a peculiar property of elec- 
tric currents as a means of introducing drugs into the system through 
the skin; the process of electric osmosis or cataphoresis causes the pas- 
sage of solutions from the positive to the negative pole, and many 
applications of it have been suggested, such as the direct introduction 
of iodide of potassium into a syphilitic node or gumma, or the elimina- 
tion of metallic poisons from the system. Its chief value, however, 
may consist in the production of local anaesthesia of the unbroken skin 
by cocaine: this can readily be done by placing on the skin a few thick- 
nesses of blotting paper wet wuth 10 per cent cocaine solution and 
applying the positive pole over it, the circuit being completed through 
the body to the negative pole placed on some remote part. With a 
moderately strong current of five to ten milliamperes the skin can be 
rendered anaesthetic in five minutes. 
The phenomena of electrotonus, of electrolysis, and of electric- 
osmosis are peculiar to the direct current; the stimulating and trophic 
effects belong both to direct and to alternating currents, though they 
are more apparent with the latter. 
In medicine both the direct and the alternating current are in daily 
use; the consideration of what has just been written will serve as a 
guide in the choice of one or the other for the treatment of particular 
cases. Fashion has had no little influence in deciding the preference of 
one or other of these electrical methods. 
351 
The apparatus required for electrical treatment and diagnosis is in 
reality a simple matter, although the elaborate catalogues of the instru- 
ment makers are apt to give the idea that it is rather complicated. 
The words Franklinism, Galvanism, and Faradism will not be used in 
this article; but in their place I shall speak of electrostatic methods, 
of treatment by the battery current, and of treatment by the induction 352 
SYSTEM OF MEDICINE 
coil current. Electro-static treatment consists in the use of charges from 
an electrical machine of high potential, with sparks, the brush discharge, 
or the discharges of Leyden jars. These electro-static methods were 
applied to medicine almost on their discovery; and the early writers 
on medical electricity enumerated long lists of cures effected by their 
means; these old records, however, hardly repay a study, partly because 
many of the patients seem to have been hysterical, while the others are 
so described as to make it difficult to diagnose the respective diseases. 
After the discovery of the voltaic pile the use of the electrical machine 
gradually fell into disuse; but it is now being revived with modern 
apparatus and a better knowledge of the subject. In France especially 
these methods have been much in vogue during the last few years, and 
a certain amount of scientific work has been devoted to them, so that 
we are beginning to gather some little trustworthy knowledge of the 
physiological effects of high potential electrification. There seems to 
be no doubt that in this way certain general nutritive changes can be 
brought about; the effect on healthy persons probably being to increase 
the metabolic activity of the tissues, and in some cases to such an extent 
as to do harm. Thus, in some careful experiments upon himself, Truchot 
found that as a result of a course of electro-static treatment a feverish 
state of body was produced, with accelerated pulse, raised temperature, 
and increased elimination of nitrogen. In certain morbid states this 
increase of activity seems to be useful, notably in people of a torpid 
condition of body, in the angemic, the debilitated and the convalescent. 
These effects have been noticed from the simple electro-static charge. 
When sparks are combined with this certain local effects may be super- 
added, and with Leyden jars forcible muscular contractions also occur. 
The whole of this branch of medical electricity requires fresh investiga- 
tion on physiological lines, and much which was written by the older 
writers requires to be forgotten. The clinical gains have been in the 
treatment of some skin diseases, especially eczema and eczematous ulcers; 
the removal of certain states of abnormal obesity; the relief of neuralgia, 
and so on. Moreover, electro-static methods have above all the power of 
combating many hysterical manifestations, such as pains, angesthesias, 
contractures and paralyses: these last, however, depend rather upon 
the psychological than on the physiological effects of electricity. In 
this country, unfortunately, electro-static methods of treatment have 
not yet received proper study, and are generally regarded as having no 
effects except through the mental impressions produced by the treat- 
ment ; but there is probably more of value in them than is yet believed. 
The best type of electro-static machine is the Wimshurst machine; 
and it is advantageous to use one with eight or twelve plates, each 
having a diameter of twenty inches, and to enclose the whole machine 
in a roomy glass case to protect it from the dust which is abundantly 
attracted by the machine when in action. Details of management must 
be looked for in the special handbooks. 
For carrying out the methods in ordinary use with battery and THE MEDICAL APPLICATIONS OF ELECTRICITY 
353 
induction coil, it is perhaps best at the beginning to procure a portable 
-combined battery from a good maker. This can be used either in the 
consulting room or in the patient's home, and is therefore superior to 
a fixed installation. It is unwise to multiply batteries; they gradually 
deteriorate with keeping, whether used or not, and it is easier to bear the 
expense of maintenance of one battery than of two or more. The com- 
bined battery should consist of twenty-five or thirty small size Leclanche 
or " dry " cells, with a current collector or switch for progressively tak- 
ing cells up into circuit one by one; a galvanometer graduated in milli- 
amperes ; a commutator for reversing the direction of the current in the 
external circuit; a pair of binding screws for the attachment of the con- 
ducting wires; an induction coil with one or two separate and larger sized 
cells to drive it, and a key for switching on either the induction coil cur- 
rent or the battery current to the terminal binding screws at will. Some 
mode of regulating the strength of the induction coil is necessary. 
Such an apparatus can be had at prices varying from eight to fifteen 
pounds, and is the most convenient arrangement for all medical purposes 
of testing and treatment, though it is not suitable for the large currents 
needed for galvano-cautery or for instruments with electric lamps. A 
pair of flexible conductors of insulated wire and a few electrodes make 
up the outfit. It is best to procure any special electrodes as occasion 
arises: those wanted for general purposes are of two kinds, - one a flat 
pad of metal, oval, four inches long, covered with wash-leather or ama- 
dou, and fitted with a binding screw; and the other, a handle to which 
metal discs ranging from half an inch to two inches in diameter can be 
attached. The former is called the indifferent electrode; during treat- 
ment it is applied to some indifferent part of the patient's body, where 
the pressure of the clothes usually suffices to keep it in place - on the 
back of the neck, for example, on the sternum, or the sacrum. The other 
or active electrode is manipulated over the region affected. For testing 
the nerves and muscles it is convenient to have a special electrode fitted 
with a key for closing the circuit at will. 
A sheath for the indifferent electrode with one side waterproof is con- 
venient, as it protects the patient's clothing from being wetted. It is 
important to have clean coverings for the electrodes; and so far as pos- 
sible to provide each patient with a separate electrode and sheath; a 
handy form of electrode is made in which the wash-leather covering can 
be changed in a few moments. Salt water is not necessary for the 
moistening of the electrodes, and, as it corrodes them more rapidly than 
plain warm water, the latter is to be preferred. The silk covered con- 
ducting cords should be light and flexible, four or five feet long, and of 
two colours, to distinguish their attachments the more easily. 
Units of Measurement. - It is impossible to have clear ideas upon 
medical electricity unless the meaning of the words Volt, Ohm and 
Ampere are understood. These terms stand for the units in which elec- 
trical quantities are expressed, and are as necessary to the subject as 
are the better known units of measurement, such as the inch, the pound 
VOL. I 
2 A SYSTEM OF MEDICINE 
354 
and the pint, to matters of everyday life. The volt is the practical unit 
of electro-motive force, or electrical pressure; and the electro-motive 
force of a battery expresses the tendency of such a battery to produce 
an electric discharge, just as the pressure in a steam-boiler signifies the 
tendency of the boiler to emit steam; in the former case the closure of 
a conducting circuit, and in the latter the opening of a valve is necessary 
to cause the discharge. 
The ohm is the practical unit of resistance, and is necessary because 
electrical conductors differ from one another in their specific conductivity; 
those which conduct well are said to have a low specific resistance, and 
those which conduct badly are said to have a high resistance. Metals are 
good conductors; and of metals silver and copper have the least resistance. 
The resistance of a wire or rod or other mass of any substance depends 
upon the specific resistance of the substance, and varies directly as its 
length, and inversely as its sectional area or thickness: thus a long or 
a thin wire of copper will have a greater resistance than a short or thick 
one. The ampere is the unit of current, and the three units are so related 
to one another that an electro-motive force of one volt acting upon a 
conductor with a resistance of one ohm will set up in that conductor a 
current of one ampere. This relation, known as Ohm's law, can be 
E 
expressed, in symbols, by C = -, where C stands for current, E for electro- 
R 
motive force, and R for resistance: if two of the three quantities are 
known the third can be calculated from them; thus when an electro-motive 
force of 12 volts act upon a resistance of 8 ohms, C = -, or C = -, or 
. R 8 
C = 15 amperes, which is the resulting current. 
As a current of one ampere is never applied to patients in medical 
treatment, the thousandth of an ampere (-001 ampere) or milliampere 
forms a more convenient unit, and medical currents are usually expressed 
in milliamperes; thus five milliamperes is a common magnitude of cur- 
rent, and it is more easily expressed in that way than by the fraction 
•005 ampere. 
The resistance of the body is high, very much higher than that of a 
metal; and it varies considerably with the moisture or dryness of the 
skin: under conditions of medical treatment with wetted electrodes, it 
may be taken as ranging between 1000 and 5000 ohms. It is worth while 
to calculate the electro-motive force necessary to send a current of five 
milliamperes through such a resistance. First, in the case of 1000 ohms- 
c = 5 RC = E 
R = 1000 C = '005. E = 1000 x -005 = 5 volts. 
Secondly, in the case of 5000 ohms - 
E = RC = 5000 x -005 = 25 volts. THE MEDICAL APPLICATIONS OF ELECTRICITY 
355 
A medical battery must therefore have an electro-motive force of 
twenty-five volts if it is to drive a current of five milliamperes through 
a body whose resistance is 5000 ohms. 
The Leclanche cells usually supplied in portable batteries have an 
electro-motive force of 1-5 volts per cell; thirty cells (a usual number) 
properly connected together have a combined electro-motive force of 
forty-five volts : this gives an ample margin, and would send a current 
of fifteen milliamperes through a resistance of 3000 ohms. As this cur- 
rent is very rarely exceeded, and as, by thoroughly moistening the skin, 
the body resistance can usually be brought well within 3000 ohms, this 
number of cells is sufficient. Beyond this the weight and cost of the 
battery increases out of proportion to its efficiency. The current from 
the cells of the battery flows through the circuit in one direction from 
the positive to the negative terminal, and, so long as the circuit is closed, 
with almost unvarying strength; when it is broken, by removing the elec- 
trodes from the patient or by opening a key in the circuit, the current 
ceases abruptly. If the electrode be caused to slide over the surface 
of the body there will be variations in the lines of flow in the neigh- 
bourhood of the moving electrode; and the point of entry of the cur- 
rent, or point of greatest density of flow, will vary in position, even 
though the total current flowing in the circuit, as indicated by the 
galvanometer, be steady and uniform. 
The current from the induction coil is of a different kind, inasmuch 
as its strength is continually varying with the electro-motive force of the 
coil which rises and falls in the form of a wave with each vibration of 
the moving contact breaker; each rise and fall of electro-motive force 
means a rise and fall of the current through the circuit. If the primary 
coil of the induction apparatus be used the consecutive waves of current 
are all in one direction; if the secondary coil be used they change or 
alternate in direction. In medical coils the current of the primary cir- 
cuit is not always adapted for use, and it has no therapeutic advantages 
over that of the secondary coil; the secondary current is a current alter- 
nating in direction about fifty times per second and wave-like in char- 
acter ; that is to say, it rises from zero to a positive maximum, then 
falls away again to zero, rises to a negative maximum, and again returns 
to zero; each electrode is thus alternately positive and negative. There 
are several ways of regulating the strength of the secondary coil: one 
of the best is by winding it on a separate bobbin which can be made to 
slide between guides so as to vary its position in the magnetic field of 
the primary coil; as the secondary is withdrawn from the primary the 
current becomes weaker, and vice versa. 
The measurement of the alternating currents of the induction coil 
(which do not affect an ordinary galvanometer needle) has been for a long 
time a serious difficulty, and, in electrical testing, comparisons have been 
usually made by the aid of an arbitrary scale marked along the slide of 
the coil; this does indeed enable the relative positions of primary and 
secondary coils to be reproduced at will, but is of very little use in com- 356 
SYSTEM OF MEDICINE 
paring the results obtained with two coils which may differ. Now at 
length an instrument is made which gives readings of the induction coil 
currents in milliamperes, and as soon as its use becomes general our 
knowledge of the actions of the induction coil current will be placed upon 
a surer basis. Different instruments differ much in the painfulness of the 
sensation to which they give rise. In few of them are the successive dis- 
charges sufficiently equal to produce a smooth sensation. In the choice 
of a coil this point should be attended to, and pains should be taken to 
obtain one which has a contact breaker working smoothly and evenly. 
The least painful rate of vibration is from sixty to a hundred impulses 
per second. 
The properties of the discharges of the induction coil are modified by 
the number of turns of wire in the secondary windings. A coil of few 
turns (two or three hundred) has a lower electro-motive force and a lower 
resistance than a coil of many turns (two or three thousand) ; and besides 
its resistance there is another factor which increases with the number of 
turns, and is known as its self-induction : this retards the rate,of rise and 
fall of current in the coil, and diminishes the magnitude of the current 
which can be taken from it. Thus a coil of many windings has a high 
electro-motive force so long as very small currents are taken from it, but 
this falls rapidly when the resistance of the external circuit is low; a 
short coil has a lower electro-motive force, but is capable of giving a pro- 
portionately larger current without fall in its electro-motive force. For 
treatment with moistened skin and wet electrodes a long coil is not 
needed, but for the stimulation of the superficial cutaneous nerve end- 
ings with a dry skin and a wire brush - a method sometimes adopted 
- a long coil is needed, as the dry skin has a very high resistance, and 
requires a high electro-motive force to drive through it even the small 
current required in this mode of treatment. Some medical coils are 
therefore provided with two interchangeable secondary coils; but the 
same advantage can be had from one coil, if its windings can be tapped 
so as to use either a part or the whole of it at will. 
Too much has been made of the various qualities supposed to be 
obtained by varying the thickness of the wire and the numbers of turns 
in the winding; the rise and fall of the wave of current is rather more 
gradual from a long than from a short coil; this difference and the point 
mentioned above - that a long, fine wire is the best for stimulating the 
dry skin - give the pith of the matter. Recently very rapidly vibrating 
contact breakers have been advocated, because of a peculiar benumbing 
effect upon the cutaneous nerves which is produced by them. These, 
however, are not often useful. 
Nerve and Muscle Reactions. -There is a marked difference in the way 
in which nerve and muscle respond to the battery current and the coil 
current respectively; and this has been made the basis of the elec- 
trical testing of nerve and muscle. In health the battery current pro- 
duces a single twitch of a muscle when the circuit is closed, and another 
when the circuit is opened. In the interval between closure and opening TWA MEDICAL APPLICATIONS OF ELECTRICITY 
the muscle is quiescent, although the muscle or its motor nerve is being 
traversed by the current; the minimal current necessary to produce the 
contraction when the negative electrode is most favourably placed over a 
superficial nerve trunk is about one milliampere. With the positive pole 
357 
•Region of central 
convolutions 
Region of 3rd frontal 
conv. and island 
• of Reil (centre for 
speech) 
-M. temporalis 
Upper branch of facial 
- in front of the ear 
- Facial n. (trunk) 
- Post, auricular n, 
-.Middle branch of facial 
- Lower branch of facial 
-M. splenius 
_M sternocleido- 
mastoideus 
-Spinal accessory n. 
r M. levator anguli scapul 
sM. cucullaris 
* Dorsalis scapula 
> Axillary n. 
''Long thoracic n. (M. 
serrat. ant. maj.) 
M. frontalis 
Upper branch of facial^ 
M. corrug. supercil. _ 
M. orbic. palpebr. 
Hasa! muscles j 
M. zygomatici« 
M. orbicul. oris ] - 
Middle branch offacial - 
IL masseter- 
M. levator menti _ 
M. quadr. menti- 
IL triang. menti- 
Hypoglossal n. - 
lower branch of facial 
M. platysma myoid. - 
Hyoid muscles | E 
JL omohyoidens - 
Ant. thoracic n. - 
CM. pectoral.) 
Phrenic n. Supraclavicular paint. Brachial plexus 
(Erb's point. M. deltoid., 
biceps, brachial is intern. 
and supin. long.) 
Fig. 26. -The Motor points. The Head and Neck 
a current of about twice the strength is needed, and in both cases the 
contractions are more easily produced by closure than by opening of the 
circuit. Thus there are four possible ways of causing a contraction: - 
1. Closure with Kathode on the nerve or muscle, KCC, Kathodal 
closure contraction. 
2. Closure with Anode ,, ,, ,, ACC, Anodal 
closure contraction. 
3. Opening with Anode ,, ,, ,, AOC, Anodal 
opening contraction. 
4. Opening with Kathode ,, ,, ,, KOC, Kathodal 
opening contraction. 
These are arranged in the order of their appearance in health. In disease 
the order may be modified. 
When the currents are stronger the muscle is not quiescent during 
the steady passage of the current, but is in a state of imperfect tetanus, 
which is called closure tetanus. 
With the induction coil current the muscle passes into a state of 
tetanus, and remains so during the passage of the current. This is what 358 
SYSTEM OF MEDICINE 
one would expect from the continual change of strength of the induction 
coil current, which acts as a rapid succession of separate stimuli. 
These muscular contractions are obtained either by stimulating the 
motor nerve trunk at any part of its course, or by stimulating the 
muscle by placing the electrode directly over it. But even in this latter 
M. deltoid. 
(binder part) 
II. triceps (caput 
longum) 
M. triceps (caput 
extern.) 
Radial Nerve • 
M. brachial, intern. 
M. supinator long. 
M. radial, ext. long. 
M. radial, ext. brev. 
M. extensor digit. / 
communis 1 
M. ulnar, extern. 
M. supmat. brer. 
M. extensor indicis 
M. abductor pollic. long. 
M. extens. digiti minim. 
M. extens. indicis 
M. extensor pollic. brev. 
! M. extens. poll. long. 
M. abduct, digit, min. 
M. inteross. dorsal. I. f 
etlL 1 
M. Inteross. dorsal. 
m. et iv. 
Fig. 27. -The Motor points. The Extensor Aspect of the Upper Limb. 
case the stimulus is still distributed through the muscle by means of the 
ramifications of its motor nerves, which convey the stimulus more rapidly 
than the muscle fibres could do it. 
In certain forms of paralysis the reactions become altered and the 
following condition is found: the motor nerve responds neither to the 
induction coil nor to the battery current; the muscle does not respond 
to the direct application of the induction coil current, and to the battery 
current it responds in an altered way, viz., the contractions at closing 
and opening the circuit produce a slow, sluggish contraction instead of 
the sudden twitch seen in health; often, too, the anodal closure proves a THE MEDICAL APPLICATIONS OF ELECTRICITY 
359 
more effective stimulus than the kathodal. These contractions (slug- 
gish) may be produced by very small currents, or, on the contrary, 
strong currents may be needed to produce them. The irritability of the 
muscle to battery currents (galvanic irritability) is said to be increased 
,, M. deltoid, 
(anterior half) 
SL triceps (long head) 
- Mutada- 
cutaneoue n. 
M. triceps (inner head). 
- M. biceps brachii 
Ulnar n. | 
. M. brach. 
in tern us 
Median n. 
- JI. supinator longus 
M. flexor carpi nlnaris 
' M. pronator teres 
M. flex, digitor. common,. 
profund. 
- M. flex, carpi radialis 
M. flex, digitor. sublim.. 
(digiti II. et in.) 
-M. flex, digitor. sublim. 
M. flex, digit, subl. (digit., 
indicia et minimi) 
Ulnar n._ 
- M. flex, pollicis longus 
- Median n. 
JI. palmaris brev.. 
JI. abductor digiti min. 
M. flexor digit, min.. 
IL opponens digit, min.. 
M. abductor pollio. brev. 
- Id. opponens pollicis 
II. flex. poll. brev. 
Mm. lumhricales i 
' M. adductor pollic. brer. 
Fig. 28. -The Motor points. The Flexor Aspect of the Upper Limb. 
or decreased accordingly; the irritability to induction coil currents 
(faradic irritability) being abolished both in the nerve and the muscle. 
This condition is known as the reaction of degeneration, and is found in 
cases of serious injury or disease in the motor nuclei of the anterior 
cornua, or in the nerve trunks. 
The importance of the reaction of degeneration lies in the valuable 
help afforded by it for localising the seat of disease. 360 
SYSTEM OF MEDICINE 
Other modifications of the normal reactions are a general increase of 
irritability to coil and battery, a corresponding general decrease of irritability, 
and a partial reaction of degeneration, whose essential features are the 
presence of sluggish contractions when the muscle is stimulated directly 
by a battery current, and a partial retention of the excitability of the 
nerve and muscles to the induction coil current. This partial reaction 
of degeneration most usually occurs as a transient phase in a paralysis 
which is becoming either worse or better; and it may be seen in other 
cases where the damage is not sufficient to produce a complete reaction 
of degeneration. 
Practical Electrical Testing. - This should be carried out as follows : 
Crural n.» 
Obturator n. 
M. pectineus 
M. adductor magnns- 
IL adduct, longus ■ 
M. oruralis 
M. vastus lutoraus | 
M. tensor fasci® lai® 
M. sartoriua 
M. quadriceps femoris 
(common point) 
M. rectus femoris 
M, vastus external 
Place the indifferent electrode in a suitable position on the patient,, 
and take the limb to be tested in the left hand, holding in the right 
the testing electrode with one inch disc which should have a key in the 
handle for closing the circuit. Moisten the skin thoroughly over the 
muscles to be tested, and set the induction coil in action at a weak 
strength; then apply the testing electrode to the hand which holds the 
patient's limb, in order to estimate the strength of current. This should 
invariably be done before the electrode is allowed to touch the patient, 
as the protection afforded to him by this procedure is obviously very 
great. When thus the strength of the current is found suitable, apply 
the electrode to the motor points of the muscles in order, noting whether 
they contract. A finger placed lightly upon the tendons will often help 
Fig, 29. - The Motor points. The Front of the Thigh. THE MEDICAL APPLICATIONS OF ELECTRICITY 
361 
us to decide whether they contract or not, and will obviate the use of 
very strong currents. The limb should also be disposed in such a way 
as to exhibit the action of the contracting muscles. If the opposite limb 
be sound a comparison should be made of the two sides in order to 
discover whether there be any changes in the contractility to the induc- 
tion coil. A rough comparison can be made by the help of the graduated 
slide of the induction coil or by a suitable galvanometer, if such a one 
be at hand. 
If the muscles all react satisfactorily to the coil test the case cannot 
[• IL gluteus maximum 
Sciatic n. - 
M. biceps, fem. (cap. - 
long.) 
M. biceps fem. (cap. - 
brer.) 
■M. adductor magnus 
•W. semitendinosus 
•M. semimembranosus 
Peroneal n._ 
IL gastrocnem. (cap. - 
extern.) 
IL soleus < 
M. flexor hallucis longus . 
Tibial n. 
- M. gostroonem. (cap. Int.) 
-M. soleus 
- w flexor dlgitor. comm, 
longua 
- Tibial n. 
Fig. 80. - The Motor points. The Posterior Aspect of the Lower Limb. 
be one of the complete reaction of degeneration. This should always 
be confirmed by going over them again with the battery current, noting 
whether the contraction is quick or sluggish, whether the anodal or 
kathodal closure is the more effective; and noting also the current in 
milliamperes required to produce contractions. If the electrode be ever 
so little off the motor point the minimal contraction will require a 
stronger current than when it is rightly placed. Tables of motor points 
are given in most books upon medical electricity, but the best way to 
learn them is by careful practice upon one's own muscles. The nerve 
trunks of the limb should also be tried with both forms of current, and SYSTEM OF MEDICINE 
362 
their responses should tally with those obtained from the muscles them- 
selves. 
A knowledge of the positions and actions of the muscles, and of their 
nerve-supply, is quickly gained by the practice of electrical testing; and 
from the data obtained valuable opinions as to the seat and extent of 
the injury or disease can be formed. 
Sensibility can also be tested electrically; the coil is to be used and 
the electrode applied to the surfaces of the skin, noting the position of 
the secondary coil at which a sensation is first felt. If the active 
electrode be applied to the operator, and the fingers of his own hand be 
Peroneal n. 
■IL gastrocnem. extern. 
-M. peroneus longus 
JI. extens. digit, comm. - 
long. 
M. tibial, antic.- 
IL soleus 
IL peroneus brevis - 
IL extensor hallucis - 
long. 
IL flexor hallucis long. 
-X extens. digit, comm, 
brevis 
Mm. interossei dorsales 
-Mi abductor digiti min. 
used as the electrode to convey the current to the patient, the sensibility 
of the patient's skin can be directly estimated; in this way the presence 
or absence of ansesthesia can be gauged with great nicety. In cases 
where tactile and common sensation are unequally affected, the electrical 
test determines analgesia rather than anaesthesia. Thus a patient with 
analgesia may be able to feel the touch of the electrode, though uncon- 
scious of the strong current which it is conveying into the skin. 
Electrical Treatment. - This may be locally applied for the sake of 
influencing a particular part, or it may be applied generally. The appli- 
cation of localised electrification to cases of nervous disease has had the 
effect of diverting attention from the treatment of general morbid con- 
ditions by general electrification; but the value of the latter treatment is 
Fig. 31. - The Motor points. The Leg- and Foot, outer side. THE MEDICAL APPLICATIONS OF ELECTRICITY 
363 
now becoming more fully recognised. General electrification is very 
useful as a stimulating method of treatment in states of malnutrition or 
debility; for example, during convalescence after exhausting illness, in 
rickety children, in anaemic people, in the earlier stages of rheumatoid 
arthritis, and in some other conditions, such as general neuritis and 
neurasthenia. The best mode by far of obtaining the effects of general 
electrification is through the medium of the electric bath. For this an 
earthenware or wooden bath-tub is to be used, which is fitted with large 
metal electrodes at the head and foot. The patient is put into the bath 
with the water at a temperature of 99°, and the current is passed through 
it. The water carries off a large part of the current, but the patient's 
body is traversed by about one-eighth part of the total. 
The induction coil current is the most effective, and the most gen- 
erally useful in the electric bath. The patients make good progress 
under this mode of treatment and gain in weight; a large number of 
patients receive electric baths every year at the electrical department 
in St. Bartholomew's Hospital, and the value of the treatment is un- 
doubted. Rheumatoid arthritis, if not too far advanced, is relieved. 
The use of a small bath as a means of carrying out electrical treatment 
for children is very convenient; it is well borne by them, and they like 
it; the action of the current is also more uniform and thorough than 
when treatment with the ordinary moistened electrode is used. The 
electric bath may also be used as a means of applying local treatment if 
the parts involved be of considerable extent; by so doing the risk of 
chill is diminished, and the currents affect the cutaneous nerves less 
painfully because of the good moistening of the skin. Thus children 
with infantile paralysis of the lower limbs improve more quickly when 
their treatment is applied through the medium of a small warm bath; 
and if one leg only be affected, the sound leg can be drawn up, and 
the current diverted into the paralysed limb. I have been extremely 
pleased with the results obtained in this way. The electric bath un- 
fortunately has suffered much in repute from the abuses connected with 
it; but there is no doubt whatever that, when properly applied, it is 
a most valuable means, and its uses will in time be more fully recognised. 
The deplorable quackery which has degraded medical electricity of late 
years has had the effect of destroying the confidence of the medical 
profession in the treatment; but this attitude tends to perpetuate 
the evil, which should rather be dealt with by medical men themselves 
taking up the study and practice of medical electricity, and withdraw- 
ing their support entirely from all unqualified " medical electricians," 
who are uniformly to be regarded with suspicion. It may be assumed 
that all such persons are likely sooner or later to abuse the confidence 
placed in them, and to yield to the temptations of treating patients on 
their own account, either by selling them " electric " or " magnetic 
appliances," or by promising impossible cures. 
General electrification by means of an electro-static machine has 
already been referred to. It has the advantage that it does not require 364 
SYSTEM OF MEDICINE 
the patient to undress, and it appears to be of some value in certain 
cases; the use of electro-static treatment for cutaneous affections, and 
especially for pruritus and for chronic varicose ulcers, deserves a trial, 
as it has been found to be of great value by certain French observers. 
The methods of application will be found in the special handbooks. 
Localised electrification for local affections has been tried in a vast 
number of diseases; indeed there are few morbid conditions for which 
electricity has not at one time or another been recommended. The modes 
of application are simple. The indifferent electrode is applied to the 
body in such a way that the path of the current from it to the active 
electrode shall follow as closely as possible the line of the nerves of the 
part to be treated. An active electrode of suitable size and shape is then 
moved over the affected region (labile application), or held firmly over 
one part (stabile method), the skin and the electrode being well mois- 
tened ; ten minutes is a suitable length of time. The treatment should 
be repeated two or three times a week, the choice of current - whether 
of induction coil or of constant current - will depend upon the effects 
desired; for the stimulating and trophic effects which form so large a 
part of ordinary electrical treatment the induction coil is the best as 
a rule. 
The properties of the current can be represented by the accompany- 
ing table: - 
Effects desired. 
A. Stimulating 
and trophic 
B. Anodyne. 
(1) Induction coil. (2) Battery current with 
variations, interruptions, and reversals. 
Battery current. Positive pole without interrup- 
tions or sudden variations. 
C. Electrolytic 
D. Alterative and. 
vasomotor 
Battery current, without reversals. C. Peripolar 
effect. D. Interpolar effect. 
E. Osmotic . 
Battery current. Positive pole. 
The striking effect of electrical currents in causing contractions in 
paralysed muscles has naturally attracted attention from the first as a 
possible therapeutic method. In certain kinds of paralysis electricity 
affords a very useful means of treatment. In Hemiplegia from organic 
disease it cannot indeed be expected to restore parts which have been 
destroyed; but a short course of treatment during the period of recovery 
does help materially in the restoration of power to those which are not 
too severely damaged. It appears that the paralysis which follows a 
hemiplegic attack is often more extensive than is warranted by the 
actual destruction of fibres in the brain, and the electrical treatment 
favours the return of functional activity in those parts which have been 
disused, or impaired though not destroyed by the cerebral lesion. I 
have seen few cases of hemiplegia which have not gained something from 
a month's treatment by electricity. The application of a fairly strong 
induction coil current to the affected limbs, so as to produce lively con- THE MEDICAL APPLICATIONS OF ELECTRICITY 
365 
tractions of the muscles, is the proper method; it should be done twice 
or thrice a week for ten minutes at a time, and this treatment carried 
out for a month. By the end of that time the patient will have 
derived whatever benefit he is likely to obtain. It is important not to 
begin electrical treatment until from four to six weeks after a seizure. 
Infantile Paralysis. - In this disease electrical treatment is of great 
value, but demands much perseverance on the part of all concerned. 
After the close of the febrile attack which usually accompanies the onset 
of the disease, the damaged muscles rapidly waste to a greater or less 
degree, and the reaction of degeneration may be well marked in some 
of the muscles within a week of the onset. At the end of three weeks 
the muscles may be tested, and the extent of the damage estimated; 
electrical treatment should then be begun. It is customary to use the 
induction coil if the muscles react to it; if they do not, to use the 
battery current instead: in either case the active electrode is moved 
over the surface of the paralysed parts. It is at present by far too com- 
mon a practice to leave cases of infantile paralysis to themselves, in the 
belief that the muscles will recover spontaneously if the motor cells in 
the cord are not destroyed; or will remain incurably atrophied if these 
cells are destroyed. This, however, by no means represents the true 
state of the case. From a fairly wide experience of electrical testing 
and treatment in infantile paralysis, I may definitely assert that there 
are many cases of children in which weak and damaged muscles remain 
inefficient during years of such " expectant treatment," although they 
present no reaction of degeneration. These are cases which will at once 
begin to improve with electricity, and will continue to improve if the 
electrical treatment be continued. There are also many cases where 
muscles, atrophied and degenerated for two or three years, and giving 
no response to any form of electrical stimulation, may be made to grow 
and recover normal reactions by patient electrical treatment. The 
secret is that infantile paralysis does not of necessity destroy the whole 
of an affected muscle; this is the exception rather than the rule. A 
few normal fibres and a few of their ganglion cells very often survive, 
and by the persevering treatment of these a new muscle can be slowly 
cultivated. Thus in one case a new and useful calf gradually grew 
where there had been complete atrophy, the new muscle consisting 
almost wholly of a highly-developed outer head of the gastrocnemius; 
the inner head of the same muscle and the soleus remained atrophied. 
If, by treatment, a certain degree of development can be gained, so as 
to enable the muscle to be of service, then the voluntary use of it con- 
tinues the process of repair. Exercises are therefore an important 
adjunct to the electrical treatment. 
In brief, the treatment of infantile paralysis is most encouraging, 
and should by no means be neglected in children. No case should be 
regarded as hopeless, for however bad it may be, some gain from a 
course of treatment is certain; the gain may be but trifling, or it may 
be great, but there is no better treatment; and the parents should be 366 
SYSTEM OF MEDICINE 
encouraged to continue it for years if necessary. I have had several 
cases under treatment for three years or more. When the disease is of 
several years' standing the prospects are less favourable, but even these 
will make some progress under careful treatment. The method of 
treatment to be followed may be with one electrode applied to the nape 
of the neck in the case of paralysis of an upper limb, or to the dorsal 
or lumbar region for the lower; the active electrode is to be moved 
over the affected muscles for ten minutes three times a week or oftener. 
The induction coil is to be used for all the cases; and for those showing 
altered reactions the constant current also, five minutes with each. The 
strength of current must be regulated by the feelings of the patient, 
some children being more timid than others; but as a general rule the 
current should be as strong as they are able to bear without discomfort 
or distress. The skin should be well soaked in hot water to diminish its 
resistance. Two-inch electrodes should be used and kept in movement 
over the affected muscles all the time. In this way children may bear 
the passage of three, four or five milliamperes; but if not, then smaller 
currents must suffice. Although the constant current has the reputation 
of being the best for these cases, the grounds for its preference are more 
theoretical than real, and an induction coil apparatus will give good 
results. When the parents or the nurse are to carry out the treatment 
for a year or more the coil is the best apparatus, as it is simpler and 
cheaper, and any failure in its action is easier to detect by the cessation 
of the audible vibration of the contact-breaker. There is also no risk 
of damaging the patient's skin by electrolytic action. 
The best way of treating these cases when the paralysis affects the 
lower limbs, as it so commonly does, is to arrange two metallic plate 
electrodes at the ends of an ordinary foot-bath of wood or earthenware 
filled with warm water. The child can be put into the bath in a sitting 
posture with legs extended, and the coil current passed through the bath; 
the strength of the current can be gauged by putting the hands into the 
water, one close by each of the electrodes. The bath can be given daily 
in the evening; after it the limbs are to be well rubbed, and the child put 
to bed. A little warm jacket can easily be contrived to cover the arms 
and trunk during the bath. Rubbing and manipulation of the affected 
limb, with some suitable gymnastic exercises, are of great advantage as 
auxiliaries in the treatment of this disease. The only way of ensuring 
proper treatment for these children is to entrust it to the mother or to 
a good nurse, to teach them carefully how to do it, and to have it done 
every day. It is useless to leave it to the visits of a medical man. The 
treatment must be made a part of the child's daily life; but the medical 
man must see it done now and then, and must test and measure the 
limbs from time to time to estimate the progress of the case. For this 
reason a simple apparatus is essential, and such an one has been contrived 
by rayself for the express purpose of enabling the parents to manage the 
daily treatment for themselves without the possibility of going wrong. 
Injuries of Nerves.- The different forms of paralysis, due to contusion, THE MEDICAL APPLICATIONS OF ELECTRICITY 
367 
compression, or other injury of nerve-trunks, improve rapidly under treat- 
ment if the nerve-trunk be not actually divided or torn across. When 
this is the case, an operation to unite the ends must be performed before 
electricity can be of service. When a nerve-trunk is involved in scar tis- 
sue the cases are likely to be tedious; but even here perseverance with 
the treatment will do much. There are few forms of paralysis more 
likely to improve under electrical treatment than those of damaged 
nerve-trunks, but the prognosis should be a guarded one until the actual 
severity of the injury can be gauged. If the electrical reactions be not 
altered, and if the reactions to the induction coil be present, the case may 
be expected to recover within four weeks; often it will get well in a 
shorter time. In neglected cases electricity will often start an immediate 
improvement. The exciting cause of the mischief, if still present, must 
be removed; this applies, of course, chiefly to crutch palsy. When there 
is a marked reaction of degeneration the case may be a longer one; the 
progress of the case during the early days of treatment must be watched, 
and the prognosis based on the state of atrophy and the amount of vol- 
untary power and sensation present. Often it happens that improved 
nutrition and voluntary power begin to return before any change in the 
electrical reactions can be detected; in fact, this is the rule. In every 
case perseverance with the electricity, aided by rubbing and shampoo- 
ing, is to be insisted on; in electrical treatment of these cases one need 
never despair except when the wasting and paralysis grow worse in 
spite of all that is being done: in such cases the nerve-trunk has prob- 
ably been torn, and a surgical operation, to explore and, if necessary, to 
reunite the nerve, should be considered. When the reaction of degen- 
eration becomes more and more difficult to elicit, requiring stronger cur- 
rents than it did before, the prospects are unfavourable. The site of the 
lesion in the nerve-trunk can be localised very closely by electrical test- 
ing and examination of the affected muscles. The commonest types of 
paralysis from injury to nerves are sleep palsy, crutch palsy (musculo- 
spiral nerve), paralysis from blows about the shoulder (circumflex 
nerve, supra-scapular nerve, and nerve to serratus magnus), and median 
or ulnar paralysis from fractures and wounds of arm and forearm or 
from tight bandaging or badly-applied splints. These last two causes 
are not very uncommon, and they should be borne in mind. In the lower 
limb paralysis from injuries to the nerve-trunks is less frequently seen. 
Facial Palsy. - Facial paralysis in most cases also belongs to the same 
group: its symptoms need not be described here. It is important to 
remember that the electrical examination of the muscles of the face must 
be carried out with very weak currents; the skin is very sensitive, and 
as the muscles lie close beneath the surface they are readily thrown into 
contraction. Care must therefore be taken not to alarm the patient by 
the use of strong currents on the first visit. If the electrical reactions 
be normal the prognosis is good, and the patient may be expected to 
recover in from three to four weeks. If there be a reaction of degener- 
ation, partial or complete, a longer time must be allowed. As a rule, 368 
SYSTEM OF MEDICINE 
cases of facial paralysis recover unless some progressive disease in the 
course of the nerve be the cause of it. The cases which come on spon- 
taneously and are usually ascribed to cold may be expected to recover. 
Too confident a prognosis must not be given, as now and then an 
apparently simple case resists treatment obstinately. Cases of long 
standing and those in elderly people are as a rule less favourable; but 
treatment must be persevered with, as improvement may begin to show 
itself as late as three months after the onset. 
Electrical treatment will often start improvement in cases which are 
stationary; and it is desirable to begin electrical treatment early, and 
not to neglect it until a late stage of the complaint. Many cases of 
facial palsy recover without electrical treatment; but it is not wise to 
leave the cases untreated. The induction coil is best for those with 
normal reactions; if the reaction of degeneration be present, it should 
be supplemented by the constant current, negative pole. The indiffer- 
ent electrode should be applied to the back of the neck, and the active 
electrode moved over the face, following approximately the lines of the 
main branches of the facial nerve. The skin must be very thoroughly 
moistened to diminish the unpleasantness of the current. The electrode 
should be kept away from the points of emergence of the main branches 
of the fifth nerve, as these are very sensitive. 
Neuritis. - In the various forms of paralysis due to general or mul- 
tiple neuritis, the best treatment by far is by the electric bath; the 
induction coil and fairly strong currents are to be used, and the same 
treatment should be adopted in paralysis following specific fevers, of 
which diphtheritic paralysis is the type. Failing the electric bath, the 
induction coil may be used with large sponge electrodes. The patient 
must be guarded from the risks of chill by using hot water and a well- 
warmed room, and it is often most convenient to apply the treatment 
at bedtime, as the patients will probably sleep all the better after the 
electrical treatment. The electric bath is much more agreeable and 
efficient than the treatment by sponge electrodes. Cases of advanced 
alcoholic neuritis sometimes recover completely under prolonged bath 
treatment. If the interrupted current cause painful sensations the con- 
stant current may be used instead. 
Lead Poisoning.-The treatment of lead poisoning is slow: in hos- 
pital patients it is usually made slower because the patients return to 
their work as soon as they begin to recover power, and then they again 
come into contact with the sources of lead poisoning. 
In this disease one may occasionally notice that muscles give a 
reaction of degeneration even before they are affected with paralysis; 
and, conversely, the atrophy and paralysis may improve considerably 
before there is any return of the normal reactions. 
The electric bath with constant current has been proposed in cases of 
metallic poisoning as a means of eliminating the metal from the system. 
I have found unmistakable traces of lead deposited upon the copper 
electrodes of the bath from a patient with lead poisoning. It is doubtful, THE MEDICAL APPLICA TIONS OF ELECTRICITY 
369 
however, whether the lead so deposited has been obtained from the tis- 
sues of the body, or whether it comes from the contamination of the 
surface of the skin with lead compounds. Further experiments are 
necessary before the point can be cleared up. The battery current, 
labile over the affected muscles, is the treatment most favoured. It 
should be combined with induction coil treatment, each current being 
applied for five minutes at each visit. 
Neuralgia.-Neuralgia sometimes yields quickly to electricity, at 
other times it is most obstinate. Often the pain is made worse by the 
induction coil, but by using a secondary coil of many windings and a 
rapidly vibrating contact-breaker, an anaesthetic effect can be obtained 
which has proved to be decidedly useful in many cases. In general the 
an-electrotonic effect of the positive pole of a constant current battery 
should be tried; there must be no abrupt makes and breaks of current, 
and the strength must be raised and lowered very gradually by the use 
of an adjustable resistance of about 10,000 ohms. With this in circuit, 
and set for its maximum resistance, the current collector is slowly turned 
on to twenty cells, the contact of the electrode with the patient being 
steadily maintained; the current is then increased by sliding the traveller 
of the rheostat from its maximum to a lower value, until five or six 
milliamperes are indicated on the galvanometer. The electrode is kept 
moving slowly over the neuralgic area, but without any interruptions of 
contact until the end of the sitting, then the rheostat is again brought 
into use to lower the current, and afterwards the current collector is 
turned off. Five minutes is a sufficient time for each sitting. 
Sciatica is a painful affection which commonly comes under electrical 
treatment; the results are usually good, and may be manifested rapidly. 
As the nerve is deep-seated, large electrodes and currents of ten to twenty 
milliamperes are to be employed. The indifferent electrode (negative 
pole) is to be placed on the sacrum or over the sciatic notch, while the 
other pole is moved slowly along the trunk of the nerve, and also ap- 
plied to any painful points which may be present. The electric bath is 
also a valuable method of treating sciatica: one electrode may be placed 
near the posterior surface of the thigh, while the other is at the head 
of the*bath; or the electrodes at the head and foot of the bath may be 
used, and an accessory wire led from the foot-plate to a pad electrode 
placed under the thigh; this electrode must be covered with a flannel 
or wash-leather covering. The painful counter-irritation of a strong in- 
duction coil current, applied with a wire brush to the dry surface of the 
skin of the affected region, will sometimes dispel a sciatica. 
The treatment of Lumbago is similar in all respects to the treatment 
of Sciatica, except that the electrodes are to be applied to the lumbar, 
and not to the sciatic region. The results of electrical treatment for 
sciatica and lumbago are very satisfactory. 
Hysterical affections may often be dispelled by electrical treatment, 
and many of the remarkable cures to be found in the early books on the 
application of electricity to medicine are of this sort. This use of 
VOL. I 
2 B SYSTEM OF MEDICINE 
370 
electricity is none the less valuable in medical treatment because its 
effects may be due to an action upon the mind of the patient, for in 
hysteria some such profound mental impression, acting through the sen- 
sory nerves or otherwise, is chiefly required; but the cures effected by 
its means can only be attributed in an indirect way to the electrical 
properties of the apparatus employed. Occasionally the mere sight of 
the electrical apparatus is sufficient to dispel hysterical symptoms. 
Electrical treatment, though it may cure the particular symptoms 
which are present at the time, does not alter the peculiar hysterical 
tendencies of the patient. In anaesthesia, contractures, paralysis, pain- 
ful joints, weak spines, aphonia, etc., local stimulation with the induc- 
tion coil, either with the ordinary electrodes or with the wire brush, are 
to be used. The symptom often departs suddenly during the course of 
the first sitting, or it may gradually disappear afterwards. It is seldom 
that more than a few repetitions of treatment are needed, and meanwhile 
other treatment to improve the patient's general state of health should 
be adopted. The electro-static machine is also a very useful engine for 
the treatment of hysterical manifestations. 
Neurasthenia and Hypochondriasis. - Patients suffering from these 
maladies are usually very ready to try electrical treatment, partly from 
the general tendency of such patients to seek remedial measures of any 
kind. From electricity, as from any other new thing, they seem to de- 
rive benefit for a time. Perhaps the best thing for them is to apply 
general electrification, particularly the electric bath with interrupted 
current. The general fillip to the system afforded by this may help to 
raise them out of their unhappy condition, especially if combined with 
a diet and regimen calculated to improve their digestive functions. In 
many of these cases the symptoms are associated with disorder of the 
alimentary canal, such as dyspepsia or constipation; and it may be that 
improper diet and malnutrition are the immediate cause of most cases of 
hypochondriasis and neurasthenia. Electricity can help them by stim- 
ulating their metabolic processes, and so can indirectly provide them with 
a chance of escape from their miserable condition, provided that in other 
respects their diet and mode of life can be improved. 
Insomnia. - It has often been observed that patients sleep better 
after electrical treatment, electricity is therefore a proper means to try 
in cases of sleeplessness. General treatment with the induction coil, 
either in the electric bath or by means of large bath sponge electrodes 
moved over the trunk and limbs, will thus enable many patients to sleep 
soundly. 
The treatment of locomotor ataxy and progressive muscular atrophy by 
electricity has been hitherto very unpromising, although the pains of 
tabes have been alleviated by the treatment. Favourable reports are 
published from time to time of cases of these diseases improved by 
electricity, but no thoroughly definite results of an uniform character 
are yet to hand. 
The troublesome symptom of tinnitus aurium may often be relieved, THE MEDICAL APPLICATIONS OF ELECTRICITY 
but rarely cured by electrical treatment. The tinnitus is sometimes as- 
sociated with increased electrical irritability of the auditory nerve, and 
it can be diminished if the anode is applied to the ears by means of a 
divided electrode shaped like the metal part of a binaural stethoscope, 
the indifferent electrode being placed on the nape. To protect the skin 
from electrolytic effects, there should be a thick covering of wetted ab- 
sorbent wool upon the active electrode, which is to be applied just in 
front of the_ tragus. A current of ten milliamperes is to be used for ten 
minutes. It may be turned on rapidly, but should be turned off very 
slowly, and with the help of an adjustable resistance. In favourable 
cases the tinnitus is arrested during the passage of the current, and 
after a few sittings the remissions become longer and longer until the 
symptom disappears altogether. When patients with tinnitus come for 
electrical treatment, they should be submitted to an electrical testing. 
If the anode modify or arrest the sounds, the cases are favourable, and 
electrical treatment may be confidently recommended. If the current 
leave the sounds unaffected the cases are unfavourable. The kathode 
usually increases the sounds, the anode diminishes them. Sometimes 
the converse is the case, then the kathode must be used as the active 
electrode. If the sounds are unaffected by either kathode or anode, 
treatment is not likely to be of much use. 
Disorders of Circulation. - Dr. Barlow has recommended electricity 
in those cases of local asphyxia, known as Raynaud's disease, in which 
the extremities become blue and cold, and are liable to chilblains, or even 
to gangrene. The mode of treatment is as follows: The hand or foot is 
immersed in a basin of warm water in which one pole of the battery is 
placed, while the other is fixed to the upper portion of the limb, or to 
some neighbouring part of the trunk ; the current should be as strong as 
the patient can bear. Dr. Barlow advises the use of the continuous cur- 
rent, but probably the interrupted current would prove equally effica- 
cious. The same treatment is very good for patients who are subject to 
chilblains, and will prevent their formation, or dispel them, if the treat- 
ment be begun as soon as the first signs of the chilblains show them- 
selves. If the skin be broken it is difficult to apply electrical treatment, 
as it produces a good deal of pain in the excoriated surfaces. 
A course of electric baths usually cures any acne of the skin of the 
back that the patients may suffer from, and I have seen a chronic ec- 
zematous ulcer of the leg, after having been a great trouble for years, 
resisting many remedies, heal in a few weeks under the use of the 
induction coil bath. 
Exophthalmic Goitre. - The electrical treatment of this disease has 
received a good deal of attention, and from time to time favourable re- 
sults have been obtained and published. Among the most recent publi- 
cations on the subject is an account by Dr. Rockwell of forty-five cases; 
the method which he recommends is to use strong electrical currents - 
twenty, forty, or even sixty milliamperes. These are applied by means 
of electrodes of very large surface; the kathode over the pit of the 
371 372 
SYSTEM OF MEDICINE 
stomach, and the anode to the nape of the neck. General electrical 
treatment by the electrical bath, or otherwise, may be used concurrently. 
Vigouroux has recommended the use of the induction coil, applying it 
in turn to the eyeballs, the chest, the thyroid, the sides of the neck, and 
the cardiac region. Other writers advise other operative procedures; 
there is no certainty of relieving the patient by any of them. Electrol- 
ysis of the enlarged gland is perhaps the most promising method. 
Incontinence of urine is also a favourable subject for electrical treat- 
ment. In the reflex nocturnal incontinence of the young it is usually 
successful. One electrode is applied to the lower dorsal spine, and the 
other to the perinaeum, and the induction coil current is used for six 
minutes, followed by the battery current for three minutes. The latter 
current should be repeatedly made and broken and reversed by hand; 
about fifty such interruptions will suffice. Current five to ten milliam- 
peres, positive pole to spine, negative to perinaeum. Improvement soon 
shows itself, but treatment must be continued for a month, or several 
months, as the cases are very apt to relapse. The effect of elec- 
tricity here is to stimulate the centres, both cerebral and spinal, by the 
repeated setting up of painful local impressions, which in time bring 
the inhibitory cerebral mechanism into closer relation with the reflex 
centres in the lumbar cord. Usually the patients begin by being 
free for a night or two after each application, and they go on grad- 
ually improving. It may take some time to overthrow completely 
the bad effects of habit in these cases, but with perseverance they 
will all improve, if there be no organic mischief behind. It is impor- 
tant to try to combat the tendency to very deep sleep which many of 
these patients exhibit. This may be done by various means - for 
example, the bedclothes should be scanty, and a clock which strikes 
the hours loudly may be placed in the bedroom. When the inconti- 
nence is diurnal, and due to weakness of the sphincter, the best mode 
of application is the introduction of a metal-tipped sound into the 
urethra, the indifferent electrode being as before; the same treatment 
with the induction coil followed by galvanism should be employed. 
This state sometimes follows when patients have been forced to hold 
their water for a long time. In women a small want of tone in the 
sphincter is not at all uncommon, and the urine is apt to be expelled 
involuntarily during any muscular effort. I have seen electrical treat- 
ment cure a number of such cases permanently, even when one hardly 
dared to hope for so fortunate a result. When the bladder symptoms 
form part of a general paraplegic state, the local treatment described 
above will not be of use unless the condition of affairs in the spinal 
cord can be improved also. 
Electricity has been applied for various uterine affections, par- 
ticularly for uterine fibroma. The methods of Apostoli have fallen into 
discredit in this country, but no doubt there is some value in his treat- 
ment; in Paris he continues to carry it out, and is able to publish 
favourable results in large numbers of cases: moreover, independent MASSAGE: TECHNIQUE, PHYSIOLOGY, ETC. 
373 
observers have confirmed his statements. It is quite possible that it 
may again be revived here. 
The use of electricity for surgical purposes - for the heating of 
wires in the galvano-cautery; for the lighting of small incandescent 
lamp instruments; for the destruction of naevi, moles and warts, and 
the removal of superfluous hairs, are fully dealt with in the special 
articles and handbooks. 
H. Lewis Jones. 
Among the standard works on the medical uses of electricity the 
following may be enumerated: - 
1. Boudet de Paris. Electricite Medicale, 1888. - 2. Dawson Turner. Medical 
Electricity. Balliere, Tindall and Son, 1892.-3. Duchenne. Electrisation Localisee, 
1872.-4. Duchenne. Electrisation Localisee, translated in part by Dr. G. V. Poore. 
New Sydenham Society, 1883.-5. Erb. "Electro-therapeutics," in von Ziemssen's 
Handbook of General Therapeutics, vol. vi., translated by De Watteville. Smith, Elder 
and Co. 1887.-6. Hedley. Hydro-electric Methods in Medicine, 1892.-7. Lewis 
Jones. Medical Electricity. H. K. Lewis, 1895. - 8. Onimus and Legros. Traits 
d'Electricite Medicale, 1888. -9. Steavenson. Electrolysis in Surgery. Churchill, 
1890. 
H. L. J. 
MASSAGE: TECHNIQUE, PHYSIOLOGY, AND THERAPEUTIC 
INDICATIONS 
No endeavour will be made in the present article to consider the history 
of massage, but to give simply and briefly an outline of the technique 
sufficient to enable a physician to judge whether a masseur is well 
taught and works conscientiously; then to recapitulate the physiologi- 
cal effects which experimental studies have of late firmly established, 
to deduce from these its applicability in disease, and to indicate the 
diseases in which clinical experience has taught us its usefulness. 
No doubt some of the distrust of massage has been due to the igno- 
rance or incompetency of many of the professional manipulators, and to 
the absurd and extravagant efforts to proclaim it as an exclusive method 
of treatment. Unless inflammation be present, or some unusual tender- 
ness or susceptibility, little direct harm, beyond discomfort, is likely to 
be done to a patient by rough or wrongly applied massage, but failure 
of any good result is harm enough. The practice of " mechano-therapy " 
by manipulators usually quite ignorant of medicine, certainly with no 
scientific training, and independent of proper diagnosis and directions 
from a physician, is altogether to be deprecated, and is one of the great 
sources of the prejudice against the method still existing in the minds 
of many medical men. It is not necessary that such work should he 
undertaken by the practitioner himself - though this has been done in 
Germany and Sweden - but that he should be sure, if need be by per- SYSTEM OF MEDICINE 
374 
sonal observation, that the person he employs is well taught, industrious, 
conscientious, and obedient to orders. 
The technique of massage is not difficult to acquire; and, as the whole 
value of the treatment lies in the proper execution of minute details, one 
who prescribes it should be familiar at least with the movements com- 
monly used. " The various manipulations and their modifications natu- 
rally suggest themselves to one who clearly comprehends the anatomical, 
physiological, and pathological indications in any given case " (1). 
With the single exception of Dr. Granville's percussor, no instru- 
ment, among the hundreds devised for the performance of some of the 
movements, can usefully replace the human hand. Great manual 
strength is not necessary, though a hand not too small is desirable; but 
very large and muscular hands lack the delicacy of touch which is so 
desirable. The most rational classification of the various movements is 
that into four kinds, for which the French names are usually employed, 
as follow: Effleurage (stroking), petrissage (kneading), friction (rubbing), 
tapotement (percussion or striking). These may all of them be used 
lightly or strongly, deeply or superficially, and in various combinations, 
as needful for special ends. 
Effleurage is performed with slow strokes, made with the flat or with 
the heel of the hand, or with its ulnar edge or with a finger only. The 
stroking should always be centripetal, the hand in the return movement 
only lightly grazing the skin. The chief usefulness of effleurage, apart 
from its slight stimulation of the skin-nerves, is in hastening the move- 
ment of the contents of the veins and lymphatics. 
Petrissage - the most important and most difficult of the several 
movements - is done by grasping with the whole hand the tissues to be 
manipulated, lifting them somewhat, and kneading them with an alter- 
nate tightening and loosening of the hold. In large masses of muscle, 
like those of the thigh or calf, it is sometimes best to use both hands. 
The movement is very different from pinching. Care must be used that 
the skin moves with the hand over the underlying tissues. The surface 
hairs will be painfully dragged if the hand is permitted to slip over the 
skin. In certain favourable situations - in the upper arm, for example 
- the extended hands are placed upon opposite sides of the limb and 
moved rapidly back and forth with firm pressure, rolling the muscle 
masses between them and pressing them together or against the bone, 
- a motion entitled "fulling," from its likeness to the movements used 
by fullers in handling linen. The effects are identical with those of 
ordinary petrissage, but somewhat more stimulating from the greater 
speed of the manipulation. A slight contraction of the muscles is in- 
duced by this operation, the absorption of infiltrations in the tissues is 
promoted, and their progress through the lymph-vessels assisted. 
Friction is performed by firm rubbing in small circles with the thumb, 
finger-tips, or whole hand. It might well be included as a modified form 
of petrissage, as it has precisely similar effects, and is useful where the 
tissues are too closely attached to bones to be picked up by the hand, as MASSAGE: TECHNIQUE, PHYSIOLOGY, ETC. 
375 
in the neighbourhood of joints; in such situations it is especially of 
value in the removal of articular effusions. 
Tapotement is the application of rapid blows delivered with the ulnar 
edge of the hand, with the tips of the bent fingers, or with the flat of 
the open hand. The end to be attained and the tissue to be affected 
decide which method shall be used. It acts for the most part as a 
mechanical stimulant. If we wish to excite the peripheral skin-nerves 
we use the flat hand - for instance, in anaesthetic areas; to reach a 
nerve-trunk, blows with the finger-tips, rapidly delivered from the wrist 
(not using the whole forearm in a hammering fashion), are employed, 
and, to excite muscles, " chopping," with the edge of the hand, trans- 
versely to the long axis of the muscles. 
The French and the Swedish masseurs have wasted much ingenuity 
in subdividing the several manipulations with great subtlety, and some 
operators perform a great variety of what can only be called ornamental 
movements, fantastic flourishes and airy graces, like the affectations of 
a fashionable pianist. 
In the consideration of the force and frequency of application desir- 
able in any particular case, the usual direction to the student of massage 
must be remembered, namely, that his mind is to be given not to the 
movements his hands are making, but to the tissues upon which he is 
operating and the effect he wishes to produce. The force, therefore, must 
be such as to attain the desired end, and this will necessarily vary with 
the state of the tissues and the condition of the patient. In a chronic 
arthritis with firm exudation vigorous friction will be required; in a more 
acute trouble - a sprain, for instance - much less force will be needed; 
at first, certainly, only light eflleurage. Nervous, hysterical, or excitable 
patients must be very gently handled at first, and only for short periods. 
In certain cases (again a recent sprain may be cited as an example) mas- 
sage three or four times daily will be of service, each application lasting 
only from five to fifteen minutes. Most massage procedures, to be of 
use, should be repeated at least once daily. General massage, such as 
is used for convalescent patients or " rest-cure " cases, must last from 
thirty minutes to an hour every day. 
The usefulness of massage is greatly lessened by the common practice 
of employing some oily substance for lubricating the skin. Moreover 
it is dirty; and the excuses offered that, unless an oil be applied, the 
operator will pinch unpleasantly or will pull the hairs painfully, are con- 
fessions of incompetency. In old or much emaciated patients, whose skin 
is harsh, dry, and scaly, it is sometimes desirable to use an emollient; 
and for such purposes the best unguent is lanolin with the addition of 
enough oil of sweet almond to render it of the consistency of thick cream. 
Vaseline is difficult to remove satisfactorily after use, is not absorbed, and 
to some skins is irritating. Generally it may be said no oily application 
should be used without the physician's orders. 
There can be no question of the much greater value to the patient of 
massage when used directly upon the skin. Done through clothing, even 376 
sys/Adz of medicine 
the thinnest, the operator must fail in technique: the palpation of the 
tissue will be imperfect, and an additional amount of force must be used. 
General massage is a form of passive exercise for those unable to take 
active exercise, or for whom active exercise is undesirable. It is usual, 
but not important, to begin with a lower extremity. After manipulating 
the foot the leg is worked with kneading, fulling, effleurage, and friction 
about the joints. It is best to put a sock or stocking on the foot when 
the massage is over; and every care must be taken to keep the parts 
warmly covered with a blanket as they are finished. After the legs the 
operator proceeds to the arms and treats them in the same way. In mas- 
sage of the back vigorous, rapid effleurage over the spine is employed, as 
well as the treatment to the muscles. In rubbing the chest in women 
the breasts are usually left untouched. Last comes the very important 
operation of abdominal massage. In order to obtain relaxation of the 
abdominal muscles, the head is raised upon a pillow and the knees bent, 
while the patient is directed to breathe deeply. At first there is always 
difficulty in overcoming the tension, largely involuntary, of the recti 
abdominales, especially in hysterical women, but as they grow accus- 
tomed to the manipulation the muscles slacken. Deep friction in small 
circles, continued over the whole abdomen, is made first, using the 
fingers of one hand; kneading movements, chiefly with the heel and 
palm, in a large circle round the navel; then similar applications are 
made over the large intestine, beginning at the right iliac fossa, and 
following the course of the ascending, transverse, and descending colon; 
the hands are placed on the two sides below the ribs and drawn forward 
with deep pressure several times; the region of the liver and the left 
hypogastric and hypochondriac regions are kneaded, reaching in this 
way the small accessible portion of the stomach, and the whole process 
ends by the operator grasping the abdominal walls lightly, but firmly, 
and imparting a rapid vibratory movement to them and to the underlying 
structures. Occasionally tapotement or clapping with the hand over the 
liver may be added to these procedures. After the completion of the 
massage the patient should be warmly covered and lie quiet for an hour. 
The effects of general massage are very decided and apparent. The 
immediate results are a fine sense of well-being, a feeling of comfortable 
tiredness without exhaustion, and a pleasant drowsiness. In rare cases 
hysterica] patients are aroused and excited by it, and more rarely still, 
persons are found whom massage leaves chilled, irritated, and uncom- 
fortable. In such cases the experiment may be tried of reversing in 
part the order of procedure, rubbing the abdomen first instead of last, 
then the chest and back, and finally the arms and legs. Occasionally it 
may be found that massage has been overdone, and that lighter appli- 
cations are needed to give good results. Very seldom indeed do we 
find patients to whom massage is so disagreeable as to make its appli- 
cation entirely impossible. 
The later effects are also well marked; the skin softens and shows 
a better colour; the appetite is improved as well as the digestion; the MASSAGE: TECHNIQUE, PHYSIOLOGY, ETC. 
377 
bowels act more freely; sleep is more prolonged and sounder, and the 
muscles become larger and firmer. The results in cases of disease will 
be considered later in more detail. 
Studies of the results of massage in health and in various maladies 
have been numerous and valuable in late years; the work of Bunge, 
Brown-Sequard, Ziemssen, Weir Mitchell, Playfair, Sinkler, Gerst, Good- 
hart, Kleen and Profanter, taking the subject from the clinical side, has 
been confirmed and wider possibilities for massage application suggested 
by the physiological experiments of several of these same observers, as 
well as by the labours of Lombard, Mosso, Maggiora, Lassar, Eccles, 
Glovetzky, Mosengeil, Mezger, Kronecker, Lauder Brunton and Tunni- 
cliffe, Winternitz and Zabludowsky. 
The immediate effect of massage is to increase the amount of blood in 
the region rubbed; the skin is flushed, the vessels in the muscles receive 
a larger amount of blood, and the flow of blood is greater through the 
part for some time subsequently. Accompanying this there is a fall of 
general blood pressure and a slowing of the pulse, if the manipulation 
has been a deep muscular stimulation. Superficial skin stimulation 
increases blood pressure. An increased activity in the movement of 
the lymph-stream has also been accurately demonstrated. 
It is obvious that we have here a useful indication for the treatment 
of recent local inflammatory conditions, such as result from sprains, luxa- 
tions, etc. The increased circulation will not only prevent stasis and the 
migration of white corpuscles into the tissues, but will rapidly remove 
the corpuscles and lymph which have been already thrown out. Again, 
the secondary effect of the larger amount of blood passing through the 
region is valuable in case of any local disturbances of nutrition, indolent 
ulcers, undue amount of deposit following fractures, contusions and 
myositis. 
Bonders, Pagenstecher, Damalix, Klein and others have reported 
successes in the treatment of both catarrhal and phlyctenular conjunc- 
tivitis, opacities of the cornea, pannus and even cataract, by means of 
massage. For full descriptions of their methods the articles by these 
and other ophthalmic surgeons must be consulted [yide References]. 
Besides these and such effects other general consequences are per- 
ceived. One result of the changes in blood pressure is an increased secre- 
tion of urine, another is that fatigue - whether local, as in an over-used, 
group of muscles, or general - may be rapidly and pleasantly removed 
by massage, that is, by the removal of fatigue-products and by the 
flushing of the muscles and nerve-centres with quantities of fresh blood. 
Lombard, Mosso, Maggiora and Zabludowsky have shown by experiments 
in their own persons, or upon animals, the prompt power of massage to 
restore functional ability to exhausted muscles. Maggiora found that 
this improvement did not take place in muscles whose blood-supply had 
been shut off. He further concluded that tapotement and friction were 
less effectual than kneading, and this again not so useful as mixed 
massage; and that the beneficial effects of manipulation were, within 378 
SYSTEM OF MEDICINE 
certain limits, directly proportional to its duration. That more blood 
actually flows through the tissues during and after the rubbing has 
been proved by the careful experiments of Lauder Brunton and Tunni- 
cliffe. A series of clinical examinations of the blood before and after 
massage under very varied conditions of health and disease have recently 
been made by myself. Originally it was my intention to study the 
effects of massage in anaemia, but a wider field opened itself out as the 
very marked results in such cases appeared. In sixty observations upon 
thirty patients only three failed to show an increased number of red 
corpuscles after general massage. The conclusions reached were as fol- 
lows : - In health massage increases the number of red corpuscles, and 
to a less degree and not so constantly, their haemoglobin value. In all 
forms and grades of anosmia there is a very large and constant increase 
in the number of red corpuscles after massage; this is greatest about an 
hour after treatment, slowly decreasing from that time. This decrease 
is, however, postponed further and further if the manipulation be daily 
repeated. There is an occasional but inconstant increase in the haemo- 
globin value, an increase proportionately less great than that of the 
cellular elements. The additional red corpuscles discovered by the 
Thoma-Zeiss haemocytometer after an hour's massage was often as 
great as 20 per cent, and in some cases reached 50 per cent of the 
number originally observed. 
The increased activity of the superficial circulation does not suffice to 
account for so great a change: moreover, if the increase arise merely 
from an addition to the number of red cells in the peripheral vessels 
at the expense of the rest of the circulating fluid, there should be an 
increase of haemoglobin directly proportional to the increase in the red 
globules; yet in no case did the haemoglobin-increment exceed 15 per 
cent, even when the cell-increase reached 50 per cent. It can scarcely be 
supposed that an hour's massage, much as it hurries the current in the 
vessels, can actually cause a greatly increased production of blood-cells; 
although the repetition of treatment no doubt stimulates cell-making. 
Still, the effect of this new activity and movement of the cells upon 
metabolic processes must, at any rate for the time, be much the same as 
if a considerable addition were made to their number. Further, these 
examinations make it seem in every way probable that, in health, there 
are vast numbers of corpuscles ready for use if called for, and also 
probable that a part of the trouble in anaemic diseases may be a lack of 
availability or of activity in the corpuscles, that many of them are slug- 
gishly lingering in the by-ways of the circulation, and only forced or 
pushed into greater activity and usefulness by the direct stimulus of 
massage. " The state of things in the system in anaemias may be, to 
draw an analogy from economic conditions, like the want of circulating 
money during times of panic, when gold is hoarded and not made use of, 
and interference with commerce and manufactures results." 
Effusions of lymph or blood in serous cavities, in the substance of 
muscles, and in the sheaths of the tendons or nerves, may be removed by MASSAGE: TECHNIQUE, PHYSIOLOGY, ETC. 
379 
means of massage. Reibmayr and Hoffinger injected water into the 
abdominal cavity of rabbits, subjected some of the animals to massage 
afterwards, and on opening the abdomens found that in those which had 
been massaged the proportion of the fluid absorbed in a given time was 
more than one-third greater than in those not so treated. 
Von Mosengeil made injections of Indian ink into two joints in 
rabbits, and massaged one joint. Upon examining the articulation 
treated very little of the injected matter could be discovered in it, even 
when opened after only a few minutes' massage. The ink could be 
traced through the lymphatic vessels into the neighbouring glands. In 
the untouched joints the ink was found unchanged, no attempt at absorp- 
tion having taken place. 
Acute arthritic disorders, like rheumatism and gout, accompanied by 
general constitutional disturbance, are not suitable for massage until the 
acute stage has passed; but localised or traumatic arthritis and synovitis, 
where there is no risk of promoting the resorption of toxic products, may 
properly be so treated. The results in sprains, teno-synovitis and the 
like, are sometimes amazing; and, if massage be instituted immediately, 
speedy recovery may be confidently predicted. The sooner after the 
injury manipulation can be begun the better. At first the swollen, 
bruised, and tender structures should not be touched at all, but effleurage 
made from the seat of the accident centripetally, to hasten the circulation 
from the congested part and help to carry off the exudation. Similar 
stroking should be used below the injured part, and, before the end of 
the application (which should last ten to fifteen minutes), it will be 
found possible to give effleurage and light friction directly to the 
inflamed tissues. At first manipulations should be made several times 
daily, and a firm bandage put on in the intervals. 
Where we find old synovial inflammation with thickened connective 
tissue and firmly organised deposits, much more force may advantage- 
ously be used; and such a case presents one of the few occasions where 
the use of some unguent is desirable, since sufficiently strong and fre- 
quently repeated friction will sometimes injure the skin unless a lubri- 
cant be applied. 
Massage of the neck, in the form of downward stroking on the sides 
of the neck and friction and stroking from the occiput downwards, serves 
as a means of lessening the amount of the blood in the head by pushing 
onwards the venous flow. This manner of relieving cerebral congestion 
may be made use of for insomnia, where the activity of the brain is so 
great as to prevent rest, as it brings about that mild degree of cerebral 
ansemia which is the physiological condition necessary for sleep. Even 
where flushing, headache, sleeplessness, dizziness, and confusion of mind 
point to a threatening apoplexy, the same procedure is of service; and 
in migraine the effects are occasionally most happy. In the easily recog- 
nised complexus of symptoms somewhat loosely described under the 
vague name of " spinal irritation " - a state in which insomnia is fre- 
quently very persistent - effleurage, vigorously applied, will be found a 380 
SYSTEM OF MEDICINE 
valuable aid in inducing sleep : here, however, it must be used upon the 
back as well as upon the neck. The technique is of the simplest. The 
operator, standing behind the sitting patient, lays the hands flatwise 
upon the lateral aspects of the neck below the ears, and pressing gently, 
strokes downward, over the jugular veins, at first with the ulnar edge 
of the hand, gradually turning the hand as it moves until the palm and 
then the radial edge carry on the movement. Pressure upon the hyoid 
bone and the larynx should be avoided. 
Gerst has used the same means for the removal of the hypersemia 
attendant upon concussion of the brain and upon fracture of the skull. 
In migraine, trigeminal and supra-o rbital neuralgias, or neuritis, much 
relief is felt from local massage; of course its use should not cause neg- 
lect of other measures, such as electricity, the regulation of the bowels 
and digestion, or remedies to combat the accompanying anaemia. In 
migraine especially it will be found necessary to continue the treat- 
ment for some weeks to be sure of benefit. In these affections it is very 
common to see the masseur work from the centre of the forehead toward 
the temporal region, a violation of the maxim, stated above, that move- 
ments should be in the direction of the venous currents. Manipulation 
should follow the course of the frontal vein, from the temples toward 
the root of the nose. 
Sciatica, whether we consider it as neuralgic or neuritic, is much 
helped by carefully-applied effleurage. The German physicians prefer 
massage to any other treatment for this rebellious affection. Kleen's 
prescription is that as infiltrations (myositis in the glutaeus maximus and 
medius muscles) frequently accompany or cause sciatica, careful palpation 
is to be made for these; and although, "on anatomical grounds, such in- 
filtrations may readily escape the perception of the masseur, still the rule 
holds good . . . that energetic frictions should be made in this place, 
even if no pathological changes can be found. Furthermore, one should 
make vigorous tapotement with the fist along the course of the sciatic 
nerve as far as the hollow of the knee." Overstretching the nerve, by 
flexion of the thigh with a straight knee, pushed to the point of endur- 
ance, is, according to Kleen, to be added to the prescription. 
Dr. Weir Mitchell has long abandoned these methods in obstinate 
sciaticas for a plan of his own which has been attended with remarkable 
success. To lessen the blood in the limb, and to remove the irritation 
caused by motion, the patient is confined to bed, the leg bandaged firmly 
from the toes to the groin with a flannel bandage, and the hip and knee 
joints fixed by a long splint from axilla to ankle, or, in patients who 
can be trusted to keep quiet, by sand-bags. The bandage is removed and 
the leg rubbed twice daily, general kneading of the muscles being used 
except of those near the nerve; even indirect pressure upon that struct- 
ure is to be avoided. The nerve tract is to be " effleureed " with long, 
steady strokes; the hip and knee joints passively flexed once or twice 
in a gentle manner, and the bandage reapplied. Three weeks of this 
procedure will usually suffice for a cure, even in obstinate cases. MASSAGE: TECHNIQUE, PHYSIOLOGY, ETC. 
381 
Activity must be resumed gradually, and the use of the bandage and of 
a certain amount of rest in a recumbent position insisted upon for a time. 
The treatment outlined for these neuralgias may serve to indicate the 
manner in which any form of neuritis or painful affection of a nerve may 
be handled by massage, whatever the origin of the disorder. The results 
of injuries, bruises, crushes, and even sections of nerves are relieved by 
the same applications, though of course the methods employed will vary 
somewhat with the character and seat of the injury, and the stage of the 
disease. Manipulations cannot be begun upon wounded surfaces until 
skin-healing is complete. The atrophy of muscles consequent upon nerve- 
section can be minimised, the period of disability much shortened, the 
subsequent contractions prevented, and the danger of pressure upon the 
nerve by scar-tissue lessened. In old cases of wounds of nerves where 
contractions, joint-stiffening, muscle-atrophy, andthe various disturbances 
of sensation have all appeared from neglect of early treatment, massage is 
an indispensable instrument. It may perhaps be necessary to repeat 
what I have already urged, that such a statement must not be construed 
to imply the neglect of other aids - douches, faradisation of the atrophied 
muscles and of the muscles opposed to contracted groups, galvanism to 
the nerves, the forcible breaking up of joint-adhesions, etc.1 
Contracted scars may advantageously be subjected to the same 
manipulations as contracted muscles, though, as such tissue is but ill- 
supplied with blood-vessels, the residts are less striking. Firm pressure, 
squeezing, pinching, kneading, and, where possible, stretching are the 
methods employed. Of course, the earlier the case is seen, and the less 
firm the cicatrices, the more successful the result, as the further increase 
of scar-tissue may be prevented, and that already formed thinned and 
softened. 
Writer's cramp and the allied forms of muscular difficulty, whether 
paralysis, tremor, or spasm from over-use of single groups of muscles, 
cannot be better combated than by massage and galvanism. The muscles 
usually affected are the flexors of the forearm or in the hand, and the 
occupations most commonly subject to the professional neuroses are 
writers, telegraphers, watchmakers, masons, or type-setters. The bicycle 
has of late given us a new form, in which the muscles of the thigh are 
affected; and one or two examples of an undescribed neurosis have re- 
cently been seen at the Infirmary for Nervous Diseases in Philadelphia 
in tram-car drivers, from the constant pushing upon the hand-brake. In 
all such disorders absolute rest of the affected part is the first require- 
ment, and massage the next. Authors differ as to the proper technique, 
but probably the most effectual method is strong effleurage and petris- 
sage followed by tapotement to the affected muscles and to their nerves 
where these are accessible. In instances where muscular infiltrations 
1 For detailed cases of such disorders and their successful treatment by the means sug- 
gested the well-known work of Dr. S. Weir Mitchell on Injuries of Nerves may be consulted. 
The present writer has reported the later history of a number of Dr. Mitchell's cases in 
Remote Consequences of Nerve Injuries and their Treatment. Philad., 1895. 382 
SYSTEM OF MEDICINE 
are found in connection with these palsies, or where neuritis is present, 
especial attention must be given to the parts thus affected. 
Torticollis, when rheumatic in origin, yields readily to massage of the 
affected muscles. Where its cause lies more obscurely in an affection of 
the cervical portion of the cord massage is of less use, though it helps to 
relax the spasm, and may be of important service by strengthening the 
opposing muscles. 
An excellent instance of the difficulty with which a new systematic 
treatment of disease makes its way is furnished by the facts concerning 
the application of massage in chorea. Blanche in 1854 presented to the 
Academie de Medecine in Paris a report of 108 cases of chorea success- 
fully treated by massage, and for a time the method was fashionable, and 
has continued in use in France to a certain extent; but the majority of 
medical men continue to rely upon drugs, with a confidence unimpaired 
by the fact that no matter what or how much medicine be given the clonic 
movements continue for weeks. In the lesser degrees of chorea minor, 
arsenic, iron, fresh air, and proper feeding may be sufficient. In the more 
severe cases, even omitting the consideration of chorea major, bed, with 
massage, will be found to effect a very rapid and usually perfect cure. 
As the co-ordination improves, and the involuntary jerkings lessen, cau- 
tiously increased gymnastic movements should be added. Besides its 
influence over the muscles general massage is of value in counteracting the 
anaemic or chlorotic condition so commonly associated with the disease. 
Drs. Goodhart and Phillips in their series of cases of chorea treated by 
massage rather understate than overstate the favourable results. 
In the treatment of many other disorders of the central nervous 
system massage has a recognised and well-established place. In acute 
atrophic paralysis it is at least helpful in maintaining nutrition. Dr. 
Gowers, Prof. Eulenberg, and others describe improvement in cases of 
pseudo-hypertrophic paralysis during its use. In the early stages of this 
disease it has certainly been my good fortune to see arrest of the pro- 
gressing paralysis, and a decided increase in the strength of the weakened 
muscles. 
In locomotor ataxia the effect is often astonishing, although one should 
remember that periods of rest, even of improvement, occur in this dis- 
order without treatment. But the results exhibited appear too con- 
sistently in case after case to be the result of a fortuitous coincidence of 
the " normal " cessation of activity in the degenerative process with the 
beginning of treatment by massage. Patients with ataxia usually suffer 
less pains if they take little active exercise; and the mechanical treat- 
ment is useful in overcoming the ill-effects of this inactivity. Yet this 
alone would not account for all the improvements; the ansesthesia and 
parsesthesia disappear or lessen, as well as the lancinating pains; the in- 
somnia, so often present, is bettered; even the difficulties of defsecation 
and micturition diminish. Recovery is not to be looked for - no power 
can renew sclerosed nerve-cells - but in a large majority of cases decided 
improvement may be confidently expected. TECHNIQUE, PHYSIOLOGY, ETC. 
383 
Persistent kneading, effleurage, and tapotement of the paralysed parts 
will do much to restore function in muscles palsied by anterior polio- 
myelitis, and massage and faradism should be continued in such cases for 
a year at least before giving up to despair, even if there be no apparent 
improvement in the muscles. The local temperature, usually very low, 
can always be raised several degrees by massage, and even if the muscu- 
lar tone and voluntary movement are not restored, the increased activity 
of the circulation, which by persistent effort can be established, will make 
a great difference in the patient's comfort. 
The direct influence of massage upon nutrition, the peripheral circula- 
tion, secretion, and excretion, the indirect effects upon the heart and upon 
respiration, combine to render it a most important aid in treating the 
protean aspects of hysteria and neurasthenia. Individual aspects of each 
case, in the way of sensory disturbances, disorders of digestion, and the 
like, may require special modifications in the application of massage; 
but for the most part what has already been described as "general 
massage " will be found the most useful. Combined with rest, full 
feeding, and isolation, it is an indispensable part of the " rest-treatment " 
of Weir Mitchell (13). For the details of the application of these means 
the original essay in which it was proposed may be consulted, or Dr. 
Playfair's book (14) by which it was introduced in England. Care must 
be taken at first not to overwork patients; but after a few days massage 
may be ordered for a full hour daily, or even, as Dr. Playfair has used 
it, twice a day. Especial attention should be given to the proper and 
thorough performance of abdominal massage, on which much of the 
patient's ability to take and digest food, as well as the regularity of 
the intestinal action, will be found to depend. A weekly weighing of 
the patient will tell whether massage is properly performed or not. If 
weight is not being gained some oversight will be found, either the diet 
is insufficient or imperfect, or the massage ill performed. Dr. Playfair is 
of opinion that the desire for food and the power to assimilate it is the 
best guide as to the efficiency of the rubbing. Another indication will 
be found in the urine, where the presence of deposits of urates or uric 
acid will quickly tell of mal-assimilation. 
Patients with melancholia and various forms of insanity may advan- 
tageously be rubbed should the general indications call for it. Those 
often need it who refuse to take active exercise, or if forced out of doors 
drag listlessly about. Melancholia, occurring about the time of the 
menopause, has many of its most disagreeable symptoms greatly miti- 
gated by massage; for instance, the flushing so often complained of in 
various forms is improved by the better balance of circulation which is 
brought about by manipulation. 
Massage for gynaecological ends is a matter for a special treatise - at 
least so far as the direct manipulation of the uterus by P>randt's method 
is concerned. Its desirability is open to very grave doubts, although its 
utility seems to be established by the testimony of Profanter's reports of 
Schulze's cases (15), Bunge's (16) articles, and the studies of Reeves 384 
SYSTEM OF MEDICINE 
Jackson (17) of Chicago. These authors have described successes in 
the treatment of the various forms of displacement of the uterus and 
its appendages, of hyperplasia, of chronic metritis, and most decidedly 
of pelvic exudates, para- and peri-metritis. 
The technique consists in raising the uterus (and, so far as may be, 
its appendages) by a finger of the left hand in the vagina, by which it is 
held against the abdominal wall, where it is kneaded and pressed upon 
by the right hand. That such treatment may be of great usefulness in 
the removal of old inflammatory deposits, and restore tone to the uterine 
walls and to the ligaments, is evident from the effects of like manipula- 
tions elsewhere. Pregnancy, acute inflammation, and of course the 
presence of catamenia, are contra-indications. Further, it is obvious 
that such treatment can only be carried out by the hands of a physician, 
whether man or woman; and whatever the results may be, it is so 
tedious, fatiguing, and unpleasant to the performer, so annoying and 
painful to the patient, and open to so much abuse, that it is little likely 
to find favour. 
Massage, in conjunction with other and more useful measures, may 
be applied to the reduction of obesity. Dr. Weir Mitchell, Dr. Goodell, 
and others have used it, together with a minimum quantity of food, to 
reduce the unwholesome adipose deposit of that very troublesome class 
of patients, the fat anaemics. By keeping them quiet in bed and giving 
nothing but skim milk in small amounts, weight may be rapidly and 
safely lost. [Fide art. on "Obesity."] Unusual or excessive local 
accumulations of fat may be removed by massage limited to the abnor- 
mal areas, and used with considerable vigour at short intervals. 
There is a remarkable unanimity of opinion among those who have 
used it as to the value of massage in morphia habit, and the other forms 
of drug addiction. It should be used throughout the course of treatment 
whatever be the plan employed, and with special care during the collapse 
which almost inevitably follows the final withdrawal of the accustomed 
stimulus, be it opium, cocaine, chloral, or alcohol. The weak heart calls 
loudly for help in such patients, especially in the slaves of morphia; and 
as the stomach is apt to be very irritable, it is an advantage to have this 
means of strengthening the movement of the blood without risk of up- 
setting a feeble digestion. Moreover, it has a remarkable sedative 
effect, due in part, no doubt, to the resulting relaxation of the peripheral 
vessels and in part to its soothing influence upon the irritable nerves. 
Though the conditions which render massage undesirable or impossi- 
ble are implied in much that has already been said, a few words on the 
contra-indications may be added. 
Acute skin inflammation, burns, unhealed wounds, in fact any break 
in the cutaneous surfaces, render the use of massage impossible, at any 
rate upon the affected locality; although, as has been stated, it may 
sometimes be employed in the neighbourhood for its derivative effects. 
The presence of fever should act as an absolute prohibition on account 
of the rise of temperature induced by manipulation. Treatment may in THE GENERAL PRINCIPLES OF DIETETICS IN DISEASE 
385 
certain cases - in consumptive patients, for example - be used in the 
afebrile interval. 
In all processes in which pus is formed, as well as in cases of malig- 
nant tumour, it is obviously undesirable to apply a means which may 
result in the dispersion of infective products into the tissues or through- 
out the system. 
Weakened vessel walls from general causes, fragility of the arteries, 
or dilated veins, forbid deep kneading, though efileurage may be em- 
ployed. 
Pregnancy contra-indicates abdominal massage, though no hesita- 
tion need be felt in using muscle-kneading, and friction to the rest of 
the body up to a very late date in the period of gestation. 
John K. Mitchell. 
REFERENCES 
1. E. Kleen. Handbook of Massage. Translated by E. H. Hartwell, M. D., 1892, 
the best and most moderate treatise on the art and science of massage. - 2. Pagen- 
stecher. Centralblatt f. prakt Augenheilk. 1878; Archiv f. Augenheilk. 1880-1.- 
3. Damalix. Arch. <T ophthalmologic, 1880-1.-4. Klein. Wien. Med. Presse, 1882. 
- 5. Mosso. Archiv. Anat, und Physiol. 1890.-6. Maggiora. Archivio per le Sc. 
Medisch., xvi. 2, 1891.-7. Brunton and Tunnicliffe. Jour, of Physiol, xvii., 5, 
1894. - 8. J. K. Mitchell. Am. Joum. of the Med. Sci. May 1894.-9. Mansell- 
Moullin. On Sprains. -10. Graham. Treatise on Massage. -11. Gerst. Uber d. 
Therapeut. Werth der Massage. Wurzburg, 1879. -12. Goodhart and Phillips. 
Lancet, Aug. 5, 1882. -13. S. Weir Mitchell. Fat and Blood. -14. W. S. Play- 
fair. Systematic Treatment of Nerve Prostration and Hysteria. -15. Profanter. 
Die Massage in der Gynacol. Vienna, 1887. -16. Bunge. Berl. klin. Wochensch., 
xix. 1882. -17. Reeves Jackson. Boston Med. and Surg. Jour. 1880. -18. A. Symons 
Eccles. The Practice of Massage. London, 1895. 
J. K. M. 
THE GENERAL PRINCIPLES OF DIETETICS IN DISEASE; 
OR, THE FEEDING OF THE SICK 
The best writers on medicine from the earliest times have been careful 
to include in their treatises some account of the conduct of diseases by 
means of diet; and, with the advancing changes and improvement in 
the art of medicine, the subject of dietetics has not failed to receive an 
increasing share of attention. 
As in respect of treatment by means of drugs or other therapeutic 
measures, so here we find that many changes of opinion have occurred; 
methods at one time in vogue have been subsequently discountenanced, 
and at a later date again enjoined. It must be admitted that the whole 
subject of dietetics has rested on an empirical basis, and been destitute 
of any scientific principles till within the last half of this century. 
2 c 
VOL. I 386 
SYSTEM OF MEDICINE 
With the progress of chemistry and physiology, and by more exact 
clinical researches, a truly scientific basis has been laid; we have now 
indeed attained a measure of certainty in respect of dietetics as an 
instrument of medicine which may fairly be counted amongst the 
triumphs of modern therapeutics. This work has been done by many 
labourers: it has required the combined efforts of the chemist, the 
physiologist, and the clinical physician; and in no other manner could 
such a task have been accomplished. 
Dietetics have always formed part of any system of medicine, how- 
ever peculiar or erroneous; and contributions to the subject have come 
from many, and sometimes strange sources, all tending to throw light 
on difficult and •unillumined parts of it. Of this we may feel sure 
when we review the claims made for their several methods by those 
who have enjoyed high-living, low-living, "vegetarianism," hot-water 
drinking, total abstention from alcoholic liquids, and full stimulation 
with them; to say nothing of many varied and fantastic fashions in 
diet, all of which have been tried and fairly appraised. We have wit- 
nessed the results of so-called homoeopathic treatment of patients, in 
which a large amount of attention is paid to diet, and feel that, in all 
fairness, it should be granted that at one 'time some accession to our 
knowledge of clinical dietetics came from this source. 
In this article we are only concerned to set forth the principles and 
practice of dietetics, in so far as they relate to the needs of patients 
suffering from various diseases; and to illustrate their application in 
practice. This effort necessarily comprises a due consideration of the 
best methods of which we have now certain knowledge, and can only be 
grounded upon extended and carefully-weighed clinical experience. 
In recent times less and less heed has been paid to drug-treatment, 
and more attention has been given to diet and general hygienic environ- 
ment. This waning faith in drug-administration, which is unwarrant- 
able and, to a large degree, unwise, has come of a fuller knowledge of 
the natural course of many morbid conditions. More reliance is placed 
on the vis medicatrix natures; and the art of the older drug-giving phy- 
sicians has gradually fallen into desuetude, and ceased to engage the 
attention of many of the most capable minds in medicine. In the mean- 
time, however, much certain knowledge has been secured, - knowledge 
which is absolutely necessary in order to guide our efforts successfully in 
relieving suffering and helping on recovery. It would plainly be beyond 
the limits of this article to attempt to discuss the dietetic treatment of 
each malady: it will suffice to lay down the principles, and to suggest 
the practical application of them in dealing with disease of the several 
systems of the body, referring more in detail to the more important 
general morbid states, and to the requirements of some special disorders. 
I propose to discuss clinical dietetics in relation to the following: - 
1. Specific Infectious Diseases; 2. Diseases of the Nervous System; 
3. of the Respiratory Organs; 4. of the Circulatory Organs; 5. of the 
Digestive Organs; 6. of the Blood, Lymphatic System, and Ductless THE GENERAL PRINCIPLES OF DIETETICS IN DISEASE 
387 
Glands; 7. of the Urinary Organs ; 8. Chronic Intoxications; 9. Diseases 
of the Locomotory System; 10. of the Skin; 11. Atrophy. Obesity I 
shall deal wTith in a later article. 
I prefix a few remarks on the Feeding of Helpless Patients. Refer- 
ence will frequently be made in the following pages to feeding of patients 
who cannot help themselves. This is conducted by means of a spoon, by 
the feeding-cup, or by the nasal tube. The best size of spoon, in the case 
of adults, is that known as the dessert-spoon, or small tablespoon, hold- 
ing two or three fluid drachms; a teaspoon is the most convenient for 
Fig. 32. - Feeding-cup with well-curved spout and 
india-rubber tube attached. 
Fig. 33. - Apparatus for nasal feeding. 
children. When the sensorium is dull, liquid nourishment is best intro- 
duced slowly at the side of the mouth. The best form of feeder is 
depicted in Fig. 32. The spout should be well curved, and it is often 
advisable to add a piece of soft rubber tubing to the end of it with a glass 
nozzle. Feeders with straight spouts are unsuitable; the contents of such 
feeders are apt to be shot out in spurts which may be spilt over the patient. 
Dr. F. M. Watt, of Edinburgh, has recently recommended a feeder with 
three handles as being easily seized by a recumbent patient-one right, one 
left, and one posterior, with a flattened tubular mouthpiece. The most 
useful form of apparatus for nasal feeding is that shown in Fig. 33. It is 
readily made by taking the barrel of an ordinary glass urethral syringe, 
and affixing to the nozzle a piece of soft red rubber tubing of a size suitable 
for passage along the floor of the nose, and about ten inches or a foot in 
length. This, after being well oiled, is passed along the nose in a line 
backwards towards the external auditory meatus, and slipped over the SYSTEM OF MEDICINE 
388 
posterior surface of the velum palati into the pharynx and gullet. 
This is a simple method, and even children soon become tolerant of it. 
The nutriment is to be poured from a small lipped jug into the glass 
barrel held up vertically over the patient's face. With this arrangement 
the progress of the fluid as it passes into the gullet can be accurately 
determined, and as much food as is necessary can thus be readily intro- 
duced at regular intervals. In cases of apoplexy, insensibility, melan- 
cholia, or other forms of insanity, and after tracheotomy, this method 
of feeding is of supreme value and importance. Half a pint to a pint of 
nutriment may be given at one time. A small piece of glass tubing may 
be introduced into the length of india-rubber tube to allow the transit of 
food to be observed. 
Dietary in Specific Infectious Diseases. - A consideration of this 
subject naturally includes the dietetic management of the febrile state 
as such. 
The condition common to all these temporary acute illnesses is that 
recognised as fever or pyrexia. Pyrexia is a symptom which is now 
acknowledged by many modern observers to be no longer an inimical, but 
rather a friendly process so long as it is restrained within certain limits. 
In febrile conditions the alimentary system is more or less disturbed, 
almost without exception: the common indications of this are - first, 
the loss of natural appetite; secondly, the presence of thirst. Solid food 
is loathed, and if taken or pressed, commonly rejected by vomiting. The 
changes in the mucous surfaces tend to dryness and greatly reduced 
secretion from salivary and mucous glands, gastric tubular glands, 
duodenal (Brunner's) glands, Lieberktilmian follicles and the pancreas. 
The condition of the intestinal solitary and agminate glands when they are 
not specifically involved, is hardly known; nor that of the four million, 
more or less, villi of the intestine; but it may fairly be believed that these 
are in a more hypersemic and sluggish condition, as regards normal absorp- 
tive function, than in health. Certainly, in most cases, we have clinically 
to note a greater or lesser degree of catarrh as pervading the entire course 
of the alimentary canal and of the ducts which lead into it; and we take 
heed to this condition in determining a diet for patients thus affected. 
With respect to digestive capacity we particularly note the absence 
of sufficient saliva and pancreatic secretion on the one hand, and of gastric 
and intestinal juices on the other, and are thus in the presence of in- 
capacity to deal effectually either with amylaceous food or with the 
several varieties of albumins. In the severer forms of prolonged fever, 
gastric digestion is commonly more in abeyance than that carried on in 
the intestines. Pyrexia thus reduces digestive capacity somewhat to 
that which is the normal state of the infant during the first six months 
of life, more particularly in respect of the inactivity of salivary and 
pancreatic functions. 
In practice, however, it is possible to pay too much heed to these 
facts and, as in politics " the Queen's Government must be carried on," THE GENERAL PRINCIPLES OF DIETETICS IN DISEASE 
389 
so here our patients must be fed and sustained through the exhausting 
conditions associated with and dependent on fever. Ample experience 
has proved the value of a diet consisting mainly of milk and meat juices. 
The points to attend to in such a dietary relate to the purity and dilution 
of the milk, and to the variety and quality of the meat juices. First, 
with respect to milk: it is of essential importance to employ fresh milk 
whenever procurable. Preserved milk, in all forms, is vastly inferior for 
nutritive purposes. As a rule, unless the source is beyond suspicion, 
fresh milk is best scalded, but not boiled. It is then to be diluted with 
barley water, or toast and water, to the extent of one-third or one-half. 
If diarrhoea be present lime water should be added, and half the amount 
of barley water may be thus replaced. If constipation prevail, the 
addition of sodium bicarbonate, instead of lime water, to the mixed fluids 
is advisable - one drachm (a teaspoonful) being stirred with each pint. 
These measures prevent the formation of curd in any but a finely-granular 
condition, and so prevent pain, flatulency and intestinal disturbances. 
When milk is badly borne whey is often available, and to it cream may 
be added if desirable. 
Beef juices may be given at intervals in the form of well-made beef 
tea, mutton tea, chicken or veal tea; or, occasionally, if the stomach be 
queasy, in the form of essences, of which there are now several trust- 
worthy preparations. Fresh beef essences, if they can be procured, are 
probably better than any of the latter; and vegetable juices may be 
incorporated with all forms of these by immersing in the cooking-vessel 
a muslin bag containing finely-divided vegetables such as cabbage, carrot, 
etc., and so securing variety both of flavour and nutrient elements. A 
good rule is to change the meat juice from day to day, so as to prevent 
the monotony of the spoon-food. Nothing better relieves such monotony 
than the regular administration of draughts of iced watei- which are 
always grateful to fever patients and are too often omitted. In many cases 
both tea and coffee may be given with advantage. Refreshing drink is 
available in most febrile states - enteric fever and rheumatic fever ex- 
cepted - in the form of freshly-made lemonade containing a drachm of 
acid tartrate of potash in each pint, and a very little sugar. Regard is 
to be paid to the amount actually consumed, and care taken that enough is 
presented in each twenty-four hours. Modern skilled nursing commonly 
secures this, and a register is to be kept from hour to hour. Fruit is 
sometimes of use, and cooked apples may be given, carefully prepared, 
also grapes and oranges. In small-pox the latter are especially grateful. 
Whenever it is advisable to add to the nourishment, yolks of eggs may 
be added to milk or beef juice, or given with brandy as egg-flip. 
We have thus considered the essentials of a so-called fever diet. The 
question of alcoholic fluids now presents itself. These form no routine 
part of dietetic treatment either in febrile or in any other morbid con- 
dition. They may, however, be necessary, and are often indispensable, 
in the conduct of particular cases. The skill demanded in the prescription 
of alcohol (that is, of alcoholised fluid of whatever kind) is of the same SYSTEM OF MEDICINE 
390 
order as that which is required in determining the use of any other article 
of food or medicine for the sick. We do not affirm that because the 
patient has fever, or has pneumonia, he therefore requires wine or spirit. 
He may or he may not. We are guided by various considerations as to 
the specific requirements of each patient, and we give or we withhold 
as the case may be. We lend ourselves to no fashion or wave of opinion 
in respect of food or drugs, and study the precise indications of the case 
for the time being. The opinions to be here stated are the result of no 
small experience, and have been gathered only at the bedside. 
We are met at the outset by those who contend that alcohol is not a 
food, and has therefore no place in any dietary. We might put this 
opinion aside, and still contend that it has a high place in the treatment 
of disease. As clinicians we maintain, however, that alcohol, is practically 
available as a food, even in the form of a pure spirit; and if the several 
constituents of wine be taken into consideration we have to deal with a 
variety of nutrient materials in subtle combination, with which alcohol, 
in moderate percentage, is bound up. We recognise that alcohol holds 
an intermediate place between carbo-hydrates and the fats, being 
less oxygenised than the former and more so than the latter. In its 
circulation through the system, within certain well-understood limits, 
it becomes destroyed and indefectible; we must therefore believe, as 
physiologists, that this process of destruction and transformation is 
attended by oxygenation and a correlative liberation of energy. We may 
thus explain some of the benefits derivable from the use of alcoholised 
fluids in various morbid states. 
The clinical indications for alcohol in febrile states are now fairly well 
understood and reduced to principles. It is recognised that if no extreme 
pyrexia be present, if the action of the heart continue sufficiently vigorous, 
and food be well taken, alcohol is unnecessary. But if high fever pre- 
vails, the heart's action falters, and ordinary nutriment is taken with 
difficulty, at any age, and in any such case, alcohol is indicated, and its 
effects are under such conditions uniformly satisfactory. Thus by its 
use we control pyrexia, we sustain the action of the heart and the 
vigour of the circulation, and we secure a substitute for other nutriment 
till such time as a better appetite returns. We gather all these indications 
from the thermometer, the stethoscope, the character of the pulse, and the 
capacity for taking nourishment. The best form for alcoholic administra- 
tion is either that of brandy or whisky well diluted with milk. Neither 
should be given with beef tea or any meat juices, and the quantity is 
best administered at regular intervals of two or four hours, according to 
the particular indications, both by day and by night. The amount re- 
quired is to be determined by the age and previous habits of the patient, 
and no less by the conditions requiring to be met. Young children bear 
alcohol well when it is indicated; and the amount sometimes called for 
may be very large. In practice it is seldom found necessary to exceed 
for an adult of average condition in any febrile state six ounces of 
brandy or whisky per diem, and two or three will often secure all that THE GENERAL PRINCIPLES OF DIETETICS IN DISEASE 
391 
is needed. Over-stimulation is harmful, and is *recognised by flushing, 
foul breath and discomfort. Hyperpyrexia demands the use of alcohol, 
and the patient is benefited by it. The cardiac indications for the use 
of alcohol in fever are a notable loss of tone in the first sound, especially 
if this be inappreciable at the base (Stokes' sign), and the associated 
condition of pulse that of low arterial pressure, and the phase of 
it known as dicrotism. The tendency to formation of sordes on the 
tongue or gums in grave febrile states also indicates the employment of 
alcohol. 
Preparations of malt are certainly available in febrile conditions, 
and are agreeable to patients. Granulated malt extract dissolved in 
warm water or milk constitutes a grateful variety of readily digestible 
nutriment when the constant use of milky food palls on the appetite. 
When the stomach is irritable, and most of the food already indicated 
disagrees, recourse may be had to koumiss in small quantities (Koumiss, 
No. 2). Milky food may sometimes be better borne if given in doses 
of half an ounce to an ounce every quarter of an hour by the clock. 
After a few hours larger quantities may be tolerated. 
The dietary thus enjoined is available for most febrile conditions, 
however induced, including pneumonia, all the exanthemata, and the con- 
tinued fevers, with the exception of enteric fever, to which reference will 
presently be made. The same holds good for paroxysmal stages of re- 
mittent and intermittent fevers, allowance being always made for the 
degree of pyrexia, the age, and bodily state of each patient. 
Certain precautions are of extreme importance in the case of enteric 
fever, the specific conditions of the intestinal tract from day to day being 
always borne in mind. The necessity for introducing only bland and 
unirritating nutriment is paramount. Hence the importance of prevent- 
ing any masses of milk-curd from passing through the pylorus which may 
chafe or lodge upon ulcerated patches in the ileum and colon, and induce 
diarrhoea or constipation. Attention is further necessary to prevent 
fruit in any form being administered by injudicious attendants or friends. 
Lemonade is to be forbidden, and all wines, for these are distinctly apt 
to promote action of the bowels. Vegetable juices may be introduced, as 
already indicated, with meat juice. Alcohol is only permissible in the 
form of brandy, whisky, or gin. These matters appear to smack of 
pedantry, but the rule enjoined has been dictated by the amplest ex- 
perience, and no point, however small, is unimportant which may turn 
the scale in favour of life or death in these terrible cases. Lives have 
been needlessly sacrificed by inattention to or inappreciation of matters 
seemingly trifling such as these. 
It has been freely asserted of late that milk is an inappropriate food 
in enteric fever, inasmuch as it is a pabulum highly favourable to the 
growth of the specific bacilli of the disease, and it has been urged that 
preparations of malt are much safer. Indeed, Dr. Springthorpe, of 
Melbourne, has strongly urged the use of a sterilised hopped malt 392 
SYSTEM OF MEDICINE 
extract, which resists the growth of Eberth's bacillus in cases of enteric 
fever.1 The value of malt has been already noted. The disadvantages 
of milk, properly diluted and alkalised, are, however, by no means 
proved, and it would require very strong evidence to convince careful 
physicians that it is not a satisfactory basis of diet in these cases. Voit 
asserts that three and a half pints of milk per diem are insufficient for 
nourishment in a case of fever, there being a lack of albumin, twice too 
much fat, and deficiency of carbo-hydrates by two-thirds. Further, that 
even with the addition of animal broth such a dietary is inadequate. 
Clinical experience does not justify the acceptance of these statements. 
The average patient, as a matter of fact, does very well on such a diet; 
and beef tea or mutton tea may be fortified with essences of one or other 
as required. 
It is found that where diarrhoea is a prominent feature of the illness, 
beef tea or beef essence may act as a peristaltic stimulant, or otherwise 
as a purgative; whereas mutton tea and essence, veal broth and chicken 
broth have no such effect, and it is a good rule of practice to attend 
to this point. In cases, not uncommon, where constipation prevails 
beef juices may be used, and sodium bicarbonate, rather than lime 
water, should be added to the milk. In rebellious diarrhoea, or where 
haemorrhage occurs, milk is better avoided and whey employed, the latter 
in the form of alum whey, made by adding one drachm of powdered sul- 
phate of alumina to each pint of scalded milk and straining through 
muslin. Mutton essence is best in such cases. 
The greatest care is called for in the dietary during convalescence from 
this disease, no solid food, or nutriment entailing debris, being permissible 
for many days after all fever has passed away. Ordinary diet may be 
resumed at once in cases of typhus fever or in pneumonia, but not in 
enteric fever. We do well to begin with milky arrowroot, with yolk of 
eggs in milk or brandy and water, then to pass on to boiled pap of bread- 
crumb and milk, custard pudding, and lightly-boiled fresh egg. Next, 
pounded fish may be cautiously given, pounded mutton or beef in puree, 
rusks soaked in tea or milk, and so on to fish of delicate fibre, mashed 
potatoes, etc. In all cases it is better to be too late rather than too early 
in reinforcing the dietary. 
Typhus, Relapsing, and other Fevers. - In arranging the dietary for 
patients suffering from typhus and other continued fevers, no special pre- 
cautions, such as are of imperative necessity in enteric fever, have to be 
taken. The indication is to meet the exhausting character of the febrile 
processes by the introduction of such food in liquid forms as the patient 
can take, and with the abatement of symptoms following on the crisis 
solid food may be safely given, care being taken not to overload the 
stomach by excessive amounts, the appetite being large. The indications 
for alcohol are the same as in enteric fever, but wine may be safely given, 
or malt liquors if preferred. Good wine, of which mature port, Bur- 
gundy, or Bordeaux are the most desirable, is as a rule preferable 
1 Australian Medical Journal, 22nd July 1894. THE GENERAL PRINCIPLES OF DIETETICS IN DISEASE 
393 
in febrile exhausting conditions to pure spirit. The aethers of old wine 
are especially sustaining to flagging cardiac action, and the associated 
salts in wine are further beneficial. Champagne of good quality is useful 
in many cases when other wines are distasteful, but it can seldom be 
safely employed in enteric fever. There is no routine treatment in any 
case, and in early life, and in constitutions otherwise sound, it is some- 
times unnecessary to resort to any alcoholic support, either during the 
fever or the convalescence from it. Each case must be judged by itself, 
and a well-trained clinical observer gives or withholds stimulants as 
circumstances indicate. Elderly patients, as a rule, need stimulants 
earlier and in larger amounts than younger ones. Typhus fever is almost 
certainly fatal after the seventh climacteric, whatever the treatment. 
Habitual drunkards, under the stress of continued fever, require some- 
times very large amounts of stimulants. The tendency to collapse after 
the crisis in relapsing fever demands free stimulation, especially in 
elderly patients. 
Exanthemata. - In the exanthemata the dietary is that for the py- 
rexial state generally. Later complications may occasionally demand 
moderate stimulation and a generally supporting diet, the condition of 
the kidneys in scarlet fever demanding especial attention. 
Sterilised Milk; Boiled Milk and Water. -No reference has, so far, 
been made to the employment of sterilised milk, or of peptonised milk 
and animal broths. As to the first, it is a good rule to scald all milk, 
unless the source and treatment of it be certainly beyond suspicion: this 
holds good not only in India, but all over the world. The same may be 
affirmed for water under all conditions, and in India and in most parts 
of the world the rule holds good, especially in the case of children and 
young adults. 
Peptonised Foods. - With respect to peptonised food I think there is 
now too great a tendency to employ it. All articles of diet come best 
direct from nature, as far as possible; and without more chemical or 
culinary meddling than is absolutely necessary. Food is one thing, 
physic is another. I feel sure that peptonised foods are now too fre- 
quently administered, and are often unnecessary. They have their 
place, without doubt, for gastric and for rectal alimentation as a tempo- 
rary measure, the object being to present predigested albumin for rapid 
assimilation when digestive power is at a minimum, as malted foods 
present predigested starches in cases where salivary and pancreatic 
secretions are inadequate; but it has become a fashion to resort to the 
use of predigested food in many cases which do not require it. Most 
cases of pyrexia can be treated successfully without peptonised food, but 
if the digestive powers be enfeebled, it may certainly be used. The 
liquor pancreaticus is probably one of the best agents to employ in 
peptonising milk, animal broth or gruel. 
Parotitis. - In cases of mumps spoon-food only is to be given, and 
generally in a concentrated form, the act of deglutition being painful. 
Pertussis. - In whooping-cough nourishing diet is necessary. Vomit- 394 
SYSTEM OF MEDICINE 
ing is frequent after paroxysms, but the patient is commonly ready to 
replace what is lost. 
Influenza. - There is loss of appetite in the primary stage. But soon 
the specific depression of this malady necessitates the use of a supporting 
dietary in any desirable form, and alcohol is required, sometimes in large 
amount, to counteract the tendency to asthenia and cardiac failure; 
especially in elderly persons with pulmonary complications, and during 
convalescence which may be very prolonged. Yolks of eggs with brandy, 
strong soups, oysters, and pounded meat are suitable forms of nourish- 
ment, also strong coffee with plenty of milk. 
Malarial Fevers and Yellow Fever. - In the intervals between the 
paroxysms it is desirable to employ a supporting diet. Alcohol is best 
given well diluted, and diluted champagne is valuable. 
Dysentery. - Few diseases call for more skill and discretion in feeding 
than dysentery. In simple and acute forms the diet must be fluid, 
and the same holds good for many cases of the chronic form. It is 
common to find milky and farinaceous food recommended and weak 
animal broths. Without doubt milk should be the staple aliment, and 
it may be given alone for weeks together, diluted with warm toast and 
water and lime water. My reading and experience lead me to recommend 
nothing else. Beef tea is distinctly to be avoided. Veal or chicken 
broth are the least harmful of animal broths, and the yolk of eggs may 
be added. An adult will need four or five pints of milk diluted, as 
advised (three parts of milk, one each of barley water or toast and water 
and lime water), in the course of twenty-four hours. And it is to be 
borne in mind that neither diet nor drugs will be of any avail without 
strict confinement to bed and the use of draw-sheets for defaecation. No 
vegetable food or fruits are admissible, and starchy food is undesirable; 
in chronic cases freshly-made bael jelly or extract in drachm doses twice 
a day is allowable. Food should be administered warm, to prevent too 
active peristalsis. Alum whey is useful as an alternative when milk 
diet has to be long submitted to, and the mouth should be washed out 
occasionally with warm boracic lotion. 
Erysipelas. - Supporting and stimulating diet is necessary. Milk 
and animal broths, containing plenty of salt, with brandy or port wine 
are to be given. 
Diphtheria. - The main indications here are for a supporting diet. 
The chief difficulty arises in the cases of infants or young patients. 
The tendency is to collapse and cardiac failure all through the illness 
and early convalescence. After tracheotomy, which is necessary in the 
majority of cases of the laryngeal form, feeding can often be carried 
on only by means of the soft rubber nasal tube, and by this means 
many lives have undoubtedly been saved which would otherwise have 
perished from inanition. Milk, yolks of eggs, chicken essence and brandy, 
are almost always required. Young children bear brandy well given in 
milk, and it may be needed in divided doses in quantities varying from 
one-half to two ounces in the twenty-four hours. The presence of albu- THE GENERAL PRINCIPLES OF DIETETICS IN DISEASE 
minuria is no contra-indication to its employment. From two to four 
ounces of milk, etc., may be given by the nasal tube at intervals of three 
or four hours by day and night; medicines also have to be given with 
the food in this manner. Sometimes the nasal tube may be dispensed 
with, or it may be advantageously used for a few days after tracheotomy. 
Asiatic Cholera. - In the algide stage it is of no avail to press nour- 
ishment, everything taken is rapidly ejected. Sips of iced water or 
pieces of ice may be given to suck. In the stage of reaction small 
quantities of milk and soda-water, with bicarbonate of sodium, may be 
given in small amounts at stated intervals, and water arrowroot is admis- 
sible, a gradual return to very light food being cautiously carried out. 
Syphilis.-The indications in all stages of syphilis being to secure 
the highest attainable level of the general health, good diet is necessary. 
The continued use of mercury or iodide salts still further necessitates this 
course. So-called diet drinks are of extreme value. None is superior 
to a pint or more of a good compound decoction of sarsaparilla taken in 
the course of each day. 
Hydrophobia. - In this disease feeding must be carried out by nutrient 
enemata, and remedial agents are conveyed by the same means, or hypo- 
dermically. Swallowing may be possible towards the end of the case, 
and food be thus freely taken, too late, however, to save life. 
Tetanus. - Feeding presents great difficulties here. It is best con- 
ducted by the use of the nasal tube, or advantage may be taken of a 
gap in the teeth to insert liquid nourishment. Rectal feeding is apt 
to induce spastic paroxysms. Alcohol is necessary, sometimes in large 
quantities. [ Vide art. on " Tetanus."] 
395 
Dietary in Nervous Diseases. - Neuritis: (a) Gouty, (&) Alcoholic; 
Sciatica. - In cases due to gouty influence the diet is that proper for 
the gouty state present at the time. This will vary according to age, 
previous habits, and the vigour of the constitution. In alcoholic neuritis 
a plain nourishing diet is necessary, and complete abstention from all 
alcoholic fluids. 
Diseases of the Spinal Cord; Bulbar Paralysis. - A generous, readily 
digestible diet, containing an abundance of milk and fatty elements, is 
required in these cases. In bulbar paralysis constant supervision is 
necessary to prevent choking. A soft tube should be passed into the 
stomach and liquid food injected as often as it can be tolerated. Failing 
this, nutrient enemata must be employed. 
Cerebral Haemorrhage. - Liquid food is to be given by the mouth if 
there is power to swallow; otherwise nutrient enemata must be used. 
No stimulants are to be given. On recovery the diet must be light, 
consisting of fish, milk, vegetable and farinaceous foods. In many 
cases the renal condition demands careful study in respect of diet. 
Embolism and Thrombosis of Cerebral Arteries; Endarteritis; Athe- 
roma.- In most convalescent cases it may be necessary to administer 
more nourishing food and stimulants in small quantities: the conditions 396 
SYSTEM OF MEDICINE 
of the heart and circulation are the guides in this respect. The age 
and general state of nutrition must also be considered. 
Epilepsy. - In patients subject to epileptic paroxysms much benefit 
is derivable from carefully-prescribed diet. This should be so arranged 
as to prevent any overloading of the stomach, and all food difficult of 
digestion is to be withheld. The principal meals are best taken in the 
earlier part of the day, and only a light meal consumed in the evening. 
Experience clearly indicates that a diet not too rich in albuminoids is 
advisable. Animal food should be sparingly taken, but fish may be 
used freely. Butchers' meat is better given on alternate days, if at all, 
and never in large amount. Farinaceous foods and fat are desirable. 
Milk in large quantities is harmful. Alcohol is better dispensed with, 
or very sparingly taken in the form of diluted light wines. Butter, 
cream, and fat bacon may be taken freely, and butter-milk in moderation 
has been found useful. Coffee and cocoa are commonly preferable to 
tea. There can be no doubt that recurrence of paroxysms may be 
materially checked by strict attention to the points just noted. 
Migraine. - Few disorders are better controlled by careful dieting 
than this. There is distaste for food during the paroxysms. Iced 
aerated water is sometimes helpful in the attack. Tea and coffee are 
also sometimes of avail. There is a gouty element in many cases, 
especially in females, and errors of diet leading to goutiness may induce 
migraine in such persons. In the intervals between attacks regard must 
be had to this fact, and to the il growing-up " tendency to outbursts of 
varieties of paroxysms. More water drinking is desirable, and a strict 
limitation of animal and rich foods. Abundance of well-cooked green 
vegetables, such as spinach, is important. Malt liquors and strong 
wines are not to be taken. 
Chorea. - In acute cases only " spoon-food " is to be given. At the 
height of the disorder nasal feeding may be necessary. Abundance of 
nourishment is necessary, and wine is usually beneficial. The rheumatic 
nature of the disorder (as held by the writer) does not in this case forbid 
the use of animal broth, but milk appears to be the most suitable form 
of nourishment. Assiduous attention on the part of the nurse is needed 
to secure a sufficiency of liquid food in grave cases. In milder cases care 
must be taken to prevent the patient suddenly bolting any masses of 
unmasticated food. 
Hysteria; Anorexia nervosa; Vomiting; Refusal of Food. - The dif- 
ferent and multiform phases of hysteria demand special attention in each 
case. The main principles relate to the use of a sufficiently nourishing 
diet, care being taken to avoid incautious resort to stimulants. Loathing 
of certain foods and many idiosyncratic vagaries may be encountered. 
These must be overcome as far as possible, or substitutes for any one of 
them provided. Aversion from red meat and from fat is not uncommon. 
Firm but gentle discipline is often needed to secure due nutrition. 
Morbid cravings demand special study, and the practitioner must beware 
of becoming an inflexible doctrinaire. There may be digestive capacity THE GENERAL PRINCIPLES OF DIETETICS IN DISEASE 
397 
for articles of food theoretically reckoned as unfit. Thus, lobster and 
pork may be desired, and beef, mutton and fish found repulsive. Com- 
plete anorexia is occasionally met with, and " fasting girls " may come 
under notice. These " phenomena " are not to be watched with vulgar 
curiosity, but the miserable subjects of them are to be forcibly fed, if 
necessary by the tube, and medically treated. Remarkably good results 
have accrued from such treatment in the hands of Weir Mitchell and 
others who have followed this method. Seclusion from friends and 
ordinary environments, with rest, massage, and enforced meals of strong 
soup, milk, cream, eggs and pounded meats constitute this method. Its 
great demerit is its costliness, which render it unavailable for any but 
wealthy patients, and, unfortunately, the good results are not always 
permanent. The infirmity of will, and the general instability of the 
nervous centres, have to be dealt with, and such patients, though much 
has been secured for them of late years, -and they tend to grow more 
numerous with what we are pleased to call" civilisation," - mostly remain 
objects of pity, and a sore tax both upon their friends and their medical 
attendants. 
Hysterical vomiting and dysphagia demand the disciplinary use of an 
oesophageal bougie, rectal alimentation being carried on, or nasal feeding, 
the bougie and nasal tube being subsequently threatened in terrorem. 
Neuralgia. - Generally speaking, supporting diet is called for. If 
neuralgia be " the prayer of the nerve for healthy blood," that prayer 
must be answered. We distinguish between nerve pain due to specific 
morbid condition, capable of removal, and that due to lowered vitality 
and exhaustion with poverty of blood. Thus gouty, syphilitic and 
diabetic neuralgias have to be considered, and appropriate dietetic 
measures adopted for each. In the neuralgias due to exhaustion we 
have to insist on a full supply of digestible food with plenty of fatty 
elements. Butter, cream, Devonshire cream, and fresh unburnt fats are 
thus of value. Post-catarrhal and influenzal neuralgia, the miserable 
paroxysms of pain in affections of the fifth and occipital nerves, and post 
herpetic (zonal) neuralgia are often benefited by the temporary free use 
of mature port wine, best taken with meals. 
Disease of the Respiratory Organs. - Tubercular, Syphilitic and 
Cancerous Laryngitis. - In advanced cases of any of these diseases feed- 
ing becomes difficult and painful. Spoon-food is necessary, and the most 
nourishing fluids must be given. Yolks of eggs, milk thickened with 
arrowroot, and thin jellies are suitable. Care has to be taken that no 
food enters the larynx. It is sometimes advisable in painful cases to 
paint or spray the pharynx and glottis with a solution of cocaine (to be 
freshly made every week, 5 per cent strength) five minutes before 
attempts are made to swallow. A soft tube may have to be passed into 
the oesophagus to conduct liquid food in these cases and in the sensory 
paralysis dependent on diphtheria and bulbar disease. 
Bronchitis: (a) acute, (&) chronic. - The diet should be light and 398 
SYSTEM OF MEDICINE 
nourishing in acute bronchitis. In chronic bronchitis the patient com- 
monly requires strong nourishment and abundance of fatty food. 
Alcohol in some form is generally useful. 
Asthma. - The diet is often an important element in successful treat- 
ment of these cases. Indiscretion and inappropriate diet often induce 
paroxysms. Small meals of readily digestible food are best. Many 
idiosyncrasies are met with respecting tolerance or intolerance of articles 
of diet. I have known fresh butter to be constantly and immediately 
provocative of an attack. Hard meats, cheese, pastry, beer and ill- 
cooked food are generally inadmissible. Full evening meals are to be 
avoided, and the chief meal is best taken early in the afternoon. 
Emphysema. - The chief point to guard against is the use of any food 
that may create flatulent distension of the stomach and bowels. 
Pneumonia. - The diet here is as for fever till the crisis occurs. 
After this the patient may have solid food if desired, and the amount of 
liquids be somewhat restricted. Alcohol may be required, as in fever, 
and is often beneficial. It may have to be freely given in elderly persons 
and confirmed hard drinkers. The onset of gangrene is the signal for 
free stimulation, strong meat essences and milk. 
Phthisis Pulmonalis. - The indications in all forms and stages of 
pulmonary phthisis in respect of diet are to supply as much digestible 
nutriment as can be disposed of. The condition of dyspepsia which 
is often concurrent needs appropriate dietetic treatment. The meals 
should be smaller and more frequent than in health. All* varieties of 
flesh, fowl and fish, with abundance of fatty food, are proper. Milk is 
of great value. An early breakfast in bed is often advisable, consisting 
of tea made with cream, or instead, half a pint of warm milk with the 
yolk of a raw egg stirred into it. Where night-sweats are present, a cup 
of cold tea made with cream, or two ounces of claret and water, may be 
taken on awaking at four or five o'clock in the morning. Malt ex- 
tracts are certainly of use, and may be given in warm milk. Diluted 
warm drinks of nourishing quality aid in promoting free expectoration 
and lessen harassing cough. Malt liquors are excellent if they can be 
digested. Failing these, any form of alcoholic liquid taken with meals is 
advisable. Half an ounce of rum taken in half a pint of milk is a well- 
approved combination taken early in the morning, and again in the fore- 
noon. Eggs, oysters, sweet-bread, fat bacon and tender ham, roe of fish, 
caviare and brains, are all useful in varying the diet and encouraging 
languid appetite. In early cases of phthisis there is no better midday 
meal than a large fat mutton chop, grilled, and half a pint of good 
draught porter. Junket and Devonshire cream with custard pudding 
or stewed fruit may be taken. The presence of tubercular enteritis 
demands the diet found useful in diarrhoea or dysentery, the curds of 
milk being harmful and solid food unsuitable. Alum whey and 
koumiss may be of service in such cases, and mutton or chicken essence 
preferable to beef essence. To promote good digestion of suitable nour- 
ishment is to secure the first line of defence in resisting the progress THE GENERAL PRINCIPLES OF DIETETICS IN DISEASE 
399 
of tuberculosis in any part of the body, and no therapeutic measures 
are of any avail in default of this. A great modern error is to be 
guarded against. It is now sought to combine food and physic in 
numberless preparations foisted on the practitioner by manufacturing 
chemists. These are mostly nauseous and harmful. It needs good 
judgment to keep well apart food, which is to be enjoyed if possible, 
and physic, which is to be tolerated only so far as is necessary. Too 
often one finds the stomach oppressed by continual alternations of food 
and physic, and the end sought is not attained. Simplicity and orderly 
method will accomplish much more than an elaborate and fanciful scheme 
of diet; and, certainly, in the earlier stage of phthisis the patient must 
not be too much regarded as an invalid to be coddled and stuffed. We 
have to seek robustness, and to cultivate all the bodily powers of resist- 
ance. 
Coryza ; Common Colds ; Febrile Catarrh. - In ordinary catarrhal 
states of the nasal, faucial and bronchial mucous surfaces, there is hardly 
any justifiable interference with the usual diet. In severer febrile 
attacks a slop diet is advisable, and alcohol should be withheld. It is 
a common error to over-feed and over-stimulate in this condition. Ani- 
mal broths, well salted, milky and farinaceous food, with plainly-cooked 
vegetables, are best. Lemonade, freshly made, and taken hot at bed- 
time is an approved remedy, and tamarind tea, barley water sweetened 
with liquorice, and linseed tea, are all useful varieties of diluents. A 
diet restricted in liquids has been recommended, but has found little 
favour. During the course of a progressive febrile process diluents are 
in many ways advisable. 
Diseases of the Organs of Circulation. - Inflammatory Conditions of 
the Heart and Pericardium. - In these cases we have practically to do 
with the conditions which underlie and induce the several disorders in 
question. These relate to the peccant matter of rheumatism, to morbid 
blood-states in renal diseases, and to specific toxaemia due to bacillary 
invasion. 
The diet proper for patients with cardiac complications of rheuma- 
tism is mainly that for febrile states, except that animal broth is harm- 
ful. Milk properly diluted and farinaceous food only are allowable. 
Rusks and biscuits soaked in milk, bread-pap, arrowroot, simple nurs- 
ery puddings (without eggs), and mashed potato may be given. In 
pericarditis with effusion the diet should be restricted somewhat in 
respect of fluids, and all sources of flatulence be avoided. The pulse 
condition will determine the employment of alcohol. 
Malignant (Ulcerative) Endocarditis. - In malignant endocarditis 
stronger nutriment is necessary, and animal broths, eggs and pounded 
meat may be given, and spirit or wine will commonly be needed. 
Myocarditis. - Myocarditis calls for the use of alcohol whenever 
recognised. In simple rheumatic pericarditis stimulants are best 
avoided as far as possible. 400 
SYSTEM OF MEDICINE 
Pericarditis in Bright's Disease. - In these cases the condition of 
the kidneys determines the diet. These organs are inadequate to the 
performance of their functions, and can ill bear any undue work thrown 
upon them. A milky and farinaceous diet is suitable; lemonade or 
imperial drink are useful; so likewise are whey and koumiss. Vomit- 
ing may be a serious complication, and, in any case, the prognosis is as 
grave as can be. 
Valvular Diseases of the Heart and Complications; Hypertrophy; 
Dilatation. - The main objects are to give sufficient supporting food, 
but to ensure its digestion with comfort, and never to overload the 
stomach. Gastric and intestinal catarrh are often present, and a light 
diet is then imperative. The condition of the kidneys must always be 
considered together with that of the circulation, and no less the state 
of the pulse in respect of arterial tension. Alcohol is commonly useful 
and necessary, and no form of cardiac valvular disease per se contra- 
indicates it; in aortic reflux it is generally advisable, especially in ad- 
vanced stages, and some should be given at bedtime in addition to that 
taken with meals. When hypertrophy of any cavity is sufficient, espe- 
cially in young persons, there may be no need for alcohol. When dila- 
tation sets in alcohol is valuable. In the latter condition it is well to 
restrict the amount of fluid taken, a " dry diet " being advisable and pro- 
ductive of much benefit. Four or five small meals may be taken in the 
course of the day, and liquids taken after them. Whey, milk and lime 
water, or milk and bicarbonate of sodium, are useful when nausea and 
anorexia are present, with engorged liver and acute gastro-enteric catarrh. 
Prudent medication in these conditions much aids the appetite. Impe- 
rial drink is of service, and fresh or well-cooked fruits are admissible. 
Coffee and cocoa are generally better than tea, though the latter is well 
borne by many people if not too strong. 
Congenital Malformations. - In these cases gastric catarrh is apt to 
recur, and the diet must be adapted to this condition. The digestion 
is feeble, and very plain food suits best. Alcohol is only needed for 
cardiac failure in the later stages. 
Functional Heart Disorders. - Overloading of the stomach and even 
a discreet use of tea and coffee may cause or aggravate some of these. 
Alcohol is not advisable in tachycardia, and in many cases of infrequent 
and intermittent cardiac action it is unnecessary. Each case requires 
special study. 
' Angina Pectoris. - In this disorder care must be taken to provide 
small and digestible meals, especially towards evening. The specific 
character of each case must determine the employment of alcoholic 
drinks. 
Exophthalmic Goitre. - The same rules apply here as in the two fore- 
going conditions. Vomiting and diarrhoea often need special care. 
Aneurysms; Arterial Degeneration. - Much benefit is to be derived 
from a more or less close practice of Tufnell's dietetic treatment. This 
is not available for elderly patients, or for persons with aneurysm and THE GENERAL PRINCIPLES OF DLETETICS IN DISEASE 
401 
aortic reflux, and in very few cases is it a successful remedy. One main 
principle of the plan consists in a small intake both of fluids and solids, 
the chief benefit being probably derived from the reduced amount of 
fluid. Eight ounces of fluids and ten of solids may be enjoined for 
several weeks on a bedridden patient; a water-bed and a bed-pan are 
imperative. In summer this restriction is often found intolerable, thirst 
is common, and constipation the rule. Two or three ounces of port wine 
form part of the fluids. The latter have often to be increased, and 
towards the end of six or eight weeks the whole diet is gradually in- 
creased. A modification of this system is found to answer well in most 
suitable cases. Some lemon juice is necessary in addition to this dietary. 
The subjects of arterial decay are to be sparingly fed, but some wine 
is commonly advisable, especially in elderly persons. The condition of 
the kidneys must be carefully ascertained before enjoining a diet. 
Thrombosis ; Embolism. - The particular feeding of patients with 
thrombosis of veins will depend on the conditions which caused it. In 
anaemic persons good diet is necessary, with alcohol. In gouty persons 
a very plain diet is imperative, and alcohol, if required, is best given in 
the form of diluted spirit. Abundance of green vegetable, such as 
spinach, is useful, and any cruciferous vegetable. Water drinking and 
diluents are important. 
The presence of arterial embolism commonly demands a good diet, 
with some alcohol, especially in elderly patients. 
Diseases of the Digestive Organs. - Stomatitis. - Fluid nourishment 
is alone to be employed in all forms of stomatitis. Milk and sodium 
bicarbonate is best, and should be given tepid or warm. Milk arrow- 
root, and a little brandy with it, is useful. Yolk of egg with milk is 
admissible. After feeding, the mouth should be washed out with warm 
boracic lotion. 
Tonsillitis. - Supporting liquid nourishment is to be given. Milk, 
beef essence, yolk of eggs, and port wine are best; and in severe cases 
these must be firmly pressed in spite of painful deglutition. Nutrient 
enemata may be required for a time. 
(Esophageal Obstruction. - Concentrated liquid food is best, and when 
this no longer passes, nourishment must be given by a small tube, with a 
funnel-shaped end, worn in the gullet, its lumen being kept patent by a 
cat-gut bougie, both being affixed to the side of the mouth by diachylon 
plaster (Symonds' and Berry's method). Rectal feeding is usually neces- 
sary in addition, or by the stomach directly, if gastrostomy has been 
performed. 
Gastritis (acute').-Nutrient enemata are best, perfect rest being 
given to the stomach. Milk and soda water and small pieces of ice 
may be given by the mouth after twenty-four hours. Subsequently, 
milk and sodium bicarbonate, with barley water, custard puddings, and 
yolks of eggs. 
Gastritis (chronic). - Only the most digestible and bland nourish- 
2 D 
VOL. I 402 
SrST'.fi'J/ OF MEDICINE 
ment is advisable. Tea, coffee, and alcohol are inadmissible. Milk and 
farinaceous food, soft fresh fish, pounded meat, mutton, chicken, mashed 
potato, and lightly-boiled fresh eggs may be given in small quantities. 
Sugar is inadvisable. Nourishment is to be given at regular and not too 
long intervals - every three or four hours. 
Dyspepsia, Varieties of. - Each case must be specially studied. Gen- 
erally the diet is as for chronic gastritis. Many idiosyncrasies may be 
noted in respect of tolerance and digestive capacity. Alcohol will aid 
in some forms, given with or just after a meal, and painful dyspepsia will 
sometimes yield to a few spoonfuls of hot brandy or whisky toddy at the 
end of a meal. Many cases do best without alcohol in any form. Malt 
liquors are generally inadvisable. Excess of bread-eating is sometimes 
harmful. Toast or " pulled " bread or biscuits often well replace bread. 
Browned and over-cooked fats generally provoke acid dyspepsia, and all 
rich, twice-cooked, or highly-seasoned dishes are inadmissible. Small 
meals, no second helpings, avoidance of soups and of much liquid with 
meals, are points to be attended to. All vegetables should be sparingly 
used, and cooked as a French cook always - and an English cook never 
- cooks them. Indulgence in the sweet courses is a fertile source of 
acid dyspepsia, and indigestion of amylaceous food leads to the same in 
more cases than is generally supposed. Boiled fish and plain roasted 
and grilled meats are generally well digested, also custard pudding and 
light omelettes. 
Recumbency is to be avoided after meals, and no brain-work under- 
taken during or soon after them. Solitary meals are disastrous, and 
that customary, but very unwholesome, combination, the tea-dinner, is 
to be avoided. No meals should be taken after eight o'clock in the 
evening. Very weak tea or some hot water may be taken an hour after 
the evening meal. A glass of water may be slowly sipped at bedtime, 
but no alcohol is permissible with it. Further details cannot be set 
forth here. No food is advisable between meals, and full intervals of 
rest must be secured for the digestive organs. Many strange dietetic 
methods for treating the varieties of dyspepsia are in vogue. Of all of 
them I will only affirm that they are unwarrantable, and that common 
sense and experienced clinical skill will effectually secure all that is 
attainable for the permanent welfare of the patient. 
Gastric Ulcer. - Rest to the stomach is the key-note of treatment - 
nutrient enemata alone being employed for some days. A little water 
by the mouth or pieces of ice may be taken, but even this may be in- 
advisable if vomiting be urgent, or haematemesis have lately occurred. 
Afterwards,whey, or milk with lime water and barley water, may be given, 
in tablespoonful doses, each quarter of an hour by the clock. I object 
to peptonised food in these cases, as the ulcer may be injured and checked 
in healing thereby. Subsequently, milk arrowroot, yolk of egg, biscuit 
powder and milk in thin pap, bread crumbs and milk in fine pappy 
condition, and milky cocoa (without sugar) may be given. Beef essence, 
liquid jelly, pounded fish, pounded chicken or mutton may next be tried, THE GENERAL PRINCIPLES OF DIETETICS IN DISEASE 
once in each day, and the effects carefully noted. Vegetables, fruits and 
alcohol are to be avoided. Strict confinement to bed is absolutely 
essential. 
Cancer of the Stomach. - The diet is as for ulcer of the stomach. 
Peptonised foods, however, are admissible when there is no vomiting, 
pain or haemorrhage, and pultaceous or even solid food may be remarkably 
well borne. Light wine, champagne, dry Moselle wine, or port wine may 
be employed. A teaspoonful of neat brandy sometimes much relieves 
pain in these cases. When vomiting is rebellious, iced foods and well- 
aerated waters may do good. Some patients tolerate an ordinary mixed 
diet very well if the pylorice orifice is free. 
Pyloric Stenosis from cancerous or simple over-growths ; Gastric Dilata- 
tion. - The diet here is as for chronic gastric catarrh. Dilatation from 
pyloric stenosis leads to retention of contents, and to fermentative decom- 
positions, growth of sarcinae ventriculi, etc. Washing out of the stom- 
ach daily or every second day, before the principal meal, is of great value, 
and amylaceous food is to be much restricted. Beef essence, yolk of 
egg, custard, pounded meat, jellies and milk, with some diluted alcohol, 
are admissible. Much fluid is undesirable, and a somewhat dry diet is to 
be enjoined. 
Intestinal Diseases; Enteritis. - The food should be the same as for 
gastric ulcer, and not taken too hot. 
English Cholera; Cholera nostras. - Milk and barley water with a little 
brandy are best when the vomiting subsides. Chicken and mutton broth 
are preferable to beef tea. 
Infantile Enteritis. - Inquiry is necessary as to the mother's milk. If 
this is unsuitable, diluted cow's milk, one to two or three of barley water 
and lime water, ass's or goat's milk is advisable. Sterilised milk is 
often desirable; it is made by steaming it in bottles for half an hour 
before adding the lime water. If milk be rejected malt food is generally 
available; or raw beef juice, or Valentine's essence diluted freely, may be 
tried. Brandy is commonly of value, especially if any signs of collapse 
set in. The feeding-bottle must be kept scrupulously clean. 
Ulcerative Colitis. - The feeding here is as for cases of dysentery or 
chronic diarrhoea. A drachm of fresh suet melted into a pint of warm 
milk is useful (the " Lac Sevi " of Guy's Hospital), and malted foods are 
available. 
Typhlitis; Perityphlitis. - Milk diet with lime water or sodium bicar- 
bonate, whey, mutton essence. Any food likely to leave debris of tough 
or irritating matters must be avoided. If vomiting occur, the diet should 
be as recommended in cases of peritonitis. 
Diarrhoea. - Milky diet, arrowroot and milk, a little raw arrowroot 
being stirred into each cupful. Mutton tea with rice; brandy or port 
wine with arrowroot. Sometimes equal parts, half an ounce each, of old 
port wine and good brandy, prove useful, taken two or three times a day 
when exhaustion occurs after severe vomiting and purging. No hot food 
is to be taken. When milk disagrees, veal or chicken broth, and malted 
403 404 
SYSTEM OF MEDICINE 
foods may prove of value. When arrowroot is not available, a few 
spoonfuls of flour, baked to a light brown pastry colour, may be given 
with water or milk. 
Diarrhoea, as a symptom of tubercular enteritis, requires similar feed- 
ing, and the dietetic treatment of diarrhoea from whatever cause must 
generally be the same. 
Constipation. - The diet should be varied, and should include vegetable 
food well cooked, especially spinach, fats, oil, fish or cooked fruits, brown 
bread, oatmeal porridge, whole meal bread, " parkin," gingerbread, and 
molasses. Cocoa is preferable to tea or coffee. Half a pint of cold water 
may be taken before breakfast, and the same at bedtime. Beef, white 
bread, cheese, and milk favour constipation. 
Intestinal Obstruction. - The feeding in these cases is as for those of 
peritonitis. The less food given in any form the better. Nutrient 
enemata may be employed. Hot water in spoonfuls is useful, and whey. 
All food tending to leave curd or debris, as milk, is to be avoided. 
Diseases of the Liver ; Jaundice. - In cases of obstructive jaundice it 
is advisable to limit the amount of farinaceous and fatty foods. Beef 
and other animal foods and green vegetables are best. Milk and sodium 
bicarbonate with barley water is advisable. Water drinking is certainly 
of use. Alcohol should be avoided as a rule. However induced in any 
patient, the diet should be simple and unstimulating. Extra water 
drinking is often advisable, and Vichy water may be taken to the extent 
of fifteen or twenty ounces in the day. 
Hepatic Dyspepsia; Litheemia. - Plainly cooked animal food. Dimi- 
nution of amylaceous food and fatty matters. Avoidance of seasoned 
and spiced food. Grilled mutton or beef, boiled white fish, spinach. 
Sugar in small amount and fruits. Claret or dry Moselle with water, 
or weak spirit and water, with meals, if desirable. Cold or hot water 
drinking is advisable between meals. 
Cirrhosis of the Liver. - In this condition there is often gastro-enteric 
catarrh and vomiting of ingesta. Liquid nourishment in small quantities 
is necessary. Alcohol is to be withheld, as a rule, but it may be neces- 
sary to employ it for the patient even if contra-indicated for his disease. 
In many cases solid food may be given with advantage. If there be 
much ascites, restriction of fluids is advisable. 
Cancer of the Liver. - The diet in these cases should be such as can 
best be digested. Saccharine and fatty matters are undesirable. A 
little alcohol is commonly of use, well diluted, or given in the form of 
champagne. 
Gall-stones. - Saccharine and fatty matters are unadvisable. Mutton 
fat appears to favour formation of biliary calculi if taken to excess. 
Alcohol should be moderately employed, if at all; it is best given in 
the form of dry white Moselle wine with some sodic mineral water. 
Peritonitis. -Vomiting and thirst are troublesome symptoms. Small 
pieces of ice to suck are useful, but no food should be given by the 
mouth. Hot water is sometimes well borne. Nutrient enemata are THE GENERAL PRINCIPLES OF DIETETICS IN DISEASE 
405 
to be given, consisting of milk, animal broth and yolk of egg, in quan- 
tities of not more than four ounces, every four or six hours. Nutrient 
suppositories are available. A little laudanum may be added to each 
enema. If the vomiting is in abeyance, alcohol may be given in iced 
water in small quantities. After abdominal section it is best to give 
no food by the mouth, and use small sips of hot water for twenty- 
four or thirty-six hours. Small nutrient enemata or suppositories may 
be given. 
Chronic Peritonitis; Tubercular Peritonitis; Cancerous Peritonitis.- 
The diet must be adapted so as to avoid any articles difficult of diges- 
tion or likely to leave irritating debris behind them. Nourishing slop 
diet, pounded meats, arrowroot with cream, custards, mutton essence 
and jelly are available. Cocoa and malted foods are good. 
Diseases of the Blood, Lymphatic System, and Ductless Glands.- 
Anaemia; Chlorosis; Pernicious Anaemia.-The dietary must vary in 
these cases according to the digestive capacity in each patient. The ob- 
ject is to supply abundance of nourishment in a readily digestible form. 
Red meat, milk, eggs, and fats are needed. The possible presence of 
associated gastric ulcer must be always borne in mind in young women, 
and appropriate feeding employed if there be even a suspicion of it. 
Wine is generally necessary, and four to six ounces of good Bordeaux or 
Burgundy may be given, or four ounces of port wine daily with food. 
In some cases marrow may be given with benefit, and this is well worthy 
of employment in cases of pernicious anaemia. The marrow from 
grilled ox-bones may be eaten with dry toast at one meal each day. 
Leuchcemia. - Nourishing food is necessary in this disorder. Marrow 
is well worthy of trial. Some generous wine is also advisable. 
Purpura. - Although there is no evidence to prove that this disorder 
in its ordinary forms is due to defect in diet, a simple nourishing dietary 
is always advisable, together with a plentiful supply of milk. Some 
wine is generally useful. 
Scorbutus. - It is clearly proved that deprivation of fresh food, vege- 
table or animal, is the essential cause of this disease. It suffices to add 
this to a good nourishing diet to ensure complete recovery. Lemon 
juice is by itself sufficiently anti-scorbutic. The blood is deficient in 
alkalies. The gums being spongy and tender, and the teeth loosened in 
severe cases, it is necessary to employ spoon-food. Mashed potato, green 
vegetables, especially of the cruciferous variety, animal broths, softly- 
boiled onions, eggs, and fresh milk are then advisable. Red wines are 
of value. Freshly-made lemonade may be freely given. If vegetables 
are not available, fresh meat and blood prove of use in averting scurvy. 
In marine or other expeditions preserved vegetables and fruits should 
be provided. Vinegar is also useful. Lime juice should be served out 
daily in quantities of one ounce, and is generally mixed with 10 per 
cent of rum or other spirit to enable it to keep well. 
Haemophilia. - Great care is necessary to ensure that all food taken 406 
SYSTEM OF MEDICINE 
is readily digestible. Fish should be given in place of excess of meat, 
and wine be sparingly employed, best in the form of diluted claret with 
meals. Note is to be taken of any periodic tendency to plethora. 
When haemorrhages occur in the alimentary tract the diet should be 
that employed in cases of enteric fever with similar symptoms, whey 
and thin animal jellies only being given. 
Myxoedema.- The modern treatment of this disease is carried out by 
supplying with the food thyroid elements in the form of various prep- 
arations of that gland taken from the sheep. This dosage must be 
maintained in perpetuity daily, or two or three times a week, in order 
to maintain immunity from recurrence of the disorder. Nourishing 
food and a little wine are of importance. Tablets or elixir of thyroid 
gland are best given after the principal meals, and the patient should 
remain sitting or recumbent for half an hour after the dose. 
Addison's Disease. - Nourishing diet with wine is necessary. In 
exacerbations with vomiting and cardiac depression confinement to bed 
must be enjoined, and brandy in effervescing water or iced champagne 
and soda water be given. A small quantity of brandy or liqueur may 
advantageously be given after the two principal meals in the day. 
Oysters are often useful. 
Hodgkin's Disease; Lymphadenoma. - In addition to a full nourish- 
ing diet, good results may be met with from the use of marrow, taken 
daily, as recommended in cases of pernicious anaemia. 
Tuberculosis of Lymph Glands. - In these cases the diet is as for 
pulmonary phthisis. Fatty foods are of much value. Cream, suet and 
milk, malted food with cream or milk. Ass's and goat's milk, and 
whey, the latter charged with calcium chloride, twenty grains to the 
pint, are worthy of confidence. 
Diseases of the Urinary Organs; Acute Tubal Nephritis.-It is now 
acknowledged that milk diet alone is desirable in this condition. Some 
skill is requisite to ensure its digestion, and to prevent aversion from 
it on the part of the patient. Fresh skimmed milk is best, diluted with 
one-third part of barley water. This may be alternated with whey. 
Draughts of distilled or Nieder-Selters water may be freely given. Only 
in mild forms, or when the kidneys begin to secrete actively, should 
farinaceous food be added. Arrowroot, rice, or well-made gruel may 
then be given. Next, bread and milk, sago, or rice and milk, bread and 
butter. Fresh lemonade, with a drachm of acid tartrate of potassium 
in each pint (imperial drink) may be given. No flesh food of any kind, 
or eggs, are to be employed in the acute disorder; as these are 
cautiously introduced, the effects on the urine must be noted daily. Any 
recurrence of hsematuria at once contra-indicates flesh food. If vomit- 
ing occur it is well to cease administration of anything but iced soda 
water in small quantities. 
Chronic Tubal Nephritis. - The diet best suited is that just advised 
for recovering stages of the acute form, great care being taken at first 
to watch the effect of animal (nitrogenised) foods on the amount of THE GENERAL PRINCIPLES OF DIETETICS IN DISEASE 
albumin eliminated. Lemonade and green vegetables, as spinach, may 
be given if well cooked, also fresh fruits, potatoes, and saccharo-fari- 
naceous elements. Fish is also available, and may be alternated with 
mutton or other tender meat. The patient, and not the disease, has to 
be treated, and too prolonged dietetic restrictions of a pedantic character 
may lead to wasting and a degree of low health incompatible with ulti- 
mate recovery. There are worse things than the mere loss of albumin. 
Chronic Interstitial Nephritis. - The best diet in these cases is that 
compatible with the best health of the patient. The exact degree of 
adequacy of the kidneys must be gauged. Fish, vegetables, and farina- 
ceous foods agree best. Animal food must be given in moderation, if at 
all; and red meat not more than once in the day. Alcohol is best 
avoided, or very sparingly allowed with one meal and well diluted. 
Any gouty element in a case must be appreciated. The high arterial 
pressure so commonly associated with granulating kidneys may be mark- 
edly reduced by diet alone, and a better level of health thus maintained. 
Urcemia. - Milk and soda water or whey may be given. If vomit- 
ing is urgent, hot water may prove of use, and, after the bowels have 
been well cleared, enemata of milk (peptonised) may be given at 
regular intervals. 
Lardaceous Disease of the Kidneys. - Milk diet is useful, and may 
also check tendency to a diarrhoea due to the lardaceous disease of the 
digestive mucous tract, which is commonly associated with that in the 
kidneys. In other respects the diet is as for chronic nephritis. 
Renal Colic.-Warm diluent drinks are of use, unless vomiting is 
rebellious. 
407 
Morbid. Urinary Conditions without Disease of the Kidneys. - 
Diabetes Insipidus. - The difficulty here is to meet the ardent thirst. 
Ordinary nourishing diet is to be given, and large amounts may be 
required as in saccharine diabetes. Fluids should not be freely taken 
with or immediately after meals. Some check to the craving for fluids 
may be secured by only permitting warm or slightly salt water to be 
drunk ; but it is cruel and unavailing to limit materially the amount 
desired. Some Bordeaux or Burgundy wine may be given, also fresh 
lemonade. 
Diabetes Mellitus ; Glycosuria. - A very large clinical experience is 
needed in order to determine the dieting of any case of this disease. 
Every tiro in medicine knows what articles are theoretically prohibited 
for diabetic patients. For a fuller discussion I must refer to the article 
on Diabetes. The dietary may either be strict or partially so. It may 
need to be strict for a time, with subsequent and gradual relaxation, or, 
as in the case of chronic glycosuria which may or may not be a chronic 
form of diabetes mellitus, it may require but few or occasional restric- 
tions. The strict diet precludes the taking of starchy and saccharine 
elements. This is a severe measure, and is hardly to be completely 
achieved or long endured. All varieties of animal food and white fish 408 
SYSTEM OF MEDICINE 
are admissible is this case (with, perhaps, the exception of liver),, 
fat in all forms, cream, milk sparingly, green vegetables, and sugarless 
wines and spirits. Bread stuffs can only be represented by gluten or 
almond bread or cakes. Tea, coffee, cocoa-nib decoction, and cocoa 
free from starch may be taken. In most cases this dietary causes disgust 
after a few weeks. Weight may be lost or gained in individual cases 
while submitting to it. If persisted in, patients of all classes may become 
demoralised, and take, by subterfuge, forbidden articles. Loss of sugar 
may in some cases be well borne, but the deprivation of bread, and 
the substitution for it of the sorry stuff, even in its best and cost- 
liest form, known as gluten "biscuits " and cakes, commonly intolerable 
after a time. Relaxation of rigid rules must then be permitted if we 
are to treat the patient and not merely his disease. Toasted stale 
bread, and bran bread made of the finest milled bran, may be given. 
Gluten bread as a cake may be soaked and toasted with plenty of butter, 
and so made more toothsome. Loosened teeth have to be reckoned 
with in severe cases. The appetite may be enormous, and no stint need 
be exercised either in solids or fluids. Dieting without medicinal treat- 
ment is, of course, in many cases insufficient, and in the worst forms 
the strictest diet is unavailing to check the disorder, even with associated 
medication. Each case is a study in itself. 
Cases of glycosuria in obese persons of gouty proclivity calls for no 
rigid dieting, starchy food being taken in moderation, and sugar omitted. 
Biscuits, brown bread, toasted white bread can generally be taken, and 
potatoes occasionally in small quantities; rice, maccaroni, beans, and 
Jerusalem artichokes may be taken at intervals. Spinach is always 
advisable; sorrel, rhubarb, tomatoes, and fruits, fresh or preserved, and 
jams are all to be shunned. Dry Moselle wines and sound Bordeaux 
are the best forms of alcoholised fluids, or well-diluted spirits. Extra 
water drinking is commonly advisable, or Vichy, Nieder-Selters, Vais, 
St. Galmier water, or Saratoga water may be taken from time to time. 
A course of a dozen bottles in a month is very suitable in the case of 
Vichy (Celestins spring) or Vais water. Sweet courses may be replaced 
by light omelettes. Saccharin may be used to simulate the sweetness 
of sugar. 
In all these cases regard is to be paid to the general health and well- 
being of the individual before us, and the bodily weight should be 
regularly ascertained at intervals. 
Chronic Intoxications. - Alcoholism ; DeliriumTremens. - The diet in 
these cases is as for chronic gastric catarrh. The patient is practically 
starved, and must be well fed by any available means. Nasal feeding may 
be necessary. Milk, strong soup, and coffee are useful. Peptonised foods 
may find a place here. Alcohol may or may not be required : there is 
no hard and fast rule respecting its use. A pint of porter or bitter beer 
may prove the best sedative or hypnotic in delirium tremens. If pneu- 
monia occur stimulants may be freely needed, but the complication is THE GENERAL PRINCIPLES OF DIETETICS IN DISEASE 
most grave. In chronic alcoholism, with gastric catarrh, all alcoholic 
liquids must be forbidden, and fluid nourishment be given till the appe- 
tite returns. 
Lead Poisoning ; Colic; Encephalopathia ; Paralyses; Cachexia.-The 
diet must be regulated according to the special features in each case. 
Vomiting may be troublesome before colic supervenes, and may indicate 
uraemia in chronic cases with granular contraction of the kidneys. Milk 
and beef tea are best. In the chronic forms fatty food is very useful. 
The amount of nitrogenous food must be restricted if the kidneys are 
seriously inadequate to their functions. 
Diseases of the Locomotory System. - Rheumatic Fever.-Without 
doubt the most satisfactory diet in this disease is that of milk and 
farinaceous matters. Milk and barley water, bread and milk, arrowroot, 
rice and milk, are the only allowable articles in the acute stage. Beef 
tea, animal broths, and nitrogenised foods are positively harmful, and 
prevent the most certain medicinal agents from acting efficiently. When 
all pain is subdued, and the temperature remains normal, remedial agents 
being still continued, possibly in diminished doses, mashed potato may 
be added to the diet; chicken broth, or tender white fish may be also 
carefully tried. Any return of pain or fever necessitates recourse to 
the earlier diet. Relapses are certainly induced by too early a return to 
animal food, however simple, and the employment of beef tea is par- 
ticularly to be deprecated. Alcohol, as a rule, is best withheld, unless 
collapse and cardiac failure, as from pericarditis or myocarditis, occur. 
A relapse is practically certain if medicines be omitted and better diet 
be simultaneously prescribed. The return to ordinary diet should be 
very gradual. 
Chronic Rheumatic Arthritis; Osteo-arthritis. - In pure cases of this 
disorder, which is in no sense rheumatic gout, the diet should be 
abundant and very nourishing; it may include meat, milk, fatty, 
farinaceous, and vegetable food, and alcohol or wine in any form. A 
full supply of cruciferous vegetables is advisable. 
Gout, Acute and Chronic. - In acute gout, in young persons, a re- 
stricted diet is essential, and should consist for the most part of milk and 
farinaceous food. In older patients the diet may be more liberal, and 
include fish and green vegetables. Young persons may require no alco- 
hol, older patients sometimes do better with diluted alcohol only at one 
or two meals in the day. There are many diversities of opinion as to 
the dietary of the gouty, both during acute attacks and in the intervals. 
Some physicians recommend animal food to be freely taken, and 
allow wine, others urge a contrary system. The fact is that there 
is no treatment for gout, but much for gouty patients. The age, ante- 
cedents, type of case, condition of organs and tissues, all require to 
be carefully considered in each. Farinaceous food in excess may be 
gout-provoking for some who do well on a moderate allowance of animal 
food. Some patients can take fruit or port wine with impunity, 
others suffer' very soon from such a course. Without question the 
409 SYSTEM OF MEDICINE 
410 
majority do best on a moderate mixed diet of articles they can digest 
with comfort, care being taken to avoid excess in any one of them. 
Indulgence in the sweet courses, in rich dishes, in varieties of wine and 
malt liquor, in burnt fats and jams, and in large evening meals, 
is commonly gout-provoking. Any wines employed should be well 
matured and of good quality. Mature spirit and water is better than 
any wine when gout is threatening. The aged commonly require a little 
wine. Water drinking is certainly beneficial between meals. Fresh 
fats, starch and sugar have no direct influence on the production of uric 
acid. Caution is necessary in the use of meat, fowl, game and cheese. 
Bread, rice, green vegetables and fruit may generally be taken freely. 
Salt meats and salt should be used very sparingly by the gouty. Sherry, 
Madeira, Burgundy and Rhine wines are inadvisable. Champagne, of 
the best quality, and not less than six or eight years old, may be 
occasionally taken by many gouty persons. Dry Moselle and some 
Bordeaux wines are the least harmful, but of these the quantity taken 
should be moderate. Mature port wine may sometimes agree well, and 
not provoke gout, but the quantity is to be measured by a very few 
ounces. Diluted whisky or gin may generally be well borne, but should 
only be taken with food. 
In subjects of gouty cachexia and tophaceous gout the diet should be 
as supporting as the adequacy of the kidneys will permit. Much harm 
may come in many gouty cases from withholding alcohol. Such a plan 
is occasionally imperative, but each case must be carefully considered 
by itself, and no routine practice is possible. 
Gonorrhoeal Synovitis. - After the severer pains have passed away 
it is necessary to give a good diet to these patients. The disorder is a 
lowering and depressing one, and the level of general health must be 
maintained as far as possible. 
Rachitis.-The main treatment of rickets consists in improving the 
diet. Weaning is necessary, and cows', asses', or goats' milk substi- 
tuted : this must be diluted according to the age of the patient, and 
lime water and cream may be added. Beef juice, chicken and veal broth, 
beef gravy, pounded mutton, yolk of egg are all advisable, and one or 
two meals of granulated malt, dissolved in milk are certainly valuable. 
Mashed potato, with milk or gravy, is useful. Condensed milk is most 
undesirable. Cod liver oil I regard as almost a part of the dietary. 
Infantile Scurvy.- This disorder is practically a variety of rickets, 
with haemorrhagic and scorbutic tendency superadded. The same diet 
is necessary here as for rickets, fresh milk and puree of potatoes being 
especially valuable. Orange or lemon juice, diluted and sweetened, and 
grapes may be given daily in small quantities. 
Diseases of the Skin. -Parasitic Diseases. - In the varieties of para- 
sitic skin diseases it is important to secure the highest general nutrition. 
In ringworm it is found advantageous to employ milk and fatty food 
freely, and a thoroughly good digestible diet. THE GENERAL PRINCIPLES OF DIETETICS IN DISEASE 
411 
Erythemata. -A rheumatic element is often present in many of these 
manifestations, but it can hardly be specifically reached by dietetic 
measures. Chilblains attack persons of this habit, and those of gouty in- 
heritance, with some frequency. A good diet, with some wine, is often 
helpful in preventing their occurrence. 
Urticaria. - The diet should be plain, and personal idiosyncrasies 
should be noted as to the influence of fruit, honey, shell-fish, or certain 
wines. 
Eczema. - Much benefit is to be derived from precautions in diet in 
many varieties of eczema. Condiments should be dispensed with alto- 
gether, or as far as possible. Sugar and salt are sometimes provocative, 
and highly-seasoned, salted, and concentrated foods, and even ham and 
bacon should be avoided. Vinegar and even fresh fruits are sometimes 
harmful. Tomatoes, sorrel and rhubarb are inadvisable. Soups are not 
seldom to be placed in the same category. A gouty tendency is often 
expressed in eczema, and the dietetic management for the former is 
commonly effectual in disposing of outbursts of the latter. In acute 
diffused eczema the diet should be that suitable for a febrile condition. 
Pityriasis rubra; Exfoliative Dermatitis. - Good diet is certainly 
helpful in many of these cases. The general level of nutrition is com- 
monly low. 
Psoriasis. - The diet in these cases should be that recommended for 
eczema. Thyroid feeding has certainly proved of benefit in some cases, 
and may be tried. 
Acne vulgaris ; Gutta rosacea.- Some variety of dyspepsia is com- 
monly associated with these disorders. Plain food, with avoidance of 
alcohol, seasoned and hard meats, coffee, cheese, pickles, and much fat 
is advisable. 
Lupus. - The tubercular nature of this disorder naturally suggests 
a diet which is suitable for those so disposed. Of late some good results 
have been obtained by thyroid feeding as for myxoedema. 
Boils ; Carbuncles. - The most satisfactory diet when these disorders 
are in progress is a milky-farinaceous one, without stimulant. If there 
is obvious debility an ordinary good diet is necessary, and wine may be 
given. Otherwise it is better to reserve the use of wine till the sloughs 
are separating. One or two ounces of fresh yeast (brewer's barm), taken 
several times in the day, has been found of use where successions of 
boils are in progress. It is important to recognise any associated gouty 
or glycosuric condition in these cases, and of course to modify the diet 
accordingly. 
Atrophy. - The dietetic treatment of this condition must vary with 
the essential cause of it in every case. Some degree or variety of 
dyspepsia is often a cause, and inability to take appropriate nutriment is 
also often an underlying condition. Digestive incapacity for starch and 
milky food may have to be overcome, and effort is to be made to give a 
fair proportion of these with fatty and albuminoid stuff. Oatmeal gruel, SYSTEM OF MEDICINE 
412 
malted food, with milk, yolk of egg, oysters, tender meats, game, fat 
ham, cream, butter, cocoa, and porter are all of service if they can be 
digested. Half an ounce of rum in half a pint of warm new milk may 
be given before leaving bed each morning, and a fat mutton chop, with 
half a pint of draught porter, constitutes an appropriate luncheon. 
Custard pudding with Devonshire cream, or suet and milk (a drachm of 
fresh beef suet dissolved in half a pint of hot milk), are worthy of trial. 
In the foregoing article I have endeavoured to set before the reader 
the general principles relating to clinical dietetics as adapted for patients 
suffering from various morbid conditions. It will be understood that 
nothing herein recommended can ever replace the necessary and as- 
sociated medicinal and other means which are requisite in order to favour 
restoration to health. Diet may, and can do much in this direction, 
but the clinical practitioner must conduct as well the dietetic as the 
other therapeutical measures in each case, and if he fail at the same 
time to manage his patient, neither the one nor the other will avail 
him to promote the sole object of his art, which is to ensure the 
recovery of the sick. Dyce Duckworth. 
REFERENCES 
1. Pavy, F. W. On Food, 2nd edit., 1875. - 2. Ebstein, W. Das Regimen bei 
der Gicht, 1885. - 3. Beaumetz, Dujardin. Leqons de clinique therapeutique, 5th 
edit. Paris, 1888. - 4. Yeo, Burney. Food in Health and Disease, 1889. - 5. Burnett, 
R. W. Food and Dietaries, 1890.-6. Beaumetz, Dujardin. L'Hygiene alimentaire, 
aliments, alimentation, regime alimentaire dans les maladies. Paris, 1890. - 7. 
Parkes. Practical Hygiene, 8th edit., edited by Notter, 1891. - 8. Dukes, Clement. 
Essentials of School Diet, 1891.-9. Roberts, Sir Wm. Collected Contributions on 
Digestion and Diet, 1891. -10. Martin, Sidney. Art. " Food " in Treatise on Hygiene 
and Public Health, Stevenson and Murphy, p. 391. 1892. -11. Duckworth, Sir 
Dyce. "Dietary for the Sick," Practitioner, Jan. 1892. -12. Pavy, F. W. The 
Physiology of the Carbo-Hydrates, 1894. -13. Cheadle. Artificial Feeding of Infants, 
etc., 3rd edit., 1894. -14. Noorden, Von. "Diabetes. Diet Tables," XX. Century 
Practice of Medicine, p. 168. New York, 1895. -15. Griffith, W. S. A. "Artificial 
Feeding of Infants," Clin. Journal, 15th May 1895. 
D. D. 
THE DIET AND THERAPEUTICS OF CHILDREN 
Although on account of his special constitutional peculiarities the 
young child bears but a faint resemblance to the fully developed adult,, 
in one respect the likeness is close enough. It is that young children, 
like their elders, differ curiously amongst themselves not only in general 
digestive capacity, but also in their individual ability to assimilate this 
or that kind of food. One baby thrives upon fare which is innutritions 
if not actively hurtful to another; so that to prescribe a dietary for a THE DIET AND THERAPEUTICS OF CHILDREN 
413 
young infant is to engage in an experiment which, if it do not succeed 
at once, may require many changes in detail before it can be brought to 
a successful issue. 
So long as the infant can be fed from the breast all is likely to go 
well; for in human milk he meets with a digestible and amply nutritious 
fluid which he swallows straight from the gland, pure and uncontami- 
nated by germs. There are few children who do not thrive when thus 
fed, provided, of course, that the supply of milk be sufficient and its 
quality good. But so many mothers are unable to nurse their babies 
that a large proportion of infants have to be brought up by other means. 
The problem is to imitate the natural food of which the child has been 
deprived. The more closely this can be done the better the prospect of 
rearing the infant with success. 
To be accurately adapted to the wants of the infant, the required 
food must contain all the elements of nutrition as nearly as possible in 
the proportions observed in human milk; it must be well within the 
powers of the stomach, so as to leave little undigested residue to ferment 
in the bowels and be a source of mischief; it must be fresh and in good 
condition; and, lastly, to be a perfect food, it should contain a sufficient 
proportion of the vitalising element-whatever that may be - which 
endows it with its antiscorbutic properties. Now milk contains in itself 
all the elements of nutrition; and the milk of many animals approaches 
human milk in composition more or less closely. Any of these may be 
used; but practically we are forced for convenience' sake to fall back 
upon cow's milk, which is always at hand; and this can be adapted to 
our purpose without much difficulty. 
As compared with human milk,1 the milk of the cow contains a 
larger proportion of curd, but is deficient in sugar and to a small extent 
in fat. To bring it, then, to the standard of human milk it must be di- 
luted and sweetened. But this is not enough. The curd of cow's milk 
coagulates in one large, tough lump which resists digestion; while that 
from the human breast forms a light, loose clot which is easily penetrated 
by the digestive fluids. When, therefore, cow's milk is used, steps must 
be taken to prevent this firm clotting of the curd. If we add to the milk 
some thickening material the particles of curd are kept apart, so that 
when the casein coagulates in the infant's stomach by the action of the 
gastric juice the clot consists, primarily at any rate, of a multitude of 
little lumps of curd instead of one solid mass. For the thickening 
material some form of starch is often used; but as this is difficult 
of digestion by the young child, barley water is to be preferred. Barley 
water itself contains starch, but in comparatively small quantity 
and very finely divided. It rarely disagrees, and when mixed with a 
fourth part of milk suits the large majority of new-born infants. The 
1 For purposes of comparison Dr. V. A. Meigs' (1) analysis is subjoined: - 
Water. 
Sugar. 
Casein. 
Fat. 
Ash. 
Woman's milk 
87'163 
7-407 
1046 
4-283 
•101 
Cow's milk 
88-549 
4-898 
2-792 
3-310 
•451 414 
SYS FEM OF MEDICINE 
meal should be sweetened with white sugar; and it is important that 
the barley water should be freshly made, for it cannot be given with 
safety if more than six hours old. If the cow's milk be used uncooked 
as it is delivered to the house, it retains all its antiscorbutic properties: 
on the other hand, in this state it is probably loaded with germs of 
various kinds, which may indeed be harmless, but may be capable 
of exciting dangerous fermentations, or conveying the seeds of serious 
disease. Epidemics of diphtheria and scarlatina, as well as bowel com- 
plaints of great gravity, may owe their origin to impure milk. Un- 
fortunately boiling the milk renders it less active as an antiscorbutic; 
but it is wiser to make this sacrifice for the sake of avoiding the greater 
evil, and to use milk which has been boiled or sterilised. If the latter, 
it is best to add the barley water to the milk before sterilisation,1 and to 
allow the child to suck the mixture from the sterilising bottle fitted with 
a mouthpiece. 
This method of feeding is to be preferred to the common plan of 
giving milk and water alkalised with a third part of lime water. The 
lime water acts by partially neutralising the gastric juice, so that a con- 
siderable proportion of the milk passes uncoagulated from the stomach 
and is digested in the bowels. Healthy babies doubtless often thrive 
upon this food, although thus deprived of a very important agent of 
digestion. 
It may happen that the new-born infant has a special inability to 
digest fresh cow's milk. In that case he will often do well for the first 
few months upon condensed milk and water; but cow's milk sterilised 
and thickened with barley water should be tried again after an interval, 
varying the proportion of milk in the mixture to suit the child's digestive 
capabilities, for an infant who is greatly overtasked by a third part of 
milk may digest a sixth with ease. No effort should be spared to enable 
the child to digest the fresh milk, for condensed milk is a very undesir- 
able food for him after he is three months old. In all cases of difficulty, 
cow's milk peptonised in the house should be tried, and will often agree. 
We should also never fail to inquire as to the cleanliness of the feeding- 
bottle and the times of feeding. Much may often be done by careful 
regulation of these matters. 
The temperature of the meal should be 95°, and the food can be 
easily warmed to this heat by placing the bottle in a small basin filled 
with hot water. The quantity given in the first week should be a 
couple of ounces, but more will very soon be required. The regulation 
of quantity is a matter of small importance. If a proper interval be 
allowed for digestion the quantity taken at each meal may be left safely 
to the child himself. A very young baby can be trusted to stop sucking 
when he has had enough, and any excess which may have been swallowed 
is usually regurgitated without effort shortly after the meal. 
Children may do well for the first six months upon milk and barley 
1 Milk sterilised in the house by Sohxtet's apparatus is greatly to be preferred to that 
supplied by a company. THE DIET AND THERAPEUTICS OF CHILDREN 
water alone without any change; but often they require more variety in 
their food: in all cases where the digestion is difficult, and has to be 
humoured, variety in the diet is too important a stimulus to be neglected. 
Sooner or later, then, the question of "Infant's Foods" has to be con- 
sidered. All these are preserved or tinned foods, and therefore destitute 
of antiscorbutic properties^ On this account they are only allowable as 
aids in the diet, for cow's milk, when this can be borne, must always be 
our mainstay. 
The tinned foods may be divided into four classes, viz., - 
1. Milk concentrated by evaporation to the consistence of thick cream 
and preserved with sugar or malt. 
2. Milk desiccated and mixed with partially converted starch. 
3. Foods consisting of wheaten flour more or less completely digested, 
or mixed with malt or pancreatine. 
4. Foods consisting merely of the flour of some cereal baked. 
All these, as foods, leave something to be desired ; for besides that none 
of them possesses antiscorbutic properties, all are found in some respects 
to be faulty as nutritives. According to the analyses of Dr. A. Stutzer 
(2), of Bonn, most are lacking in fat; and in many the amount of protein is 
too small and its proportion to the other nutritious matters too narrow. 
Some are weak in bone forming material; others contain insoluble 
carbohydrates (unconverted starch) in excessive quantity, and therefore 
trying to the digestive capacities of an infant. But although beneath 
the standard of perfect nutrients, and ill fitted to be for long together the 
sole nourishment of a young child, these foods are by no means useless. 
As additions to the cow's milk, providing supplementary nourishment, 
furnishing material for flattering the palate and giving variety and relish 
to the meals, their value is great. For infants who cannot digest fresh 
cow's milk we find in the foods containing desiccated and condensed milk 
a fair temporary substitute; and even if the inability prove permanent, 
we can often by this means and a little management maintain the child 
in a fair state of nutrition until he is of an age to supply the deficiencies 
of his dietary by other means. 
The choice of the food is of great importance. Class I., which 
contains the syrupy condensed milks, should be reserved for the first 
three months of life. Dr. Botch (3) advises that these milks be diluted 
with nine parts of water, and that 20 per cent of cream be added to 
supply the deficiency in the fat. This should be about a teaspoonful of 
cream to the bottle of food. The only other tinned food allowable at 
this age is Mellin's Food, which belongs to Class III. In this the starch 
is almost completely predigested and converted into dextrine and 
maltose. One or two teaspoonfuls may be added to each alternate meal 
of milk and barley water for the sake of giving variety. Starches are to 
be used for infants below the age of six months with great caution. 
The secretion of saliva is very small for some tkne after birth, and does 
not become free until the third month; and the pancreatic secretion is 
very scanty for the first six months of life, and does not acquire its full 
415 416 
SYSTEM OF MEDICINE 
diastasic action for some months longer. Up to the age of six months 
starch should only be given when guarded with a digestive, as in the 
malted foods or Benger's pancreatic food. Later it may be tried 
cautiously and in small quantity without this safeguard, in the form 
of baked flour or a rusk, but always with milk. Any of the foods in 
Class IV. may be used at this time. 
The child should be fed every two hours for the first six weeks; then 
the interval between the meals can be gradually increased, and the meals 
themselves made larger and more satisfying. When a tinned prepara- 
tion is used it must not be added to the milk until the meal time 
comes round, for if the food be allowed to stand ready made it quickly 
begins to ferment. 
It would be out of place here to refer to the various derangements 
which may affect the hand-fed infant, or the changes in the diet which 
such disorders require. The reader should consult special treatises 
for information upon these important points. It will be sufficient to 
state, as a general rule, that whenever digestion is difficult and the 
nutrition of the child unsatisfactory we should aim at plenty of variety 
in his meals; that we should not persevere with a food which is found 
not to agree; and that as cooked milk is weak in antiscorbutic properties 
we must be always on the watch, while using it, for early signs of 
infantile scurvy. It may also be remarked that healthy digestion 
depends in a great measure upon the general management of the infant. 
Soiled linen should be removed from the nursery without delay, and the 
room should be frequently ventilated so as to keep the air fairly pure. 
Great attention, too, should be paid to warmth of the child's feet and 
legs; and the washing of his body should be carried out as quickly 
as possible and without undue exposure. An infant whose feet are 
habitually cold never has a good digestion; and many a fatal attack 
of gastritis has owed its origin to a chill contracted by careless exposure 
in or after the daily bath. 
At the end of the first twelve months the infant may be allowed 
for his dinner some weak veal or chicken broth thickened with barley 
and strained. On alternate days he may take the yolk of a new-laid 
egg lightly boiled or beaten up with milk. At this time it is advisable 
to accustom the child to take food from a cup or spoon, so as gradually 
to wean him from the bottle; and when he enters upon his second year 
a light pudding made from sponge cake or rusk may be given two or 
three times a week. 
Meat must not be allowed until the child is sixteen months old: he 
may then begin to take a little underdone mutton chop. At first this 
should be pounded in a mortar and rubbed through a wire sieve; but 
after a month or so it will be sufficient to mince it very finely. It is 
important that all changes made in the diet be made cautiously and with 
judgment. A time shtfuld be chosen when the child is happy and 
cheerful, digesting without trouble and sleeping quietly, and the new 
food must be given in small quantity at first. A change made when the THE DIET AND THERAPEUTICS OF CHILDREN 
417 
child is teething or fretful or restless at night is hardly likely to be 
attended with success. At first meat should be given twice a week only. 
On other days the dinner should consist of strong soup with some well- 
boiled vegetable, such as cauliflower, vegetable marrow, or tender French 
beans. Once or twice a week the child may take some chicken or boiled 
fish. Potatoes are not to be allowed every day; and batter pudding, and 
puddings made from bread and rusk, are to be preferred, as less purely 
farinaceous, to rice, sago, and tapioca; although the latter are, no doubt, 
sanctioned by nursery tradition and prejudice. But an excess of starch 
in their diet is to be avoided for growing boys and girls. At no time 
of life do young children find the digestion of starch an easy matter; 
and it is unwise to overload them with a food which fattens but gives 
little strength, and is but too apt to make them lethargic and dull. Beef 
and mutton, as a rule, they can digest without difficulty. I have been 
told many times that this child or that could digest no meat, but have 
always found that it was not the meat, but the potato eaten with it 
which disagreed. Cold meat, again, is as harmless as hot; and minces 
and hashes are not to be withheld from children through any groundless 
fear of " twice cooked " meat. Nursery superstitions, like other delu- 
sions, die hard; but dishes in which the meat is merely warmed through 
without being really cooked a second time are innocent enough. At all 
ages variety in diet is to be aimed at; and ham and tongue (thinly sliced) 
and bacon for breakfast, help to lighten the monotony of the daily meals 
and stimulate the digestion as well as gratify the palate. 
A word may be said as to the arrangement of the meals. Arbitrary 
■custom ordains that the two substantial meals of the day - the breakfast 
and dinner-must be confined to six hours out of the twenty-four; and 
that for the remaining eighteen hours the child must take nothing but 
milk and bread and butter, with the addition, perhaps, of cake or a little 
jam. This arrangement answers fairly well with sturdy subjects who 
can be prepared with an appetite at the prescribed times, although even 
with these a more rational distribution of their food is to be preferred. 
But many children, especially those who are anaemic and fragile, cannot 
thus be hungry at command. Often in the forenoon they do not care to 
■eat at all. They hardly touch breakfast, and only trifle with the mid- 
day dinner. Towards evening, however, the appetite improves, and at 
five or six o'clock they would eat a hearty meal if allowed to do so. For 
years in these cases I have adopted the plan of ordering a substantial 
meal towards the end of the day, at the time when the child is best dis- 
posed to take it; and if the more fermentable articles, such as sweets and 
potatoes, be excluded from the menu, and a good hour before bedtime be 
allowed for digestion, I have rarely found the patient anything but the 
better for the change. In these cases a little stimulant is often a help in 
improving the appetite and aiding digestion. It should be given with 
the principal meal. I often order the St. Raphael wine, but any sound 
wine will usually agree provided it be not acid. I think a good Burgundy 
is to be preferred to a claret. Alcohol must be regarded strictly as a 
VOL. I 
2 E 418 
SYSTEM OF MEDICINE 
medicine in the case of a child, and is not to be ordered except to serve 
a temporary purpose. It has no tonic properties, and must be discon- 
tinued when the appetite improves. 
Diet enters so largely into the treatment of children's diseases, and 
the rate of recovery may be so influenced by a judicious selection of the 
food, that an intimate acquaintance with these matters is indispensable 
to success as a practical therapeutist. Children, especially young chil- 
dren, are more dependent than adults upon a daily supply of nourishment, 
and suffer more in proportion if this be withheld. The digestion fluctu- 
ates from day to day in strict relation to the general health; and flags at 
once when this is impaired. In acute disease with a high temperature 
the digestive power is very limited, and in order that the nutritive supply 
be not cut off altogether, the food provided must be of the lightest and 
most digestible kind. But "light" food is not to be taken to mean fari- 
naceous food. Starches, especially when cooked with milk, are ill-suited 
to such a condition, and must be given, if given at all, with great caution, 
or they may do harm. As a thickening material for broth they are more 
useful, and beef tea thickened with tapioca or arrowroot will often agree 
when a common tapioca pudding only excites discomfort from acidity and 
flatulence. It is important to realise early that rice and sago and such- 
like puddings are not " light " or easily digestible foods; and that to task 
a disordered or weakened stomach with such highly fermentable material 
in a case of acute illness, or during an early stage of convalescence from 
grave disease, is to aggravate the symptoms and seriously retard recovery. 
In the dieting of febrile diseases in the child the rules which regulate the 
hand-feeding of infants should be observed. Starch should not be given 
with milk unless guarded by a digestive; and milk itself, if not pep- 
tonised, must be thickened with barley water or gelatine. The meat 
jellies and cold extracts of meat agree well with children beyond the 
age of infancy, if not given too liberally. The quantity allowed in each 
case is to be determined by the strength of the child and the state of his 
stomach. A rise of temperature, disturbed sleep, or discomfort after 
the meal, may be taken to show that the quantity must be reduced. So, 
also, if during convalescence the urine be habitually thick with lithates 
it is usually a sign that the patient is being overfed. 
It is often curious to note the immediate improvement which takes 
place in the condition of a sick child when an excessive dietary is reduced, 
and the food both in quantity and quality is adapted with judgment to 
the enfeebled powers of the patient. But it is not enough to see that 
nourishment is assimilated with little effort; we have also to take care 
that waste products are freely eliminated; that the bodily heat, if 
excessive, is controlled; and that the skin, the kidneys, and the bowels 
are encouraged to the full discharge of their duties. Moreover, we must 
be careful to enforce proper rest, and to have the air of the room main- 
tained at a suitable temperature and frequently renewed. 
The constitutional peculiarities of the young child have an important 
bearing upon the treatment of disease in early life. The curious sensitive- THE DIET AND THERAPEUTICS OF CHILDREN 
419 
ness of the nervous system gives an especial value to counter-irritants of 
the skin and external applications generally. Amongst these remedies 
baths take the first place. The hot bath (100° F.) is an important 
general stimulant in cases of extreme depression either from haemorrhage, 
profuse diarrhoea, vomiting, pulmonary collapse, severe nervous shock, 
or any other depressing agency. When used with this object, the child 
must not remain longer than three or four minutes in the hot water. 
This bath can be made more stimulating by the addition of flour of 
mustard in the proportion of one ounce to each gallon of water. The 
mustard is first mixed into a paste with cold water, and is then squeezed 
through a piece of fine muslin into the bath. 
The warm bath (90° F.) calms excitement, allays spasm, and in- 
duces sleep. It is useful in cases of reflex convulsions and every form 
of nervous agitation. Its diaphoretic action makes it of great service in 
Bright's disease, especially if the child be afterwards wrapped in blankets 
to keep up the action of the skin. The duration of the warm bath should 
be from fifteen to twenty minutes. 
The cold douche (65°-70°F.) is only useful in the morning before 
breakfast. If given rapidly it is a bracing tonic for children in whom 
the system responds readily to the shock. Even pallid, delicate subjects 
derive great benefit from it if proper precautions be taken to promote a 
healthy reaction. In the case of a weakly child the patient should be 
first rapidly sponged in a hot bath (100°), and should receive the douche 
as he sits in the hot water. Immediately afterwards he should be 
wrapped up undried in a hot blanket, and returned for a few minutes to 
his bed. Reaction is hastened if the child drink a cup of hot milk ten 
minutes before being put into the water. This is the only way in which 
cold or nearly cold water can be used to advantage with children whose 
nutrition is at fault. The cold sponging so often employed is highly 
objectionable for such patients on account of the long exposure it involves. 
Even when the douche is used as described above, its temperature must 
be carefully adjusted to the readiness of reaction shown by the patient. 
Some children respond best to a comparatively low temperature, while 
others, whose power of reaction is slight, require a douche of 75° or even 
80°, and are depressed instead of strengthened if the water be colder. 
There is another method of using water externally, which is sometimes 
of the highest value. In cases of ptomaine poisoning, with or without 
vomiting or diarrhoea, the skin loses its elasticity more or less completely, 
so that when pinched up it lies in loose folds upon the abdomen. This 
state of skin is probably a sign of imperfect action of the kidneys, for 
the urinary secretion at the time is almost invariably scanty, and is some- 
times suppressed. At any rate, unless the elasticity of the skin can be 
restored the patient will almost certainly die. It is my custom in these 
cases to pack the child in a large towel wrung out of cold water, or of 
water containing a sixth part of eau de Cologne or brandy, and to keep 
him well covered and packed in with many blankets for hours together. 
At the end of every three hours the child is unswathed, rubbed dry, and 420 
SYSTEM OF MEDICINE 
repacked as before. After some hours of this treatment the kidneys 
begin to act more freely and the skin to recover its elasticity. I have 
kept young children, thus packed, for twenty-four hours together with 
the very best results; for if by this means the elasticity of the skin re- 
turn, the prospects of the child's recovery are very materially improved. 
This form of blanket bath should be reserved for cases where it is desired 
to increase the action of the skin or kidneys. It cannot be relied upon 
to lower the temperature when this is high; for unless the process set up 
copious perspiration, the heat of the blankets increases the pyrexia instead 
of lessening it. Children as a rule bear high temperatures well; but if 
the bodily heat exceed 105° steps must be taken to reduce it. The 
plan I prefer consists in wrapping the patient in a sheet wrung out of 
cold water, and covering merely with another dry sheet. Under this 
treatment the temperature quickly falls ; and if the pyrexia have been 
accompanied by convulsions or great excitement, the nervous disturbance, 
as a rule, quickly subsides, and the child sinks into a quiet sleep. 
Of the baths above described the hot and mustard baths may be 
considered as counter-irritants and general stimulants. Children respond 
well to counter-irritation, whether this be used generally or locally. In 
cases of bronchitis or catarrhal pneumonia, long-continued counter-irri- 
tation with mustard poultices diluted with four or five times the quantity 
of linseed meal, and thoroughly mixed, is of the utmost service. A large 
weak poultice kept on the skin for six or eight hours is to be preferred, 
as a rule, to a stronger application used for a shorter period; but in cases 
of imminent danger, where an immediate effect is required, a mustard 
leaf or even dry cupping of the back will often produce speedy relief. 
Mustard leaves, however, and violent applications such as blisters, are 
not to be recommended in the case of babies and the younger children, 
and must be used with caution even with older subjects who are cachectic 
or ill-nourished; for troublesome ulcerations or even gangrene of the skin 
are occasionally seen to follow their use. Moreover, it must be remem- 
bered that a blister is equal to a burn of the third degree, and may have 
a seriously exhausting effect upon a weakly chi 1 d. In a properly selected 
case, however, the value of this form of counter-irritation is great. In 
peri- and endo-carditis no time should be lost in having recourse to it. I 
believe I have often succeeded in cutting short an attack of pericarditis 
by a timely blister; and the value of a vesicant in promoting absorption 
when the pericardial sac is full of fluid admits of no reasonable doubt. 
In such a case, when used to a young child, the blister must be of small 
size, and must be kept in contact with the skin for a short time only. 
Thus it can be applied for two hours to a child of three years old, and 
half an hour longer for each additional year of life. If the blister have 
not formed when the irritant is removed, a bread and water poultice will 
soon cause it to rise up. In cases of exceptional delicacy of skin a sheet 
of oiled tissue paper may be interposed between the blister and the 
surface to be acted on, as recommended by Bretonneau. 
Frictions of the skin with almond oil or stimulating liniments are THE DIET AND THERAPEUTICS OF CHILDREN 
421 
useful in various conditions. Threatened collapse of the lung may often 
be averted by this means; and if atelectasis have occurred, persevering 
friction with strong counter-irritants may do much in helping the lung 
to re-expand. In whooping-cough the use of rubefacient embrocations is 
held in high esteem as a domestic remedy ; and in all cases of chronic 
disease friction of the surface combined with systematic massage of the 
muscles has a general as well as a local value. In chronic digestive 
derangements the skin is often dry, scaly, and inactive. For this con- 
dition the application of warm almond oil becomes a useful resource. 
The patient is first well sponged in a bath of hot soap-suds, then quickly 
dried, and freely anointed all over the body with the warm oil. He is 
then put to bed in a flannel night-dress or wrapped in a blanket. The 
efficacy of a few repetitions of this treatment in improving nutrition and 
making the skin soft and supple is remarkable. 
Children are very easily depressed by acute disease, so that it is im- 
portant to watch for early signs of failure. On this account alcoholic 
stimulants take a high place among internal remedies, and a few doses of 
this medicine will often in a few hours completely alter the aspect of a 
case, and turn the scale in favour of recovery. In chronic disease, also, 
the effect is equally beneficial. It is a matter of common observation at 
the East London Hospital for Children, that the young patients who are 
enfeebled and wasted by privations of all kinds, combined with long-con- 
tinued ill-health, often make no response to the action of drugs until their 
exhausted energies have been revived by a few doses of wine or brandy. 
The rapidity with which nutrition suffers in early life, when any 
hindrance arises to the easy assimilation of food, gives great value to all 
invigorating remedies. But tonics are not to be ordered indiscriminately. 
It is of small use to prescribe iron or the mineral acids for a sickly- 
looking child merely because he is anaemic and weakly, and leave un- 
noticed a chronic gastric derangement which is the cause of his poor 
appetite and feeble digestion. The dyspepsia must first be treated with 
alkalies and stomachics, and by a judicious limitation of the more ferment- 
able articles of food, before tonics can be given with any good result. As 
the digestion is liable to suffer in all the ailments of childhood the alkalies 
are perhaps the most useful of our remedies. By this means we check 
the excessive secretion of mucus and neutralise acidity. Moreover, the 
addition of an antiseptic, such as spirits of chloroform, and of warming 
aromatics, arrests fermentation and reduces flatulence. At this period 
of life, whenever alkaline remedies are prescribed, an aromatic, such as 
cinnamon, dill, or peppermint, should always be included in the mixture. 
When tonics are given the dilute nitro-muriatic acid is very useful 
with small doses of nux vomica; and children take quinine with great 
benefit if the dose be not too small. After any of the infectious fevers 
quinine is always indicated. A child of twelve months old will take a 
grain three times a day ; and half a grain may be added for each year of 
the child's life until a dose of three grains is reached. This can be given 
three, four, or six times in the day as may seem desirable. The usual SYSTEM OF MEDICINE 
422 
doses brdered for children are too small; for young patients are not at 
all susceptible to the alkaloid, and rarely suffer from cinchonism. Cod 
liver oil is the favourite remedy for every form of wasting or pallor. 
The oil is only useful when the digestion is in fair order, and should 
never be given to a bilious or dyspeptic child. It is usually administered 
in quantities far too large. A child of twelve months old can rarely 
digest more than ten drops at one time, and a teaspoonful should be the 
maximum dose at any age. 
The dosage of medicine for children is often a cause of some per- 
plexity. Of certain drugs they show a curious tolerance. Belladonna 
they can take in large doses, for although a few drops of the tincture 
may bring out the characteristic rash, this is not a symptom of excess, and 
has no relation to the size of the dose. To opium, as is well known, they 
are keenly susceptible. It is wise to prescribe this narcotic in very small 
quantities, but to repeat the dose as frequently as may be necessary. If 
this be done, and we give directions that the child is never to be waked 
up to take his medicine, we need have no fear of his becoming narcotised. 
In connection with this subject it may be remarked, that infants who are 
being drugged by unscrupulous nurses with " soothing syrups," or other 
opiates, invariably show it by symptoms which are characteristic enough 
to the experienced eye. The child lies in a drowsy state with contracted 
pupils, he often vomits, his bowels are obstinately confined, his water 
is scanty, and his skin is curiously inelastic. If this combination of 
symptoms be noticed in a young baby we have the strongest reasons for 
suspecting the secret administration of a narcotic. 
Antipyrin, like quinine, children take well; and arsenic and iodide of 
potassium may be given to patients of four years old and upwards in the 
doses usually prescribed for the adult. Ergot, digitalis and lobelia are 
other remedies which may be ordered with a liberal hand. The making of 
these and other drugs palatable to young children is far from easy. The 
bitterness of quinine it is impossible to disguise completely; but it may 
be modified by giving it suspended in glycerine and water. Nauseous 
powders are best given in " cachets "; and young children soon learn to 
swallow them. It is wise to avoid the use of syrups for sweetening pur- 
poses : there are few illnesses in young people which are not complicated 
by a certain amount of gastric disturbance; and the quantity of sugar 
contained in the syrups must provide additional material for fermentation, 
and excite acidity and flatulence. There is no doubt that the medicated 
syrups, which are manufactured so largely, are often the cause of great 
discomfort to the patient, if not of worse evils; the syrup, by increasing 
the digestive derangement, may be more productive of ill than the drug 
dissolved in it is of good. 
Eustace Smith. 
1. Archives of Paediatrics, April 1884, p. 229. - 2. Pharmaceutische Central Halle, 
Berlin, 1886, No. 8. - 3. Keating's Cyclopaedia, article, "Infant Feeding," by T. M. 
Rotch, M.D. 
REFERENCES 
E. S. NUXSING 
423 
NURSING1 
Tending the sick has risen to the dignity of a profession, and a special 
training is required for those who undertake it. The keynote of good 
nursing is an intelligent obedience, only attainable by systematic educa- 
tion. Women who wish to be nurses need practical skill, powers of ob- 
servation, and tact in dealing with various idiosyncrasies. They must 
also remember that time is needed in which to gain these qualities and 
the knowledge which experience alone can give. 
Hospitals, which offer facilities for regular instruction both in theory 
and practice, have become training schools for nurses. Order, method, 
punctuality, obedience are part of the groundwork of a training school; 
but to these must be added thoroughness, promptness, accuracy in ob- 
serving and correctness in reporting observations, and a loyal attitude 
towards doctors and patients. The whole art of trained nursing depends 
upon the maintenance of this attitude. Nurses are bound, by their very 
position, to render loyal obedience to medical men. It is not their duty 
to suggest or initiate treatment of any kind, except by express permission 
or in some sudden emergency. They have no responsibility whatever 
save that of faithfully obeying orders, and the higher the discipline the 
more readily this is recognised. 
With regard to patients the gravest fault, short of negligence, is love 
of gossip, personal or professional. To talk to patients about their ail- 
ments and treatment, to describe other cases to them, to indulge them 
in medical histories, and to discuss the comparative merits of medical men, 
work infinite harm; especially to those of nervous temperament who are 
chiefly disposed to seek such confidences. It is true a nurse is often at 
a loss to interest her patients, but to gratify unwholesome curiosity, to 
criticise methods of treatment, or to reveal private affairs learned in the 
course of her profession, is most reprehensible. 
Age for Training. -While probationers are being thus educated they 
are also instructed in the special branches of the work. The demands 
upon physical power and mental assimilation are alike heavy, and should 
not be undertaken too soon in life. From 23 to 24 is the earliest age at 
which a nurse should begin her training. Even in children's hospitals to 
accept younger probationers is an error. The actual strain of lifting, 
moving, etc., may not be so heavy; but the incessant watchfulness, 
cheerfulness, and absolute self-control necessary in dealing with children 
are a heavier task than is usually supposed. 
General hospital training may be divided into surgical and medical 
work, and the probationers are moved from ward to ward at the discre- 
tion of those in charge of the training. For the sake of order and dis- 
11 have asked Miss Hughes to write this article for me in order that medical men may 
know what to expect of their nurses - not that I for a moment suppose any one of my 
readers to be unfamiliar with the smallest of these bedside services. -Ed. 424 
SYSTEM OF MEDICINE 
cipline this power should be vested in the matron, herself a trained 
nurse, who is guided by the reports of the " sisters " or " charge nurses " 
of the different wards. 
Surgical Ward Work ; Ventilation. - The first essential in a surgical 
ward is pure air, the second absolute cleanliness. On the nurse devolves 
the management of windows and ventilators so as to obtain the maximum 
of change of air with the minimum of draught. Common sense must be 
brought to bear on the matter; the direction of the wind and its effect 
on the ventilating arrangements of the ward must be considered, so as 
to avoid a through draught, also the nature of the warming apparatus, 
whether open fireplaces or hot pipes, and its position in regard to doors 
and windows. The usual temperature -from 50° F. to 60° F. - should 
be recorded at regular intervals during the twenty-four hours, and fresh- 
ness must be equally maintained day and night. 
Absolute cleanliness applies to every detail of a ward, from the patients 
and their beds to the smallest appliance and fitting. Dusting means 
not merely moving the offending material, but removing it from every 
part of the walls, floor, furniture, etc. A damp, not wet duster is most 
effectual; and if desired, it can be used with a disinfectant. Floors 
should be sprinkled before sweeping, and the bedstead of every patient 
dusted daily. 
Every appliance must be scrupulously cleansed, no stains nor fur 
allowed on utensils, test tubes, etc.; strong soda water, or spirits of salt 
(applied with a mop) will cleanse any glass or earthenware vessel, but 
the latter must not be used for metals, nor for lavatories, on account of 
the metal fittings. Bedsteads, bedding, mackintoshes, splints, etc., must 
be kept absolutely clean. 
Surgical cleanliness is a higher matter than general cleanliness. It 
aims at the destruction of every germ; bacteria are not merely to be 
removed, they should be non-existent. 
This is attained by boiling all glass and metal appliances for twenty 
minutes, maintaining the temperature at 212° F. Dressings, sponges, 
wool pads, are also sterilised, and kept hermetically sealed till the moment 
they are needed. Other antiseptic dressings, such as sal-alembroth, 
cyanide, etc., have the same object in view; and here the most careful 
watchfulness is demanded from the nurse that she shall not nullify the 
treatment by any such careless action as laying down a dressing, scissors, 
or any of the appliances, on an undisinfected surface. She must herself 
be scrupulously clean in person and dress, and her hands must be care- 
fully kept, with short clean nails. 
Cleansing of Hands. - In attending upon the surgeon, or in preparing 
for dressing cases, etc., her hands may be rendered free from suspicion 
by first thoroughly washing in hot water, using carbolic soap and nail 
brush freely; hands and forearms are then immersed in strong Condy's 
fluid for a minute, the stains being next removed by the use of a saturated 
solution of oxalic acid. After drying, they are again soaked in 
solution of perchloride of mercury, and may then be considered as really NURSING 
cleansed. This process does not take long, and is especially necessary 
in moving from any doubtful case to another patient. 
A knowledge of the various strengths of disinfectant and antiseptic 
lotions is important to the nurse. 
(a) Perchloride of Mercury is used for hands, for douches, 
etc., other strengths being specially ordered. Metal instruments 
should be wiped at once if immersed in it. 
(&) Carbolic acid lotion is used for hands, instruments, and 
external washing of sound skin, and for wounds, etc. 
(c) Condy's Fluid, 3j. to Oj. (or three to four crystals of perman- 
ganate of potash to 1 pint) for douches, wounds, etc.; it stains 
linen, instruments, and hands. 
(d) Saturated solution of Boracic acid, Jg- or about 4 per cent for 
wounds. 
(e) Sanitas, 3j. to Oj., a pleasant deodorant for foul wounds, and 
for cancer, gangrene, etc. 
(/) Creolin, 3j. to Oj. for hands and instruments; must be mixed 
with a little cold water before adding hot, and can be used with 
soap. Same strength useful for irrigating wounds. 
0) Boiling water for instruments. Boiled water for douches and 
irrigations. 
Poison Bottles and Lotions. - Every poisonous lotion should be in a 
special bottle, with conspicuous label, and kept under lock and key; any 
possibility of confusion with medicines, or beverages, whether in or out 
of use, should be prevented. Corrosive sublimate is usually coloured 
pink or blue to avoid mistakes; the other lotions, except boracic lotion, 
have each a distinctive and easily perceptible smell. 
Symptoms of their absorption must be looked for and reported, e.g. 
in carbolic poisoning, dark green urine, drowsiness, muscular weakness, 
and sometimes vomiting. 
If a nurse has dressings to prepare for granulating wounds, the lint or 
gauze must be cut exactly to cover the sore to avoid softening the edges. 
Ointments must be very thinly spread, and must never be allowed 
to accumulate on the sound skin. If a moist dressing is ordered, a 
piece of gutta percha tissue considerably larger than the lint must be 
applied over the lint, no portion of which should be left uncovered; 
but if an evaporating lotion be required, the tissue must be omitted, 
and the application frequently changed and never allowed to dry. In 
washing or syringing a wound a receiver must always be placed to col- 
lect the water or lotion that has touched the sore; and if wool be used 
to cleanse, each piece as used must be placed on a receiver, and never 
dipped again into the lotion. To place the foot of an ulcerated leg, for 
example, in a basin of disinfectant, and use one piece of wool to cleanse 
the wound and surrounding skin is not surgical nursing. 
In dressing burns the fresh application should be ready to put on as 
the soiled one is removed; thus unnecessary exposure to the air, which 
causes great smarting, is avoided. In every dressing the nurse must 
425 SYSTEM OF MEDICINE 
426 
observe strict cleanliness in every detail. Soiled dressings should 
always be removed by forceps, placed in a receiver at once, disposed of 
in the manner of the hospital, or burned without delay. 
The forceps must be cleansed with a nail brush in soap and water, 
and either boiled, or soaked in disinfectant for a few minutes before 
being used again. 
Windows should always be closed when a dressing is being done, 
and every wound should be covered as quickly as possible. 
In offensive cases inhalation of the odour must be avoided, and the 
patient should never be made to feel the unpleasantness of which he 
is, as a rule, only too fully aware. The nurse must report the effect 
of the applications. 
Cancer patients vary greatly, and by observing that which suits each 
special case much pain may be avoided. In dressing extensive cancerous 
surfaces a styptic should be at hand in case of haemorrhage; in these 
cases, and for gangrene, burns, etc., gentle, firm handling is needed, com- 
bined with quickness and lightness in removing and reapplying dressings. 
In padding splints evenness is ensured by lacing the padding down 
the back of the splint with strong thread, so that it can be regularly 
tightened. Special care must be given to ensure the edges being well 
protected, or pressure sores may arise. Children's splints, and others 
likely to be soiled, can be covered in addition with jaconet, which can be 
cleansed easily. In preparing for extensions the nurse must have ready 
a long even strip of strapping, known as the stirrup (preferably on 
holland), cut with regard to the width and length of the limb; also two 
or three thin strips long enough to go at least twice round the limb 
diagonally, to avoid any arrest of circulation: the block, pulley, cord, 
the weight ordered, sand-bags, and a couple of thin flannel bandages must 
also be at hand. If the nurse be desired to apply an extension in cases of 
hip disease, the ends of the stirrup must be well above the knee (quite half- 
way up the thigh), and the loop so arranged that its sides are exactly equal 
in length, the block and cord with the attached weight being in the centre. 
The block is easily fastened to the stirrup by a length of strapping extend- 
ing from above the ankle on each side, and is applied with its adhesive side 
to the stirrup, so that the block is enclosed between the strips. It may 
be further secured by a strip wrapped round on each side of the hole 
through which the cord passes. The strips which keep the stirrup in 
position must not be too tight, and the edge of the lowest one must be 
kept from chafing the skin just above the heel. The patient must be 
kept flat, with only one pillow, the foot of the bed raised, and the limb 
retained in position by sand-bags; careful washing and powdering are 
necessary, when the extension is changed, to prevent chafing of the skin, 
turpentine being used to remove the adhesive material from the skin. 
The art of even bandaging, applied intelligently after due anatomical 
instruction, is very important. The bandage should be gently yet firmly 
applied, alternate slackening and tightening avoided, also any jerking or 
pulling. In dealing with an injured limb it should be lightly, yet NURSING 
427 
firmly grasped, supported as much as possible, and moved evenly. To 
carry it on the palms of the hands gives less pain than holding it in 
the fingers. 
In receiving accident cases in a ward orders will be given as to 
bathing, etc. If the accident be a fracture, fracture boards must be 
placed under the mattress in the bed, and the splints suitable for the 
case, according to the use of the hospital, should be got ready, padded, 
etc., and, if necessary (i.e. in fractures of thigh), an extension prepared. 
In removing the clothes the patient must be kept recumbent for fear of 
syncope in consequence of shock, and the garments removed as gently as 
possible. Trousers, coat-sleeves, shirts, socks, etc., can all be divided at 
the seams, and lifted from the injured parts, which should always be 
freed first. The same applies to a woman's garments; skirts can be 
slipped downwards by raising the back slightly, and pushing down the 
bed underneath to make room for them to be drawn away. 
The necessary washing must be done between blankets, one being 
placed on the bed before the patient is laid in it, and another over him; 
the nurse must watch for signs of exhaustion. Turpentine is useful to 
remove stains from the hard skin of hands, feet and knees, but it must 
be well washed off with soap and water to avoid irritation. Except in 
the neighbourhood of scalp wounds hair must never be cut without a 
direct order from the doctor. In head injuries the nurse must report 
any discharge from ears or nose, any peculiarity of the eyes, and if there 
are fits, she must specially observe where the convulsive movements 
commence. In abdominal cases, swelling, tenderness in any special 
area, bruises, etc., must be reported; also all cuts, scars, wounds, ulcers, 
skin eruptions, vomiting, discharges or hsemorrhage; in fact, anything at 
all abnormal. After washing, the blankets are removed, and if the pa- 
tient be cold or collapsed, hot bottles securely wrapped in flannel may be 
applied to the extremities. Fractured limbs must be steadied by sand- 
bags, and if the bed-clothes press on any injured part a cradle must be 
used to support them. No stimulant must be given without direct orders. 
In preparing a patient for operation the nurse acts under the orders 
of the surgeon; it is usual to give an aperient over-night, a simple enema 
early in the morning, and no solid food or milk for at least four hours 
beforehand, a cup of good beef tea being given about two hours before 
the appointed time. Antiseptic compresses are often ordered to the 
place where the incision will be made. If a woman, the hair must be 
arranged in two plaits for future convenience, and the catheter may be 
ordered shortly before the operation. Ordinary bed-clothes are usually 
worn, with a special wrapper. The arrangements at the operation depend 
on the custom of the hospital; but the nurse is often required to wash 
sponges, hand instruments, and even to support a limb. Sponges or 
wool pads must be squeezed as dry as possible before handing to the 
surgeon, and the exact number counted. The table is prepared by 
folding a blanket double on it, and covering this with a large mackintosh, 
over which is a sheet. A low pillow and a draw-sheet are usual, with 428 
SYSTEM OF MEDICINE 
small mackintoshes and towels tightly wrung out of a disinfectant lotion, 
and arranged to suit the special case. A hot water bed is sometimes 
used, placed next the table. The bed to which the patient is afterwards 
taken must be well warmed by hot bottles, and a warm water-pillow 
may be ordered. A receiver and a couple of soft towels must be in 
readiness in case of vomiting after the anaesthetic. 
After-Care. - In moving a patient back to bed the head should be 
kept as low as possible, and careful attention given that before complete 
consciousness is recovered the dressings are not disturbed, nor the patient 
allowed to raise himself hurriedly, for fear of haemorrhage or syncope. 
In amputation cases a tourniquet should be within reach of the nurse, to 
be applied if haemorrhage occurs, until the surgeon can be summoned. 
Every detail regarding nourishment, stimulants, opiates, use of the cath- 
eter, etc., must be obtained from the surgeon. 
After an operation the dressings should be inspected at frequent 
intervals, and if discharge or blood soak through them the fact should 
be reported at once. If the surgeon be not at hand the dressing should 
be " packed," i.e. pads of absorbent wool bandaged over the points where 
the discharge appears. 
No food should be given for some hours after an operation, unless 
specially ordered, or the effects of the aneesthetic have passed off; but 
small pieces of ice, a little soda water, or a teaspoonful of hot water 
may be given to allay thirst and relieve vomiting. If the latter be 
severe, it should be reported. 
The nurse should have all in readiness for the visit of the surgeons 
to a ward. Hot water, towels, disinfectant lotion for hands and instru- 
ments, dressing forceps, probe and director, and a tongue spatula im- 
mersed in lotion should be carried round by the nurse; and artery forceps, 
bistoury, etc., should be in readiness if required: a good lamp should 
always be ready, and a receiver for soiled dressing, prepared notes of cases 
beside each patient, splints, etc., so that no unnecessary delay is caused. 
Medical Nursing. - The ventilation of medical wards is most im- 
portant, the temperature must be higher -usually fron 60° to 65° F. - 
and yet the air kept quite fresh. It is advisable to have two or more 
thermometers in each large ward, to ensure an evenly-distributed heat. 
In small wards, where a moist and higher temperature may be required 
(70° F.), draught may be avoided by the Hinckes Bird method of venti- 
lation, i.e. a piece of wood, three or four inches deep, exactly fitting the 
window frame, is placed so that the lower sash closes on it, and the 
outside air passes up between the upper and lower sashes in the middle 
of the window, and is directed upwards into the room. 
To give an accurate report, the use of the clinical thermometer 
needs greater care than is often bestowed upon it. If given to a patient 
able to hold it in the mouth, it must go under the tongue, and be held 
by the closed lips (not by the teeth), for always the same time, at least 
five minutes. The so-called "half-minute " thermometers are deceptive 
if used for this interval. If placed in the axilla the skin must first be NURSING 
dried, and the thermometer so inserted that the bulb touches the skin on 
every side, the arm being drawn across the chest; if necessary, the arm 
must be held there for the required time. In children the fold of the groin 
is often convenient, or the rectum. In every case the record should be 
written down at once, not trusted to memory, and the thermometer 
placed in carbolic," or perchlor.,v for a few minutes before 
replacing it in its case. It is a good plan to dip it into clean water, and 
wipe it with a clean napkin, before giving it to each patient, especially if 
used in the mouth. The temperature of a patient in a bath or pack must 
never be taken in groin or axilla. 
Accurately counting the rate of the pulse, and reporting its character, 
are matters of training and experience, and of great importance. A 
nurse should be able to notice the more important changes that may oc- 
cur, also whether drugs, stimulants, etc., produce any marked effects. 
It is better not to let the patient know when the respirations are 
being counted, as this may alter the rate, and this record is at times of 
more value to the doctor than that of the temperature. 
Bed-making is one of the most important duties of a nurse. In hos- 
pital wards where the beds, mattresses, etc., are of right size and height, 
no special difficulties arise. A single blanket is spread over the hair 
mattress, and over this a sheet, the upper end of which is rolled round 
the bolster, not spread over it, and tucked firmly in all round. A draw- 
sheet, consisting of a sheet folded about three feet wide, is placed across 
the bed, one end being tucked in at one side, and the extra length flatly 
folded and tucked in on the other. If necessary, a square of mackintosh 
is placed under the draw-sheet, and may conveniently be kept in place by 
a small safety pin at each corner. The top sheet and each blanket should 
be put on and tucked in separately, and the feelings of the individual 
patient consulted as to folding back blankets or quilt at the top. The 
quilt should be so pinned or folded that it does not touch the floor at the 
bottom or sides of the bed, and prevent free circulation of air underneath. 
In changing bed-linen for a helpless case the upper sheet and quilt 
must first be removed, and the patient covered with his blanket or 
blankets; he must then be gently turned on one side (if possible the 
right to avoid any risk of syncope in cardiac or pleuritic affections). 
This can be done with little effort by means of the draw-sheet; this is then, 
with the mackintosh, rolled up tightly towards the patient, the bottom 
sheet untucked, also rolled up tightly, and with the other pushed well 
under the shoulder and buttocks of the patient. The clean sheet, draw- 
sheet, and mackintosh are also rolled up together lengthwise for half their 
width, and placed close to the patient, the other portion being smoothly 
spread over half the bed. For a weak patient this is a good opportunity 
for washing the back and applying spirits and dusting powder, so that he 
need not be disturbed again. The patient is then turned back over the 
rolled linen, and just turned sufficiently to the left side to allow the soiled 
linen to be removed; the clean roll is then drawn through and evenly 
spread over the other half of the bed, and all well tucked in. It facilitates 
429 SYSTEM OF MEDICINE 
430 
matters to raise the feet and legs, and place them on the clean linen before 
turning the patient back, -and the head should always be comfortably sup- 
ported by pillows. The top sheet can be passed in under the blankets from 
the bottom of the bed, and then they are separately tucked in and the quilt 
replaced. By placing the rolled part of the sheets, etc., next the bed, 
the hands can be slipped underneath it, palms upwards, to draw it 
through; thus the nurse's knuckles are not pushed against the back of the 
patient. Heavy bed-clothes must always be avoided, and the feelings of 
the patient consulted as to warmth whenever possible. 
In removing body linen of helpless patients, it is well to draw it up 
from the back, and, having unfastened the collar, to bring the garment 
over the head, taking the arms out of the sleeves last. In putting on 
fresh linen, it is easier if the arms be first placed in the sleeves, and then 
the shirt lifted over the head, and drawn down at the back. Where all 
movement is undesirable, a shirt or night-dress can be divided down all 
the seams of one side, neck, shoulder, sleeve, etc., and fastened by tapes; 
it has then only to be put On at one side, and the back rolled and passed 
under the patient like a draw-sheet. 
Medical Examination. - The nurse must be ready to remove and ad- 
just all personal or bed clothing for medical examination. When the 
abdomen is to be examined the quilt and blankets must be turned back 
but the sheet left upon the patient for the medical attendant to arrange 
for his own convenience. 
Helpless Cases. - In changing the bed-linen for cases which must not 
be turned at all on either side, the dirty under-sheet, with mackintosh 
and draw-sheet, can be rolled up from the bottom of the bed, and pushed 
well under the buttocks; the rolled part of the clean linen is now laid 
close to it, and the lower part of it spread and tucked in at the foot of 
the bed. By gently raising the buttocks the two rolls are passed under- 
neath, and the patient now rests on the clean sheet. The upper part of 
the soiled sheet is then rolled and pushed well up under the shoulder- 
blades, and the clean one also; and then, by gently raising the shoulders 
a very little, both are drawn up to the top of the bed, the dirty linen 
removed, and the clean spread smoothly. By changing from below 
upwards, the patient is not pulled down the bed, which entails the extra 
fatigue of lifting up again. 
Lifting is readily done by two persons, who pass hands - left or right 
as the case may be - under the buttocks, and the other hands just below 
the shoulder-blades, while a third helper, if the patient be very weak, 
supports the head and shoulders. By lifting exactly simultaneously, the 
heaviest patient can be raised without over-exertion. Or two assistants 
may grasp the draw-sheet close to the buttocks and under the shoulders, 
the head being supported as before, and the patient raised, but this is apt 
to bring the draw-sheet too far up the bed, and the patient is pulled down 
again in endeavouring to rearrange it. A pillow is useful in abdominal 
cases where the knees are drawn up; and it can be efficiently protected 
by placing a piece of mackintosh round it under the pillow-case. When NURSING 
used to support a limb it is more comfortable if hollowed in the middle 
so as to form a trench. 
When a cradle is used to keep off the weight of the clothes, a thin 
blanket or the sheet should be upon the patient. 
Water-beds and water-pillows are filled with lukewarm water, so as 
neither to chill nor overheat the patient. They should be covered by a 
mackintosh and thin blanket under the sheet. A water-bed must be 
filled before the patient is placed in it, but a water-pillow can, if neces- 
sary, be slipped in empty underneath him as he lies. 
The nurse should be careful that the patient is in the middle of a 
water-pillow, as if allowed to rest on the edge bed-sores will form. 
Bed-rests are useful when the patient needs to be more or less up- 
right - special care is needed in such cases to prevent the formation of 
bed-sores, as extra pressure is thrown upon the sacrum and buttocks, 
and in these cases the circulation is usually defective. 
When a patient has been ordered to be placed between blankets, as 
in acute rheumatism, those next him should be frequently changed, and 
a draw-sheet should be always used to keep the back in a good state. 
Flannel night-shirts must be worn. 
Bed-sores. -The prevention of bed-sores consists in cleanliness, dry- 
ness of the skin, and smoothness of the bed-linen. Except, perhaps, in 
some very rare cases of cerebral and spinal disease, when they are said to 
form with appalling rapidity, bed-sores are always preventable; indeed, 
it is with some hesitation that I allude to any possible exceptions. In 
such cases as fevers or general paralysis bed-sores need never be seen. 
Constant cleanliness and watchfulness, a vigilant eye to discharges, 
attention to the smoothness and dryness of the sheets, and judicious 
changes of position, are the secrets of success. If waterproof sheeting 
must be used a considerable thickness of linen and blanket should lie 
between it and the patient's skin. The use of water-pillows or beds is 
imperative in long or severe cases, and, being made of smoother material, 
are preferable to air-beds or pillows; they are also more elastic. All 
parts exposed to pressure and soiling must, at least twice daily, be washed 
with soap and water, well dried, rubbed with spirit, and dusted with 
powder. A useful mixture is one part boracic powder to two of starch 
powder. If inclined to be tender, the skin may be painted with collodion 
or balsam of Peru and powdered. When it is difficult to maintain dry- 
ness, lanoline or zinc ointment may be rubbed in and powdered. 
Dryness of Bed. - When there is no control over bladder and rectum, 
careful and frequent cleansing and changing is necessary. Incontinence 
of urine may be met by the use of glass urinals for either male or female 
cases, supported by pads of wood wool or carbolised tow in butter mus- 
lin ; in the former cases care must be taken to avoid pressure on the 
scrotum; and, in both, absolute cleanliness and frequent dusting with 
powder is essential to avoid chafing. In female cases the vulva, par- 
ticularly within the labia, must be attended to carefully. When there 
is loss of control over the rectal sphincters, similar pads on a piece of 
431 432 
SYSTEM OF MEDICINE 
mackintosh may be advantageously used; they can easily be removed, 
destroyed, and new ones applied. In washing stout patients, especially 
women, the parts under the breasts and the folds of the groin and thighs 
need careful drying and powdering, as neglect may soon cause eczema 
or painful sores. Nurses cannot have too constantly before them the 
suddenness with which sores may appear after what may seem to them 
but a trifling neglect. 
When bed-sores have formed the treatment is in medical hands. The 
nurse may be desired to apply charcoal poultices to separate sloughs, 
and to irrigate the wound with creoline carbolic or sanitas, cutting 
away the slough as it becomes loose. She may have to protect bony 
excrescences by pads made of several layers of lint, with a hole in the 
centre over the wound, secured by strapping, and not removed, if pos- 
sible, for two or three days. Iodoform and dressings of resin, zinc, or 
other ointments may be ordered, and in such cases the dressings must 
be laid on the wound only. 
The physician or surgeon requires faithful reports of all that occurs 
to the patient between his visits - hence the importance of a nurse 
trained to accurate observations and statements, familiar with symptoms, 
and aware of their practical indications. 
For example, in enteric fever the physician should be informed on 
the following* points : - 
1. Temperature, every four hours, in mouth or axilla, as desired. 
2. Pulse, at same intervals, with statement as to strength and vari- 
ation, if any, at any stated times; or after food, drugs, stimu- 
lants, etc. 
3. Respirations, at same intervals ; cough is important as a warning 
of lung complications. 
4. Stools. Frequency, colour, and character, noting if undigested 
food be passed, blood, etc. If much flatulence. 
5. Amount of urine and its colour - watch for symptoms of retention. 
6. Vomiting. Frequency and nature, whether rejected food, such as 
curdled milk, or " coffee grounds," etc. 
7. Any eruption, characteristic or otherwise, to be watched for and 
reported; also abdominal pain, tenderness or distension. 
8. Amount of sleep, exactly: its character - restless or quiet; 
whether delirium, muttering, twitching of muscles ; alsoMman- 
ner of waking - quietly or with a start. 
9. Condition of skin, dry or moist - of tongue, and amount of sordes 
on teeth. The mouth and teeth should be frequently cleansed 
by lint or linen wrapped round the forceps dipped in the 
lotion, and gently passed round the mouth; and, if able, the 
patient should be encouraged to rinse the mouth and gargle 
with the prescribed wash. 
10. The exact kind and amount in ounces of the nourishment taken, 
the hours when it was given, and the readiness or otherwise 
of the patient for it; also, the amount of stimulant and 
medicine, and the times of each. NURSING 
433 
11. Effect of any drug prescribed for temperature and pulse; or, if 
for sleep, when sleep is induced, how long after, and for what 
length of time. 
12. Effect of sponging, if ordered; when done, for how long, and the 
result as shown by temperature, pulse, respiration, sleep, and 
general condition. 
Such a report should be written both by the day and by the 
night nurses for each other, to ensure that no important change is 
overlooked. 
In Pneumonia the rules for temperature, pulse, and respiration 
would be the same, with a report on cough, expectoration (its colour, 
consistency, whether difficult, profuse or the reverse); pain in any 
particular place; effect of hot or cold applications; amount of sleep; 
amount of nourishment; evacuations, etc. 
In acute Rheumatism, temperature, respiration, and pulse; pain, its 
locality and intensity, specially if in cardiac region ; breathlessness on 
the least exertion; state of joints; evacuations; condition of urine; ac- 
tion of skin, etc. Effect of medicine, and any special symptoms con- 
nected with it, such as deafness and noises in the head after salicylate 
of soda, quinine, etc. Effect of sponging or other treatment, amount 
of sleep, exact amount of nourishment, etc. Nothing is too small to 
report, especially with regard to the action of medicines and drugs. 
Effect of certain Drugs. - The nurse should be able to recognise the 
more important effects of these, such as - 
In connection with opium - drowsiness, contraction of the pupils, 
heavy breathing, constipation. 
While digitalis is being taken the pulse must be carefully noted. 
Diarrhoea or sickness may result from the use of arsenic. 
Quinine may produce headache or noises in the head. 
Salicin or the salicylates - deafness, excessive perspiration, and 
headache. 
Mercurial treatment may produce tenderness of the gums, salivation 
and diarrhoea. 
Iron preparations turn the tongue black, and produce very dark, 
almost black stools. Bismuth has a like effect. 
When antipyrin and like febrifuges are given, the nurse must watch 
for any symptoms of collapse, as occasionally patients do not bear such 
drugs well. 
In administering medicine the nurse should ascertain whether it is 
to be given before or after food. Quinine is usually taken before a 
meal, iron and arsenic afterwards. Cod liver oil is digested more 
readily after food. 
Administering of Medicines. - All medicines must be accurately 
measured in a graduated glass, as spoons vary greatly in size. "Drops" 
also must be measured in a minim glass. The glasses must be washed 
directly after use, and, if in a ward, between each patient. Medicine 
bottles should never be put down near lotion or liniment bottles. 
VOL. I 
2 F 434 
SYSTEM OF MEDICINE 
The special applications required in nursing are many, and a trained 
nurse should know the best possible way of dealing with them. 
Poultices need dexterity to make them of the right size and weight 
for the case. If jacket poultices be ordered, the nurse must prepare two 
pieces of calico, shaped at the neck and under the arms, so that the poul- 
tice covers the sides of the chest from the axilla downwards. Two pieces 
of thin mackintosh, a little larger and similarly shaped, sufficient cotton 
wool to cover both chest and back, a poultice jacket, safety pins, linseed 
meal, a spatula (ordinary painter's), a basin, and boiling water are also 
needed, and, if the poultice be made at any distance from the patient, two 
hot plates. The basin and spatula must be made hot, sufficient boiling water 
poured in to make the required poultice (about | pint for an adult), and the 
linseed sprinkled in, being well stirred all the time. A well-made poultice 
when turned out should leave the basin quite clean. It is then quickly and 
evenly spread by the spatula, the edges (not more than half an inch wide), 
neatly turned over, rolled up, placed between the hot plates if necessary, and 
brought to the patient. He must previously have been placed on one side, 
with the night-shirt ready to be pulled well up at the back, if he be too 
weak to have it removed. The poultice is then half unrolled and applied, 
care being taken not to injure the skin, though this is not likely if the 
poultice be not too wet. It is next covered with the jaconet and a layer 
of cotton wool, both half rolled, also with the poultice jacket; the shirt 
is then pulled down, the patient turned on his back, and the rolled part 
of poultice, wool, etc., brought round to the other side. The front half 
of the poultice is made in the same way, applied to the chest, covered with 
jaconet, wool, and the jacket; then both are secured by safety pins on 
each shoulder, and down the sides, the poultice jacket being pinned 
down the front. The shirt is drawn down, and the patient should have 
some nourishment after the fatigue. Well-made poultices thus applied 
retain their heat for many hours. Sometimes the poultice is placed in 
a bag of flannel, but these require more frequent changing, and more 
care lest the skin be injured by applying it too hot. A little oil spread 
over the linseed is soothing if the skin is becoming tender. 
"Poultice" or " Pneumonia jackets" are garments made of a strip of 
thin flannel or flannelette, the right width for the patient, shaped at 
the neck, and well cut out under the arms, meeting in front and over- 
lapping a little. They are lined with a layer of cotton wool neatly 
tacked in, and can easily be placed over the poultice, and secured on 
the shoulders and down the front by safety pins, which are firmer and 
more comfortable than tapes. In bronchitis cases also this is useful, 
and the poultices can be changed without removing the jacket. In 
pleurisy a band of flannel pinned firmly round the lower ribs gives 
relief by restraining muscular movements. 
Charcoal poultices are made of equal parts of charcoal and linseed 
mixed in the same way - usually ordered for sloughing wounds. 
Mustard poultices are conveniently made by adding the proportion 
of mustard ordered to the boiling water, and then stirring in the linseed. NURSING 
435 
Mustard plasters are made by spreading thickly-mixed mustard on a 
square of brown paper of the exact size ordered, and covering it with a 
piece of muslin. Mustard and any proportion of flour may also be 
mixed and applied in the same way. Mustard leaves are dipped in 
tepid water and placed on the spot. These applications are left from 
ten to twenty minutes, as ordered; and, after removal, the skin must 
be covered with a layer of cotton wool. 
Bread poultices are conveniently made by placing the crumb of white 
bread (stale if possible) on a piece of calico or small towel across a basin, 
pouring boiling water over it, wringing as dry as possible, placing be- 
tween muslin, and applying, with jaconet and wool over, as before. 
Blisters. - In applying blistering fluid, none must touch the skin 
except at the place ordered, and the cover of cotton wool must not be 
strapped at all tightly, or pain will ensue as the blister rises. If a 
plaster be used, and the blister do not rise, after an hour a small poultice 
may be applied, which usually produces the desired effect. In cutting 
the raised cuticle, the small snip should be at the lowest side of the 
blister, and wool arranged to catch the fluid. If it is to be kept open, 
all the raised skin must be cut off, and the dressing applied exactly to 
the sore: if not, a simple ointment dressing is usually put over the skin, 
and secured by wool and strips of strapping. 
Liniments must be applied always to both chest walls if ordered for 
bronchitis, etc., and in every case rubbed in with the palm and not with 
the fingers. Painting with iodine must not be continued without orders 
when smarting follows the application. 
Fomentations and stupes are conveniently made of a length of flan- 
nel doubled. This is placed on a strong towel over a basin, boiling 
water poured over it, and the towel then wrung out quite tightly; a 
good wringer is made by a strip of ticking sewn at both ends, and a 
stick passed through each. They are applied to the painful place, 
covered with thin mackintosh or jaconet,- at least one inch wider in 
every direction than the fomentation, - and a layer of cotton wool; and 
are kept in position by a flannel binder or bandage. Such stupes may 
be made with decoction of boiling poppy-heads, or may be sprinkled 
quickly with 40 to 50 nt turpentine or 10 to 30 tinct. opii, as may be 
ordered, just before application. 
In applying leeches, the skin must be well washed with hot water, 
and plain (not scented) soap; the leech is placed in a test tube, medicine 
glass, or small tumbler, half full of cotton wool, held over the place. If 
slow in biting, a little milk may be placed on the patient's skin, which 
usually succeeds if the leeches are good ones. They fall off when full, 
but if they remain too long, a little salt sprinkled on them will remove 
them at once. They should be handled as little as possible before being 
applied. 
Orders will be given about the amount of bleeding desirable - a 
warm poultice over the bites encourages it. If to be arrested, a very 
small piece of cotton wool, a mere film, placed in the bite generally 436 
SYSTEM OF MEDICINE 
causes coagulation. Failing this, pressure, cold, applications, or a 
styptic, such as balsam of Peru, may be tried, and. the medical attend- 
ant must be informed. Leech bites must be noticed from time to time 
for some hours lest the bleeding begin again. The patient should not 
be alarmed or agitated, either in the application of the leeches or in 
controlling the bleeding. If leeches are pulled off they are apt to leave 
their teeth, which form a tiresome little wound. 
Dry cupping is done by exhaust glasses, or by placing in a cupping 
glass or small tumbler a small piece of blotting paper dipped in methy- 
lated spirit, setting it alight, and at once applying. The edges of the 
glass should be previously oiled, and it is easily removed by pressing 
away the skin from the edge, and allowing air to enter. 
In administering enemata, the nurse should be able to give them 
equally well whether the patient is lying on the back or side. Gener- 
ally, however, he is placed on the left side, with the buttocks close to 
the edge of the bed, and the knees flexed. The nurse, having the 
enema ready, lubricates the nozzle of the syringe with a little oil or 
vaseline, and seeing that it is full, so as not to inject air, with the fore- 
finger of her left hand, also lubricated, ascertains the entrance to the 
rectum, and gently inserts the nozzle with her right hand. Great care 
must be taken if haemorrhoids, fistula, or fissure be present, all exqui- 
sitely tender. In cases of faecal accumulation, the nurse may be desired 
to break up the mass gently with her finger well oiled, and her nail filled 
with carbolic soap; she must also give the enema at intervals. When 
this is so, or when there is irritability of the bowel, or relaxation of the 
sphincters, the gum elastic tube supplied with the Higginson syringe is 
useful. It is softened by immersion in hot water, well oiled, fixed to 
the syringe or irrigator, and gently inserted. I find this tube safer and 
better to use as a general rule. Indeed the short, hard bone nozzles 
usually supplied for rectal use, are not to be recommended: it is better 
always to draw three or four inches of stout rubber tubing over them 
before insertion. The bed should be specially protected by a mackintosh 
and folded sheet. Restoratives should be within reach as some patients 
turn faint after the operation. In this, as in douching, washing backs, 
etc., no exposure of the patient is necessary or justifiable. 
Simple enemata should not be made with scented or medicated soaps, 
curd or yellow is the best. 
Starch enemata are made by mixing from a teaspoonful to a table- 
spoonful of starch powder, according to the quantity required, with a 
little cold water into a smooth paste, and then adding boiling water 
until a mucilage is formed, to which the special medication is added. 
For a starch and turpentine enema, 5 j- turpentine to §xv. starch muci- 
lage may be ordered; for a starch and opium, the prescribed number of 
minims of opium are added to the prescribed number of ounces of starch 
mucilage. 
Castor and olive oil enemata are conveniently given by warming the 
oil in a cup, and then placing the cup in the basin containing the simple NURSING 
437 
enema which usually accompanies the oil. The end of the syringe is 
readily transferred from the water to the cup after §ij. or §iij. have 
been injected; and when the oil has been given, it is readily replaced 
in the water without fear of admitting air. 
In rectal feeding it is desirable, when possible, first to wash out the 
lower bowel by a small enema of warm water. The quantity and 
materials of a nutrient enemata vary according to special orders; they 
are most easily given by a ball syringe holding the right number of 
ounces. The tube, being longer and thinner than that of the ordinary 
syringe, is less likely to irritate the bowel, and cause the enema to 
be returned. It must be carefully cleansed after use each time. Nu- 
trient enemata must be given very slowly to ensure retention, not a 
bubble of air should find its way into the bowel, and a napkin should 
be held to the anus for a few minutes after: in all these applications 
great gentleness is essential. 
Glycerine enemata are usually given in a special syringe holding the 
exact amount required. 
In nasal feeding the nurse must be careful that the tube is really in 
the oesophagus, and only administer 3j. to 3ij. at a time. Nasal feed- 
ing, however, should always be done by a carefully instructed person, 
if not by a surgeon [yide art. on "Dietetics," p. 387]. 
In passing the female catheter the vulva must first be thoroughly 
cleansed with warm water, and a disinfectant, perchloride, -Jg- 
carbolic, creolin, or Condy. The patient should lie on her back with 
the knees drawn up, though in some cases (e.g. ruptured perinaeum), 
she is better on her left side. The catheter - generally a gum-elastic 
or flexible india-rubber one, size seven or eight - must be perfectly 
clean, not rough at all on the surface, and soaked before using 
in Perchl. or carbolic. It is lubricated with carbolised 
glycerine or vaseline, and the nurse, holding it in one hand, with 
the index finger of the other also lubricated, finds the entrance 
to the vagina; just above this the hard round meatus urinarius (with 
its depressed central orifice) is easily felt, and the catheter passed into 
it, the other end being placed in a convenient receptacle. If there be 
much vaginal discharge, or the nurse cannot pass the catheter into the 
orifice at once, the catheter must be thoroughly recleansed, and the 
nurse, separating the labia, must ascertain the position of the meatus 
by the eye, and insert the catheter after carefully wiping all discharge 
away; it is most important that no discharge be carried into the 
bladder, as there is great danger of cystitis if the strictest cleanliness 
is not observed. Glass catheters can be boiled each time after use, and 
no impurity can remain unnoticed, but there is danger in their fra- 
gility. A catheter must be thoroughly cleansed in warm water, held 
under a tap to allow the water to run from the eye downwards for a 
few minutes, and then placed in a disinfectant. If boracic lotion be 
used, care must be taken that crystals do not become deposited on the 
catheter, as one used in this condition may injure the urethra. Any 438 
SYSTEM OF MEDICINE 
marked tenderness in passing the catheter must be reported, as it may- 
be due to urethral caruncle or other special cause. 
In washing out the female bladder the catheter is passed in the usual 
way, and the water drawn off. The nurse has ready in a jug the pre- 
scribed quantity of the warm lotion to be used (frequently " boracic "), 
and an india-rubber tube, about one yard long, to which is attached a 
glass funnel holding § iv. to 5 vj. The free end of the catheter is placed 
in the tube, which the nurse compresses a few inches above the catheter 
between the second and third fingers of her left hand, holding the funnel 
between her thumb and index finger. With the right hand she fills 
the funnel and tube from the jug, and then, releasing the tube and 
raising the funnel, she allows the lotion to flow into the bladder, com- 
pressing the tube again just before the funnel empties itself. After 
repeating this once, or even twice, she removes the tubing from the 
catheter, and allows the bladder to empty itself. It is wise to have a 
glass measure to receive the contents of the bladder, in order to ascer- 
tain either that no lotion remains or only the right number of ounces 
ordered. The tube is then readjusted, and the process repeated until 
the prescribed quantity of lotion has been used. The nurse must care- 
fully examine the catheter lest the eye become blocked by mucus, as is 
often the case in cystitis. 
In giving vaginal douches the nurse should protect the bed with 
a piece of mackintosh and folded sheet. The patient should lie on 
her back, with head rather low, and a pillow under the loins. The 
bed-pan should be warmed before being used, and a towel be at hand. 
Having prepared the douche as ordered, testing its heat by the bath 
thermometer, and, if of Condy's fluid, not making it too strong (3j. to 
Oj. of the fluid, or two or three crystals of the permanganate), the nurse 
lubricates the glass nozzle with carbolised glycerine or vaseline, and 
allows it to fill with the lotion, to exclude air. Having placed the 
irrigator at a convenient height above the bed, she inserts the tube 
gently into the vagina, unless the patient prefer to do it herself, which 
may be better in cases of cancer, etc., where there is great tenderness. 
The tap is then turned, the douche given, and the tube removed with- 
out allowing any air to enter. If a Higginson's syringe be used, the 
glass nozzle is easily fixed to it by removing the bone nozzle, and putting 
the glass into the india-rubber tube; it is then filled with lotion, and in- 
serted in the same way. The douche is conveniently contained in a jug 
supported at the side of the bed. Glass nozzles (without a terminal 
hole, lest the nurse unwittingly administer an intra-uterine douche) are 
the cleanest and safest, as they can be boiled and left to soak in disin- 
fectant until wanted. If hot douches are ordered (110° F.), the vulva 
may be smeared with a little carbolised vaseline to protect the skin, 
which is often very sensitive. The bath thermometer should invariably 
be used, and a careful report given of the result of the douche. 
Vaginal plugs and tampons are made of absorbent cotton wool, 
rolled into the required shape, and secured by linen thread. Tampons NURSING 
are pear-shaped with the thread attached to the lower end, and are 
generally used for applying medications to the vaginal walls. Plugs 
may be made by turning in the edges of a square of wool, and forming 
it into a sausage-shaped roll secured in the middle by a long thread. 
For supporting the uterus and packing round the cervix several of these 
rolls are attached to the one string, forming the " kite tail " plug. For 
plugging with a speculum, rounds of cotton wool, of varying sizes, with 
the thread passed through the middle, are convenient. In every case the 
threads should be long enough to be well beyond the vagina, and the 
exact number of plugs inserted noted down. 
Gynaecological Work. -A nurse should understand how to arrange a 
patient for examination, bringing her well to the edge of the bed on her 
left side, the spine as nearly as possible in a line with it, the knees 
flexed, the right one being rather more drawn up than the left, and the 
left arm brought round to the back, so that the patient is lying almost 
on her chest. 
She should also know the names of the various specula (Ferguson, 
Sims, etc.), and be able to pass them if required. This is done by plac- 
ing the two first fingers of the left hand, previously lubricated with 
carbolised vaseline or glycerine, in the entrance to the vagina, and draw- 
ing the perinseum backwards so as to admit the edge of the speculum, 
which is passed gently in a backward direction, holding the perinaeum 
well back so as to avoid touching the clitoris, or causing pain, until the 
os can be seen. It may be necessary to alter the position of the speculum 
a little, if a " Ferguson," to bring the os into view, in order to carry out 
special directions for plugging round the cervix in any given way. The 
nurse must be able to prepare uterine probes for use, by placing a very 
thin layer of cotton wool on her left palm, laying the probe at the edge 
of it, and, by a little manipulation and rotation of the instrument, wrap- 
ping it smoothly and firmly round. After use the wool is removed and 
fresh supplied. Medicated bougies are placed in the vagina to dis- 
solve. Suppositories are gently passed into the rectum, the finger being 
previously oiled. 
Hypodermic injections are given, after seeing the needle is clean 
and firmly screwed on, by first accurately filling the syringe, and then 
driving the fluid to the point of the needle so as to expel the air. The 
skin, previously cleansed, is then firmly held and raised into a fold, while 
the needle is gently but quickly inserted into the fold in a direction 
nearly parallel with the surface, and pressed onward till the point has 
passed through the skin into the subcutaneous tissue; the syringe is 
then emptied and withdrawn, a finger being placed over the puncture for 
a minute or two. If the needle is properly inserted below the skin no 
bleeding or swelling will ensue. The same care must be taken in 
purification of this syringe and its parts as of other instruments. 
Baths.-In giving baths everything must be ready before the 
patient is disturbed, and the temperature verified by the thermometer. 
In a large bath the hot and cold water must be well mixed before this is 
439 440 
SYSTEM OF MEDICINE 
done, and on no pretext whatever should any patient be left with the 
taps running. The cold water must always be turned on first, and no 
patient or junior assistant should ever be permitted to touch the taps. 
Except under special circumstances - such as the special treatment of 
fever, and then only by the charge nurse - the taps should never be 
turned after the bathing has commenced. 
Towels, a blanket, and if necessary a screen should be in readiness. 
The temperature is ordered to be from 98° to 110° F. for hot baths, 
92° to 98° warm, 85° to 92° tepid, and 70° cold, and the water must be 
tested by the thermometer during the length of time ordered. That the 
bath may not fall below the degrees required, the water should stand a 
little above these limits at first, and should have lain long enough in 
the bath to warm it through. Thick stoneware baths absorb a larger 
quantity of heat. The patient has a blanket laid over him, and as he 
is lowered into the bath, this remains spread across it, and is wrapped 
round him again when lifted out. 
With children the blanket may be spread over the bath first, and 
they are then rolled in it and placed in the bath. 
In giving a hip-bath the same arrangement is desirable, and a small 
blanket can be placed over the shoulders to avoid chill. 
Warm towels and wrapping in a blanket are desirable after hot baths, 
the bed being warmed by a hot bottle. 
In cold bathing we are usually ordered to lower the patient in a 
sheet into tepid water (75° F.) first, and to reduce the temperature by 
adding cold water gradually. 
Of special baths the following are usually ordered: - 
(a) Mustard, §ij. to 5iv. to every 4 gallons water. 
(&) Salt, 1 lb. to every 4 gallons water. 
(c) Alkaline, carbonate soda or potash, 3 ij- to § iv. to every 4 gallons 
water. 
(d) Sulphur, sulphide of calcium, §ij. to §vj. to every 4 gallons water. 
The time for which the patient remains in the bath is ordered by 
the medical attendant. 
Vapour and hot air baths can be administered in bed, by covering the 
mattress with a waterproof sheet and a blanket. The patient is stripped 
and placed in a blanket, with another over him. A long cradle is then 
placed in the bed, well covered with blankets, so as to exclude all air 
except at the foot, where a funnel over a special lamp, or from a steam- 
kettle on a lamp, conveys the heated air into the bed. Hot drinks, 
such as milk, hot water, etc., may be given with advantage to promote 
perspiration. The temperature should be taken before, during, and 
after; and the pulse felt at intervals, in case of faintness. After the 
stated time, usually from twenty to thirty minutes, the hot air or steam 
is withdrawn, the patient wrapped in hot dry blankets, and left a while 
before dressing him and remaking his bed. 
If the bath be given out of bed, a lamp, specially protected, is placed NURSING 
under a cane-chair, which is covered all round by a blanket; the patient 
is undressed, wrapped in blankets, and placed on it with a screen round. 
The same routine is followed after the time has elapsed, except that the 
bed should be warmed by hot bottles. 
Hot and cold packs are given by placing a patient on a bed similarly 
prepared as for the air-bath, and enveloping him from head to foot in a 
thin blanket wrung out of hot water for the hot pack, or a sheet wrung 
out of cold for the cold pack. If the latter be to reduce the temperature 
it may need renewing after an interval, the temperature being taken in 
rectum or mouth before and at frequent intervals during the process. 
A cold towel should be on the head. The patient in both cases is to be 
left for a time before being dressed. 
Icebags should be filled with small pieces of ice, and have a piece of 
lint or linen between them and the skin. If for the head they must not 
be too heavy, and may'be tied to the top of the bed to support them. 
They must never be left until the ice is all melted. 
A tent and steam kettle are often ordered for bronchitis, tracheotomy, 
etc., and can be made of folding screens covered by quilts or blankets 
so as to exclude all draught, and enable the space to be filled with 
steam. The kettle must not be too high above the patient, or in a 
position to allow it to drop or spurt on him; especially with young 
children an equable temperature must be maintained, and the supply 
of steam be constant. 
Inhalations are given in an inhaler, or in a jug with a towel placed 
round it so that the patient breathes only the steam. Water at 140° F. 
must always be used, and care taken that a weak patient does not be- 
come faint by bending over too much in a crouching attitude. The 
nurse should be familiar with the use of asthma powders, nitrite of 
amyl capsules, etc. 
Sick Cookery. - Gruel. - A nurse should understand the making of 
gruel by mixing the fine oatmeal or grouts into a smooth paste with a 
little cold milk or water, and then pouring it into the boiling milk or 
water, and letting it boil some minutes after thickening, stirring mean- 
while to keep it smooth. Arrowroot and cornflour are prepared in the 
same way. White wine whey is made by adding ?iv. sherry to a pint 
of milk just as it boils, and then straining through muslin. 
Junket is made by adding a few drops of rennet to a pint of luke- 
warm milk, and letting it stand. 
Peptonising milk, gruel, etc., is the nurse's duty, and is conveniently 
done by means of the various powders or peptonising fluids, according 
to printed rules. The food must not stand too long, or it will become 
bitter; the process is checked either by boiling for a few minutes, or 
placing in ice. 
The preparation of raw beef tea, scraped raw beef (given with brown 
sugar in certain cases), raw meat juice, beef tea, mutton broth, veal 
tea, chicken broth, chicken jelly, custards, etc., are all necessary. The 
nurse's duty is to give the nourishment in an appetising manner. 
441 442 
SYSTEM OF MEDICINE 
Dainty arrangements, small quantities, served regularly and punctually, 
with as much variety as possible, and absolute cleanliness of every detail, 
are essential. The nurse must never touch the food with the finger, or taste 
it with the patient's spoon to test its temperature. In feeding a patient 
whose head is on the pillow, the nurse's hand, raising the head, must be 
put under the pillow. The food must be cautiously given, but the food 
must not be dribbled ineffectually or too slowly into the mouth. 
The disinfection of sputa from phthisical patients is a necessary pre- 
caution. The best spittoons are white mugs with an inverted conical 
lid. A disinfectant, such as carbolic" or 3 ij- creoline in 5j. water 
can be used, and the whole utensil is easily cleansed. Stiff paper may 
be folded for the same use, but it is not so sightly, and does not allow 
the sputa to pass readily into the disinfectant. All handkerchiefs used 
by such patients should be placed in carbolic at once. 
Typhoid stools must be freely covered by strong carbolic, or a solu- 
tion of sulphate of iron, and allowed to stand, if possible, about twenty 
minutes before being emptied into the drain. The utensil must be 
closely covered. 
It is usual to have a sheet wrung out of carbolic or creoline (§ iv. 
to 5 vj. to 1 gallon of water) over the door of a room in which there is an 
infectious case. Sheets on folding screens may be placed round a septic 
case in a ward until it can be removed. The carbolic spray is sometimes 
ordered also. All bed-linen, and whatever has been worn by an infec- 
tious patient, must be immersed in carbolic or other disinfectant at the 
bedside; they must not be carried across the ward first. Special cups, 
glasses, etc., must be kept, and, if necessary, boiled or heated in the 
oven before using again. 
Bedding, outer garments, etc., are best purified by the special appa- 
ratus which is provided in most hospitals, and in connection with the 
vestries. 
A nurse in attendance on infectious cases must take a carbolic bath, 
(not forgetting her hair), change every article of clothing, have all gar- 
ments worn in the room disinfected, and if possible have some days' 
interval before returning to general work. She must not eat in the 
room of an infectious case, her hands must be thoroughly cleansed after 
contact with the patient, and she must rinse the mouth and gargle with 
Condy's fluid (5 j- to Oj.) at intervals. 
The nursing of children calls for special watchfulness, and that keen 
and sympathetic power of observation which can distinguish between 
fretfulness and pain, hunger and temper, caprice and loss of appetite, 
etc. In nursing fretful children kindness is essential. I need scarcely 
say that corporal punishment should never be administered. 
One very common error is moving sick children about too much. A 
nurse who would not dream of giving unnecessary exertion to an adult 
with acute bronchitis or pneumonia, will not realise there is harm in 
raising a child similarly affected into a sitting position to change linen, 
poultices, and so forth; and will even take it out of bed to wash it on NURSING 
her knee by the fire, forgetting that if easy to her to lift and move a 
child, it by no means follows that it is easy to the child. Sick children 
should be handled as nearly like adults as possible. Special care is 
necessary to keep them dry and clean; every two hours by day they 
should be attended to except when sleeping soundly - when four hours 
may elapse - and twice at least during the night. Attention after each 
meal is desirable, and the habit of regularity taught as far as may be. 
Careful washing and powdering are essential. Flannel or flannelette 
night-gowns made long, and even to button below the feet, prevent chill 
when a restless child throws off the bed-clothes in its sleep. When 
dressing wounds, the attention of the child should be diverted as much 
as possible, half the crying is from fright rather than pain. Also chil- 
dren should never be deceived with regard to pain, the taste of medi- 
cine, and the like; if they find they have been told what is untrue the 
power of the nurse is gone. 
In clothing infants, whose ribs are very yielding, there should be 
nothing tight round the chest or waist; and the legs and thighs should 
always be covered with flannel or wool, not, as is usual, left naked while 
the chest is swathed in layers of useless clothing. 
In feeding children they must be induced to take the amount 
ordered; firmness and kindness go far to succeed in this. 
When, in whooping-cough, food is rejected from the stomach, it is 
well to give more as soon as a paroxysm is well over, to ensure that some 
be assimilated before the next fit of coughing. In convulsions, when a 
bath is ordered, it ought to be from 90° to 95°, deep enough to immerse 
the child up to the neck, and the thermometer kept steady by adding 
more hot water from a can, not from a tap; a blanket is thrown over 
the bath, and cold or iced applications may be placed on the head. 
It is essential to remember that the stomach of an infant a few 
weeks old only holds a small quantity of fluid, and no more than §j. 
to ?ij. should be given at one time or vomiting will follow. 
In feeding infants by hand the bottles must be scrupulously clean; 
those with the teat on the bottle are the best; the tubes of the ordinary 
shape are difficult to clean. In either case two must be kept, one being 
soaked in cold water after a thorough cleansing in hot soda and water 
while the other is in use. 
In cases of diphtheria great care must be taken that none of the 
discharge or mucus is coughed or spat into the nurse's eyes or face, 
especially during feeding, and the nurse must not put her face close to 
that of the child. 
In cases of tracheotomy the nurse must keep the temperature of the 
room perfectly equable, and the steam kettle, usually charged with a 
disinfectant, always going. A small piece of moist sponge over the 
tube is generally used, and is frequently changed. The tube must be 
kept clean from membrane and mucus by means of feathers, which 
should stand in a solution of carbonate of soda. The nurse must under- 
stand the use of the tube, so that in an emergency she could replace it, 
443 SYSTEM OF MEDICINE 
444 
or at the worst keep the tracheal incision open with her forceps till the 
doctor can arrive. The child must be regularly fed, kept dry and clean, 
and notice taken if there be any regurgitation of liquid through the nose. 
Private Nursing. - This branch of the profession affects the general 
public more closely than any other, as both doctors and patients depend 
almost entirely on the trustworthiness and experience of the nurses; 
and yet it is the one most open to women of little or no pretensions to 
knowledge. That this is possible is due to the ignorance of the com- 
munity at large, the apathy or mistaken kindness of medical men, and 
the cupidity of speculators. If women can be engaged at low salaries, 
with little or no investigation of their antecedents, and sent out as 
" trained nurses " at fees calculated to yield a handsome profit, who can 
wonder that things are as they are ? The remedy lies in the hands of 
those whose work has called trained nurses into existence - the mem- 
bers of the medical profession. As long as they accept such arrange- 
ments so long only will they continue. 
If every medical man would but ask a few leading questions of the 
nurse supplied to him from an institution, concerning her length of 
training, where obtained, her experience of cases similar to the one in 
hand, her method of carrying out certain orders, meeting any emergency 
that may arise, etc., semi-trained incapable women would be detected. 
No feelings of pity or wish to avoid trouble should be allowed to screen 
an incompetent, unsatisfactory nurse. The issues involved are too 
great, and nursing is too responsible a calling to be placed in prentice 
or untrustworthy hands; neither for sentiment nor economy, both 
equally false, should life be endangered or unnecessary pain and dis- 
comfort inflicted. 
The manner and dress of a nurse serve as guides to the thoroughness 
of her training. A woman who is scrupulously neat, in a suitable incon- 
spicuous uniform, businesslike in manner, yet bright and pleasant, who 
takes her orders quietly yet intelligently, and who keeps strictly to her 
own position, is likely to be suitable. Nurses need a " professional " 
manner as much as physicians, and the latter would add to the dignity 
of both professions by recognising and encouraging the fact. Flippancy 
and familiarity are especially unworthy of those whose work involves 
such grave responsibilities. Mutual respect is the groundwork of the 
confidence which must exist if the patient is to receive the full benefit 
of the treatment. The medical man must feel able to trust the nurse's 
ability and trustworthiness in carrying out his instructions to the 
smallest detail; and the nurse must prove herself deserving of such 
trust, and add to her other duties an absolute loyalty towards the 
doctor. By her manner of obeying orders she can also inspire the 
patient with wholesome confidence. If at any time the nurse cannot 
be present at the doctor's visit, a written report must be left for him, 
and his orders for her should also be in writing so as to avoid any 
misunderstanding. Orders should be given directly to the nurse, not 
through the friends; and care taken that she really understands them. NURSING 
445 
Her report also should be given to the medical man, if necessary before 
he sees the patient, or after, if not desirable in the sick-room. 
The nurse should never take the friends into confidence about the 
case, nor express her own opinion to them. Infinite harm is done in 
this way, and often remarks are quoted to the medical attendant in a 
different manner from that in which they were originally spoken. 
The vice of gossiping is a very grave one, and unfits a nurse for her 
office almost as much as the vice of intemperance. If a woman persist 
in thus offending she should not be employed. Criticism of the medical 
treatment, suggestions of further advice, or even of a change of the 
medical man, should never be tolerated; such behaviour is unconscien- 
tious in the highest degree, opens the door to suspicions of touting for 
special doctors, and might lead to the gravest results to the patient. If 
a nurse cannot conscientiously continue to work for a certain medical 
man she must have the courage of her convictions, and leave the case 
without reflecting on him in any way. 
When sending for a nurse the medical attendant can do much to put 
her on a right footing with the household she is to enter. Too often 
training is supposed to render a nurse indifferent to sleep, exercise, or 
regular food. It should be clearly explained that eight continuous hours 
for sleep, at least one hour for exercise, and time for each meal, are 
necessary as a rule, though a good nurse will make exceptional efforts 
in case of emergency. Her meals should not be served in the sick-room ; 
and if on night duty, her bedroom should be in a quiet part of the house. 
Necessary sleep and exercise are essential to keep a nurse fit for the 
duties and responsibilities which devolve upon her. The medical at- 
tendant generally knows something of the household, and can give the 
nurse some valuable hints which may enable her to avoid friction. 
A private nurse needs special neatness and refinement, so as to 
keep both the patient and his surroundings in pleasant order. The 
toilet of the patient calls for scrupulous nicety; nails, hair, etc., being 
carefully attended to. The housemaid's work will depend upon the 
domestic arrangements, and is generally done by a servant, but the 
nurse is responsible for the room being in order. She can do much to 
comfort her patient by avoiding all unnecessary noise in remaking the 
fire (using housemaid's gloves to lift the coal, which should be in 
lumps); shading his eyes from too strong light, either from lamp or 
window; arranging flowers; finding out any particular like or dislike, 
and if possible attending to it; avoiding all whispered conversations, 
creaking doors or windows, flapping blinds, creaking shoes, rustling or 
rattling dress or ornaments, not shaking the bed in passing, in fact, 
feeling with as well as for the patient. When her services are not 
needed the nurse is better out of the patient's sight, though close at 
hand; and this is especially desirable if the nurse be reading to herself 
as in some long watches she may lest she sleep. Needlework, however, 
is never resented by a patient. A nurse should invariably wear her 
uniform when on duty whether by day or night. 446 
SYSTEM OF MEDICINE 
Much depends on the way in which the nourishment is presented as 
to whether the patient will take it or not. This is entirely the nurse's 
province, and she should have a sufficient knowledge of sick cookery 
to supply any deficiency in this respect in the household. Everything 
should be served as daintily as possible, glasses, spoons, etc., perfectly 
clean and polished, clean tray-cloth, if possible a few flowers, small 
portions, and any particular fancy as to sweetness, etc., remembered. 
Every particle of fat should be removed from broths and beef tea, toast 
should be thin and crisp, bread and butter thin and lightly spread, 
nothing spilled on plate or saucer. The patient should not be told as a 
rule what is coming, as an unexpected thing is often more readily taken. 
Rigid punctuality is necessary, nothing spoils an invalid's appetite like 
delay. No stimulant should ever be given or allowed to be given with- 
out direct medical orders, and the kind and quantity must be entered 
in the diary. Food should never be tasted or cooled by being blown 
upon, it disgusts the patient. Food should never be kept in the sick- 
room, and plates, glasses, etc., are to be removed as soon as possible. 
Ice may be kept much longer if wrapped in flannel and placed on a 
colander to let the water drain away. 
A private nurse needs great tact in so dealing with the friends and 
relations that orders may be carried out without offending them. If in 
any difficulty they will not yield to her persuasions she must appeal to 
the doctor for advice. Thoughtfulness for their natural feelings, and 
also for the household arrangements, so as to avoid giving unnecessary 
trouble, will do much to promote friendly relations. The present sys- 
tem of private nursing leaves much to be desired, but valuable reforms 
can only be obtained by those most interested, the medical men them- 
selves. The nurses are too often isolated units, without a centre or 
standard, and so are apt to put themselves before the needs of patient 
or doctor. After their time of training and agreement is over they are 
inclined to think they know all that is necessary; they have no system 
on which to arrange their work, and unless they are specially fortunate 
no one to give aid or advice. Half the troubles that occur are due to 
inexperience in adapting themselves to the altered conditions in which 
they have to work; and it needs both tact and disciplined training to 
enable them to adjust themselves satisfactorily to the new circum- 
stances. 
Those interested in nurses as a class may give material help to 
individuals by advising and helping them in habits of thrift. The 
Royal Pension Fund for trained nurses and similar schemes offer 
unusual advantages for old age pensions, sick pay, etc., and grateful 
patients may do much for the nurses by helping them to become mem- 
bers of such associations. 
District Nursing. -Nursing the sick poor in their own homes is now 
a recognised branch of the profession, though it is not equally realised 
that this work requires specially trained women. The cases are as 
varied and critical as any to be met with in hospital or private work, NURSING 
with none of their favourable surroundings. In many places, manufac- 
turing centres for instance, where the population has rapidly outgrown 
the hospital accommodation, or in scattered country districts, where the 
nearest hospital or infirmary may be many miles distant, the most seri- 
ous cases must perforce be nursed at home. There are innumerable 
instances where removal would probably cause a fatal termination to the 
illness, and is only attempted as a lesser evil than leaving the patient 
to suffer untended. If a parent, especially the mother, is removed to 
hospital, the whole family may be broken up, and the worst moral 
results ensue. Where there are young children, also, the anxiety about 
them in her absence is a serious drawback to the mother's recovery. 
There are also many cases unsuitable for hospital, such as chronic 
rheumatism, paralysis, cancer, phthisis, children with hip and spine 
disease, etc., who can perfectly well be attended in their own homes 
by a trained nurse. It has a good moral effect in many cases for 
children thus to support aged parents, or for brothers and sisters to 
keep a delicate member of the family at home, instead of sending 
them into the poor-law infirmaries at the expense of the ratepayers. 
Therefore a district nurse needs full hospital experience if she is to 
carry out medical orders efficiently; and in addition she requires 
special training to meet the difficulties of the work. 
Ignorance, prejudice, dirt, foul air, and often the want of the 
commonest necessaries, have all to be met; and nursing knowledge 
alone is of little value if it cannot be used to the best advantage under 
the circumstances. Still less can a woman who has only given three or 
six months' time to acquire both nursing and district experience prove 
a satisfactory district nurse. 
The method of work usually accepted is for the nurse to have a 
certain number of cases within reasonable distance under her care, 
which she visits once, twice, or even oftener, every day, taking entire 
charge of each patient with regard to washing, bed-making, changing 
linen, applying poultices, dressing wounds, etc. She also is responsible 
for the sick-room and all its appliances being kept as far as possible in 
a cleanly, tidy condition, and fresh and sweet. It has been objected 
that unless the nurse remain with the patient no real good can result 
from her attendance. But part of a district nurse's duty is to teach 
the friends the right way to wait upon the sick person. They are 
generally anxious to help, and a sensible man or woman can be 
educated to be an intelligent assistant who can be trusted to administer 
nourishment, medicine, etc., at the proper intervals between the nurse's 
visits. Too frequently some benevolent person, feeling the need of 
nursing in a special district, forms a committee, selects a nurse, and 
sets her to work without thinking it necessary to consult those most 
concerned, the medical men of the place. Even when they are con- 
sulted and their views considered, there is doubt as to how and where 
the nurse is to be procured; generally she is obtained by means of 
advertising, and even then a lay committee is apt to select an unskilled 
447 448 
SYSTEM OF MEDICINE 
or unsuitable worker, because the real needs of the work are not under- 
stood. 
Good hospital training, two years at least, and six months' experi- 
ence in a district home, should be the minimum standard. To put 
women with no more than six months' experience of nursing the sick, 
and often of limited education and intelligence, in the position of 
district nurse, is a form of cheap philanthropy that cannot be too 
strongly condemned. A half-trained woman is worse than one with 
no pretensions to knowledge, and to place such responsibility in her 
hands (too often because she asks less remuneration than a fully-trained 
nurse), is an injustice to her, the patients, and the doctor who attends 
them. However sensible and willing, no woman could attain in the 
time even sufficient practical dexterity to do the best for the cases, and 
for lack of the special training faults of inexperience must greatly limit 
her usefulness. 
No nurse, however well trained, should ever be expected or allowed 
to treat or prescribe for any case whatever beyond rendering first aid in 
emergencies. She should never undertake the nursing of a case that is 
not under a medical man, nor initiate or alter any treatment without his 
direct orders or permission: as in private work, all suggestions, criti- 
cisms and discussions of his methods are utterly inexcusable. Gossip 
is, if possible, even a more fatal fault in district than in private work. 
Besides not talking of one patient to another, the nurse should be 
reticent concerning her cases to those above them in the social scale. 
The respectable poor resent their private affairs being made known to 
district visitors, committee ladies, etc., and a nurse who thus betrays 
confidence will lose all influence over her patients and their friends. 
A district nurse is generally sent to cases by medical men, clergymen, 
district visitors, or the friends of the patient. If not sent by the medical 
man in charge of the case, it is more courteous for the nurse to ask his 
permission before beginningher work, though in an urgent case she might 
help the friends to carry out orders at her first visit, and then ascertain 
if he wishes her to continue. A written daily report should be left for 
the medical man, and in acute cases twice daily, or even oftener, with 
the record of temperature, pulse and respiration, action of bowels and 
bladder, amount of sleep, food, stimulants, etc. In chronic cases a writ- 
ten report once or twice a week may be sufficient, stating the general 
state of health, condition of wound, such as an ulcerated leg, etc. By 
thus keeping in full communication mistakes and misunderstandings are 
avoided. One rule would save many difficulties, viz., that both doctor 
and nurse invariably communicate in writing, never giving or receiving 
verbal messages from patients or their friends. By implicitly carry- 
ing out medical orders, and by exact obedience, she will impress the 
friends with the importance of following directions. The nurse must aim 
at being the friend, not the supplanter, of the wife or mother, who may 
resent a stranger's intrusion until experience teaches how much more 
can be done by skilled hands. It is generally much easier to put the NURSING 
449 
patient than the room in nursing order. But by degrees the most 
disorderly room can be rearranged, and whenever possible this should 
be done, not by the nurse personally, but by the friends acting on her 
advice. The lesson is more permanent if they realise themselves that 
they can make and keep things tidier and more orderly. They prefer 
themselves to put away the extra garments that have accumulated, to 
remove the family linen 11 airing " between the bed and mattress of the 
sick person, to clear out boxes, sacks, and other rubbish that may be 
under the bed. Still, if there be no one else available, the nurse must 
ensure cleanliness herself, for she is responsible that all the appliances 
and surroundings are in order. She must be prepared to extemporise 
many kinds of contrivances. If it be not possible to move the bed from 
a draughty position a screen can be made from a clothes-horse and the 
family shawl, if a quilt or blanket are not available; or the same gar- 
ment may be fastened as a curtain on a clothes-line. A roll of news- 
paper or brown paper will convert a common kettle into a steam one for 
the time. A sheet of the latter material is an excellent substitute for 
mackintosh. A small teapot forms a good feeder, a chair can be con- 
verted into a bed-rest; in fact, a good district nurse is rarely nonplussed 
for ways and means. 
A stock of necessary appliances, such as water-pillows (more gen- 
erally useful than the large water-beds), mackintoshes, bedpans, etc., 
should be kept for lending; also sheets, bed-garments, etc. Flannel 
shirts, open down one side, are particularly useful for rheumatic cases. 
A free use of Keating's powder, carbolic acid, or Jeyes' fluid for bed- 
steads, floors, etc., with carbolic soap and turpentine are useful in dimin- 
ishing insect life. 
Except under special circumstances night duty is the exception for 
a busy district nurse, as it prevents the other work. Trustworthy women, 
working under orders, can generally be found to relieve the friends at 
night. 
The nursing of infectious cases depends entirely upon the local 
medical men. Except in epidemics, scarlet fever, typhus, and small-pox 
are not usually attended by the nurse. With due precautions, most 
careful disinfection of hands, hair and instruments, and the use of sepa- 
rate sleeves and aprons, enteric fever, measles, whooping-cough, diph- 
theria, and erysipelas may be attended without risk to other patients. 
Care would necessarily have to be taken not to go straight to a child 
after visiting measles, nor to a surgical case when attending erysipelas; 
but ordinary chronic cases might easily be nursed at the same time, also 
acute rheumatism, pneumonia, etc. 
Whatever may be the local attitude with regard to midwifery, it is 
most desirable that, although the nurse may possess the requisite train- 
ing to act in that capacity, she should not do so except at the request of 
the medical men, when she must only attend a limited number of non- 
surgical cases, or in an emergency. But whenever possible she should 
act as monthly nurse under the medical men, and by their orders, visit- 
VOL. I 
2 G 450 
SYSTEM OF MEDICINE 
ing the cases twice daily for seven days, and once daily for another week, 
taking the mother's temperature, pulse, etc., and keeping her absolutely 
clean; washing the baby, taking care of its eyes, etc., and, by inculcat- 
ing cleanliness and uprooting traditional prejudices, help to lessen the 
mortality amongst mothers and infants so largely due to neglect at these 
times. 
District nursing should be entirely distinct from any form of alms- 
giving. All relief should be obtained from the proper local sources, 
never given directly by the nurse. Also the work should be unsectarian 
if it is to reach those most in need of its help. When arranging for 
a district nurse in any locality it is helpful to obtain information from 
one of the established systems of this work. A nurse fully trained is 
supplied, with every detail of cost worked out, and definite rules on 
which she must act. She is bound to send a monthly report of her 
work, with full particulars, to headquarters, in addition to that furnished 
to the local committee; and she is visited and her work inspected at 
regular intervals from the centre. The same holds good for homes, 
only there the superintendent, herself a trained nurse, is held responsible 
for those working under her. No interference with local arrangements 
takes place under this scheme; it does but ensure a supply of properly- 
qualified women, and a uniform standard of work. Experience has also 
shown that refined, well-educated women exercise a stronger influence 
and produce better results than those drawn from the same class as the 
patients. One they instinctively recognise as their superior can do more 
in combating their prejudices than one who is rather inclined to share 
them. 
Whenever possible it is well to make the people help to support the 
nurse, on the lines of a provident club. A monthly payment of 4d. for 
a family (or less if local wages are low), and a charge of |d. or Id. per 
head for those over fourteen years of age is conveniently spared, and is 
better than the giving of skilled labour for nothing. Cases in receipt 
of poor-law relief would not be expected to join such a club, but the 
guardians should contribute towards the nurses' fund. 
Puerperal Nursing. - The fact needs wider recognition, that though 
the puerperal state is naturally a normal one calling for little beyond 
cleanliness and ordinary attention, yet from constitutional or accidental 
causes the gravest complications may arise, which require trained skill if 
the case is to be nursed successfully. Therefore maternity work should 
only be undertaken by women with general as well as special nursing 
knowledge. Even in the most straightforward case much depends upon 
the nurse to ensure a good recovery for the mother and a contented, well- 
cared-for infant. It is not possible for a woman unaccustomed to attend- 
ing sick people or young children, ignorant of the rudiments of anatomy 
or physiology, and often of the simplest laws of hygiene, to become 
acquainted writh all that is essential for a monthly nurse in three months, 
much less in six weeks, the time considered sufficient for this training 
in most of the lying-in hospitals and training schools. NURSING 
451 
It is often stated that the modern nurse falls short of her untrained 
predecessor in the management of infants after the first ten days. It 
cannot be otherwise if the nurse have not seen anything of a baby after 
the first fortnight, and is as much at a loss as the inexperienced mother 
in dealing with it. Then the child becomes the victim of the ignorant 
advice of zealous friends as to feeding, quack remedies for infantile 
ailments, etc., and the seeds are sown of rickets and other diseases for 
which medical aid is sought too late. The mere handling of mother 
and infant needs time and experience to do it well, and with comfort 
to the patient; and in the washing and bed-making of a lying-in 
woman great care is necessary to avoid exposure and risk of chill. 
Also it frequently happens that the doctor . does not arrive until after 
delivery has taken place. The safety of mother and child depends then 
upon the nurse; fortunately, in the majority of cases, masterly inactivity 
carries her safely through. But a smattering of knowledge, or the 
audacity of inexperience, will often cause undue meddling, and injuries 
to both mother and infant may ensue. 
The more highly trained the nurse, the less danger is there of her 
taking too much upon herself; she realises the risk, and is more willing 
to depend upon medical aid and instruction. 
Absolute cleanliness is the secret of successful puerperal nursing. A 
nurse attending confinement cases should always wear dresses of washing 
material, and large white aprons and sleeves that will turn up above the 
elbows. She must be scrupulously clean in person, especially having 
her hands free from roughnesses and scratches, with short nails kept 
absolutely clean. Her hair should be frequently washed and neatly 
arranged. She should be quite free from any wounds or sores; many a 
case of puerperal septicaemia might have been traced to the unsuspected 
ulcerated leg of the old nurse in attendance. 
The nurse's duty is to prepare the patient and bed, to have all in 
readiness for the infant, to wait upon the doctor, to put mother and child 
comfortably back to bed when all is over, and to nurse the case under the 
medical orders. It is advisable for her to ascertain beforehand if her 
patient has the necessary appliances, so as to avoid confusion at the time. 
The room should be bright and cheerful, as quiet as possible, not near 
any closet or sink, and easily ventilated. The bed should be in such a 
position that it can be approached on both sides. The fire should be 
lighted, plenty of hot and cold water in the room, two or three basins, a 
quart jug (in which to warm the forceps if needed), a slop pail, towels, 
napkins, infant's clothes, dressing for the cord, dusting powder, olive oil, 
threaded needles, thimble, safety pins, blunt-pointed scissors, linen 
thread ligatures, flannel receiver, antiseptic lubricant, flannel, plain soap, 
etc. If possible sanitary towels should be used for the patient; these 
can be inexpensively made of carbolised tow or oakum in butter muslin; 
but, if preferred, ordinary napkins may be wrung out of hot antiseptic 
lotion (Jq- carbolic or perchloride) and applied. 
Brandy, hypodermic syringe, irrigator, Higginson's syringe, glass 452 
SYSTEM OF MEDICINE 
nozzle, catheter, and a receiver for the placenta should be at hand. 
Glass catheters can readily be cleansed, but require very careful 
handling. 
The nurse should recognise the stage of labour by the pains, the 
short " grinding " ones of the first being distinct from the propulsive 
" bearing down " ones of the second stage. 
If the bowels have not been well relieved a small soap and water 
enema may be given in the first stage, especially if the membranes have 
not ruptured, which can be ascertained by external evidence. The 
patient should be desired to empty the bladder also at this stage, and if 
in accordance with the wishes of the medical attendant, a warm anti- 
septic douche (Condy, or perchlor.) is often given; but this must 
not be done without permission. A glass nozzle (without a terminal 
hole) should be used, previously boiled and soaked in a disinfectant. 
It is well in any case to bathe the vulva with a warm antiseptic lotion, 
and creoline (3j. to Oj.) is especially useful, as plenty of soap can be 
used with it, a desirable feature in district maternity cases. 
The nurse should always thoroughly cleanse her hands with hot soap 
and water and nail brush, and then immerse them in " perchlor." 
or " 2^-q carbolic " before touching her patient, and it is well for her to 
keep a basin of antiseptic lotion at hand, so that she may dip her hands 
in it each time she attends to the case. 
Preparation of Bed. - A convenient arrangement of the bed is made 
by spreading a mackintosh sheet over the mattress, covered by a blanket 
and under-sheet. In district cases sheets of strong brown paper will 
keep moisture from penetrating to the bed. Over the under-sheet 
another piece of mackintosh is laid, covering the lower half of the bed 
on the right side. This is covered by a small blanket, a folded sheet, 
and, if procurable, an accouchement sheet. In poor homes clean old 
quilts or any thick material can be used, over brown paper or an oilcloth 
table cover. The bed-hangings should also be moved from the side of 
the bed. The mackintosh, etc., may be kept in position by safety pins 
at each corner. The upper sheet, blankets, and quilt are folded back 
to the left side of the bed, ready to be replaced, and a sheet or small 
blanket, as preferred, is placed over the patient. A clean draw-sheet 
and the binder are rolled up and placed at the head of the bed, with six 
strong safety pins. A pulley is firmly fastened to the foot of the bed 
(an ordinary round towel is a useful one), and if necessary a piece of 
board or a flat stone is placed against the foot-rail for the patient's 
feet. 
Toilet of Patient. - She is dressed in clean night-clothes turned up 
and secured on each shoulder by a safety pin. A couple of clean petti- 
coats are worn, stockings without garters, and bedroom slippers, and a 
dressing-gown, which latter garment is removed and a shawl put across 
the shoulders when the patient has to lie in bed at the last. 
Food.-Warm milk, tea, beef tea, etc., may be given from time to 
time-the last being a valuable stimulant to under-fed, ill-nourished NURS/NG 
453 
women. The nurse must be prepared for vomiting during the first stage 
of labour, and sometimes a shivering fit, without a notable rise of 
temperature, announces its termination. 
Second Stage. - When the pains become decidedly propulsive, the 
patient must lie on her left side with her spine on a line with the edge 
of the bed, her head supported by a pillow or pillows, the knees flexed, 
and the feet pressing against the foot of the bed. The nurse can materi- 
ally assist the patient in the second stage by supporting the lower part 
of the back during each pain. She may also be ordered to apply 
hot fomentations to the perinseum if there be rigidity; these consist 
of wool or flannel wrung out of hot antiseptic lotion, and must be 
frequently renewed. When the child is born the nurse will hand 
scissors and ligatures to the doctor, and if desired hold the uterus 
while the child is being separated. She has the flannel receiver ready 
warmed, in which she wraps up the infant, and puts it away in a warm 
place. 
If animation be suspended, she must quickly prepare basins of hot 
and cold water, and help as directed with artificial respiration, rubbing 
with brandy, dipping into hot and cold water, etc. A small basin and 
pieces of wool will also be ready for the doctor to bathe the infant's eyes. 
After the expulsion of the placenta the nurse will take the orders of the 
doctor as to when the mother is to be made comfortable, generally after 
the child is dressed. 
First Toilet of Infant. - The water for the infant's first bath must 
be from 90° to 95° F., the child is quickly soaped, placed in the water, 
and gently, yet firmly, rubbed to remove all the adherent deposit from 
its skin. It is carefully dried, especially in the folds of the skin. Until 
the meconium ceases, oiling the buttocks and thighs will be found use- 
ful. Before dressing the cord, the ligature must be carefully examined, 
and if not firm, or there be oozing, it must be retied; the genitals and 
anus should also be noticed in case of malformation. The cord may be 
wrapped in antiseptic gauze, and placed in a square of linen with a slit 
in the centre, through which it is drawn, and then neatly folded in; or 
it may be well powdered with a mixture of 1 part starch-powder, 1 
boracic powder, and 1 oxide of zinc, and enveloped in the linen. This is 
kept in place by the flannel binder, which may be firmly, but not tightly 
applied. No pins must ever be used to fasten the several garments; they 
must be neatly sewn on, except the napkins, which are secured by a 
safety pin, and the ends of the long flannel, which are turned up over 
the feet, are similarly secured at each corner. 
Toilet of Mother. - When the child is dressed, the mother, having 
rested, is made comfortable. The soiled skirts are drawn down over the 
feet and removed. A basin of hot disinfectant, or creoline and 
water being ready, the vulva, thighs, and buttocks are thorough cleansed 
from every particle of discharge, well dried, and warm sanitary towels 
applied. The soiled draw-sheet and mackintosh are rolled tightly up 
against the patient, who turns towards the nurse, on to the clean draw- 454 
SYSTEM OF MEDICINE 
sheet, also rolled, close to her. The soiled sheet is drawn away, the other 
side of the patient washed and dried, the clean sheet spread out, and the 
patient turned gently on it. She lies on her back with the legs extended 
for the binder to be applied. 
Application of Binder. -When this duty falls to the nurse, she puts 
the rolled-up strip of material, which is better than any shaped bands, 
under the patient, bringing one end across the abdomen, so that the end 
overlap on a line with the right hip. The lower edge should be well 
below the great trochanter, and the ends pulled tightly together, the 
left hand holding the under, the right hand the upper side, securing 
them by a strong safety pin. This is repeated until the whole abdomen 
is firmly bound, and at the fourth and last pin a fold is made in the 
under side of the binder to make it fit better, and it is left rather looser 
than lower down to avoid compressing the ribs. 
Two people then gently lift the patient to the top of the bed; one 
raises the buttocks by grasping both sides of the draw-sheet, while the 
other raises the head and shoulders of the patient, and gently lifts her 
into position. Only one pillow is wanted at first. The draw-sheet and 
mackintosh may be pinned at each corner if desired, and an accouchement 
sheet placed under the patient. These are easily made, in the same way 
as sanitary towels for poor people, by placing carbolised tow or tenax 
between butter muslin. Or, if preferred, ordinary napkins may be 
wrung out of hot disinfectant lotion (say perchloride 4-^0), and applied. 
The night-dress is unpinned from the shoulders, and drawn down, the 
covering blanket removed, the bed-clothes replaced, and the child given 
to its mother. 
The pulse should be now taken, also the temperature; any rise over 
100 in the pulse should be reported at once, and the nurse must be on 
her guard for hsemorrhage. 
The placenta is placed in clean cold water for medical examination, 
and then is burned by the nurse. 
Tidying of Room.-All soiled clothes must be removed from the 
room as soon as possible, and put to soak in cold water containing car- 
bolic or other disinfectant. The room must be kept quiet, and the 
patient left to rest. Nourishment will be as medically ordered, but 
usually milk, egg and milk, or a cup of tea with much milk in it, are 
allowed almost at once. The nurse must obtain full medical instruction 
as to douches, use of the catheter, record of pulse and temperature, etc. 
The room must be warm, but well ventilated, and the patient kept 
quiet for the first week. 
After-Care of Mothers. - The mother must be kept scrupulously 
clean, the vulva being bathed at least twice daily, as after an action of 
the bowels. Douches will be given as ordered by the doctor - in every 
ordinary case the bed-pan, sanitary towels, sheets, night-dress, etc., should 
be warm when given to the patient. 
The nipples must be well bathed and carefully dried before and after 
suckling and the breasts should be alternately relieved. If the nipples NURSING 
become tender the doctor must be informed, as special applications, such 
as glycerine and tannin, eau de Cologne and water, etc., may be ordered, 
or a nipple shield. The child should never be allowed to go to sleep 
with? the nipple in its mouth; this is a fruitful source of cracks and 
tenderness. If the breasts are very full and tense, with more milk 
than the child can take, they may be supported by a binder, and the 
medical attendant told, as the breast-pump may be needed. In district 
work one may be extemporised by filling a bottle with rather a wide 
neck with very hot water, emptying it quickly, and applying at once 
over the nipple - a soda-water bottle is very convenient for the purpose. 
If hardness still continue, hot fomentations and support should be 
applied until the doctor has seen the breast; the nurse must never use 
friction unless ordered to do so. The child may be put to the breast 
occasionally until lactation is established, usually on the third day. If 
it seem very hungry, a teaspoonful or two of milk and water, 1 to 4, 
warmed and sweetened, may be given. After the milk has come, the 
infant should be suckled every two hours during the day, and every 
four during the night, for the first fortnight or three weeks, gradually 
lengthening the intervals, especially at night. 
Should a mammary abscess form the breast must be well supported; 
usually the patient's arm is fastened to her side. A convenient support, 
if poultices are ordered, is a square of linen with tapes at each corner, 
two of which tie round the waist, and the other two round the neck, 
holding up the breast. The square may be folded to fit the breast, and 
secured by a safety pin. 
Light diet is usually given to the mother until the bowels have acted, 
and then ordinary digestible food. Stimulants are never to be given 
without orders. It is wise for her to avoid cheese, pickles, uncooked 
vegetables, etc., at any time while suckling, as they are apt to disagree 
with the child. » 
Torn Perinaeum. - If the perinseum has been torn and stitched, the 
nurse may be desired to pass the catheter for some days, and this is 
most conveniently done as the patient lies on her side to avoid stretch- 
ing the parts. The wound needs constant care to keep it as clean and 
dry as possible, the dressing being frequently changed. If douches are 
given the tube must not touch or rest upon the lacerated part. The 
binder should be put on as low as possible, and the knees tied together, 
the patient being kept strictly recumbent. 
If allowed to micturate naturally it should be as the patient lies on 
her face, and the parts well bathed directly afterwards. 
White Leg. - Should the patient complain of pain in the calf or 
thigh the leg must be kept perfectly quiet until the doctor comes. If 
the pain be severe hot wool may be applied, but no friction or move- 
ment of any kind attempted until orders are received for treatment. A 
cradle should be placed over the limb to take off the weight of the 
bed-clothes, and the patient must be moved as little as possible - 
special attention is to be paid to the back, ankles, etc., as sores are very 
455 456 
SYSTEM OF MEDICINE 
liable to form. The patient must never raise herself suddenly, or sit 
up while the leg is affected. 
Should shortness of breath occur the doctor must be summoned at 
once, the patient kept as quiet as possible, and a stimulant given. 
Should septicaemia arise, the nurse's duties are similar to those in 
a case of peritonitis. Any abdominal tenderness, offensive lochia, 
scanty flow of milk, or rise of temperature must be reported at once. 
A strict course of disinfection for the nurse, and for every garment 
taken by her into the house, must be carried out; and some weeks' 
interval must elapse before she attends another lying-in case. 
The Infant. - Much depends upon the nurse in training an infant in 
regularity of feeding and sleeping, and, if well managed, both mother 
and child benefit. The baby should not sleep in the bed with the 
mother, but in a cot at the side; the heat may be maintained by hot 
bottles. Many infants are killed by suffocation among the poor for 
lack of this precaution. The eyes should be thoroughly cleansed every 
day with warm water; any redness or discharge must be at once 
reported, and the lotion ordered applied. A separate piece of wool or 
soft linen should be used for each eye, and burned at once; also the 
soft linen for cleansing the mouth and nostrils. The mouth should be 
washed after taking the breast. The cord is dressed daily, and, after it 
separates, a folded pad of linen and powder should be applied to the 
umbilicus for a few days. If the navel be inclined to protrude after 
the cord is off, the doctor may order a counter covered with lint or 
linen to be fastened over it with a strip of strapping two inches wide 
and four long, under the flannel binder. 
Clothing. - The binders and the clothing should not be tight, as 
both digestion and circulation suffer, and the support to the umbilicus 
is insignificant. The mother should be advised not to dress her 
baby in gowns with low necks and short sleeves, but to keep its limbs 
covered. 
The child is bathed (90° temperature) daily, though some prefer not 
to put it into the water until the cord separates. If the bowels and 
bladder are not relieved within twelve hours after birth the doctor must 
know. Often a hot bath will have the desired effect. After the stools 
become yellow in colour, any green motions, constipation, straining, or 
distension of the abdomen due to wind must be reported. Constant 
cleanliness and dryness are necessary, and care should be taken that 
the napkins are not washed in soda and water, as this chafes the skin. 
Any rash, sore, discharge, or persistent snuffling must be reported at 
once. If the child's breasts become tender and swollen, they must be 
protected from pressure by a piece of wool and shown to the doctor. 
The nurse must never squeeze or rub them. 
In bringing up a child by hand the food will be ordered by the 
medical attendant, but the nurse must prepare it, and see it is always 
perfectly fresh, sweetened, and warm, and not given in too large quan- 
tities at a time. THE HYGIENE OF YOUTH 
The bottles must be scrupulously clean - the boat-shaped are the 
most convenient, also Timpe's (according to Prof. Escherich), which 
possess the advantage of having inscribed on the glass a scale of quan- 
tities to be prepared daily in proper proportions, and the amount for an 
infant's meals from three days old to twelve months. Other bottles 
can be kept clean with constant care. Two should always be in use: 
one, well scalded with hot soda and water, and rinsed in cold water, is 
left in boracic lotion until needed, when it is washed out with hot water 
before being used. The hole in the teat should not be too large, and 
tubes should be cleansed each time with a brush, though it is undesir- 
able this kind of bottle should be used at all. 
No stimulant or medicine should ever be administered without orders 
or permission. Warmth and dryness keep a child contented; many an 
attack of screaming attributed to " wind " is really due to cold feet. In 
obstinate flatulence dill water may be ordered, and a small teaspoonful 
of warmed olive oil, if given daily, prevents constipation. 
A monthly nurse can do much by thoughtfulness to avoid giving 
additional trouble in the household. 
In thus sketching the duties of modern trained nurses and their 
position as regards the medical profession, I would urge that more 
rather than less training and discipline is needed in every branch, and 
it is entirely in the hands of the medical men to raise and insist upon 
the maintenance of a high standard. Both callings would profit by it, 
and the sick of every rank in life would reap the benefit. In no other 
work are Browning's words so true - 
457 
Oh, the little more, and how much it is - 
Oh, the little less, and what worlds away. 
Amy Hughes. 
THE HYGIENE OF YOUTH 
I. Introduction. -Efficiency for the accomplishment of the work of life 
is a result both of the character and direction of the training received, 
and of the physical and mental vigour to which that training has led. 
And, surveying the question from a practical point of view, it is obvious 
that greater " staying power " and less training is better than excessive 
training with consequent diminution of vigour. 
^wo-thirds of the period of youth are spent in the process of educa- 
tion, and in proportion to the care and thought expended by parents and 
teachers will growth and development reach their highest expression, 
or ill-health and disease result. I have no hesitation in saying, from a 458 
SYSTEM OF MEDICINE 
wide experience, that a due amount of care has never yet been bestowed 
upon the young human being. 
In the training of the young the individual must be regarded as a 
whole, so that mind may not be developed at the expense of body, or 
vice versd, but a harmonious dual development secured. 
In the process of education, which in its proper sense necessarily im- 
plies both physical and mental development, the teacher too frequently 
ignores the former factor. It is the physician's province to point out 
that education must not be pursued at the expense of physical welfare. 
Though his advice may be too generally ignored or contemned, he must 
yet insist that his office is to guide the schoolmaster in his duties so 
far as they concern the health of the pupils; nay, even in respect of 
the teaching itself - so disastrous is the assumption that teaching needs 
no technical training - less serious consequences would ensue to the 
young were the physician's advice more frequently sought and adopted. 
The proper aim, therefore, of parents and teachers being the attain- 
ment of the highest development of mind and body, it must be impressed 
upon them in every way that this result is dependent upon an appro- 
priate training in youth. 
In order to secure the highest physical growth it is necessary that an 
approximately accurate estimate should be formed of each child's constitu- 
tion. Those who should receive the most careful forethought are: - 
1. Children who are delicate or sickly. 
2. Children who have had an ailment which may recur under 
unfavourable circumstances. 
3. Children who, though healthy as yet, come of an ailing or dis- 
eased stock, a stock in the offspring of which, as the physician knows, 
hereditary ailments and diseases are apt sooner or later to appear. If 
these children be surrounded by favourable conditions during the period 
of growth, the tendency to such disease might be eradicated or miti- 
gated. Partly through ignorance, but mainly from pure thoughtlessness, 
parents flatter themselves that, as their children seem healthy during 
youth, they have escaped the parental tendency; whereas if they would 
but admit that these children are likely to be stamped with their own 
die, and set themselves diligently to counteract the hereditary taint, the 
children would often have to bless this wise forethought for a healthy 
manhood. 
It is incumbent on parents to bear in mind what is so well expressed 
by Dr. John Harley, that "within certain limits the healthy body can 
accommodate itself with facility to considerable variations in the 
external conditions, and those are the delicate who cannot readily do 
this, and who, in the transition process, are liable to develop abnormal 
action, or, in other words, disease." To ignore such tendencies to dis- 
ease may hamper the child throughout life, and bring misery not only 
to himself, but possibly again also to his descendants, by entailing 
disease and premature death, or, still worse, that deterioration of 
character which ill-health so often engenders. THE HYGIENE OF YOUTH 
459 
Table showing the average and mean height and weight, and the annual 
rate of increase, of 7855 boys and men, between the ages of 10 and 
30, of the artisan class - town population: - 
Age last 
Birth- 
day. 
Height, without Shoes. 
Weight, including Clothes of 9 lbs. 
Average. 
Growth. 
Mean. 
Growth. 
Average. 
Growth. 
Mean. 
Growth. 
In. 
In. 
In. 
In. 
lbs. 
lbs. 
lbs. 
lbs. 
ia 
50-52 
50-50 
66-31 
66-0 
11 
51-52 
i bb 
51-50 
i-bb 
69-46 
3-15 
70-0 
4 0 
12 
52-99 
1-47 
53-50 
1-50 
73-68 
4-22 
74-0 
4-0 
13 
55-93 
2-94 
55-50 
2-50 
78-27 
4-59 
78-0 
4-0 
14 
57-76 
1-83 
58-00 
2-50 
84-61 
6-34 
84-0 
6-0 
15 
60-58 
2-82 
60-50 
2-50 
96-79 
12-18 
94-0 
10-0 
16 
62-93 
2-35 
63-00 
2-50 
108-70 
11-93 
106-0 
12-0 
17 
64-45 
1-52 
64-50 
1-50 
116-40 
7-66 
116-0 
10-0 
18 
65-47 
1-02 
65-50 
1-00 
123-30 
6-97 
122 0 
6-0 
19 
66-02 
0-55 
66-00 
0-50 
128-40 
5-08 
128-0 
6-0 
20 
66-31 
0-29 
66-25 
0-25 
130-60 
2-20 
132-0 
4-0 
21 
22 
66-60 
0-29 
66-50 
0-25 
• 135-40 
4-81 
136-0 
4 0 
23-30 
66-68 
0-08 
66-50 
139-00 
3-58 
138-0 
2-0 
Table showing the average and mean height and weight, and the 
annual rate of increase, of 7709 boys and men, between the ages of 
10 and 30 years, of the most favoured classes of the English popu- 
lation - public-school boys, naval and military cadets, medical and 
university students: - 
Age last 
Birth- 
day. 
Height, without Shoes. 
Weight, including Clothes of 9 lbs. 
Average. 
Growth. 
Mean. 
Growth. 
Average. 
Growth. 
Mean. 
Growth. 
In. 
In. 
In. 
In. 
lbs. 
lbs. 
lbs. 
lbs. 
10 
53-40 
53-00 
67-4 
67-0 
11 
54-91 
1-51 
54-50 
1-50 
72-9 
5-50 
73-0 
6-0 
12 
56-97 
2-06 
56-50 
2-00 
80-3 
7-39 
80-0 
7-0 
13 
58-79 
1-82 
58-50 
2-00 
88-6 
8-27 
88-0 
8-0 
14 
61-11 
2-32 
61-00 
2-50 
99-2 
10-61 
98-0 
10-0 
15 
63-47 
2-36 
63-50 
2-50 
110-4 
11-21 
110-0 
12-0 
16 
66-40 
2-93 
66-50 
3-00 
128-3 
17-92 
126-0 
16-0 
17 
67-84 
1-46 
68-00 
1-50 
141-0 
12-69 
1400 
14-0 
18 
68-29 
0-43 
68-50 
0-50 
146-0 
4-97 
146-0 
6-0 
19 
68-72 
0-43 
68-75 
0-25 
148-3 
2-20 
148-0 
2-0 
20 
69-13 
0-41 
69-00 
0-25 
152-0 
3-87 
150-0 
2-0 
21 
69-16 
0-03 
. - . 
152-3 
0-27 
152-0 
2-0 
22 
68-93 
154-7 
2-44 
23 
68-53 
151-7 
24 
68-95 
149-2 
25-30 
69-06 
69-00 
155-2 
0-42 
154-0 
2-0 
The height and weight should annually increase, not, it is true, with 
steady regularity, for in autumn and winter the advance is less than 
during spring and summer. But the weight always bears a certain 
definite ratio to the height. 460 
SYSTEM OF MEDICINE 
In a child a constitutional disease is usually regarded as a necessary 
evil, and the parent never dreams that a rational readjustment of the 
circumstances in the light of modern preventive medicine might have 
prevented the mischief. 
We should never forget that a vigorous manhood is the greatest of 
all blessings, and that the vestibule to its attainment is a healthy child- 
hood; parents must be educated to understand that the highest and 
most acceptable endowment which they can bestow upon their children 
is good health, and after that, a sound education; these blessings by fore- 
thought and foresight may usually be obtained. 
Health must depend largely upon two conditions: - 
1. The inherent properties of each individual. 
2. The environment in which the individual is reared. 
Only so long as the individual organism is placed in its appropriate 
surroundings - i.e. grown on its proper soil - can we expect to produce 
typical health and strength. Failing these necessary conditions we can 
only anticipate imperfect growth, meagre health, an absence of robust- 
ness of character and manliness, the manifestation of early disease, and 
the absence of vigorous old age. 
II. The Environment. - I would first point out the necessity, as far 
as possible, of bringiilg up the young in the country rather than in town; 
and in detached residences, rather than in the immense blocks which 
constitute some of our schools and asylums. Where parents reside in 
towns every effort should be made to arrange for education in the 
country; if this be impracticable, opportunity should be made for spend- 
ing the vacations there. The importance of this condition has repeatedly 
impressed itself upon my notice, when I have been consulted about the 
children of persons in comfortable and even in affluent circumstances 
who (with apparent exemption from any hereditary delicacy in the 
family) enjoyed all the requisites for healthy growth except this; and 
who, being brought up in a town, or even in a " healthy suburb," con- 
tinually suffered from tonsillitis, croup, bronchitis, persistent bronchial 
catarrh or pneumonia. As soon as they were removed to a school 
in the country their ailments ceased, education was uninterrupted, and 
healthy physical development succeeded. In the case of nervous 
diseases this difference of effect between town and country is still more 
marked. 
Last summer, when I joined in the inspection of a Volunteer brigade 
of five battalions comprising more than 4000 men, I observed in passing 
through the ranks of the various " companies " that the difference in 
height, breadth and aspect between companies levied in the country and 
those mustered from towns was astounding. These facts are clearly ex- 
hibited in detail in the carefully-prepared tables of Mr. Charles Roberts, 
which should exercise a decided influence on the modes of rearing the 
young. 
The air of town and country is, of course, originally the same in 
composition. But town air is rendered impure, not only by the absence THE HYGIENE OF YOUTH 
461 
of sunlight, but, as it would seem, by the presence of some deleterious 
elements. Hence the exhilarating feeling of breathing fresh country 
air as a contrast to that of the town. But the utility of transferring 
children to the country vanishes if they are confined to day-rooms and 
bedrooms with so insufficient an extent of cubic space that air has to be 
rebreathed. 
There is no habit more common, and none more deleterious and 
uncleanly, than that of living, working and sleeping in ill-ventilated 
rooms, and breathing and rebreathing the same air. It causes ill-health 
and deficient growth, from the imperfect working of the internal func- 
tions of the body; and renders the human being disposed to the attack 
of poisons from without. There can now be little doubt that these 
conditions pre-eminently favour the development of tubercle bacilli. 
The effect of pure and impure air on health and mortality, as recorded 
by Parkes, is strikingly shown in horses; for in them the question is 
more simple on account of the similarity in different times and places 
of food, water, exercise and treatment. Formerly, in the French army, 
the mortality of horses was enormous. Rossignol states that, previous 
to 1836, the mortality of the French cavalry horses varied from 180 to 
197 per 1000 per annum. The enlargement of the stables - the in- 
creased quantity of the ration of air - reduced the loss in the next ten 
years to 68 per 1000. 
It is sometimes stated that nurseries and schools need only be 
supplied with half the amount of air-space, on account of the size of 
the inmates. No greater mistake can be made. Children cannot thrive 
well without the purest air; like the young of all animals, they are 
peculiarly sensitive to pre-breathed air. Yet parents will take any 
trouble, and make any complaint, about the quality and the quantity 
of the food at schools, but show no concern about the ration of air pro- 
vided. If they have to find fault with the appearance of their children 
on their return home for the vacation, they immediately throw the blame 
on the inferior quality or quantity of food. The truth is that, in a large 
proportion of cases, the pupils are compelled to live and work hard in 
insufficient air-space, and to sleep in still less. This has been repeatedly 
proved by the diminution of excessive mortality on the provision of 
more air. The active functions of children, together with their quicker- 
breathing, necessarily produce more rapid tissue change. It was found 
by Voit, that during waking hours more carbonic acid in proportion is 
given off, while during sleep more oxygen is absorbed than carbonic 
acid eliminated. And in his eighth report to the Privy Council, 1865, 
Sir John Simon stated, "that even healthy children, in proportion to 
their respective bodily weights, are about twice as powerful as adults 
in deteriorating the air which they breathe." 
Place. - The quality of the soil on which the child is reared is of 
paramount importance, especially in relation to the position of the 
water-level. It is well kn'own that water lying stagnant on the surface 
of land is very inimical to health; but it is not so well recognised that 462 
SKSTAJf OF MEDICINE 
unhealthiness is also produced where the subsoil is loaded with stagnant 
water. 
Drainage of Soil. - Efficient surface and subsoil drainage, so as to 
lower the water-level even a foot or two, may remove consumption and 
diarrhoea from an entire district, and produce so improved a state of 
health among the inhabitants that the development of germ life in them 
is largely prevented. 
In the selection of residence for a delicate child, other things being 
equal, the nearer it is to the sea the more equable the climate; the 
farther from the sea the more is the climate one of extremes. Hence 
the child who requires a moist, equable climate, with warm winters and 
warm nights, should live at the sea-side, while those who need a more 
bracing air should reside inland. Children who possess that form of 
delicacy which renders them susceptible to constant colds; those having 
a hereditary tendency to rheumatism, consumption, feeble circulation, neu- 
ralgia, hidney disease, and other such misfortunes, might be saved much 
misery could they pass their period of youth in a dry, warm situation. It 
must constantly be borne in mind, that although consumption is a para- 
sitic disease arising from the attack of tubercle bacilli, yet these bacilli 
only find a suitable soil for their propagation in certain constitutions, or 
in feeble states of constitution; a vigorous condition of health resists them. 
Further, where insanity, or even an excitable nervous condition - 
which is often exemplified in hysteria only - is known to have occurred 
in members of the family, the child should be educated where he can 
be out of doors most of his time, on fine days, so that vigour of consti- 
tution may be produced, for in this development the brain itself largely 
participates. Such a child should not be allowed to work at night, or 
for any examination, until his brain is mature in its growth. Above all 
he should be taught that immorality in any form is especially detrimental 
to the stability of his brain. 
It is also imperative that a child born with this hereditary dis- 
position should be educated, from his earliest years to manhood, away 
from home, and apart from the management of his parents or any rela- 
tives who are tainted with the nervous constitution, in a place where 
a regular life will be maintained under watchful discipline, where all 
waywardness will be dealt with by a firm but kind hand, and where he 
will work and play with those of his own age who are more robust in 
health and in character. By such means the nervous tendency may be 
eradicated: yet these very children are too often kept at home, where 
they are petted and pampered, never thwarted or corrected lest the 
nervous condition should be induced, and where peevishness, ill-temper, 
and petty tyranny are allowed full sway. Such surroundings make a 
hotbed- for the development of the tendencies which it is essential to 
check. In the case of girls, who spend so much time at home, and 
are disposed to a nervous habit, it is still more imperative that 
their education should be absolutely freed from the influence of such 
surroundings. THE HYGIENE OF YOUTH 
463 
It is most mischievous to tamper with the emotions of the young, for 
they are so unstable during this period of life as to be certain to run into 
channels unforeseen and undesired. Even religious fervour, if excessive, 
is often perverted into the shape of sexual immorality. In youth the 
appetites, desires and passions awake, untempered by reason, uninstructed 
by experience, so that at no time of life is steadfast guidance and help 
more essential. Yet how few boys - and still fewer girls - receive the 
needful aid from their home training; a policy of silence is substituted 
with results frequently disastrous. 
III. External Conditions. - As regards clothing, it must be borne in 
mind that the skin is our most important gland, and requires protection 
to enable it to do its duty, and to prevent its functions being arrested 
by sudden chills or other changes of temperature. In this country, 
where the temperature of the body is always higher than that of the 
atmosphere, the use of clothing is to prevent the waste of the heat of 
the body. 
The skin regulates the temperature of the body by means of its 
blood-vessels, and these are dilated and contracted by their vaso-motor 
nerves, which turn on or shut off the blood as stopcocks regulate hot 
water pipes. The equability of the temperature of the body is regulated 
by a mechanism now well known to physiologists. The cooling power 
of a sweating skin is enormous, and the chill arising from clothes damp 
after exertion or getting wet are well known. But no one catches 
cold, or becomes chilled, from keeping on wet garments so long as he is 
warmly clad, i.e. so long as rapid evaporation or icing is prevented. A 
non-conductor should, therefore, be worn next to the skin, so that the 
changes of its temperature may not be too sudden. Wool of vari- 
ous thickness is the best covering of the skin in summer as well as in 
winter. 
It should be remembered that the bodies of children are less capable 
of resisting heat and cold than of adults. But the worst of all clothing 
for children is excessive clothing. From time to time I see children who, 
being considered delicate, are burdened with an inordinate amount of 
clothing which increases their delicacy - their skin is never dry. By a 
reduction of the excessive clothing the " delicacy " often disappears. 
Clothing should keep the skin warm, but not moist except under active 
exertion. When moisture is perceptible on the skin under ordinary 
circumstances by night or day, the clothing is excessive and harm will 
result. 
In this country the summer season should be well established before 
a change is made in the thickness of the underclothing; much illness 
is occasioned by a premature change suggested by a few warm days in 
April or May. 
Much care should be given to keep the feet always warm, for neglect 
of this entails unnecessary ill-health often mistakenly attributed to in- 
herent delicacy. I continually see children, and whole families too, who 
are always ailing, and are consequently described as very delicate; whose 464 
SYSTEM OF MEDICINE 
" delicacy " conies indeed of the mother, but only in this that she does 
not know the value of warm, dry socks and thick boots. That the lack of 
these is the commonest cause of enlargement of the tonsils I feel sure, 
and I suspect that it is answerable for a large proportion of the cases 
of post-nasal growths. 
The importance of warm feet in the maintenance of good health has 
so impressed itself upon the attention of a shrewd schoolmaster who has 
125 boys under his care, that every boy is compelled daily, as soon as 
he has settled indoors, not only to change his boots, but also to put 
on a pair of dry socks. The drying of damp boots before rewearing 
them has not yet received the attention it deserves, and in very few 
schools are means provided for this purpose. The miseries and deformi- 
ties (such as chilblains, ingrowing toe-nail, flat foot, anchylosed toes and 
corns) originating from out-grown and misfitting boots - boots never 
intended to fit the foot, but only to suit the fashion - I must not here 
discuss. 
IV. Internal Conditions. - Next in importance to fresh air, sunshine, 
and locality in the nurture of the young, is the material - food - necessary 
to provide for existence and for growth and development. Without 
nourishment, appropriate in quantity and quality, bodily vigour is im- 
possible, resistance to parasitic disease fails, internal maladies arise, or 
less specific general physical and mental deterioration are induced. 
A large proportion of the sufferings of adult life arise from the in- 
appropriate food and cooking and the hasty meals of adolescence. Some- 
times the diet of youth is so nicely adjusted to its cost that illness is 
barely averted, while growth and development are frustrated. A more 
short-sighted policy, even financially, it is difficult to conceive; the 
cheapest policy, in the long run, for the rearing of youths, is to feed 
them well, so that they may be advantageously started for the attain- 
ment of the maximum of size and strength. If thus helped to reach a 
vigorous adult age greater and better work will be obtained from them, 
with more vigorous brain power, higher character, and less liability to 
special incapacities or deficient energies. 
Again, variety of food is essential to efficient digestion and liveliness 
of disposition; monotony of diet seems to produce monotony of character, 
probably by way of some defect of nutrition. 
The periodical use of the scales - say, once a month-would indicate 
to parents and teachers beyond all doubt whether the child was well 
cared for or gravely wronged. It would reveal errors in the mode of 
life, - such as inappropriate, insufficient or monotonous feeding, over- 
work, or over-exercise, - and would also direct earlier attention to the 
advent of disease. Periodically carried out it would show whether the 
natural standard of height to weight was being maintained. 
In estimating the significance of the measure and scales, it must be 
remembered that most children grow by fits and starts; rapid growth 
requires great care, ample food, more rest, and little work, while on 
loss of weight work should be diminished or cease altogether. In some THE HYGIENE OF YOUTH 
465 
schools such a record is already kept, and has been found to be of the 
greatest assistance to the teacher. For instance, should the measure and 
scales disclose that all the pupils are deficient in height and weight for 
their age, it will be evident that some radical defect of management 
exists; should they indicate that one child here and there is below the 
average, a reference to the height and weight chart on entrance to school 
might show the child to be the offspring of a diminutive stock; on the 
other hand, if the original height and weight were then normal, the 
evidence would be clear that the child had been working excessively, 
fed too sparingly (perhaps on account of a squeamish stomach), or that 
illness or disease was imminent. 
On the other hand, it is quite conceivable that many schoolmasters 
and mistresses would dread the introduction of this system, since it 
would reveal the viciousness of many of the present methods of education 
and treatment, and would involve (if its indications were attended to) 
considerable thought and alteration in the administration. 
No work should ever be imposed upon boys or girls without previous 
sustenance. Food first, work afterwards, should be the invariable maxim. 
To work before food probably implies that the material necessary for the 
performance of the work must be absorbed at the expense of the system 
and to the hindrance of bodily growth. The meals, therefore, should be 
wisely arranged: a substantial meat meal should be provided for break- 
fast and dinner, so that the heavy meals may be consumed before the 
principal morning and afternoon work commences ; lighter meals may be 
taken in the after part of the day when the heavy work is ended. On 
the other hand, a meat meal three times a day is objectionable and 
injudicious on all grounds, although I continually hear of physicians 
recommending this plan in the rearing of youth: it would be found most 
inappropriate for schools at all events. 
The cooking of food for the young has scarcely received the attention 
it deserves and requires; this neglect and the supplementary stuffings 
at tuck shops are a fertile source of feeble health, meagre work, bad 
temper, and permanent damage to the digestive organs. 
Insufficient time, again, is rarely allowed to the young for efficient 
mastication and saturation of the food with the secretion of the salivary 
glands. If a child abstain, for any reason, from eating a meal or meals, 
he must not be expected to perform his tasks as usual. Every child 
who does not eat his food should be reported to his master, careful 
inquiry made into the cause, and the omission repaired. It must never 
be forgotten that it is during the years of growth that the delicate child 
may overcome its feebleness and be made permanently strong, or the 
strong child be weakened and stunted. 
I would especially point out the necessity of children being taught 
to use their teeth for the purposes of mastication, rather than be allowed 
the too frequent use of the knife, or be provided with soft foods; in 
this way only will the teeth be kept serviceable. Twice a year at least 
children's mouths should be inspected by the dentist. 
2 H 
VOL. I 466 
SYSTEM OF MEDICINE 
Concerning the suitable kinds of food for youth, I would insist that 
meat should be provided twice a day, at breakfast and at dinner; that the 
crust of bread is more suitable than the crumb, and whole meal than 
white bread; that porridge is an invaluable article of diet; that sugar, 
so frequently denied, is an indispensable requirement, forming as it does 
their main heat-forming food, as well as the most important factor in 
the growth and work of muscles; that milk should take the place of tea 
and coffee; and that young people are better without alcohol during this 
period of life. 
Food implies waste, which results from wear and tear, and is removed 
from the body by certain excretory organs. These products of com- 
bustion must be continually removed if health is to be maintained. 
As Dr. Lauder Brunton says: "As a rule, people are now fully alive 
to the risks they run from poisoning' by sewer gas, or to put it more 
widely, from poisoning by products of decomposition outside the body; 
but perhaps we do not all of us keep so clearly before us as we ought 
the fact that inside the body there are all the conditions for the for- 
mation of putrefactive products, and the most favourable arrangement 
for their rapid absorption." The need of the daily removal of these 
products from the body is not yet sufficiently taught and enforced in 
the young, and as a consequence much unnecessary ill-health ensues, 
and the appearance of piles is facilitated and encouraged. 
V. As we have discussed the suitable environment for the human 
body during early life and also the material necessary for growth, we must 
now consider the purport of this care, and we shall find that the highest 
attainable development is impossible without the exercise of functions. 
As unused organs atrophy, it is, therefore, essential that they be 
employed in order to ensure a maximum of growth and usefulness. But 
it must be borne in mind that whether we consider the exercise of the 
brain which, during this period of life we shall term work or education, 
or the exercise of the body, which we shall term play or recreation, 
exercise increases growth, while over-exercise stunts it. This is doubly 
true when we are discussing immature but growing organs; for strain 
of any description is detrimental to their efficiency. And exercise of 
function is not only essential to growth and development, but also to 
the healthy maintenance of the brain and body when normal growth is 
attained. In the performance of work energy is expended and finally 
exhausted; and this end comes sooner in the young than in those whose 
tissues are matured. Moreover, the young have to tread unbeaten tracks, 
which consumes more force than the pursuit of more or less accustomed 
studies. This opening up of new ground necessitates exertion, and un- 
less the exertion is put forth with pleasure, it is apt to become harmful; 
whereas information acquired by the young with pleasure rarely occasions 
injury. Hence the importance of the study of " likes and dislikes," and 
of fostering work for which the pupil shows a taste, slowly adding that 
which is at first distasteful. In fact, the appetite for work is very 
similar to the appetite of eating; the child will not only thrive, but get THE HYGIENE OF YOUTH 
467 
fat on that which it likes, while it will eat so sparingly of what is dis- 
tasteful that the body will suffer. It is true of mind as well as of body, 
if unsophisticated, that we all like what we can readily digest. More- 
over, as variety of food is essential for the adequate development of 
the body, so variety of work is imperative for due development and 
nourishment of the brain; and as slow and regular development of the 
body produces the finest and most permanent results in strength and 
durability of other tissues, so it is also with the brain itself. 
The prime duty of the teacher is to develop whatsoever faculties 
a pupil has, however rudimentary they may be; and he alone is the 
real educator who knows how to compass this, instead of passing all 
pupils, like corn, through the same mill. Every faculty thus developed 
becomes a stepping-stone in educating other faculties which may be 
still dormant; though sometimes special ability in one direction may 
coexist with utter incapacity in others, mentally and morally. It is 
natural to all children to desire knowledge, - a desire which, unfortu- 
nately, our teachers too often succeed in extinguishing outright. 
The true aim of training and of education should be to develop the 
best type of manhood in mental, moral, and physical well-being, - an 
aim, I regret to say, too frequently disregarded, especially in the train- 
ing of girls, who should receive the greater consideration on account of 
the peculiarity of their growth and the demands to be made upon them 
in early motherhood. The young are allowed insufficient time for 
sleep; they are often deprived of fresh air and exercise by faulty 
school regulations, or unwisely-assigned punishments; they have little 
time to masticate their food owing to the hurry of school customs; and 
their hours of work are usually too prolonged, extending throughout the 
evening and too far into the night, to permit either of good work or a 
healthy development of the brain. An intimate friend of mine, and a 
born educator of the young, has informed me that since he abolished 
evening preparation of work in his school of considerably over a hun- 
dred young boys, not one case of sleep-walking has occurred, although 
many cases happened before this reform. 
The worst feature in this prevalent method of education is that the 
long hours and clumsy educational methods compel the work to be per- 
formed under a sense of fatigue, so that the work itself is not of lasting 
value, and the brain may be damaged in the process. These imperfect 
methods of education are likely to continue until teachers receive a 
technical training in their duties, or at any rate till they cease to despise 
and abhor it. The education of the youth of the upper and middle 
classes in England is the only business for which a man is not trained. 
The successful educator considers his pupil as a whole; it is the 
disregard of this unity that leads to harmful results. Each child pos- 
sesses but its own proportionate stamina and mental ability, inherited 
and acquired. The ability may exist potentially in abundance, but of 
what avail unless the stamina be sufficient to provide a plentiful supply 
of good red blood for the sustenance of the brain. This brain nourish- 468 
SYSTEM OF MEDICINE 
ment is the product of an efficient digestion of food, appropriate in 
quantity and quality, of fresh air and exercise, and of ample sleep, for 
the nutrition of the brain takes place mainly during sleep. 
In the regulation of the hours of work will any sane man uphold the 
invariable custom which prevails of assigning the same number of hours 
of work to a young child when he enters school and to a senior pupil 
at the point of leaving ? It would be as reasonable to expect him to 
undertake work of a similar order of difficulty. To some extent it is 
recognised that one of the chief functions of the competent educator is 
to graduate the training of the brain from short and easy tasks to more 
rigorous and strenuous exercise; but the length of the hours of work 
should be similarly gauged, as the young are without that power of 
sustained endurance, which comes only with the completion of educa- 
tion. If sterling and lasting work is to be accomplished during youth, 
and the brain is to be benefited in the process, teachers must learn that 
the work of the immature brain must be proportioned in difficulty and 
duration to its age and capacity. Yet the work assigned is sometimes 
so disproportionately severe that progress is arrested, or, too often, con- 
verted into retrogression; at other times the work is too prolonged, and 
tells its tale in weakened brain, body and interest; the character also 
suffers, in consequence of the temptation to employ illegitimate means 
for its accomplishment, or to avoid punishment on account of failure. 
A scale of work should be adapted to each age; and this again will 
require revision and remission in certain cases and under special cir- 
cumstances of age and sex. In this scale should also be included any 
work assigned as punishment. 
Ages. 
Hours of work per week. 
From 5 to 
6 
6 
„ 6 „ 
7 
9 
H 7 ,, 
8 
12 
„ 8 „ 
10 
15 
„ io „ 
12 
20 
„ 12 „ 
14 
25 
„ 14 „ 
15 
30 
J» 10 5, 
16 
35 
„ 16 „ 
17 
40 
„ 17 „ 
18 
45 
„ 18 ,, 
19 
50 
Table of the Scale of Work. 
Each faculty of the brain - such as thought, memory, special sense, 
muscular co-ordination, and other functions - requires its own special 
stimulation for purposes of development. Every brain has its natural 
high-water mark of effort and capacity. The systemic circulation of 
the blood affects the central circulation so intimately that on it depend 
not only the growth of the brain itself, but its functions also during the 
process - a full circulation aiding a flow of ideas and the retention of 
facts. The debility of more rapid growth - occasionally seen in boys, 
and habitually in girls - like that ensuing on illness, causes a feebleness THE HYGIENE OF YOUTH 
of circulation, and in consequence apathy and incapacity for mental 
exertion, however eager the pupil may previously have been in the 
acquisition of knowledge. 
The quality of the blood, like feebleness of circulation, dulls the mental 
faculties, as in ansemia, whether arising from deficient food, loss of blood 
or overwork. No less injurious are the impurities which may circulate 
in the blood, and so irritate the brain matter as to give rise to all the 
symptoms of overwork, as is seen in the case of constipation, biliousness, 
albuminuria and so forth. It is, therefore, manifest that brain capacity, 
although in part it depends upon progenitors, depends also in part on 
environment. The bounds of safety can easily be overstepped where 
graduation of the amount and difficulty of work is not provided for. 
It is not always the bright and promising pupil, but frequently the 
dull, feeble, but conscientious one who is overpressed. Moreover there 
are grades of overwork, from poor health and loss of weight to a com- 
plete and often permanent breakdown; here it is that the scales tell so 
genuine a tale. Loss of weight - and even a stationary weight - during 
the years of growth means overwork, underfeeding, incipient disease, or 
recent illness. Yet children, while suffering from illnesses or well- 
marked functional disturbances, are often kept fully at work as if in 
robust health. 
The converse case is only too common, in which a brilliant pupil from 
too early pressure becomes a nonentity, with an impoverished and incom- 
petent brain. 
It is, consequently, incumbent on those who have the welfare of the 
young at heart to gauge the material with which they have to deal; and 
we repeat that it is essential for teachers to be adequately equipped with 
the requisite judgment, the necessary technical skill in teaching, the tact 
and force of disciplinarians, and a knowledge of the physiological factors 
concerned. The circulation of blood in the young brain is always in 
excess of that which exists when maturity has been attained, and thus 
provision is made for the more rapid repair and growth. Moreover, all 
mental work makes the blood-vessels distended and the brain hypersemic. 
If during this period of life work be too prolonged, and this pressure 
too frequently repeated, the blood-vessels do not recover during the brief 
periods of rest. In this way the brain becomes congested, and oedema 
of the cerebral tissue follows with alteration of function, symptoms of 
headache, sluggishness and perversion of thoughts, absence of mind, 
irritability, inability to fix the attention, which may lead even to organic 
diseases of the brain of various kinds. 
It behoves the physician of the present day, however, to be exceed- 
ingly cautious in suggesting to schoolmasters that a certain brain is 
incapable of bearing the strain imposed, for the demand for our public 
schools being greater than the supply, the unfortunate pupil who may 
only require, in order to enable him to compass his duties, a little con- 
sideration in easing or lessening his hours of work and increasing his 
sleep, may not receive the required sympathy, but may be told that if he 
469 470 
SYSTEM OF MEDICINE 
cannot keep in the running his place must be filled by another eager 
applicant; his future career may thus be compromised. The brain wastes 
in all illness, and this atrophy renders it totally unfit for work, or even 
for reading a difficult book for a considerable time. I have not yet 
succeeded in impressing upon parents and teachers that, so far as one 
can judge from the apathy exhibited in these cases, and the easily 
induced fatigue, as well as from observation of nature, the brain wastes 
in equal proportion to the waste of the body. 
It must also be remembered that knocks on the head, to which boys 
are liable from various causes, may alter the nervous structure, possibly 
from bruising and minute ruptures, and that prolonged cessation from 
work should be enforced even when the blow may have been of a com- 
paratively trivial nature. [ Vide art. on "Concussion of the Brain."] 
But overwork is yet more pernicious in its effects when the necessity 
of an ample allowance of sleep is not recognised. It is a well-established 
fact that more sleep is required for the formative than for the intel- 
lectual activity of the cerebral centres ; yet what a record do our 
schools furnish in this respect! It must not be supposed that the 
deleterious effects of overwork during youth can be compensated by an 
additional amount of sleep, for nature will not permit a forced brain to 
rest - one of the most manifest symptoms of undue pressure being wake- 
fulness. The over-exercise of the animal functions nature does not resent, 
for the more the muscles are used the more the brain will rest. Teachers 
should know that deficient sleep means stunted brain and body, and must 
not forget that it is only by graduated exercise of the mental faculties 
that the highest condition of brain development may be secured for work 
in after years. Yet the child on entering school is only allowed the 
same number of hours of sleep as the big boy who is leaving, whereas 
two hours more should be allotted as the following table shows: - 
Age. 
Hours of sleep. 
Under 10 years .... 
11 
„ 13 „ . 
10J 
„ 15 „ . 
10 
„ 17 „ . 
9| 
„ 19 „ . 
9 
The Amount of Sleep required during Youth. 
But while the child's brain may be perfectly satisfied on this scale 
until the advent of puberty, yet for some time before and after that 
date, perhaps a year - when the growth is enormous, especially in the 
case of girls, and the development of new organs entails a severer 
stress upon the system - this amount is insufficient, as much more 
sleep is required for growth than for repair. 
VI. The Exercise of the body is necessary to attain a maximum of 
growth and vigour. - But the brain can never attain its largest growth 
nor its highest quality of nervous tissue from the exercise simply THE HYGIENE OF YOUTH 
471 
of its own functions, for it is dependent to a large extent upon the 
vigour of the body, which is the manufacturer of the material on 
which it lives. As I have already pointed out, the growth of the brain 
depends upon the condition of its blood-supply; and the condition of the 
blood is dependent upon the state of the circulation, respiration, and the 
muscular and digestive systems. Hence the importance to the young 
of sufficient exercise. This exercise should take the form of games or 
recreation, in which refreshment the brain participates, rather than the 
form of a set lesson in the hands of a gymnasium instructor or the 
drill sergeant. These latter modes of exercise are desirable enough, 
but they should be an addition to, rather than a substitute for school 
games. 
Exercise during youth is excellent: games are invaluable. We, as a 
nation, owe our success chiefly to our mental and bodily vigour, - a 
vigour which is irrepressible, and dependent mainly upon the games of 
boyhood, which render possible our sports of manhood. What other na- 
tion would dream of playing football in India and polo in Burmah ? The 
physical education of the young trains them in perception and judgment, 
as well as in adroitness and courage. Even yet, however, the influence 
of physical education on mental and moral growth is not sufficiently 
regarded, nor is it yet fully recognised that bodily and mental culture 
must be concurrent if the highest development is to be attained. The 
sportsman precedes the trader in new countries, and the trader the 
statesman. Their qualities can be developed in our school playing- 
fields : let them, therefore, be encouraged in every possible way. No 
question in the training of the young is of more general importance than 
the mode of occupying out-of-school hours. This freedom from work 
should be a period of cheerful recreation and constant lively occupation, 
otherwise it becomes a time of weariness and idle lounging, and the 
character and tone of the young must consequently deteriorate. 
In physical exercise all the functions of the body are engaged; the 
circulation of the blood is quickened, more oxygen is inhaled, and the im- 
purities of the blood are thereby oxygenated and destroyed, so that the 
excretory organs of the body may remove the detritus from the system. 
Observe the young boy who is keen in games, and compare his physical 
condition with that of the dawdler. Notice his healthy complexion, good 
wind, elastic gait, splendid muscles, increased stature, and sure promise 
of vigorous manhood. Consider, again, how boys' games tend to develop 
a well-balanced mind and character; how they instil, as nothing else can, 
glowing spirits from the robustness of health, quick response to calls of 
duty, frankness of disposition, good temper often under trying circum- 
stances, love of justice and fair-play, self-reliance, endurance, confidence 
in comrades, desire to excel, quick judgment, aptness to act with others 
for the good of all, courage under pain or difficulties, self-control, and 
last, but not least, how they check morbid desires and sensations by the 
expenditure of superfluous energy, which ensures purity of life. If 
school games had no other salutary influence than that of affording a 472 
SYSTEM OF MEDICINE 
wholesome topic of conversation in out-of-school hours, they would be 
worth the infinite trouble which should be bestowed upon them. 
In the regulation of the games of the young, where healthy rivalry 
may, in the inexperienced, lead to excessive competition, I think the 
physician should have a voice. I would, therefore, suggest the following 
precautions which are reasonable, without the unnecessary fuss which 
pupil and teacher alike resent: - 
1. The physical examination of all children when they first enter 
school. In this way only can the healthy be safely compelled to play 
all games. 
2. The proper apportionment of exercise consequent on this exam- 
ination, in order that the physically weak, diseased or deformed may be 
restricted to that exercise which is suitable to each. In this way only 
should any boy be excused from the ordinary school games. 
3. The medical control of all severe exercise, so that even those who 
are physically fit to undergo it may not be permitted to do so without 
prior and suitable training for the prolonged exertion. It is excess of 
exercise, or exercise imprudently taken, which is so deleterious to those 
who are growing; exercise in proper measure promotes health and 
strength. 
Exercise should be gradual in its increase, or harmful results may 
follow. Those who think that, because they have excelled at some exer- 
cise during one season they can resume it in the next season without 
fresh training, are likely to overstrain and injure themselves. If we do 
not, therefore, wish to hear of the dangers of rowing, of running, and of 
football, of the golf arm and of the tennis leg, the muscles necessary to 
these exercises must be trained by degrees at the commencement of each 
season. All muscles may be educated to any strain within reason, but 
unused muscles are unable to bear sudden or prolonged efforts. 
Syncope in boys during exertion is usually attributed to exhaustion, 
but my experience has shown that, while it may in some cases be occa- 
sioned by the physiological condition of the heart and vascular system 
at puberty, or be due to a temporary dilation of the heart resulting from 
active physical exertion in an unfit state of body, it is more frequently 
toxsemic, the excreting organs being inadequate to the new and sudden 
call upon them. 
Physical education requires as much forethought, method, and appli- 
cation as mental, whereas too much routine is involved in both. 
For all games entailing exertion the player should be clothed in 
flannel, which should be changed immediately afterwards and dried; 
where this care is not observed, chills and even dangerous illnesses are 
apt to arise. 
It is customary for the young to undergo training for boating and 
other athletic sports. The purpose of training is to place the body in 
such a condition as to enable it to perform the hardest physical work 
rapidly, or for a prolonged period; it is, in fact, to produce the highest 
possible state of health for hard physical work. The essence of training THE HYGIENE OF YOUTH 
is that the heart and lungs should become accustomed to sustained 
exertion, and this is effected by degrees. 
In training to obtain good •" wind," it is of the highest importance 
to avoid indigestion, for nothing more thoroughly defeats that end. 
Food, therefore, as I have said, should be eaten slowly and masticated 
thoroughly, and no food should be taken between meals. There is a 
fallacious opinion among all trainers, be they trainers of mankind or 
of horses, that to those under training the smallest quantity of fluid 
should be allowed; hence these persons often suffer from actual thirst. 
Many people do indeed drink more than is requisite to satisfy thirst, 
man being the only animal which resorts to this mischievous practice. 
It should be a rule with every one, in order that the highest condition 
of health may be attained, to take only a sufficiency of fluid, say from 
two to three pints daily, except in hot weather or under great exertion 
and sweating. Water sufficient to satisfy thirst should be freely allowed, 
but in small quantities at a time; thus the athlete never becomes actu- 
ally thirsty, - for every ounce of fluid which leaves his body another 
is supplied in its place. Dry tissues and unnaturally thickened thirsty 
blood are unfit for the highest functional activity. To suffer thirst for 
minutes or hours, and then, when the exercise is over, to take, as many 
do, an excessive quantity of fluid, may well cause discomfort, take away 
appetite, and entail indigestion and loss of sleep. 
Again, change of work and change of play are as important as variety 
in diet. At the present time the games of the young are too monoto- 
nous, and insufficient attention is paid to natural tastes and aversions. 
This is not the place to discuss the merits of the several games suitable 
for boys and girls during their growth; but I would point out that the 
exercise adapted to boys is also compatible with the health and physique 
of girls up to the age of puberty; after that age the games of girls should 
gradually pass year by year into exercise of a quieter character. 
The exercise obtainable from games, as well as that from hand-culture, 
should be various, not only for the better development of bones and 
muscle, but also for the development of the brain itself, as every com- 
plex movement has its brain-centre, which, in its turn, is developed by 
the exercise of its functions; so that we want not only football, cricket, 
rowing and running, but in addition, walking, brook-jumping, high- 
jumping, skipping, swimming, skating, racquets, fives, lawn-tennis, la 
crosse, golf, hockey, baseball, wrestling, fencing, boxing, gymnastics, 
physical drill, cycling, rifle-corps drill, rifle-shooting, camping-out, work- 
shops, natural history excursions, gardening, music and drawing. With 
such variety of exercise, and mountaineering, riding, shooting and fish- 
ing in the holidays, the brain and body will be formed as a complete 
and harmonious whole. 
The physical education of girls is seriously neglected, and little or no 
attention is paid to their bodily development. Why do girls so fre- 
quently fail in health directly they undergo hard mental work, some- 
times becoming incapacitated for life, physical wrecks, and the victims 
473 SYSTEM OF MEDICINE 
474 
of hysteria and other neuroses ? Simply because they and their friends 
attempt the impossible. If we are to have the higher mental education 
in girls, of which they are quite capable without injury, they must not 
be pressed, as they are at present, during these years when their growth 
and development are enormous, viz., from 11 to 14, when they leap, as 
it were, from childhood to womanhood at a bound, for all their nervous 
force is expended in this direction. Teachers must not fail to recog- 
nise the difference in constitution between the boy and girl. Continual 
application to work from day to day, from week to week, and from 
month to month, should never be enforced on girls; nor should they even 
be allowed to make such efforts; cessation and rest at menstrual periods 
should not only be encouraged, but even enforced. Their mental edu- 
cation, again, must proceed pari passu with a thorough physical educa- 
tion, otherwise, with rare exceptions, it must end in failure; perhaps 
in serious or life-long misery. If in Great Britain we cannot yet 
manage both, let the mental education remain as it was, and the physi- 
cal education be undertaken more completely, so that girls may by 
degrees be prepared for the higher intellectual education, and become 
better suited for their womanhood. 
At the present time a girl's education is effeminate, whereas it should 
feminine. Why has it been considered unladylike for girls at school to 
be allowed any other outdoor exercise than a formal walk in the street ? 
There is no conceivable reason for this restriction. The lady who has 
the courage to break through the spell and establish a good school for 
girls, in which their physical education shall be as well organised as 
their intellectual and moral education, will deserve well of her country, 
and will carry out one of the greatest and most needed reforms of the age. 
Girls are naturally more subject than boys to nervous excitement, but 
this could be more effectually restrained by a sounder physical develop- 
ment. Our girls are so often what they are - " nothing but nerves," 
or " nothing but emotions," ready to faint on any, or without any provo- 
cation - because they are suffering from their faulty training and con- 
ditions unnatural to them; these evils will disappear when girls are 
reared under a reasonable system. 
The absence of daily, regular and sufficient exercise renders girls list- 
less and apathetic, entails pallor and anaemia, constipation with its sal- 
lowness, foul breath, and depressed spirits, crooked and stooping backs, 
and knock-knee and flat foot with characteristically awkward gaits. 
It should be the aim of parents and teachers to instil into girls' minds 
the fact that it is their duty to try to be physically strong, and to pro- 
vide for its attainment by adequate means. They should be taught the 
necessity of being vigorous as well as graceful, and naturally, instead 
of artificially shapely. But this perfection of body can only be reached 
during the period of youth, and by physical exercise, which, duly regu- 
lated, promotes not only muscular development, but also a vigorous 
nervous tissue and brain capacity, and above all, that strength of char- 
acter which curbs irregular nervous expenditure. I repeat, if girls are to THE HYGIENE OF YOUTH 
475 
receive a higher culture their physical education must precede any 
increase in their mental education. Without this the process cannot be 
safely effected, for the mental powers are developed in woman at a high 
physiological cost, which her feminine organisation will not sustain with- 
out more or less profound injury if bodily vigour go not hand in hand 
with it. It is more essential for a nation to produce strong, vigorous 
offspring than to educate girls to the highest standard. By the highest 
physical education girls can be made strong, comely and well-propor- 
tioned ; while by the highest mental education (without this physical 
basis) they may be made into "blue-stockings," or neurotics, or both 
together. By physical education I mean games and recreation which 
cheer and elate, not merely gymnastics and physical drill, which afford 
exercise without elation. These latter exercises are mainly for the 
sickly and deformed; and curative rather than animating. By physical 
exercise, too, I mean exercise taken out of doors; without this condition 
at least half of its value is lost. In wet weather dancing should be 
encouraged; graceful movements and carriage are only to be attained 
by means of well-developed springy muscles. Every educator of girls 
should feel disgraced by the lounging attitudes and awkward gaits which 
prevail at most girls' schools, with their lop-sided shoulders and crooked 
backs, for in these is manifest the vicious system of education in vogue. 
Symmetry is of paramount importance in women for ensuring the pro- 
duction of healthy offspring. 
While I hold that, subject to the restrictions I have laid down, girls 
may safely receive a higher education than has hitherto been accorded 
to them, I would urge that their moral education is of more consequence 
to themselves and the nation than their purely intellectual development. 
With a physical education such as is their due, we should, almost in a 
generation, eradicate the neuroses and anaemia to which at present girls 
are so prone; in their place we should perceive more even spirits and 
more stability of character, and the aping of man would give way to a 
more dignified respect for the qualities of their own sex. 
I trust I have made it manifest that to produce a sound human 
being, it is imperative that there should be a concurrent development of 
mind and of its physical basis during the period of youth. It is during 
these years only that we can educe faculties, form character, and invigo- 
rate the physical powers and functions. The school, where most of the 
years of youth are passed, is an epitome of the world at large, - a place 
in which to prepare the young, and not to unfit them, for their duties as 
men and women. 
Clement Dukes. 476 
SYSTEM OF MEDICINE 
LIFE ASSURANCE 
Life Assurance, although scarcely two centuries old, bids fair soon to 
embrace the whole civilised world. 
The casualties of life have become matters of scientific prediction; 
what seemed to be 11 accidents " are seen to be less and less under the 
dominion of " chance," which, indeed, is but a word to express our igno- 
rance of the laws in operation. 
The likelihood that a confidential servant will betray his trust can 
be estimated and provided for with the same precision as the probability 
of the occurrence of a storm, a shipwreck, a murder, or a suicide. 
The medical selection of lives was not attempted in the early days 
of life assurance. The first life assurance society, " The Amicable," was 
founded in 1706, and existed for years before a medical officer was 
appointed. The same premium was paid by each applicant, whatever 
his age or apparent health. He was, however, called upon to state on 
oath that he believed himself to be a good life. 
In process of time it was found desirable to exclude manifestly un- 
healthy applicants. Hence the proposer was required to appear before 
the Board. Some directors were shrewd in their judgment as to the 
value of a life, but it soon became apparent that a medical inspection 
was required for the selection of 11 first-class lives." The first medical 
officer was appointed to the " Amicable " in 1855, and to the " Equi- 
table" in 1858. 
Besides the health, the age of the life to be assured needs considera- 
tion, and the duration of the term of the assurance. 
The premium required being greater in proportion to the age or 
" expectancy of life," it is customary for the medical adviser, in estimat- 
ing the necessary addition, to ask himself the question, "Will the appli- 
cant before me, now 30 years of age, live as long as a healthy man at 
35, 40, 45, or 50 ? " If he considers that the " expectancy " of the 
invalid life before him is as good as that of a first-class life at 45, he 
advises the addition of fifteen years in estimating the annual premium. 
Other questions, besides the medical selection of lives, call for the 
attention of the profession; although in the domain of the actuary they 
have intimate relations with medical and medico-legal science. 
Term policies are issued for short or long periods, of days, months, 
or years ; a life may be accepted for a " short term " when uninsurable 
for a long one. Some disabilities that prevent the acceptance of the life 
may, however, so greatly increase the danger of speedy death as to 
demand the refusal of the risk, even for a few weeks; this is especially 
the case if the " habits " are bad. The premium receivable for a short 
period being very small, the loss involved in the event of a claim occur- 
ring is so great that no ordinary addition to the premium would cover LIFE ASSURANCE 
477 
the risk. In these cases a large premium, say 3 or 4 per cent, is 
sometimes suggested instead of the usual addition of years. 
Contingent risks, or assurance payable only in the event of one person, 
generally young, dying in the lifetime of another, are rendered unduly 
dangerous to the office if the younger life is a seriously damaged life. 
A high extra rating may then be insufficient to cover the risk. Thus a 
"weedy" youth at 25, whose habits are uncertain, may be ineligible 
against a healthy life at 50, though insurable for life with an addition. 
The medical examiner thinks only of the case before him; the actuary 
reminds him that, whilst the loss on a particular case might be compara- 
tively large, the greater number of the " contingent risks " are never 
heard of again by the doctor or by the Board; they become void by 
reason of the death of the older life, or are dropped, the assurance hav- 
ing been effected for temporary purposes. 
Furthermore, the mortality among recently examined lives (say 
within five years) is less than the tabular rate; consequently, for all 
forms of assurance where the period (five years) forms a considerable 
portion of the risk, the calculated premium is slightly in excess of the 
true net premium, and the "loading " in contingent cases is usually heavy. 
Issue risks are often affected when the " heir presumptive " wishes 
to raise money on his expectations, there being no "heir apparent; " 
also when it is desired to quash a trust in favour of children, a marriage 
having been childless. In such a case the risk to be considered is not 
so much of issue by the existing marriage as of the death of the wife 
and remarriage of the husband; the chief considerations being the health 
of the wife, and the prospect of the man marrying again late in life and 
having children. If the wife's health be uncertain, the prospects of a 
second fertile marriage by the man may be considerable. 
The cause of sterility in the woman often needs consideration. If 
this be removable the risk, of course, is greatly enhanced. Sometimes the 
issue risk to be covered is not only the birth of an heir, but his attaining 
the age of 21. A variety of issue risks has been proposed in which the 
probability of a woman, known to be pregnant, giving birth to viable 
twins has to be considered. In certain families and with certain indi- 
viduals the probability of twin births is enhanced. 
Endowment assurances payable during life, say on reaching the age 
of 50,55, or 60, have tended to modify the work of a medical examiner by 
increasing markedly the proportion of " first-class lives." A proposer 
having a shrewd, perhaps well-grounded suspicion that his life will be a 
short one, in his natural endeavour to pay as little as may be for his 
privileges, is likely to select a whole life " without profits " policy, rather 
than a short term endowment which would double the annual premiums. 
It is on this account that the medical examiner should scrutinise with 
especial care the " without profits " whole life policies, and look with a 
favourable eye on the short term endowments. 
Members of the medical profession, who feel that Life Assurance is 
a business of which they have some special knowledge, tend more and 478 
SYSTEM OF MEDICINE 
more to regard endowment assurances as a safe and remunerative form 
of investment in which they can obtain 3, 4, or even 5 per cent compound 
interest on their yearly savings, besides the security of an ordinary life 
policy in case of premature death. A man set. 25 may, for annual pay- 
ments of £28, secure an endowment of £1000 which, on attaining the 
age of 60, amounts with bonus additions to about £2000. At set. 35, 
his practice having increased, he may take out another policy for £2000 
at an annual payment of £83, so that on reaching 60 (when perhaps his 
powers are waning and his professional income diminishing) he receives, 
say £5500, and has no further premiums to pay. 
The claims on this class of assurance are exceedingly small. When 
any cause, hereditary or personal, leads to the anticipation that the life 
will not be prolonged much beyond set. 60, although normally secure up 
to that time, it is becoming customary to advise " endowment " of such 
cases; thus, perhaps, the remarkable absence of claims in this class may 
be somewhat modified. 
The relative duties of chief medical officer, medical referee, and 
medical attendant need definition. 
It is undesirable that the ordinary medical attendant should act as 
medical examiner for an office, although occasionally there is no alterna- 
tive. If he undertakes to report, and accepts the fee, he is bound to 
consider the interest of the office first, and that of his patient as of 
secondary importance; motives of personal friendship must not influence 
his report. 
The medical examiner is the adviser retained by the office, and is 
bound to consider the interest of the office as paramount. He must not 
allow himself to be swayed by the arguments pressed upon him, often 
with undue insistence, by the " agent," whose interest it is to carry 
through business, however insecure. The facts which the agent will 
supply may be valuable, but are apt to be one-sided and to need dis- 
criminating interpretation. 
In some offices, where the desire to get business is great, the actuary 
may also try to put undue pressure on the medical referee, who must 
then remember that he is responsible to the directors, and is bound to 
consider first the well-being of the office. Whilst it is the function of the 
agent, and in a measure also of the actuary, to "carry through" every 
proposal, it is for the doctor to separate the wheat from the chaff, and 
to refuse insecure lives. 
When an agent finds it difficult to mould the medical examiner, he is 
apt to try to take the proposer to some medical friend whose opinion he 
can dominate; hence it is important not to accept the report of an un- 
authorised examiner without full and satisfactory explanation. A large 
number of bad lives are thus insured in offices which do not insist upon 
reports from a medical referee of their own selection. 
In his personal examination of an applicant each medical man should 
follow the methods of diagnosis to which he is accustomed. 
He should take note of the condition of the heart and great vessels, LIFE ASSURANCE 
the lungs, the kidneys, etc. He will probably learn much from the 
character of the pulse and cardiac rhythm, and still more from the 
aspect, the morale, and general physical condition. 
Whilst taking pains to investigate the case and estimate exactly the 
probabilities of life, the medical examiner should avoid over-examination. 
Would-be insurers are frightened away by too elaborate an investigation 
and too exacting an air. It is not necessary in every case, as some 
morbidly conscientious tiros seem to think, to use sphygmograph, laryn- 
goscope, ophthalmoscope, and so forth. When the office is represented 
by a competent and carefully selected medical adviser, the end sought is 
best obtained without insisting on the registration of pulse, respiration, 
temperature, and quality of heart and lung sounds in various situations. 
Such formal inquiries tend to draw away attention from essential points, 
and vitiate, if they do not destroy, the value of the report. Even if 
now and then an obscure point be missed the office gains on the whole 
by not exacting too minute an investigation asking too many questions. 
An experienced medical man should not take very long in deciding 
" yes " or " no," and he should not look too critical or " difficile." 
If he himself has to labour through an endless series of questions, 
many of them trivial (e.g. colour of hair and eyes), and nonsensical (e.g. 
" of what temperament is the applicant ? "), he has little time or spirit 
left for forming an independent opinion, or for the exercise of that 
sagacious and comprehensive judgment which, after all, is the thing 
sought. 
Some offices receive reports from medical men having little experience 
of assurance practice, as is seen by their conclusions which have little 
relation to the observations on which they are based. Thus cardiac 
imperfections or albuminuria are mentioned, and yet the case recom- 
mended at ordinary rates, or perhaps with an addition of three years: 
or a high loading is suggested with nothing in the body of the report to 
justify it, except perhaps hernia or doubtful family history. 
Offices whose forms are filled up by all sorts and conditions of 
medical men may find it of use to try to obtain facts rather than in- 
ferences ; but where competent men are selected to make the examina- 
tion, the simpler the form the more valuable the report. The following 
simple forms have been proved by long experience to be useful ones. 
They give an opportunity for stating in order the points likely to be of 
most importance for the consideration of the chief medical officer. 
If an application be made to the " medical attendant," Form No. 2 
is suitable. 
479 
Form A. No. 1 
Name, residence, occupation, age. 
Are you married ? Have you visited the tropics, when, and for how long ? 
Are you now in good health ? Is your health generally good ? What medical or 
surgical assistance have you required, and when ? 
Questions SYSTEM OF MEDICINE 
480 
Have you any reason to suspect yourself liable to any affection of throat, lungs, 
heart, or any other organ ? 
Do you know of any hereditary disease in your family, such as asthma, con- 
sumption, insanity, scrofula, cancer, or gout ? 
Father, mother, brothers, sisters, age if living; if dead, at what age and from 
what cause ? Is your family a healthy one ? 
I declare foregoing particulars to be true (to the best of my knowledge and 
belief). Signature of proposer. 
The medical officer is then requested to report the result of his 
examination and inquiries in the following form : - 
Height and weight of applicant (about). State of lungs, as shown by physical 
examination. Haemoptysis. State of heart (by physical examination). Pulse. 
Gout or rheumatism. Digestion and abdominal organs. Genito-urinary system. 
As to habits, whether regular, temperate and healthy; occupation and 
pursuits, whether or not detrimental to health. If a woman, state of uterine 
functions. 
Is there any other circumstance calling for remark ? 
From examination do you think he seems likely to live as long as any other 
person of his age, and do you recommend his life to be accepted ? 
If so, whether at ordinary rate ? 
If not, what addition to the age do you advise ? 
Signature of medical referee, address, qualification, date. 
Family History 
Form No. 2 
Confidential. How long have you known Mr. ? Are you in the habit of 
seeing him frequently ? For what diseases have you attended him ? 
When did you last see him professionally, and for what disease ? 
Has he to your knowledge ever had any serious illness for which he has been 
attended by any other medical man ? 
Has it come to your knowledge that any of his near relations have suffered 
from consumption or any other hereditary disease ? State what you may know, 
or are able to ascertain, of the health and longevity of his parents and other near 
relations. Do you consider that he is now in good health, that his cerebral, tho- 
racic, and abdominal organs are sound ? If not, state in what respect they deviate 
from health. 
Is he temperate in his habits ? What are his pursuits, and are they detrimental 
to health ? 
Is his physical conformation such as is consistent with a fair average life? 
Is he likely to live as long as any healthy person of his age ? Do you consider that 
on the whole his life is a first-class one ? If not, state the grounds on which you 
form your opinion, and the addition you think should be made to his age to meet 
the extra risk. 
A space is left for any "special question" which the actuary or 
chief medical officer should, from other information, deem important, 
and a space left for signature, qualifications, and date. LIFE ASSURANCE 
481 
The medical examiner should secure a private interview, for in the 
presence of the agent, or of any friend or relation, people are apt to be 
less frank and unconstrained. The proposer should be placed as much 
as possible at ease, and the inquiries should be made with quietness, 
courtesy and deliberation. The proposer should realise that he must 
give honest answers to definite questions, which are neither impertinent 
nor inquisitorial. 
Directors are rightly severe in refusing applicants found to be tricky 
and secretive; when a proposer is detected in making a false statement 
it is right to decline to accept him. 
Life assurance should be an honourable transaction for mutual ad- 
vantage, and an attempt to overreach should not be lightly passed over 
by either party. 
Preparation for Medical Inspection.-Before venturing to appear for 
medical examination many candidates take a bath, visit the barber, 
attend to the tongue, the teeth, and sometimes consult their family 
doctor that " they may be put in order " and be prepared for the ordeal. 
They also avoid giving any information about family and personal his- 
tory which might lead to an extra rating, and dexterously omit all 
incriminating details. 
Tropical Rating. - The practice of applying an extra rating for resi- 
dence in the tropics, whilst giving occasion to criticism on the part of those 
who disapprove of the imposts, has been found to work fairly on the whole. 
The risk of death in the early years of tropical life is considerable; 
it should be also remembered that an extra payment is demanded only 
during residence in the tropics, and is taken off when the proposer re- 
turns to Europe, with health perhaps broken by tropical disease. 
The habit of "rating-up" for tropical fever, ague, dysentery, etc. 
(those who come for assurance after living abroad), is also fully justified 
by experience, as also are the ratings for " active service in the field." 
Ratings for dangerous avocations call for consideration, among these 
the most frequent are occupations connected with the drink trade. It is 
customary to add a 50 per cent extra to such cases, even if classed as 
"A 1 " by the medical examiner; but it is probably wiser to follow the 
rule of the more cautious offices, and absolutely to decline to accept pro- 
posals in such cases. 
Extra risks arising from hunting and other active sports, which 
occasionally lead to a broken neck or concussion of the brain, may be 
accepted at ordinary rates on the ground that the improved health and 
longevity secured by an active, open-air life will more than counter- 
balance the extra risk. 
Details regarding the diagnosis and prognosis of well-defined diseases 
may be dispensed with, but there are various conditions of imperfect 
health more difficult to assess concerning which something must be now 
said. 
Susceptibility to disease, whether catarrhal or zymotic, exhibited by 
the proposer or his family needs consideration. 
2 i 
VOL. I 482 
SYSTEM OF MEDICINE 
Vulnerability means increased risk and therefore extra rating. 
Obesity. - Among conditions which may not be classified as " disease," 
or even " impaired health," undue stoutness, or excessive weight in pro- 
portion to height, calls for consideration. If obesity do not directly 
shorten life, it greatly increases the risks from acute and chronic disease. 
When an effort is needed to meet some unexpected strain, a large extent 
of useless, cumbersome tissue, a fatty heart, loaded liver, restricted lung 
surface, or kidneys prone to disease, become powerful allies of any inter- 
current disease in the assault upon life. 
As soon as a man's weight increases much above the average weight 
(see table), and the abdominal girth exceeds the chest girth, an extra 
rating is called for. Weight alone, without consideration of the build, 
the size of the bones, the conditions of the muscles, etc., is not a sufficient 
guide. Where the muscles are flabby, the abdomen pendulous, exercise 
insufficient, and food excessive, these conditions are incompatible with 
prolonged health. 
A man, set. 40, who, since the age of 20, has steadily increased in 
weight and bulk, and finds his breathing short on exertion, should not be 
accepted without an addition of five years, even though in all other 
respects he may seem well. Experience has shown (see Report on Invalid 
Lives, Equity and Law Assurance Society) that cases rated upon the 
ground of " stoutness " have proved a very unfavourable class. Habits 
of excessive eating and drinking and insufficient exercise tend to shorten 
life, and the very obese must be declined, or accepted for short terms 
with high rating. 
Leanness. - When the weight is markedly below the average careful 
investigation as to the cause is required. If loss of weight be progressive 
the risk is enhanced, and the necessity for an explanation of the cause 
essential. It may be an early indication of phthisis, diabetes, cancer, or 
other progressive disease in the organs of digestion and assimilation. 
Table of Height and Weight 
Feet Inches 
Stones Lbs. 
Feet Inches 
Stones Lbs. 
5 
3 
8 
13 
5 
10 
12 
4 
5 
5 
9 
11 
6 
0 
13 
5 
5 
7 
10 
10 
6 
2 
14 
7 
5 
9 
11 
10 
6 
4 
15 
9 
If due to unusual slimness this need not necessarily imply delicacy 
or vulnerability, for the thin and " wiry " are (proverbially) long lived, 
or at least have so great an aptitude of recovery from disease as to justify 
their acceptance without extra rating, if careful inquiry elicit nothing 
against the life. 
Leanness associated with feeble physique calls for considerable 
" extra." A man, 5 ft. 7 in. in height (see table), whose weight is but 
8 st. 10 lbs. instead of the normal 10 st. 10 lbs., is probably a better life LIFE ASSURANCE 
483 
than a man of the same age who weighs 12 st. 10 lbs.; or a man, 
aet. 40 5 ft. 10 in. in height, weighing 10 st. 4 lbs., instead of the nor- 
mal 12 st. 4 lbs., is a more favourable life - other things being equal - 
than if his weight were 14 st. 4 lbs. 
Two stone above or below the normal need in neither case necessi- 
tate extra rating, but demand extra caution. Note should always be 
taken of such deviation, and if no explanation be forthcoming adequate 
ground exists for extra rating. 
Heredity. - Longevity is hereditary in some families, as is prema- 
ture death in others (see Analysis of Peerage Mortality, Sprague), and 
this without noticeable strength or feebleness of physique. 
When a tendency exists in the line of both parents to any special 
disease the heredity is intensified, notably in phthisis, cancer and 
insanity. The mother's power of transmitting disease to sons, who 
form the majority of insured lives, is greater than that of the father. 
As with phthisis, hereditary gout is manifested earlier than the 
acquired form. If a tendency to gout or asthma exist on both sides a 
considerable extra rating is called for; where cancer is doubly inherited 
it is safer to decline, or to require all premiums to be paid by the age 
of fifty. Where one parent only has suffered from gout, rheumatism, 
heart disease, diabetes or cancer, this may be overlooked if the case be 
otherwise unexceptionable. 
An investigation into the life and health of grandparents, aunts, 
cousins, is usually supererogatory, but the medical referee may be often 
aided by such an inquiry; he should never omit to report on the brothers 
and sisters of the proposer. 
Phthisis. - As one death in eight is attributed by the Registrar- 
General to this cause, its early detection is of primary import; and as 
the mortality from phthisis among assured lives is but eight per cent, 
it is evident that medical selection has proved of great value. Half the 
mortality from phthisis among the assured occurs before the age of 40, 
and three-quarters before 50. (A large proportion of proposers have 
passed the most dangerous years from 15 to 25.) 
The occurrence of haemoptysis needs careful consideration; if follow- 
ing strain, and there be no evidence of inheritance, of heart or lung 
defect, of wasting or constitutional disorders; and if the applicant have 
passed the age of 30, the life may be accepted with a slight addition. 
Where hereditary tendency exists, the chest is long and narrow, the 
weight light, and the pulse quick, the life should be refused. Indeed, 
the coexistence of haemoptysis with a history of hereditary phthisis 
would call for refusal. Full consideration of physical signs, etc., will 
be found in other articles. 
In insurance practice, where the opportunities for complete examina- 
tion of a case are limited, it may not be easy to make a prognosis with 
adequate confidence to justify the acceptance of a life with serious 
organic disease; but every life has its value and, with advancing patho- 
logical knowledge, accurate clinical methods and acquaintance with the 484 
SYSTEM OF MEDICINE 
natural history of disease, a prognosis may be made with sufficient 
precision to justify the acceptance of the risk. This is certainly the 
case with the varieties of valvular disease of the heart, and in some cases 
of chronic fibroid change in the lung the life may be assessed with equal 
confidence and accepted with extra rating for short periods, or under the 
" endowment " or " limited payment " system. In cases of this class, 
however, the chief medical officer would probably require to see the case 
himself, and would not recommend it to the acceptance of the Board 
on any second-hand information. 
Emphysema, when associated with chronic or recurrent bronchitis, 
especially if any signs exist of commencing cardiac dilatation, must be 
refused. If a somewhat inelastic chest wall, a prominence of thoracic 
venules, and tendency to dyspnoea on exertion, alone mark the emphy- 
sematous tendency, or if only occasional asthmatic attacks are recorded, 
an extra rating will suffice. Liability to bronchial attacks, whether of 
gouty, syphilitic, or phthisical origin, renders the life precarious even 
for very short terms. 
Pleurisy. -Where traces of pluerisy exist, if the proposer be young, 
and if family and personal history, aspect, pulse, etc., should point to a 
possible tubercular origin or complication, the case should be declined. 
If the evidence indicate no more than the local contraction consequent 
upon old pleurisy of non-constitutional origin, a small extra rating will 
suffice. 
Heart Disease. - The diagnosis and prognosis of cardiac disorders 
are fully discussed in other places; I can only say here that cases in 
which indications of muscular failure exist are uninsurable. Where 
compensatory hypertrophy conceals all evidence of circulatory defect 
the case may be considered, and acceptance advised on condition that 
all premiums be paid before degenerative changes are likely to occur. 
Aortic disease is more perilous than mitral. Cases of mitral stenosis 
and aortic regurgitation can but seldom be accepted. Less, however, 
depends on the situation and character of the murmur than on the 
history and constitutional state. 
Irregular action, with feebleness of impulse and confused rhythm, is 
of evil portent. 
Intermission of the pulse and apex beat may not prove the existence 
of serious defects, but calls for close investigation, and often leads to the 
discovery of gouty, dyspeptic, or nervous disorder. 
The rapid, nervous, palpitating "insurance heart," so constantly 
observed among candidates for life assurance, requires skill and experi- 
ence for its estimation. The beat is so rapid, tumultuous, bouncing and 
diffused that it suggests the idea of serious disease, and may indeed mask 
organic defect. Its variability and manifest association with general 
nervous perturbation will generally enable the physician to assess its 
import at the first interview; if not, a second should be arranged. 
Some proposers faint when thus examined, and may justly be regarded 
as too unstable to be accepted as first-class lives. These are persons who LIFE ASSURANCE 
485 
are morbidly sensitive to a refusal or an extra rating, and it is important 
by firmness and kindness of manner to give them confidence and self- 
reliance. A medical referee cannot be too careful to avoid causing 
distress or anxiety in an applicant, even if he be obliged to decline the 
proposal. 
Gout. - The bearing of gout on life assurance is important. Experi- 
ence proves that a high extra rating is necessary. Gout was regarded in 
the early days of life assurance as conducive to longevity. The free 
imbibition of port was followed by occasional explosions recurring for a 
quarter or perhaps half a century, and leading to no marked deterioration. 
In recent years the wide extent of gout, as a constitutional affection leading 
to heart, kidney, liver, and more general tissue change, has been recog- 
nised even when no joint affection has occurred. Gout, as we know it 
now, calls for rejection in a large number of instances; and an average 
addition of 20 to 25 per cent in cases recommended for acceptance. 
It must be remembered, too, that while phthisis is a " diminishing 
risk," gout is an il increasing " one. The mortality from phthisis falls 
mainly in early manhood, whilst that from gout falls in the years when 
life assurances are most usual, namely, between 50 and 60. 
The close relation often existing between gout and intemperance in 
eating and drinking must not be forgotten; and the extra rating applied 
for " gout " might in some cases be more accurately entered under the 
heading "habits." 
No part of insurance medical practice calls for so much discrimination 
as this. Intemperance, often markedly hereditary, may show itself in 
occasional craving for drink or other forms of nerve excitement, and lead 
to early tissue degeneration; the man who indulges freely and continu- 
ally because he is never drunk being in the greater danger. Tact to 
discern habits of life, and skill to interpret indications (which have 
been perhaps carefully masked), are essential here. 
Among the indications are the hurried manner, loud voice, foetid 
breath, bloodshot sallow eye, flushed face, red nose, tremulous cold damp 
hand, tremulous tongue (often clean, especially in women), engorged 
fauces, carelessness of dress, etc. Where such signs exist no laboured 
proof in " friends' reports," or in the statement of the applicant, must be 
allowed to shake the conclusion of the medical examiner. If he be thus 
beguiled into accepting a life he was disposed, on personal examination, 
to reject for " habits," he is nearly sure to hear of the case " as a claim " 
in a time distressingly short for his reputation and for the office. The 
evidence as to the il temperance, soberness, and chastity " of a suspected 
applicant must not always be estimated by the weight or volume of the 
letters supplied in " friends' reports " ! 
It is not customary to regard hernia, if a suitable truss is worn, 
as a reason for extra rating. Neither need piles nor varicose veins 
be so regarded, except in so far as they give evidence of hepatic 
engorgement. 
A history of fistula, if connected with piles which have been cured, SYSTEM OF MEDICINE 
486 
does not call for surcharge ; but when there is any evidence of phthisis 
or constitutional weakness the proposal should be declined. 
History of gonorrhoea justifies an extra rating; even when not fol- 
lowed by stricture, etc., it often brings in its train prostatic and vesical 
troubles which shorten life. 
Syphilis. - During the existence of this disease in any primary form 
the proposal must be postponed. 
If any secondary symptoms exist in a quiescent state an addition of 
five or seven years is required. When these symptoms have been in 
abeyance for two or more years only the case is not eligible at ordinary 
rates; it should be rejected if any lesion of brain, spinal cord, artery, 
liver, lung or kidney have occurred. 
Albuminuria, whether present or not at the time of examination, if 
connected with kidney disease, with gouty, rheumatic, or cardiac dis- 
order, or excess in eating or drinking, must be declined. 
If the albumin be reported after scarlet fever or exposure, and to 
have disappeared for years, the health being perfect, acceptance may 
be recommended. Where it has been known to exist for many years 
without detriment (such cases have fallen under my observation) the 
case may be accepted, as a case of mitral disease or emphysema might 
be accepted, with a high rating or for a short term. When a trace only 
is to be detected, after food, and recurring at intervals, after several 
examinations at sufficient intervals, and with full knowledge of the case, 
acceptance, with five, seven, or ten years added, may be advised. 
Glycosuria, while it exists, should forbid the acceptance of the pro- 
posal. It is often, however, a temporary condition, and may leave no 
ill effects; unless manifestly due to some transient state it should be re- 
garded as a ground for refusal, and in any case for addition. In every 
form of diabetes the risks are too great to justify acceptance. It must 
not be forgotten that some urines not containing sugar may nevertheless 
cause a turbidity with Fehling's solution. 
In cases of ataxia, and other forms of paralysis of a central kind, 
refusal is called for. In cases of old infantile paralysis, in diphtheritic 
paralysis, and in facial paralysis, a moderate extra should suffice (three 
to five years). 
Pregnancy. -Recently married ladies often insure for very large 
sums, and the risk during the first year of married life is great. 
The mortality in first pregnancies is high (1 in 74, Matthews Duncan) 
and it is wise to defer a proposed insurance until after confinement. It 
is usual to charge a small 10s. per cent addition to the first premium for 
a multipara, 20s. for a primipara. If the age is above 30, and the risk 
thus enhanced, an addition of 30s. is often justly made. 
Claims. - Certificates as to the cause of death should always be con- 
sidered carefully by the medical officer, and it would be advantageous if 
a medical report on each claim could be forwarded to the referee upon 
whose report the life had been accepted. Information to the chief 
medical officer would become the common property of the medical LIFE ASSURANCE 
487 
referees, whose experience would, thereby be increased, as an autopsy is 
invaluable to the physician who had charge of the case during life. 
The wording of the death certificate should be clear and definite. 
Thus syncope may refer only to the mode of death and have no bearing 
on the nature of disease. u Childbirth " may mean phthisis, and should 
be limited to fatal incidents immediately connected with confinement. 
" Gastritis " may be a term used to conceal death from intemperance or 
irritant poisoning. " Dropsy," without evidence of dependence on 
heart, kidney, liver, should not be allowed to pass without investigation. 
If the disease certified as the cause of death existed prior to the 
completion of the assurance, a question arises as to the bonafides of the 
transaction. If the statements made can be proved false the claim could 
not be maintained. 
As a matter of fact offices are most unwilling to refuse any claim; 
but they have and ought to exercise the power to refuse claims mani- 
festly unjust. 
E. Symes Thompson. DIVISION II 
FEVERS 
PART I. - INSOLATION 
PART II. -THE INFECTIONS PART I 
INSOLATION OR SUNSTROKE 
Under the designation of sunstroke, heat-stroke, insolation, thermic 
fever, calenture, heat apoplexy, heat asphyxia, ictus solis, and other 
synonyms, a variety of morbid conditions, from the simplest to the 
gravest, are included. However these conditions may be modified by 
personal susceptibility, local surroundings and climatic influences, they 
are all essentially due to heat, and are the result of direct exposure to 
the rays of the sun or to a high atmospheric temperature in the shade. 
Great heat may cause - 
1. A state of exhaustion leading to syncope. 
2. An overheating of the nervous centres, blood and tissues; with a 
tendency to produce vaso-motor paralysis, hyperpyrexia (thermic fever), 
and subsequent asphyxia through the action upon the respiratory centres. 
Therewith lesions may take place, such as cerebral tissue change and 
haemorrhage, and meningitis in various degrees. The symptoms in such 
cases are varied, and depend upon the portions of the cerebro-spinal 
centres affected. 
The effect of heat upon the human body in tropical climates or else- 
where is a subject of considerable importance and interest. Man, of all 
animals, possesses the greatest power of adapting himself to changes 
of climate and temperature, and maintaining health under them. His 
body, under favourable circumstances of climate, food and habits, has the 
power of maintaining an almost constant temperature under extremes of 
heat and cold. Vigorous healthy persons, who lead temperate and well- 
regulated lives, can tolerate a very much higher temperature than others 
not so conditioned; and the natives of tropical climates - especially the 
coloured races - can tolerate an amount of heat to which the European 
would succumb: even they, however, suffer at times if the heat rise 
above a certain point, and natives of India frequently die from uloo 
marna," hot wind stroke. 
The action of heat is much influenced by the hygrometric condition 
of the atmosphere. A dry hot air is better tolerated than a moist one at 
a lower temperature, because it favours perspiration and keeps the body 
cool; while damp air diminishes evaporation and the refrigerating proc- 492 
SYSTEM OF MEDICINE 
esses of the body. When, from any cause, perspiration fails, or the 
natural eliminative functions are interfered with, especially when the 
air temperature exceeds that of the normal heat of the body, suffering 
soon ensues, and danger from ardent fever or heat asphyxia becomes 
imminent. That these evil consequences are not due to the direct action 
of the sun alone is shown by the fact that many of the fatal cases take 
place in rooms, tents or hospitals, at night, or in the early hours of the 
morning before sunrise, especially if the air be vitiated as well as hot: 
previous disease, debility, or irregular and intemperate habits, dispose 
to insolation. 
The effects of all the conditions of hot climates, including heat, are 
not yet sufficiently determined, and we must look for further information 
to medical men practising abroad. Continued exposure to great heat 
cannot long be endured, even by the healthy human body, with impunity. 
Parkes and others have shown its injurious effects on the nervous system, 
on secretion and elimination, and on the digestive and assimilative proc- 
esses. It causes fever from the simplest to the most ardent form; and 
it is often combined with pernicious miasmatic poisoning, extreme cases 
of which may be confounded with or pass into the most aggravated forms 
of thermic fever or asphyxia. 
Insolation generally takes place in the hottest months of the year. 
April, May, June, and July give the highest returns in India; but when- 
ever the temperature is high enough in other countries the same results 
obtain. For example, it is very frequent in North America every year. 
In 1894 it proved very destructive in New York; and in 1892 many 
places in Europe suffered with a severity unsurpassed even in India or 
other tropical countries. Reports from Vienna in 1894 show many cases 
of heat-stroke; on the 25th of July twenty-seven people were conveyed 
to the hospitals. 
It has been stated that sunstroke seldom, if ever, occurs at sea; but 
this is negatived by the records of the vessels passing through the 
Red Sea, Indian Ocean, Persian Gulf, and other tropical seas. I have 
myself witnessed death on board steamers in the Red Sea from insola- 
tion. 
Maclean tells us, among other examples of insolation occurring on 
board ship, that Boudin relates that, while at Rio Janeiro, the French 
war-ship Duquesne (Statistiques Medicales) had 100 cases of insolation 
out of a crew of 600. Most of the men were attacked, not when exposed 
to the direct rays of the sun, but at night when in the recumbent posi- 
tion- that is, when breathing not only a hot and suffocating, but also 
an impure air. 
M. Bassier, a French naval surgeon, gives an account of 18 cases 
out of a crew of 78 men, which happened on board the man-of-war 
brig Le Lynx, cruising off Cadiz in August 1823. The heat, aggra- 
vated by calms, was excessive - 33° to 35° C.; the vessel small and 
overcrowded. 
It is hardly passible to fix any particular degree of external tempera- INSOLATION OR SUNSTROKE 
493 
ture as one of excessive danger, because, as before stated, the tolerance 
of heat is very great in persons in perfect health in a pure atmosphere, 
and also in the dark-skinned races; but, under the conditions before 
mentioned, the danger is great when the temperature is equal to or 
higher than that of the body. A temperature of 110° or 115° F. or 
higher, in very dry air in motion, would be better tolerated than one 
of 90° or 95° F. in an atmosphere laden with moisture; especially if it 
be vitiated, as in barracks or rooms, by human respiration, or telluric 
or other miasmata. 
All who suffer do not die; some perfectly recover, but many are 
permanently injured, and made unfit for service in a hot climate, or 
even become permanent invalids at home. 
In 1891 the numbers of the European army in India were 67,030. 
Of these there were 228 admissions from heat-stroke and 65 deaths. 
In 1892 the numbers were 68,162. There were 223 admissions from 
heat-stroke and 61 deaths. 
In 1891 there were 3137 women with the European army. Among 
these there were 2 admissions and 2 deaths from heat-stroke. 
In 1892 there were 3101 women with the army, but no admissions 
for heat-stroke; one death out of hospital. 
In 1891 there were 5886 children with the European army. There 
were 3 admissions and 2 deaths from heat-stroke. 
In 1892 there were 5762 children with the army. There were 4 
admissions and 4 deaths from heat-stroke. 
The native army in 1891 numbered 128,600. There were 22 ad- 
missions and 12 deaths from heat-stroke. 
In 1892 the native army numbered 145,340. There were 43 admis- 
sions and 18 deaths from heat-stroke. 
In 1891 the jail population of India numbered 101,019. There were 
77 admissions and 40 deaths from heat-stroke. 
In 1892 the numbers were 103,159. There were 77 admissions and 
41 deaths from heat-stroke. 
The above numbers show that the admission-rate per mille from 
heat-stroke in the European army in India was, in 1891, 3-4; in 1892, 
3-3; while the death-rate in 1891 was 0 97; in 1892, 0-90. Among the 
women with the European army the admission-rate in 1891 was 0'64; 
in 1892, 0; while the death-rate in 1891 was 0-64; in 1892, 0-32.1 
Among the children the admission-rate in 1891 was 0 5; in 1892, 0-7; 
while the death-rate in 1891 was 0-34; in 1892, 0-35. In the native 
army the admission-rate in 1891 was 0-2; in 1892, 0-3; while the death- 
rate in 1891 was 0-09; in 1892, 0-14. Among the jail 'population the 
admission-rate in 1891 was 0'8; in 1892, 0-7; while the death-rate in 
1891 was 0-40; in 1892, 0-40. 
The following statistics and tables are taken from the reports of the 
Sanitary Commissioner with the Government of India for 1891 and 
1892: - 
The one death was out of hospital. 494 
SYSTEM OF MEDICINE 
Deaths from Heat-stroke in the European Anny in India in 1891 
and 1892 at the different Ages. 
Age. 
1891. 
' 1892. 
24 and under . 
25 to 29 . 
30 to 34 . 
35 and upwards 
35 or 1-06 per mille 
14 or 0-58 „ 
8 or 1-41 „ 
7 or 3-33 „ 
26 or 0-76 per mille 
21 or 0-84 „ 
9 or 1-65 ,, 
5 or 2-40 ,, 
Deaths from Heat-stroke in the European Army in India in 1891 
and 1892 at the different periods of Residence. 
Length of Service. 
1891. 
1892. 
First and second years 
Third to fifth year . 
Sixth to eighth year . 
Eleventh to fifteenth year 
Fifteen years and upwards 
36 or 1-74 per mille 
18 or 0-59 ,, 
5 or 043 
3 or 1-81 ,, 
2 or 3-27 
23 or 1-00 per mille 
22 or 0-72 „ 
12 or 1-03 „ 
2 or 1-40 ,, 
2 or 3-85 
The statistics show how the effects of heat influence a certain class 
of persons who are under hygienic control; reliable data thus being 
afforded on which to determine the value of this element of the death- 
rate of a certain section of the population whose vital statistics are 
trustworthy. In others less protected, as in the scattered European, 
Eurasian, and immense native population, the incidence of the disease 
is often greater. In seasons when there are great accessions and waves 
of heat all over the world the disease and the mortality from it increase. 
Such waves of high temperature recur at uncertain intervals. No doubt 
the same obtains in other countries where the climatic conditions are 
similar; it is needless, therefore, to produce further statistics, as these 
sufficiently illustrate the subject. 
A number of cases of hemiplegia are reported by the Sanitary Com- 
missioner with the Government of India, which there is reason to believe 
were also due to attacks of insolation; but as it is not certain that all 
were so caused, I am content to allude to it generally as one of the 
possible results of sunstroke. 
Symptomatology and Pathology. - In addition to the general dis- 
turbance of health which occurs in all who are more or less affected by 
heat - such as restlessness, irritability, sleeplessness - the morbid con- 
ditions which are to be attributed to the effects of a high temperature 
are: - 
I. A. Syncope from exhaustion, caused either by the direct rays 
of the sun or a heated atmosphere in the shade; especially when the 
physical or mental powers are depressed: engine-room men in steamers 
in hot climates; men marching, or on parade, if oppressed with clothes 
or accoutrements, or weakened by previous illness, or by dissipation; 
labourers or artificers; men in hay-fields in England, or in heated rooms INSOLATION OR SUNSTROKE 
495 
and factories, in barracks, hospitals, tents, or ships, may suffer in this 
way. The condition is one of depression; the skin is cold and pale, 
and the pulse feeble. Death may occur from failure of the heart, but 
recovery is usual. 
B. The exhaustion above described having passed away may be suc- 
ceeded by fever, which may assume an ardent type [yide section on 
Indian fevers (thermic fever)]. The fever may, after a certain dura- 
tion, defervesce; or it may result in changes, the consequence of damage 
done by the heat to the cerebro-spinal centres. Thus a variety of morbid 
conditions may ensue, depending upon the parts affected. Such cases 
are often very prolonged, and the only hope of recovery lies in removal 
to a colder climate. 
When death occurs rapidly at the time of the exposure it may be 
due to sudden cardiac failure, as shown in the experiments of Claude 
Bernard and Brunton (8) upon animals exposed to great heat. When 
it occurs suddenly, during great exhaustion or muscular action with 
fatigue, it may be due to coagulation of the cardiac myosin, which Dr. 
Wood of Philadelphia has shown to be likely to occur during any great 
muscular exertion at a much lower temperature than usually determines 
it when there is no great muscular exertion. For example, men fighting 
in a very high temperature may fall dead suddenly; but probably 
coagulation of myosin is most frequently a post-mortem change. 
II. The gravest and perhaps most fatal forms of sunstroke occur as 
a consequence of the general heating of the whole body, blood and 
tissues, which may happen either from prolonged exposure to the sun's 
rays in a heated atmosphere, to a heated atmosphere in the shade 
(occurring, as it does, by night as well as by day), or to an abnormal 
thermotaxic state due to vaso-motor or other heat-regulating disturbance. 
In the first case the effect of the high temperature tells upon the 
brain, which becomes heated to a degree incompatible with due perform- 
ance of its functions: this may result in acute cerebral symptoms, and 
sometimes in phrenitis, rapidly passing into a state of asphyxia, if the 
respiratory centres are involved: more frequently, perhaps, the whole 
body becomes overheated, the temperature rising to 106°, 108°, or 110°, 
which, if not rapidly counteracted, proves destructive to life by asphyxia 
or sudden cardiac failure, or even by cerebral haemorrhage or meningitis. 
In heat exhaustion the primary symptoms are those of depression. 
The person becomes faint, pallid, with a pale, cold, and moist skin and 
feeble pulse, not unfrequently attended with sickness. The soldier on 
parade staggers and falls over in a faint; so with the orator when speak- 
ing, or the artisan in pursuing his calling. This may take place either 
in the sun or in the shade. The condition is one of syncope, and may 
approach collapse; if reaction be not soon established death may result 
from cardiac failure, but this is rare. Recovery is generally complete, 
but when the state has occurred from direct application of intense solar 
heat and glare, the mischief is not always confined to the transient 
shock or impression; secondary effects, such as vertigo, muscular tremors, 496 
SYSTEM OF MEDICINE 
and temporary loss of power may result; or a reaction may be followed 
by fever, or by symptoms indicating lesions of the centres or cerebral 
excitement, and this may end in mania. 
In insolation proper the premonitory symptoms may appear some 
hours or even days before the dangerous symptoms set in, as the result 
of continued exposure to a high temperature; although they may occur 
also in a much shorter period, as when men are exposed in marching or 
in other occupations to a very high degree of solar heat, in which case 
some would no doubt be affected by heat exhaustion, whilst others would 
pass into a state of hyperpyrexia as before described. These are generally 
malaise, restlessness, insomnia, apprehension of impending evil, precor- 
dial anxiety; hurried, gasping, shallow breathing; a feeling of constric- 
tion round the thorax; vertigo; headache, often severe; nausea, or even 
vomiting, anorexia, great thirst, frequent micturition, and fervent heat 
of the skin. As one or more of these symptoms become aggravated the 
temperature rises to 104°, 106°, or even 110°. Dyspnoea and restlessness 
increase; the head, face, neck, and skin of the body generally become 
red, or livid, sometimes dry, sometimes moist; the pulse full and 
labouring, carotid pulsation very perceptible, pupils contracted, but 
dilating widely before death. Unconsciousness passes into complete 
coma, stertor, and epileptiform convulsions; finally, relaxation of the 
sphincters and suppression of urine precede death. 
These symptoms all indicate a profoundly disturbed state of the 
cerebro-spinal centres and a disordered condition of the blood. The 
hyperpyrexia is incompatible with a due performance of their functions, 
and death will rapidly result unless prompt aid be given; indeed, it 
frequently does so despite all treatment. The fatal result is due to 
asphyxia and cardiac failure. There may be - though perhaps rarely - 
meningitis or cerebral hsemorrhage or effusion, the disordered state of 
the blood not unfrequently manifesting itself by petechial patches on 
the body. 
The earlier stages of this condition are those of so-called thermic fever. 
A very high temperature may be maintained for several days, and finally 
defervescence takes place without evidences of any structural lesion; but 
unless active measures be used and the temperature rapidly reduced, 
unless, that is, the causes which produce the hyperpyrexia be mitigated 
or removed, the case is apt to pass on into the grave state, and to ter- 
minate fatally by paralysis of the respiratory centres, and in some 
instances, though rarely, by cerebral haemorrhage. From the graver forms 
some recover, but many are permanently injured, and become invalids for 
life; life indeed is not unfrequently shortened by obscure cerebral or 
meningeal changes which affect the sufferer in varying degrees of form 
and intensity, such as epilepsy, irritability, impaired memory, cephalal- 
gia, blindness, or deafness, partial or complete paralysis, dementia or 
even mania. In those who have apparently recovered intolerance of 
the sun's rays or even of the heat of temperate climates may remain; 
or such cases may after a long time end in dementia, or epilepsy, or INSOLATION OR SUNSTROKE 
497 
both; or in chronic meningitis with thickening of the calvaria; fre- 
quent or intense headache, general functional derangement and dis- 
ordered innervation being persistent. 
Morbid Anatomy. - When death has occurred in the syncopal form 
there is not any very obvious morbid change. The brain with its mem- 
branes and the lungs are sometimes but not always congested. The 
venous trunks in the abdomen and also the right cavities of the 
heart may be full of blood, which is imperfectly coagulated and 
deficient in oxygen. The abdominal viscera are congested; lividity 
of the body and decomposition come on rapidly after and even before 
death. 
In death from thermic fever and insolation the heart is sometimes 
found firmly contracted - it may be from coagulation of the myosin - 
and the venous system generally is engorged. The blood is dark, 
grumous, fluid, and acid in reaction; the blood globules are crenated 
and do not rapidly form into rouleaux. The body for some time after 
death retains a high temperature. In early autopsies, necessary in hot 
climates, the body and viscera when opened feel pungently warm, dark 
blood drips freely from the incision, rigor mortis comes on rapidly. 
The brain and membranes are often congested. There may be some 
cerebral haemorrhage, effusion of serum into the substance or cavities, 
or incipient symptoms of meningitis. 
A precise degree of blood temperature incompatible with life can- 
not be defined, but the danger becomes very imminent at or above 108° 
or 109° F. 
Prophylaxis. - Prevention is the great desideratum. The clothing 
should be very light, and woollen material should always be worn next 
the skin, as cotton or linen wet with perspiration is very injurious. 
The head and spine should be protected from the direct rays of the 
sun out of doors by a pith hat and a cotton pad let into the coat over 
the back of the neck and spine, and by a good white umbrella lined 
with green. The clothing should be loose, not constricting the neck or 
any part of the body. Indoors the temperature should be reduced by 
the use of therm antidotes, punkahs, or other artificial means of cooling; 
free ventilation should be insisted on, and a sufficient amount of cubic 
space - not less than 1000 to 1200 cubic feet per head - in sleeping 
rooms, barracks, and so on. During the hot, still nights - a most 
dangerous time - the foregoing precautions are especially necessary. 
Overfatigue, excitement or depression should be alike avoided, 
though a moderate degree of exercise, physical and mental, is desirable 
during the cooler hours of the day. A short sleep during the course of 
the day is also to be encouraged. 
For soldiers all drills not absolutely necessary should be avoided. 
If they must march during the hot weather it should be in the early 
hours of the morning. Frequent halts should be allowed, and coffee 
and a biscuit given out. Plenty of water should be carried and be 
readily available. The dress should be light and loose, and all con- 
VOL. I 
2 K 498 
SYSTEM OF MEDICINE 
striction carefully avoided. The halts should be in the most sheltered 
places that can be found, with plenty of fresh air - such as open topes 
of trees. The accoutrements should be as light as possible, so as to spare 
fatigue and exhaustion. Men falling out should be attended to immedi- 
ately by the medical officer. The marches and drills in the great heat 
should be as short as the exigencies of the service will permit. 
Moderation of diet is especially to be enjoined. Very little animal 
food should be taken; the food, whilst sufficiently nutritious, should be 
light and unstimulating. Iced water should be drunk freely and fre- 
quently, and the greatest moderation in the use of stimulants should be 
observed. Excesses in eating, drinking or smoking are especially to be 
deprecated. The cold bath may be freely used. In short, regulation 
and moderation in all things, and careful attention to the state of the 
bowels, which should never be allowed to be confined, are essential. No 
one is more likely to suffer from the ill effects of heat than he who has 
undergone mental or physical exhaustion, or has suffered from intemper- 
ance in food or alcoholic drinks. Healthy persons who lead regular 
lives and observe such precautions will tolerate a degree of heat which 
would hardly be deemed credible. 
Treatment. - In simple heat exhaustion, remove the patient to a cool 
place in the shade or into the open air, according to circumstances. 
Remove all oppressive or tight clothing. Dash cold water on the head 
and chest so as to rouse but not depress. If necessary, give a stimulant 
and apply ammonia to the nostrils. If depression continue, administer 
stimulants and restoratives; let the patient avoid exertion or exposure 
to heat as much as possible. In the steamers in the Red Sea and Indian 
Ocean stokers, usually Africans, are sometimes brought up from the 
furnaces unconscious from heat exhaustion, but are generally quickly 
restored by the fresh air, by dashing cold water on their bodies, or by 
giving a little stimulant. 
If a man be struck down by the beating of the hot sun on his head, 
apply the cold douche freely to the head; if there be rise of temperature, 
apply ice to the head, but not for too long a time. The object is two- 
fold, to rouse by reflex action and to reduce temperature. 
At the capture of Rangoon in 1852, numbers of men under my 
observation were struck down by the sun, some simply from heat 
exhaustion. They were clad in the thick red coats worn in India in 
those days. In others, apparently, the exhaustion was combined with 
the direct effects of the sun upon the head and spine. They were all 
douched with cold water and placed in the shade in the Field Hos- 
pital. All but two recovered; these two were bled on the field where 
they fell, and never regained consciousness. By recovery is meant 
a favourable reaction at the time; in some there were consecutive 
symptoms of fever and cerebral disturbance; they were sent away to a 
Depot hospital, and if their history could be traced, it would probably be 
found that in some of them complete recovery never took place. Exposure 
to the sun's rays should be carefully guarded against, and unless recovery INSOLATION OR SUNSTROKE 
be rapid and complete, a colder climate should be sought, where the 
same precautions must be continued. 
In thermic fever or insolation the object is to reduce the tempera- 
ture, before more serious or fatal consequences appear. For this pur- 
pose quinine in doses of 5 grains, or even more up to 10 grains of 
hydrochlorate or sulphate, may be given in solution by the mouth, 
every three hours; or the equivalent in the form of a hypodermic in- 
jection [yide article on " Indian Fevers may be given and continued 
until an impression is produced. Morphia has also been suggested, but 
this practice seems questionable. Bleeding should not be resorted to 
except in special cases. In asphyxia, where the right heart is over- 
loaded, it may be expedient in the choice of evils. As a general rule 
it has been abandoned, for though it may have appeared at first to pro- 
duce a favourable impression, subsequent results have not justified it 
as a general practice. No absolute canon of procedure can be laid down 
with reference to bleeding in this disease; each case must be dealt with 
on its own merits. All that can be said here is that it is not desirable 
as a general rule. Should the quinine not be effective in reducing the 
temperature, antipyrin, phenacetin, antifebrin, aconite, or acetate of 
ammonia may be tried. 
The cold bath, cold affusions, and application of ice to the head - 
which should be shaved - and to the body, should also be resorted to, 
care being taken not to prolong the cooling until too great depression be 
produced - that is, not below 100° F. The bowels should be relieved 
by calomel, colocynth and saline purgatives, and by enemata; care being 
taken that sufficient daily action be maintained. In the epileptiform 
convulsions which sometimes occur the cautious inhalation of chloroform 
may be resorted to. I have seen good results from its use. Blisters are 
sometimes applied to the nape of the neck, but it seems doubtful whether, 
in the early stages at any rate, they can be of much use, if any. Light 
and unstimulating diet should be given in small quantities at tolerably 
frequent intervals. This antipyretic treatment must be continued as 
long as a high temperature lasts, to obviate the imminent risk of death 
or of tissue changes which may be permanently injurious. As the case 
proceeds, if symptoms of cerebral or meningeal mischief supervene, 
iodide and bromide of potassium and counter-irritation may be of service. 
It is essential that perfect rest of mind and body should be main- 
tained. When insomnia is distressing hypnotics may be useful; they 
must be given with great caution, and without opium if it can be 
avoided. Restriction should be imposed upon the use of alcoholic 
stimulants. The amount, if any, that may be given must depend upon 
the previous habits as well as the present condition of the patient. Here, 
again, the physician must be guided .by the special indications of the case 
before him. Precautions should be continued, not only when recovery 
has set in, but even for some time after it is apparently complete; for 
certain indications of latent chronic mischief will probably remain, such 
as loss of memory, irritability, headache, inability to concentrate the 
499 500 
SKST.AJZ OF MEDICINE 
thoughts, intolerance of heat, or of the slightest exposure to the sun or 
even of the temperature of an overheated room. Not until these have 
completely disappeared can a return to India or any other hot climate 
be permitted with any propriety or prospect of future health. I repeat 
that frequently, indeed, a patient can never return to a hot climate at all. 
It seems hardly necessary to say that cases of this kind should be 
removed from a hot climate to a colder one as soon as travelling can 
safely be permitted, and that the sufferers should be carefully watched 
on their way home. Neglect of this precaution has resulted in self- 
destruction during the mental aberration that sometimes follows. 
The sequela? of sunstroke occasionally assume a serious character, 
and are the cause of permanent disability to the patient and a source 
of much anxiety to his friends. The slighter forms of meningitis and 
of cerebral mischief not unfrequently pass away after protracted resi- 
dence in a temperate climate, but they are also not unfrequently per- 
manent, and endanger or shorten life, causing such physical or mental 
disability as epilepsy, partial paralysis, mania, chronic dementia, im- 
paired memory, and inability for mental concentration - sad examples 
of the evil effects of a tropical or hot climate. 
Treatment will depend upon the nature and extent of such mis- 
chief. These vary so much as to render it impossible to give more 
definite directions here, and the reader is referred to the special chap- 
ters of this System on Cerebro-spinal and Mental Diseases. 
I am indebted to Brigade-Surgeon Lieutenant-Colonel Hooper, Civil 
Surgeon of Lucknow, for the following cases of insolation, which illus- 
trate the hyperpyrexial symptoms, and the treatment by the application 
of cold, quinine, and other remedies. 
In all these cases but one recovery seems to have followed; but the 
subsequent history of some of them, could it be ascertained, would prob- 
ably show that such sequelae as have been described in the text ensued. 
No. 1. - Case of Insolation; Death on Third Day 
A private soldier, European, set. 22, was admitted into the hos- 
pital, Lucknow, on 4th June 1892; unconscious, breathing stertorous, 
temp. 106°, pupils contracted, reflexes abolished. Treated with douch- 
ing, sponging with iced water, enemata, sinapisms, and injections of 
strychnine. Temp, fell to 97-8° F., but consciousness was not recovered. 
Pulse feeble, respirations very shallow and quick, limbs very rigid. 
Pulse gradually failed, respiration quick and shallow, conjunctivae in- 
jected, cornea ulcerated; temp, went up again, and had reached 105° F. 
on the morning of the 6th. He died on morning of 7th. 
Post-mortem. - Sinuses of dura mater distended. No excess of fluid 
in arachnoid. 
Brain congested, with marked puncta cruenta. Ventricles filled 
with serum. INSOLATION OR SUNSTROKE 
Lungs crepitant, and not much congested. 
Liver, spleen, and kidneys all greatly congested. 
501 
No. 2. - Case of Insolation ; Recovery 
Private soldier, European, set. 34, admitted into hospital, Lucknow, 
on 22nd June 1892. Feeling sick and dizzy all day. In the evening 
temp, rose to 109°. Cold douche applied and turpentine enemata given. 
Temp, fell to 99-8° F.; continued a little raised for a few days. Thirty 
grains of quinine given daily. Discharged on 10th July. 
No. 3. - Case of Insolation; Recovery 
A private soldier, European, set. 22, was brought into hospital, Luck- 
now, on 19th May 1894. He was unconscious, skin very dry and hot, 
temp. 110° F. in the axilla, eyes fixed and staring, conjunctivae congested 
and insensitive, pupils dilated, breathing stertorous, and pulse almost 
imperceptible. He was put into a cold bath for about ten minutes, then 
into a wet pack; ice was applied to the head and back of the neck, and 
he was fanned. Cold water was injected into the rectum, and a large 
quantity of faeces came away. Brandy and ether were injected sub- 
cutaneously, and a small enema of brandy and water was given, but the 
latter was soon rejected. After a time the temperature came down to 
102°, and the breathing became easier. Convulsions were painful and 
frequent; chloroform was used, and dry cupping along the spine. The 
pulse became stronger after about six hours, the pupils slightly sensitive 
to touch, and congestion of conjunctivae diminished; but convulsions 
still occurred if he were touched or a hand passed in front of him. Two 
injections of morphia, | gr. in each, were administered. The patient 
did not recover consciousness for over twenty-four hours, and then only 
when roused. There was emphysema of the connective tissue of the left 
side of the face and neck, extending as far as the clavicle and over the 
deltoid muscle, and also under the axilla. The voice was thick; the eyes 
were very sensitive to light, and the patient was kept for some time in a 
darkened room. Cold water continued to be applied to the head, and 
iodide and bromide of potassium administered. On the fourth day after 
admission the temperature became normal; it rose slightly subsequently, 
but recovery was uninterrupted, and the patient was discharged on 20th 
June. He was sent to a hill depot on 10th July. 
No. 4. - Case of Simple Insolation; Subsequent Cerebral Symptoms; 
Recovery 
An officer, set. 34, was admitted into hospital on 27th March 1894 
with severe pain in the head, from which he had been suffering for some 
days. On 17th March, after riding in the sun all day, he was seized 
with pain in back and aching in limbs. He went out shooting the next 
day, and pain in the head with fever came on the same evening. 502 
SYSTEM OF MEDICINE 
On admission; temp., abdomen, liver, and spleen were normal. On 
the evening of 28th, while in bed, he had a prolonged attack of syncope, 
nausea, cold sweats, weak and frequent pulse, pallor, vertigo, hurried 
respiration. This passed off on the administration of brandy. The pain 
in the head ceased, but dizziness and sickness came on when he tried to 
raise it. Potas. iodide and sp. ammon. aromat. administered. On 1st 
and 4th April temp, rose to 101° and 100° as result of attempt to sit up 
in bed; vertigo also increased, with buzzing in ears. The iodide of 
potassium was discontinued, 10 grs. of quinine administered daily, | gr. 
of calomel morning and evening. After this date the improvement 
continued, the vertigo diminished, but was induced by any sudden head 
movement. Was discharged on 25th April for three months' leave. For 
many months afterwards vertigo came on with any sudden movement of 
the head, and headache was induced by the slightest exposure to the sun. 
BIBLIOGRAPHY 
1. Dr. Parkes. Practical Hygiene, by De Chaumont, 6th ed. 1883. - 2. Dr. Mac- 
lean, C. B. Diseases of Tropical Climates. London, 1886, p. 145. - 3. Sir W. Aitken. 
The Science and Practice of Medicine, 7th ed. 1880. - 4. Sir T. Longmore, C. B. Indian 
Annals of Medical Science, No. 12, July 1859.-5. Dr. Barclay and Sir T. Crawford. 
Madras Quarterly Journal, Oct. 1860.-6. Dr. Marcus Hill. Indian Annals of 
Medical Science, No. 5, Oct. 1855.-7. Dr. Austen Flint of New York. Practice 
of Medicine. Phil. 1886. -8. Dr. H. C. Wood of Philadelphia. Sunstroke, 1872.- 
9. Bassier. Dissertation sur la Calenture (quoted by Maclean). PART II. -THE INFECTIONS1 
CONTENTS 
THE GENERAL PATHOLOGY OF INFECTION 
(a) Bacterial Forms, (b) Immunity, (c) Serum Therapeutics. 
The Infective Diseases. 
I. Diseases of more or less established 
Bacteriology. 
(a) Local or General Diseases due to 
Pyococci. 
(1) Septicaemia and Pyaemia. 
(2) Erysipelas. 
(3) Infective Endocarditis. 
(4) Puerperal Septic Disease. 
(5) Carbuncle and Boils. 
(Gonorrhoea not included in this System.) 
(5) Infective Fevers. 
(6) Epidemic Pneumonia. 
(7) Cerebro-spinal Meningitis. 
(8) Influenza. 
(9) Diphtheria. 
(10) Tetanus. 
(11) Enteric Fever. 
(12) Cholera. 
(13) Oriental Plague. 
(14) Relapsing Fever. 
(c) Infective Diseases of Chronic Course. 
(15) Tuberculosis. 
(16) Leprosy. 
(17) Actinomycosis. 
II. Diseases of uncertain Bacteriology. 
(a) Not Endemic. 
(18) Measles. 
(19) Rubeola. 
(20) Scarlet Fever 
(21) Varicella. 
(22) Variola. 
(23) Mumps. 
(24) Whooping-Cough. 
(25) Syphilis. 
(Mixed Infections.) 
(6) Topical or Endemic. 
(Fevers of India.) 
(26) Typhus. 
(27) Dengue. 
(28) Yellow Fever. 
(29) Amoebic Dysentery. 
(30) Beriberi. 
(31) Maltese Fever. 
(32) Epidemic Dropsy. 
(33) Negro Lethargy. 
(34) Delhi Boil. 
(35) Verrugas. 
(36) Framboesia. 
III. Infective Diseases communicable 
from Animals to Man. 
(a) Of certain Bacteriology. 
(37) Glanders. 
(38) Anthrax. 
(5) Of uncertain Bacteriology. 
(39) Vaccinia. 
(40) Foot and Mouth Disease. 
(41) Rabies. 
IV. Diseases Due to Protozoa. 
(42) Malaria. 
(43) Blackwater Fever. 
1 The Infectious Diseases will be described in the above order, which was drawn up 
for me by Dr. Kanthack, and kindly revised in parts by Dr. Manson. {The term 
Bacteriology includes the study of all morbiferous micro-organisms.) -Ed. 504 
SYSTEM OF MEDICINE 
THE GENERAL PATHOLOGY OF INFECTION 
I. Bacterial Forms 
Bacteriology deals with the lowest forms of vegetable organisms, and 
so far as it concerns itself with the biological phenomena of these lowly 
beings it is a part of botany. But since bacteria are found in many dis- 
eased processes, bacteriology necessarily also forms a part of pathology, 
that is to say of medicine. Our knowledge of disease cannot then be 
complete without a fair grasp of the part played by the micro-organisms. 
Many symptoms and obscure changes are thus readily explained; the 
treatment of maladies, and the rules of prevention - the highest form 
of therapeutics - are often laid down or indicated by the bacteriological 
pathologist. Because so much new light has been thrown on diagnosis 
and prognosis in disease, because some of our recent therapeutic triumphs 
have been achieved by bacteriology, a System of Medicine would fail to 
be complete if it did not offer some information on the elements of this 
the youngest branch of pathology. While undertaking this share of the 
work, I feel not only the great responsibility, but also the difficulties 
which accompany it, and further realise that the physician cannot often 
be a bacteriological specialist; he desires, however, to learn the bearing 
of bacteriology on the clinical phenomena of disease and its application 
to practice. In the lines that follow, therefore, I shall endeavour to 
give a general view of the facts and opinions which the study of bac- 
teria has either disclosed or indicated, in so far as they directly concern 
the clinical physician; whether for the purposes of diagnosis and prog- 
nosis, or for those of treatment and prevention. 
Obviously we must begin with a short account of the general morphol- 
ogy and biology of bacteria, that is, with so much of it as is necessary 
to demonstrate the influence of bacterial life and activity in disease. 
Morphology of Micro-Organisms. - The vegetable micro-organ- 
isms, so far as we have to deal with them, have been classified by Nageli 
under three headings, namely, I. Hyphomycetes or Moulds, II. Blasto- 
mycetes or Sprouting Fungi, III. Schizomycetes or Cleft Fungi. Others 
have singled out the schizomycetes as mycetes or microbes, but, rightly 
or wrongly, these terms are commonly applied to all the three groups of 
micro-organisms in a generic sense; and when no harm is done thereby 
it is well to bow to custom. 
I. Moulds or Hyphomycetes. - These organisms are characterised 
by a mycelium or interlacing network of filaments which constitutes the 
fungus itself. From this mycelial network there extend other filaments 
(hyphae) which bear the fruit-bearing organs and spores. The forma- 
tion of these spores varies in the different forms, for (a) in some cases 
the terminal cell of the hypha undergoes transverse division (conidia), 
or (F) in others it enlarges, forming a receptacle enclosing the spores- THE GENERAL PATHOLOGY OF LNFECTLON 
505 
(sporangium or ascus), or (c) two hyphae fuse and at the point of union 
the spores develop (oospora). Fuller descriptions will be found in 
works on Botany. 
The following moulds are the more important among those found either 
in disease or in ordinary human surroundings: - 1. Penicillium glaucum 
(not pathogenetic). 2. Oidium lactis, found almost invariably in sour milk 
(not pathogenetic, though formerly supposed to be the cause of thrush). 
3. Trichophyton tonsurans, found in ringworm. 4. Achorion Schonlein, 
found in favus. 5. Microsporon furfur, found in pityriasis versicolor. 
6. Monilia candida, said to be the cause of thrush. 7. Mucor: various 
forms of this widely-distributed genus have occasionally been obtained 
from man, especially from the external auditory meatus. 8. Aspergillus: 
two varieties. The A. niger and A. fumigatus have occasionally been 
found in man, for example, in so-called pneumomycosis, in purulent 
conditions of the middle ear and of the antrum maxillare. 9. Actino- 
myces, pathogenetic for man and cattle. Its exact botanical position is 
not yet settled; some classify it with cladothrix, others with strepto- 
thrix. [This fungus will be fully considered in the article on " Actinomy- 
cosis."] 10. Streptothrix: various forms of pathogenetic streptotriches 
have been described. These organisms resemble the actinomyces closely. 
We are still comparatively ignorant of the physiological properties of 
these mould-fungi. Many of them certainly exert a fermentative action: 
thus Penicillium glaucum is able to convert cane-sugar into other sugars; 
some aspergilli contain a diastatic ferment which converts starch into 
dextrose and maltose; some species of mucor are able to act as true 
alcoholic ferments, and Monilia candida will even ferment cane-sugar 
as such without previously inverting it. The various lesions produced 
by some of the above-mentioned fungi will be described under their 
proper headings. 
II. Blastomycetes or Sprouting-Fungi. - These organisms are fairly 
large round or ovoid cells which, generally speaking, multiply by budding. 
As a rule they appear as separate cells unconnected by any mycelium, 
though among the budding-fungi there are some which under certain 
conditions will form a mycelium. Again, although they mostly multiply 
by means of budding, there are some which possess the property of 
forming spores in the substance of the cell (endogenous spore-formation). 
Three groups may be distinguished:-1. Saccharomyces: budding- 
fungi ; mostly without a mycelium; the cells are sometimes nucleated, 
occasionally form endogenous spores, and generally are capable of induc- 
ing alcoholic fermentation. 2. Torula: multiply by budding, form a my- 
celium only exceptionally, never form spores ; some have a pronounced 
fermentative activity. 3. Mycoderma: variously shaped cells, containing 
refractive particles; they form a film on the surface of the fluid on which 
they grow, and possess either no fermentative activity, or but little. 
The pathological importance of these forms is not great, though 
pathogenetic torulae have recently been described. However, as they 
are so widely distributed that some varieties are constantly found in 506 
SYSTEM OF MEDICINE 
the human excretions, a slight acquaintance with them is desirable. 
Some writers consider the thrush fungus to be a variety of mycoderma. 
III. Schizomycetes or Fission-Fungi.- Most pathogenetic organisms, 
or at any rate those which are best known to us, belong to this group of 
minute, unicellular vegetable organisms. They owe their generic name 
to the fact that they divide or multiply by fission. The schizomycetes, 
so far as the pathologist knows them, are small, minute cells, visible 
only when examined under the highest powers of the microscope (oil- 
immersions) with the best possible illumination (Abbe's substage-con- 
denser) ; they are devoid of a nucleus, at any rate a true nucleus has not 
been demonstrated. When dead and dried they have an affinity for 
basic or nuclear dyes, such as methylene blue, gentian and methyl violet, 
and fuchsine. Living bacteria refuse to take up the dye in a satisfactory 
manner; but when allowed to dry on a cover-glass and fixed by heat, 
they are stained readily, unless they have been fixed in a state of degen- 
eration or involution. They refuse acid dyes, such as eosin, acid fuchsin 
or picric acid. Although they may all be stained with basic anilin dyes, 
they vary greatly in the readiness with which they imbibe the stain. 
Thus tubercle bacilli are stained with difficulty, and only with the assist- 
ance of mordants ; leprosy and glanders bacilli likewise require time 
and patience, if not skill. On the other hand sarcinse and pyococci are 
easily overstained. It is impossible to lay down general rules as to the 
time of exposure to the dye, or as to the particular dye, required for the 
various organisms. Experience is the only guide. 
The schizomycetes in ordinary medical language are called bacteria; 
in fact these two names have become almost synonymous. From the 
botanist's point of view this is undoubtedly incorrect; the convenient 
confusion of terms is, however, sanctioned by usage, and we may safely 
accept " bacteria" as the generic term interchangeable with schizomycetes. 
Bacteria are generally classified according to their morphological distinc- 
tions - that is, their shapes and forms - as 1. Cocci; 2. Bacilli; and 3. 
Spirilla. This classification is not a natural one; but so long as we are 
unacquainted with the exact relation of these forms to each other, it 
is less perplexing to use a provisional classification which is both 
practicable and easy. 
We shall now consider these three subdivisions in detail: - 1. The 
Cocci or Micrococci are minute spheroidal or oval cells, and, when growing 
in artificial media or in the animal body, they always remain cocci; their 
spheroidal form is constant. The cocci are again subdivided according to 
their arrangement or grouping. Thus we may have (a) paired cocci, that is, 
cocci arranged in twos, the so-called Diplococci. These are often surrounded 
by a distinct capsule, which may be stained by appropriate methods. As 
examples may be mentioned the capsular pneumococci and the non-cap- 
sular gonococci. (&) The cocci may be arranged in chains, when they 
are called Streptococci. These chains may be either short or long. The 
shortest streptococci consist of two component members. Thus we find 
that the pneumococcus, which in the animal body is generally an encap- THE GENERAL PATHOLOGY OF LNFECTLON 
507 
suled diplococcus, occasionally appears as an encapsuled streptococcus 
of four or five or six component elements; and on artificial cultivation, 
especially in liquid media, it frequently develops as an ordinary non- 
capsular streptococcus. The encapsuled diplococcus is therefore the 
most primitive and simplest form of streptococcus, (c) The Tetracocci 
are grouped in fours, often enclosed in a capsule, though on artificial 
cultivation the capsule is frequently lost, (d) The Sarcince appear in 
packets of eight or more cocci, (e) If the cocci are arranged in irregular 
clusters, or in heaps of no particular shape and devoid of symmetry, we 
name them Staphylococci. Tetracocci and sarcinee on artificial cultiva- 
tion not infrequently appear as staphylococci; and sarcinse again under 
such conditions often appear as non-capsular tetracocci or as diplococci; 
so that the tetracocci or sarcinse, or the non-capsular diplococci, may be 
regarded as the simplest forms of staphylococci. We see then that 
there is no constancy of arrangement here, though the constancy of 
individual form is always preserved; that is, diplococci may develop 
on the one hand into streptococci, on the other hand into staphylococci; 
tetracocci readily transform themselves into staphylococci, but in every 
case, streptococci remain always streptococci and never become staphy- 
lococci ; and conversely staphylococci are never changed into streptococci. 
The staphylococci clusters are often held together by a tough mucous 
material; such clusters are termed zoogloea. 
2. The Bacilli are rod-like structures, that is, they have a long 
diameter often considerably longer than the transverse. These rod-like 
organisms may be very short and plumb, or they may be long, thin and 
graceful; they may have pointed or blunted ends; they may be arranged 
in pairs, in short and long chains, or in filaments. When fusiform or 
spindle-shaped in appearance they are often called clostridia. 
Dr. Klein and others have shown that some bacilli - for example, 
the tubercle or diphtheria bacilli - have a tendency to form true 
mycelial threads, which would suggest that these organisms possess a 
fungus ancestry; others, like the anthrax bacillus, assume a yeast-like 
appearance on artificial cultivation. On the other hand, the actinomyces 
when grown in the laboratory generally passes through a bacillary 
phase before it obtains its fully developed mycelial structure. These 
facts are of great importance, because they remind us of our imperfect 
knowledge of bacterial morphology. This variability of form, termed 
polymorphism or pleomorphism, will be discussed later. 
3. The Spirilla include all the curved or spiral forms. At one time 
a distinction was made between the spirilla and the vibrios, which are 
slightly twisted bacteria, or curved bacilli. The latter were also called 
comma bacilli, as for example the organisms of Asiatic cholera. Now 
we know that the vibrios and comma bacilli easily grow into true spirilla, 
and that we are here dealing with a good example of pleomorphism. 
We shall therefore speak of " spirilla," and more properly call the 
comma bacillus or vibrio of cholera the spirillum of Asiatic cholera. 
It appears that under certain conditions the vibrios or spirilla may lose 508 
SYSTEM OF MEDICINE 
their curved appearance, and become transformed into straight bacillary 
structures. 
The cell substance of these various bacteria is generally colourless, 
refractive and homogeneous; but occasionally it is granular or vacuo- 
lated. Many bacteria are enclosed by a distinct cell membrane; it is 
doubtful, however, whether they all possess an enclosing sheath. 
We must now consider a few special morphological features of the 
bacteria, features either recognised as specific characters, or of biologi- 
cal importance. These are - 1. Spore-formation; 2. Flagella or cilia; 
3. Involution forms ; 4. Pleomorphism and variability. 
1. Spores. - Most micro-organisms multiply by binary fission; many, 
however, are capable also of a higher or more specialised form of pro- 
liferation ; namely, by means of spores. 
Spore-formation has been observed hitherto in bacilli only; micro- 
cocci never possess true spores. When fully developed, the spores 
appear as well-defined, sharply-contoured, highly-refractive bodies, 
round or oval in shape. They are either central or terminal; that is, 
the spore may occupy the middle or one or other extremity of the bacil- 
lus. In the latter case the spore-bearing organisms have the shape of a 
drumstick: the tetanus bacillus and some water and intestinal bacilli are 
the best examples of this type. When the spores are centrally situated 
the bacillus itself may become swollen and spindle-shaped (clostridium), 
as in the case of the Bacillus acidi butyrici; or the spore may develop 
without producing any morphological change in the bacillus. Occasion- 
ally before or during the spore-formation the bacilli grow out into long 
threads or filaments, in which a beaded series of spores appears, as in 
the case of the Bacillus anthracis; or the bacilli themselves increase in 
length, as in the case of the tetanus bacillus. Spores which are devel- 
oped in the substance of the bacillus, whether central or terminal, are 
described as endogenous spores or endospores. Each bacillus contains 
only one spore, which is eventually freed by leaving its parent, or by 
the death of the latter. Under favourable conditions these spores germi- 
nate and are again developed into bacilli. They are highly resistant to 
external influences, - such as drying, heating, disinfecting, etc., - more 
or less serious disturbances which destroy the bacilli themselves, being 
easily withstood by their spores. These resisting powers, however, 
vary greatly; some spores, like those of the tetanus bacillus, remain 
unaffected after being heated for an hour at 80° C. 
Spores are formed under certain conditions only; there must always 
be the optimum of air, warmth and nourishment!-conditions which vary, 
of course, for each organism. Thus the anthrax bacillus requires a suf- 
ficient amount of air (or oxygen) and of warmth, and it refuses to form 
spores in the animal body, or at a temperature of 42°-45° C., or if certain 
substances, such as carbolic acid or alcohol, be added to the broth in 
which it is grown. By continued cultivation in carbolised broth, or at 
42° C., this bacillus may permanently lose its property of forming spores, 
and become " asporogenous "; although the morphological appearances THE GENERAL PATHOLOGY OF INFECTION 
are not otherwise modified. Although strongly resistant to most external 
influences, the spores of many bacilli - for example, of bacillus anthra- 
cis - are killed by a comparatively short exposure to direct sunlight 
in the presence of air. 
In studying the aetiology of infective diseases it is important to 
investigate the power of spore-formation possessed by any particular 
bacillus, for this is to some extent a measure of the resistance on the 
part of the infective organism, and therefore of the risk of infection or 
contagion. Asporogenous organisms, speaking generally, die sooner, or 
are more easily destroyed by antiseptics and disinfectants, and their dis- 
tribution is often more narrowly limited. To this point we shall return. 
Besides endogenous spores, another form of spore, - the so-called 
arthrospore - has been described, especially by De Bary and Htippe; 
their existence is however, doubtful. Arthrospores are supposed to 
be members of a chain or group of micro-organisms which acquire a 
greater vitality or power of resistance, and thus become the starting- 
point of new life. They may be characterised by increased size and 
refraction. It is said that streptococci may persist, or may be perpetu- 
ated by arthrogenous spore-formation. Certainly on examining chains 
of such cocci we often find larger and more striking individuals - two 
or three times as large as other members of the chain - but it is doubt- 
ful whether these peculiar forms are really spores. They stain readily 
with ordinary aniline dyes, while endospores stain with difficulty, and 
only by means of special and elaborate methods: moreover, they seem 
to be no more resistant to external influences than the ordinary cocci. 
The whole subject of arthrospores is still in obscurity. 
2. Flagella or Cilia. - It has been known for a long time that many 
micro-organisms possess the power of spontaneous movement. When 
examined under the microscope in a drop of fluid - in a hanging drop - 
they are seen to move across the field, sometimes floating away quietly 
and slowly, sometimes darting across quickly, sometimes propelling 
themselves with a screw-like action. Bacilli and spirilla or vibrios 
especially are motile, though some micrococci also share this property. 
Loftier has shown by special and difficult staining methods (which since 
have been made much easier), that such organisms generally possess 
flagella or cilia by means of which they propel themselves. Some bacilli 
have only one or two such flagella; others - as, for example, the typhoid 
bacillus - are completely surrounded by them: some, again, have a 
single flagellum at one or other end, or at both ends; others a bundle 
of terminal flagella. The vibrios, as a rule, have one, two, or three cilia 
at one extremity. The rapidity of movement seems, as a rule but by no 
means always, to vary with the number of flagella. The ciliary proc- 
esses also vary considerably in length, thickness and shape, and appear to 
spring from a sheath around the bacterial cell; as a rule they are very 
much longer than the organisms bearing them, and are spirally twisted. 
It appears that some organisms, although incapable of spontaneous move- 
ment, nevertheless possess cilia, for example the bacillus anthracis. It 
509 510 
SYSTEM OF MEDICINE 
would seem that for a given species of bacillus or vibrio the number of 
flagella is constant or varies within narrow limits, so that these have 
become important morphological factors, and are often of great use in 
distinguishing between allied or similar forms. Thus the bacterium 
coli commune closely resembles the typhoid bacillus, but it possesses 
few flagella, varying from one to six, or ten, while the Eberth-Gaffky 
bacillus is completely surrounded by them. At the same time, it must 
be remembered that the flagella are extremely brittle, and are often 
missing in greater or less numbers. 
3. Involution Forms. - Under certain conditions micro-organisms, 
especially the bacilli or the vibrios, become altered in shape, losing their 
ordinary form, or becoming even quite unrecognisable, it may be through 
age, exhaustion of the nutrient medium, or other harmful influences. 
Thus the vibrio of Asiatic cholera, when kept for some time, may be- 
come bacillary or coccoid in shape; bacilli, again, may become beaded 
or varicose, shorter or longer. On transferring such aberrant forms to a 
fresh soil, or on placing them under more favourable conditions, unless 
they have degenerated or have aged past all recovery, they assume their 
original shape and structure. Abnormal or unusual forms, in healthy, 
young, and vigorous growths, must not be confounded with involution 
forms. Thus, diphtheria bacilli, grown on the surface of blood serum or 
agar-agar, often become elongated, clubbed, or branched; tubercle bacilli 
also show a tendency to elongation and branching or clubbing; anthrax 
bacilli may grow as yeast forms. Here we have either a pleomorphism 
(or polymorphism), or a reversion to an ancestral type which is best 
seen in young colonies; but involution invariably implies degeneration. 
4. Pleomorphism and Variability of Form. - Koch originally upheld 
the doctrine of the constancy of form, "die Konstanz der Form." 
Broadly speaking this is true enough; most pathogenetic organisms ad- 
here to one type or form; but many micro-organisms show a great ten- 
dency towards variation. Thus vibrios often become spirilla; the ray 
fungus passes through a coccoid and bacillary stage; the diphtheria 
bacillus may either be long, short, straight, or clubbed. True, a strepto- 
coccus will never become a staphylococcus or a bacillus; but, as a strep- 
tococcus, it will vary, growing occasionally in short chains, occasionally 
in long chains; sometimes in the shape of fine small dots, at other times 
as larger and plumper cocci. This diversity of shape among organisms 
of the same species is called pleomorphism or polymorphism, which 
terms simply imply individual differences. Thus if we were to cultivate 
diphtheria bacilli from a single bacillus sown in broth, we should find 
the descendants very variable in shape; some are small, others larger, 
some straight, others clubbed or branched: or starting from a single 
vibrio, we should find that some of its descendants are spirillar, others 
S-shaped, but most of them true vibrios. Pleomorphism must be care- 
fully distinguished from variability: the former is a character belonging 
to a species, and is transmitted from generation to generation; variation 
of individuals depends on environment, some species, under the influence THE GENERAL PATHOLOGY OF LNFECTLON 
of adaptation, being more easily changed than others, whether tempo- 
rarily or permanently, so that new varieties or even new species may 
be produced. Upon what pleomorphism depends we do not at present 
understand: in some cases, apparently - as in those of the diphtheria 
and tubercle bacilli - it is assumed by Klein and others to be based on 
the ancestral history of the organism. We must carefully distinguish, 
however, between a true pleomorphism and an accidental contamination 
of a culture with extraneous organisms - a confusion of two very 
different things which, especially in the earlier days of bacteriology, 
led to many errors. 
Variation may lead to change of form, or to change of function; 
the latter we shall consider subsequently. Degeneration and involution 
are no more variation than are disease and old age in animals. In most 
cases change of environments - that is, generally change of soil or 
temperature - produces merely temporary variations. Thus typhoid 
bacilli in ordinary broth will appear in one form, in carbolised beef- 
broth in a widely different one: so long as they are grown in these 
m^dia they will retain these respective forms; but if transferred from 
carbolised to ordinary broth there is an almost immediate return to the 
ordinary shape. Similarly the Bacillus pyocyaneus in different media 
may be cultivated as a small bacillus, as a long rod, as a filament, and 
even as a comma form; but a return to the ordinary media is always 
followed by a return to the recognised form. Similarly variations in 
mobility and in arrangements and numbers of flagella may be tempo- 
rarily produced by change of environments. 
It seems extremely difficult to produce permanent varieties of form, 
but it is possible: thus the bacillus prodigiosus may be changed from 
the small bacillary into a permanent long bacillary form; and the 
anthrax bacillus may be converted into an asporogenous species. An 
extremely good summary of the variability of bacteria, by Professor 
Adami, is to be found in the Medical Chronicle for September 1892. 
We are comparatively ignorant of natural variations, and the greatest 
confusion exists between varieties and species. This is well seen in the 
case of the choleraic vibrios: numerous forms of these have been 
obtained from cholera stools, which by some writers are regarded as 
varieties, by others as species - the former are probably influenced by 
their opinion that cholera is caused by one specific organism only, the 
latter recognise in them different and distinct forms of the comma-shaped 
organism. Now in the case of these various choleraic vibrios, we find that 
continuous growth in identical media leads to no assimilation of charac- 
ters ; they become modified under such conditions, but when the limit 
of modification, due to adaptation, has been reached, the acquired charac- 
ters remain stable, and continued exposure to like conditions does not 
give rise to any general assimilation of characters in the similarly 
cultivated organisms. This being so, it would seem that we are dealing 
with species rather than with varieties. The question is, however, beset 
with so many difficulties that we must for the present be content with 
511 SYSTEM OF MEDICINE 
512 
an arbitrary standard based, perhaps, on preconceived ideas. As Dr. D. 
D. Cunningham says, " If the vibrio of Finkler-Prior is a different species 
from Koch's comma bacillus, its distinctive characters must be of specific 
value; if this be so, then, as many so-called choleraic vibrios differ among 
each other no more, or even less, than do Finkler-Prior's and Koch's 
vibrios, we must consider the various choleraic vibrios as so many 
species." Consistency must be preserved in all matters of doubt, and, 
whatever our hypotheses, we cannot without more evidence regard like 
differences as specific in one case and non-specific in another. 
II. Biological Requirements 
All bacteria, being protoplasmic cells, require food, for further de- 
velopment and propagation, which must consist both of nitrogenous 
and non-nitrogenous substances. To study the vital phenomena of 
bacteria, however incompletely or unsatisfactorily, we must cultivate or 
grow them. In the laboratory we can only place them in conditions 
which approximate, often very slightly indeed, to those pertaining to 
them in nature. In most cases the artificial cultivation of bacteria in 
test-tubes and incubators has no pretence to resemble natural growth; 
it is merely an experimental device by which we seek to unravel the 
mysteries of microbic life. We vary the soil as much as we can, we 
alter the surroundings, we imitate what we suppose to be the natural 
state; but as we can never reproduce this exactly, our conclusions can 
only be regarded as approximations to the truth. In bacteriology con- 
clusions are too readily drawn on incomplete evidence, yet in this study 
especially rigorous and unimpeachable evidence is required. 
There is no uniform or general nutrient medium suitable for every 
form of microbic life either in the laboratory or in nature. Some 
organisms thrive best in highly albuminous media; others on or in sub- 
stances poor in albumin: some grow better on a solid stratum, others in 
a liquid medium. No general rules can be laid down; for practical 
laboratory purposes we find that soluble and diffusible albumins and 
proteids are the best nitrogenous, and sugar or glycerine the best non- 
nitrogenous media. Some bacteria refuse to grow on any mixture we 
may compound or concoct; they refuse even blood serum and the living 
animal body - as for instance the leprosy bacilli; others will only grow 
in the living tissues; others again on dead matter only. A suitable 
artificial nutrient medium for bacteria must contain a preponderance of 
water, certain quantities of carbonaceous and nitrogenous organic sub- 
stances, and in addition potassium salts and phosphoric acid compounds. 
As already mentioned, nitrogen is best supplied by means of albuminous 
substances, notably peptones; though urea and ammonium salts are 
useful substitutes. Some organisms are capable of obtaining their 
nitrogen from nitrates, which they gradually reduce to nitrites and 
eventually to ammonia. The best sources of carbon we find in the 
various forms of sugar, in mannite and in glycerine. THE GENERAL PATHOLOGY OF LNFECTION 
513 
We cannot discuss these matters fully in a work on medicine; fur- 
ther information must be sought in special treatises, or better still, it 
must be gained by patient laboratory observation. 
Of importance in the selection of artificial media are (a) the concen- 
tration, (&) the reaction, (c) the temperature, (d) the presence or absence 
of free oxygen, (e) the light, and (/) the atmospheric pressure. 
(a) Concentration. - Some organisms are capable of thriving in 
extremely dilute albuminous solutions; the vibrio of Asiatic cholera, 
for instance, can be separated best by means of cultivation in weak 
peptone solutions. 
(&) The reaction of our artificial media is generally neutral or faintly 
alkaline. Most organisms are sensitive to an excess of alkali or to an 
excess of acid, but some develop best in decidedly acid media. 
(c) The temperature most favourable to growth in a test-tube varies, 
within certain limits, with the particular species. As a general rule 
it may be stated that all pathogenetic organisms found in morbid lesions 
of warm-blooded animals prefer 38-5° C., that is blood heat: conversely 
those which under natural conditions produce disease in fish and other 
cold-blooded animals are frequently capable of growth only at lower 
temperatures. There are also, however, many non-pathogenetic bacteria 
which refuse to grow above 20° or 22° C., especially many water and air 
organisms; and again, as Dr. Macfadyen has recently shown, there is a 
elass of microbes which refuse to grow at any temperature below 50° C.; 
such organisms are called " thermophile." Microbic life is impossible 
at very low or at very high degrees of temperature. Numerous organ- 
isms, however, have been found in the snow crystals of freezing cham- 
bers, and in ice and snow. Experience alone can tell us the optimum 
temperature for a given kind of micro-organism. 
(d) Most micro-organisms require free oxygen for their growth and 
development; but there are some which cannot thrive in an atmosphere 
containing oxygen. The latter are called anaerobes, the former aerobes. 
Amongst the anaerobes we find some which, though preferably anaerobic, 
can yet exist in an atmosphere containing oxygen; these are the faculta- 
tive aerobes: and again there are some aerobes which possess the faculty 
of growing in an atmosphere deprived of oxygen; these are the faculta- 
tive anaerobes. We have thus the following groups : - 
Aerobic germs: - (i.) Obligatory aerobes, which must be supplied 
with oxygen, (ii.) Facultative anaerobes, which preferably grow under 
aerobic conditions, but may also exist as anaerobes. 
Anaerobic germs: - (i.) Obligatory anaerobes, which can grow only 
in an atmosphere free from oxygen, (ii.) Facultative aerobes or organ- 
isms which preferably are anaerobic, but which may grow also under 
aerobic conditions. 
Among obligatory anaerobic germs we find the bacillus of malignant 
oedema, readily obtained from garden earth; the bacillus of tetanus, 
another inhabitant of the soil, and the bacillus of quarter-evil. These 
bacilli can produce their poisons or " toxins " only in media wherein 
VOL. I 
2 L 514 
SYSTEM OF MEDICINE 
they are sheltered from free oxygen. The best known facultative anae- 
robes are the pyococci, the bacillus anthracis, the bacillus of typhoid 
fever, the bacterium coli commune, and the microbes of pneumonia and 
of Asiatic cholera. The commonest obligatory aerobe is the hay bacillus 
or the bacillus subtilis. It is, however, impossible to draw a hard and 
fast line between the facultative anaerobes and the facultative aerobes. 
The following are the various methods in common use to obtain the 
suitable conditions for anaerobiosis: - 
1. The oxygen may be removed by means of a solution of pyrogallic 
acid in caustic potash (Buchner's method). This is the best and easiest 
way of obtaining an atmosphere free from oxygen. 
2. The organisms may be grown in vacuo by means of exhausting 
the tubes or flasks containing the inoculated nutrient medium. 
3. The atmosphere may be replaced by an indifferent gas, preferably 
by hydrogen. 
Whatever method be used, reducing substances may be added, at the 
same time, to the media in which the organisms are grown; such sub- 
stances are glucose, formate and sulphindigotate of sodium. 
Many pathogenetic organisms, though in the laboratory generally 
cultivated under aerobic conditions, in the animal body must grow 
as more or less strictly obligatory anaerobes. Thus in deep or closed 
abscesses oxygen is either absent or present only in minute traces. 
There can hardly be any doubt that the chemical activity of the patho- 
genetic bacteria must vary under such opposed conditions as aerobiosis 
and anaerobiosis. In the absence of oxygen facultative anaerobes will 
often display a most extraordinary fermentative action. We are still 
far too ignorant of the minute changes, chemical or physical, in the 
tissues to speculate with any degree of promise; but this much is certain 
that, even if we choose media most closely resembling the tissue sub- 
stances, we cannot reason directly from changes in the test-tube to 
changes in the animal body, because the conditions of atmosphere and 
oxygen among others, are or may be extremely different. 
(e) Recent researches have shown that many bacteria are injured by 
sunlight; and speaking generally, it is best to cultivate organisms in the 
dark. Prof. Marshall Ward, who has paid especial attention to this 
subject, has shown that the blue and violet rays of the spectrum are 
especially destructive to certain forms. Thus anthrax spores, which are 
extremely resistant to external influences, typhoid bacilli, and choleraic 
spirilla soon die when exposed to the rays of the sun; tubercle bacilli 
are either attenuated in their virulence or destroyed; and chromogenetic 
organisms lose their power of producing pigment, and in some instances 
are converted into colourless varieties. It has been shown that these 
effects are not due to the heat rays; they appear to be the result of 
oxidation; for in a vacuum, or in the depth of the nutrient medium, 
insolation is less effective or even powerless. Some observers think that 
ozone, formed by the action of the solar rays, acts as a strong germicide; 
others suggest that hydrogen peroxide is the destructive agent. THE GENERAL PATHOLOGY OF INFECTLON 
515 
It is asserted by some observers that the quality of the nutrient 
medium is not altered by the light; that the action is a direct one, 
affecting the organisms in the medium: others, however, maintain that 
insolation may have a deleterious or unfavourable effect on the soil. 
Even diffuse sunlight has an inhibitory or noxious effect on the growth 
of certain forms of micro-organisms. It must not be imagined, how- 
ever, that all organisms are injured alike by the solar rays; some grow 
well or even more vigorously in sunlight. It has been found that the 
solar rays are capable of destroying or rather of decolorising solutions 
of some of the bacterial pigments, for example, the green or blue pig- 
ment of the bacillus pyocyaneus dissolved in chloroform, or the red 
pigment of the bacillus prodigiosus extracted by ether or water. And 
here also it will be seen that the blue rays are more active than the red. 
That sunlight destroys or diminishes the power or virulence of bacte- 
rial poisons is likewise well known. 
(/) The influence of atmospheric presstire on bacterial life has not 
yet been thoroughly worked out; ordinary atmospheric variations seem 
to be indifferent. We know, however, that beyond certain depths, or 
above certain altitudes, micro-organisms cannot be detected with our 
ordinary means. Regnard has shown that putrefactive organisms are 
inhibited in their growth and activity by pressures varying from 600 to 
700 atmospheres. Albuminous substances which readily putrefy were 
kept for weeks in a sound condition under such pressures, even when 
such organisms were known to be present. It is of course possible 
that, as there are thermophile bacteria which thrive at amazingly high 
temperatures, there are also organisms which resist such pressure as is 
found in the lowest depths of the sea. 
Summary. - Most of the known micro-organisms can be cultivated on 
artificial media; but, as already stated, there are many which refuse to 
grow on such soils, for example, the bacillus of leprosy, the spirillum of 
relapsing fever, and many spirillar forms which are found in the tissues 
and in animal secretions or excretions. We must always remember that 
the artificial media used in the laboratory for the cultivation of micro- 
organisms are " artificial," and that the phenomena observed under these 
conditions are evidently not the natural ones. Scientific work, however, 
could hardly be possible, unless media could be made up for artificial cul- 
tivation. Those that are commonly in use may be divided into (1) liquid 
media, and (2) solid media. The former include broth, milk, urine, blood 
serum, vegetable infusions ; the latter potatoes, meat, gelatine, agar-agar, 
or coagulated blood serum. It would be beyond the scope of this article 
to enter into a fuller discussion or description of these various media and 
their selective advantages; it will be sufficient to say that there is no uni- 
versal medium, fluid or solid, for all organisms : some, for instance, grow 
well on agar-agar, and with difficulty on gelatine; others better in liquid 
than on or in solid media. Many bacteria suffer in an acid reaction, others 
prefer acidity. Then there are some which grow best on serum or media 
containing serum, as, for instance, the gonococcus. Such organisms 516 
SYSTEM OF MEDICINE 
may often be gradually accustomed to an existence and active life on or 
in the ordinary media of the laboratory. Thus it has not taken many 
years to " force " the bacillus of tuberculosis to grow on such ordinary 
substances as glycerine agar-agar; yet when Koch first separated this 
bacillus, it was with serum only that he could succeed. Again it is a 
common experience, on first separating an organism from the living 
animal, to find that it grows slowly or with difficulty on agar-agar; but 
if frequently transferred from one tube of agar-agar to another, it will 
soon become adapted to this soil. 
Classification of Micro-Organisms. -These observations, made in the 
laboratory and at the bedside, in respect to the question of soil have 
led us to make the following classification - 
1. The parasitic micro-organisms, which are capable of developing 
and thriving in living animal tissues. 
2. The saprophytic micro-organisms, which can live outside living 
animal tissues, that is, on dead or dying tissues, or on mineral and in- 
organic substances, or on vegetable matter. 
The parasites are again subdivided into (a) obligatory parasites, and 
(&) facultative saprophytes. The former are restricted exclusively to 
living animal tissues, while the latter, after leaving them, can continue 
to exist outside the living animal body also - although, perhaps, they 
only attain full vigour and development when they find their resting- 
place in the living tissues. Similarly the saprophytes also are classi- 
fied as (a) obligatory saprophytes, and (6) the facultative parasites. 
After what has been said the meaning of these names is obvious. Now 
organisms which can be grown in or on the usual laboratory media are 
not, strictly speaking, obligatory parasites, for they possess the faculty 
of living on dead matter outside the animal body. Later we shall see 
that a full grasp of this classification is of the utmost importance in the 
aetiology, prevention, and hygienic treatment of infective diseases. 
However, we must realise that we know very little of the natural life and 
habitat of most pathogenetic organisms; and that often when we argue 
that certain infective organisms cannot find, or can but rarely find, suita- 
ble conditions for growth outside the animal body, we may be arguing 
from ignorance. More than one organism, once thought to be a true par- 
asite, has gradually been degraded to the less dignified position of a fac- 
ultative saprophyte or facultative parasite. The tubercle bacillus, for 
instance, has been shown to grow well on ordinary potatoes, on bread, 
boiled turnips and macaroni under aerobic as well as anaerobic condi- 
tions, at the ordinary room temperature and at blood heat; it is certainly 
therefore a facultative saprophyte. To this question we shall return. 
It must be remembered that organisms found in the animal body are, 
firstly, not necessarily parasitic; and, secondly, not necessarily harmful. 
It is true, so far as we know, that the normal blood and tissues do not con- 
tain micro-organisms; but micro-organisms are invariably found on the 
mucous and cutaneous surfaces and near their various outlets. They are THE GENERAL PATHOLOGY OF INFECTION 
517 
also found in many secretions and excretions, for example, the saliva and 
faeces, which are readily contaminated with bacteria. Now it is obvious 
that such organisms are generally either saprophytes or at most faculta- 
tive parasites. Again, many of these organisms may be of distinct and 
special benefit to the host. It is well known that plants thrive badly 
when grown in sterile earth and nourished with sterile food. Similar 
experiments have not yet been made on the higher animals; but it is 
probable that an animal kept and nourished under strictly aseptic con- 
ditions would thrive as badly as would a plant. Many of the organisms 
found in the human body-especially those on the mucous surfaces of the 
alimentary tract - may have become necessary to our metabolic activity. 
Microbes which are tolerated and harboured by the body, which grow 
and thrive with it, and seem even to contribute to its welfare, are not 
parasites, but are said to live with it in symbiosis; they are " commensal." 
III. Products of Bacterial Activity 
The bacteria, while growing in the tissues, or when cultivated in an 
artificial medium such as broth, remove and use up certain substances 
for their own nutrition; but they also, by means of their protoplasmic 
activity, manufacture others which either pass into the broth and are 
there held in solution, or produce secondary changes in the broth by 
fermentation or other chemical interaction. It is obvious then that the 
liquid or medium in which bacteria are growing may become altered 
(a) by the assimilation of nutritive material by the organisms; (6) by 
the products of secretion elaborated and given out by the bacterial cell; 
and (c) by subsequent secondary changes induced by these products. 
The sum total of these chemical and physiological changes constitutes 
all that is included under the term " bacterial products." These products 
are not necessarily toxic when tested on the ordinary laboratory animals. 
It will be found that any one pathogenetic organism manufactures a 
series of substances, of which some are harmless, others poisonous; even 
these latter indeed are not equally poisonous, but differ in kind and in 
degree of activity. No doubt the specific symptoms and phenomena of 
most infective diseases are due to specific poisonous agents; but we must 
be careful not to lose sight of the complex nature of bacterial chemical 
changes which in the body lead to a series of secondary symptoms, no less 
important perhaps than the more striking specific ones. Unfortunately 
the language of the bacteriological chemist is at present far from exact. 
The processes of bacterial activity are extremely complex, and until we 
know more of them, we are compelled to use such general terms as 
"bacterial products," "toxins," and "virus." For instance, when diph- 
theria bacilli are grown in a flask of broth, the liquid is said to contain 
the bacterial products; but many of the substances held in solution 
by the liquid may not have been primarily produced by the bacteria, 
but by a secondary fermentative action. Bacteriological chemistry is a 
young branch of science, and as yet even more backward than physio- 518 
SYSTEM OF MEDICINE 
logical chemistry; we shall therefore restrict ourselves here to a few of 
the more familiar points of theoretical and practical importance. 
The assimilated substances are employed (a) for the purpose of 
building up the bacterial cell; and (b) for the purpose of manufacturing 
certain substances which are afterwards discharged from the bacterial 
cell by a process of secretion or excretion. For us the substances 
eliminated by the bacterial cells and the secondary products elaborated 
by these substances from the culture medium are of the greatest im- 
portance. We shall first take a general survey of the chemical bodies 
obtained from bacterial cultures, that is, not from any one culture in 
particular, but from a large variety of cultures taken collectively: - 
the scope of bacterial chemistry. 
1. Gases are formed or given off by many organisms, for example, the 
anaerobic bacteria, the many varieties of bacillus coli communis, and 
numerous putrefactive organisms. Among these gases are CO2, H, CH4, 
H2S and NH3. C02 no doubt is given out by all organisms. Some, 
however, possess the power of forming gas to such an amount that, 
when grown suitably in solid media, large gas bubbles will appear in the 
substance of the gelatine and the agar-agar; and when placed in the 
animal body, gas will be formed sometimes also in the tissues, to such an 
extent as to produce an emphysematous condition (some forms of septic 
gangrene, malignant oedema, " schaumleber," symptomatic anthrax). 
2. Fatty and oxy- acids and their amido-compounds are commonly 
found in bacterial cultures; for example, acetic, propionic, butyric, and 
lactic acids and their compounds; also leucin and other amides. 
3. Of importance also are the bodies belonging to the aromatic 
series, such as tyrosin, phenol, cresol, which are oftenest found in fer- 
menting and putrefying mixtures. 
4. Many organisms are capable of forming indol, a substance well 
known to the physiologist, which is formed almost certainly by bacterial 
action from proteids by a process of decomposition during their stay in 
the intestine. It is manufactured by many putrefactive organisms, by 
the bacterium coli, and numerous choleraic vibrios. 
5. Some organisms are chromogenetic, that is, they secrete or manufact- 
ure pigments. The latter may occasionally be contained in the substance 
of the organism (intracellular), more commonly in the medium outside 
(extracellular); sometimes they impart a general diffuse colour to their 
surroundings, a colour varying in intensity with the medium in or on 
which the bacteria flourish. The range of colours is very wide. Thus 
red colouring matter is formed by the bacillus prodigiosus; green or blue 
by the bacillus pyocyaneus and the bacillus fluorescens; yellow by 
many sarcinse, bacilli, and staphylococci; violet by the B. violaceus 
and the B. ianthinus. The pigment formation depends (a) on the 
nature and consistence of the medium, being most marked as a 
rule on a solid one; (&) on the presence of air and oxygen (thus the 
bacillus prodigiosus does not form pigment in the depth of a gelatine 
tube); (c) on the temperature (some organisms like the bacillus prodigio- THE GENERAL PATHOLOGY OE LNFECTION 
sus refuse to form their colouring matter in the warm incubator); (d) 
on the activity of the light to which the organisms are exposed (sunlight 
often prevents colour formation, and may cause the pigment to disappear 
after it has once appeared). 
6. Lastly, there are the ferments and enzymes, the ptomaines, the tox- 
albumins, and the products of fermentation. These substances to the pa- 
thologist are of the greatest importance, and they are taken together 
here on account of their close relation, chemical or historical, one to 
another; also because these bodies stand out prominently among the 
other bacterial products, often as physiologically or pathologically spe- 
cific substances which are found only with certain organisms. The bacte- 
rial products, as I should have said before, are either general or indifferent, 
that is, such as are common to all or, at any rate, to a large number of 
micro-organisms; or specific, that is, such as belong to a few only. 
Fermentation is a process by which complex substances are split up 
into simpler ones. It may be (a) purely chemical, initiated and effected 
by the products of secreting cells; or (&) vital, governed by the vital 
phenomena of the cellular organisms. In the latter case we are dealing 
with the manifestation of life by the cells; on their death fermentation 
ceases. The cellular organisms are the true ferments as distinguished 
from the enzymes or chemical ferments. The former are destroyed by 
disinfectants, notably chloroform or thymol, substances which do not 
affect the activity of the enzymes. Many of the vegetable organisms 
secrete or form enzymes, while they themselves act as ferments. The 
yeast cells, for instance, manufacture an enzyme, invertin, which converts 
cane sugar into dextrose and levulose; but they themselves act as an 
alcoholic ferment which changes the dextrose into alcohol. Although 
most enzymes are discharged outwards, that is, are secreted, and act ex- 
tracellularly, some of them effect their fermentative action intracellularly, 
that is, in the substance of the bacterial cell. The micrococcus (bacillus) 
urese is the best known example of an organism, capable of forming an 
enzyme, acting intracellularly. From the dead bodies of these organisms 
a substance can be separated which will change urea into ammonium car- 
bonate. It is important thus to distinguish between ferments and enzymes. 
Among the enzymes the following have been separated or isolated: - 
(1) Diastatic enzymes, which convert starches into glucose or dextrose, 
have been found in lactic acid bacilli, and in certain intestinal germs. 
(2) Invertin, an enzyme capable of changing cane sugar into dextrose, 
is found in intestinal bacteria, in yeast cultures, and in lactic acid 
bacilli. (3) Many organisms are capable of peptonising proteids, that 
is, of converting them into albumoses or peptones. The liquefaction of 
gelatine, a property of a large number of bacteria, seems to be due 
to peptonisation. (4) The presence of bacteria in milk often produces 
coagulation or curdling. The bacillus coli communis is one of the most 
active organisms in this direction. There are other enzymes, as for 
instance those capable of dissolving cellulose and of splitting up urea, 
but they are of less importance. 
519 520 
SYSTEM OF MEDICINE 
Some of these enzymes have been prepared from bacterial cultures 
in a more or less pure state. Such enzymes, forming peptones, dextrose, 
and other substances which remain in solution, must greatly alter the 
composition of the media in which the bacteria are growing. Peptones 
and albumoses are the commonest substances found in such albuminous 
media, as alkali-albumin and serum, and undoubtedly they owe their 
origin to fermentative processes; of these we shall speak later. Besides 
manufacturing these specialised enzymes, many of the pathogenetic 
organisms may act as living ferments, and by complex changes produce 
specific substances in the media in which they grow, in other words, they 
may produce fermentation. 
We see, then, that in any bacterial culture, as in the case of the 
yeast cells, two kinds of fermentation may go on at the same time, (a) 
that produced by chemical substances - the secretion of bacteria in this 
particular case - a process comparable to peptic fermentation; (b) that 
carried on by living organisms. Of this vital fermentation in disease at 
present we know but little. The best known forms of vital fermenta- 
tion do not play a part - or but a small part - in disease; they are (a) 
alcoholic (yeast); (b) lactic (bacillus acidi lactici) ; (c) butyric (bacillus 
butyricus); and (d) acetic fermentation. Fermentative processes are 
obviously capable of altering the chemical composition of a nutrient 
medium in a striking manner. 
Neither the ferments nor the enzymes are used up in the processes 
which they initiate; on the contrary, up to a certain point, the ferment 
cells multiply in the nutritive solution. The amount of enzymes present 
must of course depend on the number of organisms. A nominal quantity 
of ferment cells suffices to produce extensive fermentative changes; this, 
however, is also true of many enzymes, as, for instance, of some milk- 
curdling enzymes; roughly, however, the effect produced by the enzymes 
varies directly as the quantity used. 
As fermentation, like putrefaction, is a hydrolytic process, both 
enzymes and ferments require water to liberate their power; boiling 
destroys them, so does cooling; and the retention of the products of 
their activity eventually inhibits and impairs fermentation. Although 
the enzymes are capable of acting under anaerobic conditions, the fer- 
ment cells cannot permanently do without oxygen ; yet a temporary re- 
duction of the oxygen-supply will often raise their fermentative activity. 
Of the true chemical nature of the enzymes we are ignorant. They 
are probably proteins, soluble in water but not diffusible, and precipitated 
by ammonium sulphate and alcohol. In aqueous solution they lose their 
fermentative properties when heated to 60°-80° C., though when dry they 
will resist temperatures of 100°-150° C. In glycerine solution they 
retain their power almost indefinitely. As a rule they are easily carried 
down mechanically from their solution by various methods of indifferent 
precipitation, as by calcium phosphate, cholestearin, etc. It is important 
to keep in mind this readiness of the enzymes to come down on precipi- 
tation ; because it is quite possible that some of the many discrepancies THE GENERAL PATHOLOGY OF INFECTION 
which make the subject of bacterial chemistry so perplexing are due to 
imperfect knowledge of the difficulty of successfully separating the (so- 
called) enzymes. To this matter we shall come back in a final review 
of the present position. 
The ptomaines are certain basic compounds formed by the action of 
bacteria on dead albuminous substances; they include highly toxic sub- 
stances which have been compared to alkaloids, and have been called 
animal alkaloids. As a matter of fact, however, they differ consider- 
ably from the vegetable alkaloids, being amines (mostly di-amines); and 
they are formed most commonly in the early stages of putrefactive proc- 
esses. Brieger has separated ptomaines from cultures of the typhoid 
bacillus, the cholera vibrio, and the bacillus of tetanus; and Leber ob- 
tained phlogosin from the staphylococcus aureus and the streptococcus 
pyogenes. These bodies, with a longer series separated from various 
decomposing tissues, are highly toxic; it was therefore assumed at one 
time that the characteristic symptoms of many infective diseases are 
produced by these ptomaines, and the symptoms of many food intoxi- 
cations and of certain intestinal infections are still attributed to an 
absorption of these substances from the intestinal tract. Dr. Cunning- 
ham, for instance, regards, and possibly with justice, Asiatic cholera as 
an intoxication by ptomaines formed by the bacteria of that disease. 
Without entering deeply into this question, we may take it as cer- 
tain that there are many pathogenetic bacteria which manufacture no 
ptomaines; or, at any rate, whose ptomaines when administered to an 
animal produce none of the specific symptoms associated with the dis- 
ease ; lastly, the amount of ptomaines separable from large and copious 
bacterial cultures is so very small that in many cases a doubt of the 
specific importance of these substances is justifiable. Moreover, many 
of Brieger's specific ptomaines have not stood the test of time - for 
example, his tetanin, spasmotoxin, and tetanotoxin, on which, indeed, 
he himself has turned his back. Sidney Martin found an alkaloidal 
basic body in anthrax cultures, and in the tissues of animals dead of 
anthrax; but it was always accompanied by other toxic substances. In 
most cases chemical analysis has failed, with new methods in competent 
hands, to detect specific ptomaines. No doubt many of the ptomaines, 
where found, produce injurious effects; but before we can concede much 
importance to them we must be satisfied that they are capable of repro- 
ducing the characteristic symptoms. Anyhow, it seems that at present 
the ptomaine theory has lost ground, and in many quarters has been 
given up - it was merely a phase. Undoubtedly ptomaines exist, often 
appear during early decomposition and putrefaction [see article on 
" Ptomaine Poisoning and are found in certain cases of food-poison- 
ing and in some forms of disease; but it is erroneous to put down all 
bacterial toxins as ptomaines. Two further matters may be mentioned 
in this elementary sketch, namely, that not all ptomaines are poisonous,1 
521 
1 Brieger in his classification applies the term " toxins " to the poisonous ptomaines, 
the term "ptomaines " to those which are not poisonous-a useless method of classifying. 522 
SYSTEM OF MEDICINE 
and also that some ptomaines are extremely resistant to high degrees 
of temperature. 
With the discoveries of toxic albumoses in bacterial cultures, by 
Mr. Hankin and Dr. Sidney Martin, the ptomaines were more or less lost 
sight of, and fresh paths of research were opened up. Weir Mitchell 
and Reichert had already shown that the toxic principles of snake venom 
are albuminous substances; they supposed them to be mostly toxic pep- 
tones. Later it was demonstrated that they are not peptones but albu- 
moses. Others followed up these researches, and of great importance 
were Sidney Martin's investigations on abrin, which he also proved to 
be a toxic albumose. Indeed it soon appeared that a fairly large num- 
ber of highly, and even intensely poisonous substances, whether derived 
from the animal by glandular activity, or from seeds of plants, or from 
bacterial cultures, owe their toxic properties to albumoses. Hence these 
peptone-like substances came to be regarded as the specific poisons of 
pathogenetic bacteria, and this the more as they were obtained from a 
series of organisms. When Roux and Yersin had precipitated the active 
principle from diphtheria cultures, which they called an enzyme; and 
when Brieger and Frankel, working with different methods, had come to 
the conclusion that the diphtheria toxin is an albuminous body, or a 
" toxalbumin," Sidney Martin showed that from diphtheria cultures in 
alkali-albumin toxic albumoses can be obtained which, injected into a 
guinea-pig or rabbit, produce all the classical lesions of the disease. But, 
before Martin's researches, chemists had already suspected that the diph- 
theritic toxalbumins of Brieger and Frankel were really albumoses. Al- 
bumoses have also been found in cholera and pneumococcus cultures, and 
in Koch's tuberculin. Gradually, however, it became evident that many 
of the bacterial toxins do not react as albumoses, but that some answer to 
peptone tests, others behave more like globulins, and so forth. It seemed, 
then, that from bacterial cultures various kinds of poisonous albumins 
or proteids or albuminoid bodies may be separated, and hence the gen- 
eral term toxalbumins was applied by Brieger and Frankel to all of them. 
It is quite true that from several bacterial cultures (B. anthracis and 
B. diphtheriae) toxic albumoses can be separated, if the organisms be 
grown on an alkaline serum free from peptone; and these albumoses, 
when injected into the animal body, will produce the lesions character- 
istic of anthrax and diphtheria: but it is equally true that specific 
albumoses are not to be obtained from all pathogenetic bacteria. If, 
however, we use the more general name toxalbumin in the sense defined 
above, it may be said that specific toxalbumins have been found in 
anthrax, diphtheria, pneumonia, in almost all infective diseases, and in 
most cultures of pathogenetic bacteria. Toxalbumin, however, is an 
inaccurate name, since it would include practically only the true 
albumins and the globulins, and would exclude the proteins (nucleo- 
albumins) and the albuminoid substances. 
Now the albumoses and peptones which constitute so important a series 
among the bacterial products maybe derived by hydrolytic processes from THE GENERAL PATHOLOGY OF INFECTION 
any one of those albuminous or albuminoid substances including the 
nucleo-albumins; and, strictly speaking, they are not covered by the 
name albumin. It is better, therefore, to follow Neumeister, and to 
speak of toxic proteins, which designation includes the albumins, the 
proteids, and the albuminoid bodies. Taking this wider view, we shall 
meet with fewer difficulties than if we restrict ourselves to the terms 
toxalbumins or to albumoses. In the case of snake venom, for instance, 
we find that their composition is anything but uniform; some contain 
toxic globulins, others albumoses, primary and secondary, others perhaps 
peptones [vide art. on "Snake Poisoning In abrin, again, there are 
both an albumin and a globulin; toxic proteins exist also in ricin and 
other similar substances; and we have seen that the nature of the bac- 
terial products may vary considerably. 
Many of these proteins may be precipitated in an amorphous form 
from the culture medium in which the bacteria grow; when in solution 
they are generally readily destroyed by heat (snake poison, however, less 
readily), and are rendered atoxic by the action of the digestive secretions. 
In a dry state, like enzymes, they resist heat better; and they often 
resemble the enzymes in this also, that they set up their toxic effects 
when injected in extremely minute doses; so that they would seem to 
act not directly on the tissues, but, after the manner of enzymes, to 
produce a kind of toxic fermentation. 
Summary. - We have seen that by Brieger's researches the atten- 
tion of the scientific world was directed towards the poisonous ptomaines, 
but we soon learnt that the part which these play in infective diseases 
can only be one of secondary importance; next we were taught to look 
for the secret of these diseases in toxic albumins, albumoses, or, in short, 
in toxic proteins, that is, in substances reacting like proteins (albumins, 
globulins, albumoses, etc.), which cannot be chemically distinguished 
from ordinary known proteins, but are endowed with toxic properties. 
Duclaux and others, however, have raised a protest against this view, 
and have always assumed that the toxo-proteins in reality are mixtures 
of albuminous, proteid, or albuminoid bodies with the true toxins, the 
latter being carried down mechanically during precipitation; and recent 
researches have shown that, if for the purpose of cultivation a non- 
albuminous solution be employed, the result is not an albumose or a 
globulin or a toxalbumin, but an indefinite body, perhaps albuminoid in 
nature, and allied to the enzymes and ferments. Brieger and Cohn have 
demonstrated that it is possible to purify the toxin of tetanus (which, 
when obtained from broth, appears to be a toxalbumin) in such a manner 
as to rid it more or less completely from all the albuminous and albu- 
minoid substances clinging to it; and Sidney Martin, although his 
researches are as yet unpublished, has confirmed this in a most striking 
manner. He has shown the presence of albumoses in tetanus cultures, 
which, however, are simply pyrogenetic in their action; the true toxin 
which is obtained after the removal of the toxalbumins is not an albu- 
min, nor a proteid, nor of course a ptomaine. 
523 524 
SYSTEM OF MEDICINE 
We see then how obscure the whole subject still is, and that the 
name given to a bacterial toxin apparently varies within certain limits 
with the culture medium used. The albumoses are supposed to be formed 
by a process of fermentation, the bacterial cell secreting an enzyme which, 
acting on the albumin in the culture medium, splits it up into albumoses; 
as the peptic cells in the gastric mucous membrane secrete the pepsin 
which, acting on the proteids in the stomach, converts them first into 
albumoses. However tempting this opinion may be on account of its sim- 
plicity, in the light of more recent researches it can hardly be regarded 
as conclusive. Most investigators, while preparing the toxins from bac- 
terial cultures, use media which already contain peptones or albumoses, 
we do not wonder then that, on precipitation with alcohol or ammonium 
sulphate, they obtain toxic albumoses, or in short toxalbumins. True, 
Sidney Martin used a medium free from albumoses and peptones, but 
containing alkali albumin; and on growing anthrax and diphtheria bacilh 
in such a solution he eventually obtained toxic albumoses: it would seem 
then that these bacilli either act as ferments, or secrete enzymes, which 
change the alkali albumin into toxic albumoses. So far as diphtheria is con- 
cerned, he inclines to the view that its bacillus secretes an enzyme; for out 
of the diphtheritic membranes a proteid substance may be extracted which 
does not give albumose or peptone reactions, and yet produces the same 
effect on the animal as the albumoses, though administered in much smaller 
doses. Martin therefore argues that the bacilli set free an enzyme which, 
by hydrolysis, converts the albumin into albumoses, which latter, acting as 
poisons, produce the true diphtheritic lesions in the animal. He finds 
also that they form identical substances (albumoses) from the proteids of 
the human body. " It may be," he says, " that the chemical substances 
which are especially poisonous are produced by means of an unorganised 
ferment (that is, an enzyme) secreted by the bacillus, and in diphtheria 
there is evidence to show that this enzyme plays a direct and important 
pathological part. In this disease, in which the bacillus is limited to the 
superficial parts of the membrane, and does not diffuse itself throughout 
the body, something is secreted by the bacillus and then absorbed into 
the system, in the tissues of which are afterwards found certain digested 
products (that is, albumoses)." This secretion of the bacillus may be 
looked upon as an enzyme; so that Martin's conclusion is that the bacillus 
diphtherise liberates an enzyme which digests the proteids of the body or 
of the culture medium, forming toxic albumoses, and that the latter 
produce the characteristic morbid changes. The toxic diphtheria prod- 
ucts in the body do not all come directly from the membrane, the 
albumoses do not merely accumulate in the tissues; it is more probable 
that the enzyme, absorbed from the membrane, by digesting the tissue 
proteids forms toxic albumoses. Martin gives a useful table, which 
is here reproduced in slightly altered form, to contrast the chemical 
pathology of anthrax and diphtheria with the physiological processes 
of peptic and tryptic fermentation: - THE GENERAL PATHOLOGY OF INFECTLON 
525 
Digestion Process. 
Origin of Enzyme. 
Ezyme. 
Products of 
Fermentation. 
Peptic. 
Peptic cells. 
Pepsin. 
Albumoses. 
Peptones. 
Tryptic. 
Pancreatic cells. 
Trypsin. 
Globulin-like 
body. Peptone. 
Anthrax. 
B. anthracis. 
Albumoses. 
Peptone. 
Diphtheria. 
B. diphtherise. 
Enzyme of Roux 
and Yersin, and 
of Martin, found 
in membrane. 
Albumoses. 
Martin does not fall into the error of applying this scheme to all 
infective organisms alike; he shows that the albumoses which may be 
separated in the case of tetanus, though not innocuous, do not possess 
the specific characters of the tetanic poison; and, as above mentioned, 
the toxin of tetanus is not an albuminous or proteid substance. Yet, so 
far as diphtheria and anthrax are concerned, his views undoubtedly are 
that the pathogenetic bacteria are capable of digesting proteids in such a 
manner as to produce the agents which set up the symptoms in these 
infective disorders. This conception of the problem is very tempting, 
but it is also beset with difficulties. Thus the proteolytic action of the 
so-called diphtheria enzyme has never yet been demonstrated; this so- 
called enzyme may be the true toxin which is diffused throughout the 
body at the same time as albumoses are formed, and on precipitation 
the two substances may be carried down together [vide art. " Diphthe- 
ria "]. In tetanus, certainly, the albumoses are of secondary importance. 
But the greatest difficulty is presented by the researches of Uschinsky 
and Buchner. The latter excluded albuminous substances from their cult- 
ure media by using solutions containing asparagin and mineral salts; 
and on growing tetanus and diphtheria bacilli in such solutions, they 
obtained the active and specific toxins of tetanus and diphtheria as bodies 
clearly allied to the albuminoid substances, but not classifiable or defin- 
able except by their reactions. They are therefore disinclined to accept 
the view that the bacterial poisons are formed by a fermentative action 
from the albuminous substances of the body or culture media: they re- 
gard them as direct products of the bacterial cells, that is, as direct deriv- 
atives from the cell plasma, which, as such, must necessarily share the 
specific properties of the bacterial cell whence they came. As yet it has 
been impossible to separate these substances from albuminous solutions 
in a pure state, because all the reagents which precipitate them will also 
carry down simultaneously the albuminous and proteid bodies contained 
in those solutions. Buchner does not picture to himself the action of 526 
SYSTEM OF MEDICINE 
these toxins as a fermentative one, chiefly perhaps because within certain 
limits the rapidity and the intensity of the effect produced vary with the 
dose administered. Yet it is a striking fact, of which we can readily 
obtain evidence, that many of the bacterial and animal toxalbumins pro- 
duce fatal lesions in minute doses; and, what is still more wonderful, 
that a so-called minimal lethal dose will often be followed by no mani- 
fest signs or changes for some days, and then after a period of latency 
symptoms of astonishing acuteness may suddenly appear; and, lastly, 
that "sublethal" doses frequently lead to slow wasting, exhaustion, 
prostration and death. It would be useless with our present knowledge 
to speculate on the meaning of these phenomena, to which there is no 
analogy in ordinary toxicology. We cannot as yet answer the following 
questions - whether the toxins are themselves the poison, or whether 
they are poison-producing enzymes; or again on what the prolonged slow 
action of the toxins under special conditions depends. In the case of 
enzymes, such as pepsin and invertin, we must carefully distinguish be- 
tween their fermentative and their toxic actions. When injected into 
the animal body they produce rise of temperature, general disturbances 
and death, acting not by means of fermentation, but as direct poisons. 
To come back to the chemical nature of the toxins; we have seen that 
during the fermentative changes produced by the bacteria, besides the 
direct products of fermentation, there are other substances also which 
we may regard as the secreta or excreta; that is, as the metabolic or 
waste products of the bacteria. In most cases it is difficult to say with 
certainty what they are. This, however, is important: 11 If an organism 
growing in various media always produces certain definite substances, 
then we are forced to consider these to be the genuine metabolic prod- 
ucts." Now we find, for instance, that if the cholera vibrio be culti- 
vated on different media, we can extract a series of substances different 
in their chemical reactions, but all identically toxic. Naturally the fer- 
mentation processes must vary with the nutrient medium employed, and 
their reactions can only be complete with certain special media; but, 
nevertheless, the metabolic products appear to remain physiologically 
and pathologically constant: so we may conclude with Wesbrook that 
the choleraic toxin is the constant, associated either with the proteins of 
the nutrient medium or with the products of fermentation. This seems 
more reasonable than to assume that the vibrio may form different 
chemical toxins with constant physiological or pathological properties. 
This vibrio forms an interesting illustration of the continual change of 
our opinions. Brieger described no less than six ptomaines, all toxic, but 
none specifically so; Scholl, growing the vibrio in eggs, obtained a toxo- 
peptone; Gamaleia extracted poisonous substances from the bodies of the 
dead bacteria, which he classified as nucleins and nucleo-albumins; Voges 
also sought for the cholera toxin in the bacterial cell, and regarded it as 
an enzyme, since when obtained from suitable media it reacts neither 
as an albumin nor albumose nor peptone. Duclaux, as previously stated, 
consistently refused to regard the bacterial products as true proteins, but THE GENERAL PATHOLOGY OF INFECTION 
527 
argued that they are special bodies of unknown nature, mechanically 
carried down during precipitation, or perhaps forming compounds with 
the proteins. This view of Duclaux has much in its favour; the chemi- 
cal evidence, however, is still wanting: fresh observations are needed. 
In the meantime we may sum up that among the specific toxins there 
have been found (a) ptomaines, (&) toxic proteins, toxalbumins, (c) nucleo- 
albumins and albuminoid substances, (d) ferment-like bodies (enzymes) 
secreted by the bacterial cell; and knowing as little as we do, it is safest 
to apply to the bacterial poisons the general term toxin. 
Matters have not been made easier by Dr. Klein's division of these 
poisons into (a) intracellular and (&) extracellular poisons. Klein 
has shown that the protoplasm of the bacterial cells is often highly 
poisonous; and argues, therefore, that many bacteria contain poisonous 
substances in their protoplasm (intracellular poisons). These, as a rule, 
he says, produce none of the specific symptoms; but when injected 
into the animal cause inflammation, suppuration, and often death. 
They must be distinguished from the "extracellular" poisons formed 
by a fermentative or other action on the culture medium, the extra- 
cellular poisons being the true specific toxins. Thus, to give an 
example, the diphtheria bacillus, acting on the surrounding albuminous 
medium or animal tissue, forms its toxic albumoses, that is, " the extra- 
cellular specific poisons," which cause the classical symptoms of the 
disease; while within itself the diphtheria bacillus contains the "intra- 
cellular non-specific poison." Chemical analyses of the bacterial proto- 
plasm were made before Klein by Nencki, who obtained from putrefactive 
and other organisms albuminous or albuminoid bodies which he called 
mycoproteins. These resemble the true albumins, but are nevertheless 
essentially different in their reactions. These mycoproteins undoubtedly 
correspond to Klein's intracellular poisons. 
Buchner approaches Klein very closely in some of his views. He also 
distinguishes between "bacterio-proteins" (not to be confounded with 
Nencki's mycoproteins) (that is, mycoproteins or intracellular poisons) 
and the specific amorphous toxins, which, however, he also associates 
closely with the cell protoplasm. The former are common to many bac- 
teria, are more resistant to heat, and when injected into the animal body 
produce inflammation, suppuration, and fever. According to Buchner, 
then, both the bacterio-proteins and the specific toxins are intracellular 
poisons; and this seems, for the present at least, the soundest view to 
accept, because if, for argument's sake, we were to accept Klein's view, we 
should find that the virulence of his so-called intracellular poisons varies, 
as a rule, directly with that of his extracellular poisons. Again, immunity 
from the intracellular poisons generally, if not always, implies also im- 
munity from the extracellular poisons. It would take us too far, nor is it 
necessary at present, to discuss these views more fully; I must content 
myself with this short mention of them. I may, however, allude to recent 
researches on yeast fermentation, which show that as the yeast cells them- 
selves always contain alcohol, it is quite possible that the formation of 528 
SYSTEM OF MEDICINE 
alcohol is an intracellular process; the alcohol, which is the analogue of the 
toxin, being secreted, or excreted by the cells into the surrounding medium. 
Fuller accounts of the various toxins will be found in special articles. 
Here we can admit only a general summary of a subject full of specula- 
tions, and open to many fallacies due to personal bias and to the present 
defects in our knowledge of physiological chemistry. The chief lesson 
to be derived from the study of bacterial toxicology is this, that the 
characteristic symptoms of any infection are due to toxins; therefore 
in our study of microbic disease our aim must be to establish the 
specificity of the bacterial products. Thus while dealing writh a disease, 
such as tetanus, which is readily recognised by strikingly characteristic 
symptoms, we must show, not merely that these symptoms are produced 
by injecting the bacilli of tetanus, but that the toxins (or sterilised cult- 
ures containing the metabolic products in solution) will produce the 
same symptoms; in other words, that the toxins and microbes are alike 
specific. This has already been done for tetanus, diphtheria, and anthrax. 
We find, then, that the pathogenetic bacteria produce poisons, whatever 
their chemical nature may be, which, on obtaining entrance into the 
animal body, will cause the appearance of the specific symptoms of the 
disease under consideration. 
We have seen that the various substances, toxic and atoxic, produced 
by bacterial life, are manifold; and that any one organism may, and 
probably does, form a number of them, partly by secretion or excretion, 
and partly by fermentation. Thus we may explain the complexity of 
the symptoms of infective diseases, the specific symptoms being caused 
by the specific poisons, and the concomitant symptoms by the other 
substances formed by bacteria and bacterial fermentation. We must 
always remember that as the chemical processes and their products are 
far from simple, their effects must likewise be complex. 
The fermentative action, real or apparent, of the pathogenetic 
bacteria and their products is then perhaps their most striking and 
important property - at least in all general infective lesions; the 
organisms themselves acting partly as ferments, partly as zymoge- 
netic cells. The toxins often resemble enzymes so closely that the 
general opinion inclines to place all these bodies in one and the same 
chemical group, not as identical but as allied bodies. Hence, wherever 
in nature we find fermentation, real or apparent, the presence of living 
micro-organisms must be suspected; though of course we must not 
forget that certain zymotic or fermentative processes appear to be in- 
dependent of bacteria, as, for instance, intoxication with snake poison. 
Organisms capable of initiating and completing fermentation have been 
called zymogenetic ; and since many morbid processes are analogous, if 
not akin, to fermentative processes, and are, moreover, produced by 
organisms, the term zymotic has been applied to them, - a term, how- 
ever, to be avoided rather than recommended. 
Though we cannot enumerate and discuss all the various complex THE GENERAL PATHOLOGY OF LNFECTLON 
529 
chemical and physical changes which micro-organisms in general are 
capable of producing in their surroundings, allusion must be made to a 
few other important, or at least highly interesting phenomena of bac- 
terial activity, such as the processes of nitrification, putrefaction, and 
production of light. 
(a) Nitrification takes place especially in the soil and in water, and 
is one of the most important and essential processes for organic, and 
especially for vegetable life. In the soil, where it has been more care- 
fully studied by Winogradski, Frankland, and Warington, two separate 
changes are said to take place, (a) Some organisms decompose am- 
monia into water and nitrous acid; (/?) others, though powerless over 
ammonia, oxidise nitrites to nitrates, and in that way supply the nitrog- 
enous food to chlorophyllous plants. 
Conversely many bacteria possess the power of reducing nitrates to 
nitrites; others are capable even of absorbing free nitrogen. All these 
organisms are of the utmost importance in the vegetable economy, as 
they assist the growing plant and the germinating seed to obtain the 
necessary supply of food. These organisms collectively complete the 
processes of putrefaction by converting the ammonia first into nitrous 
acid, and the nitrous compounds further into nitrates, in the presence 
of basic substances. The nitrates are then again reduced to nitrites 
and ammonia, and so on. The cholera-vibrios possess the faculty of 
forming nitrites, while many bacteria found in faeces are capable of 
still further reducing the nitrites to ammonia. There is reason to 
believe that bacteria are as important to animal life as they are to plant 
life; experiments on lower animal forms prove this, and the laws of 
adaptation would lead us to expect it. 
(6) Putrefaction may be roughly considered as a form of fermenta- 
tion of albuminous and albuminoid matter. The whole chemical process 
of putrefaction is too complex to be considered here; a few words must 
suffice. It seems that the first change is peptonisation, effected in part 
by the peptonising enzymes possessed by most organisms of decomposi- 
tion. The peptonised substances are then further changed and split up; 
amido-derivatives (especially amido-acids), aromatic bodies, and sulpho- 
acids are next formed, and these are further split up, indol being among 
the final products. The list of substances which may appear during 
putrefaction is very extensive; it contains among the gases CO2, H, 
H2S, and CH4; among the fatty acids acetic, butyric, and valerianic 
acids, besides various amido-compounds - amines, indol, skatol; bodies 
of the aromatic series; various ptomaines; basic compounds, etc., the 
chemical combinations varying qualitatively and quantitatively with 
the particular bacterial species concerned, and with the decomposing 
medium. The result of putrefaction in all cases is the decomposition 
of highly complex substances into others of simpler and more assimi- 
lable structure. It is especially under anaerobic conditions that the 
odour of putrefaction is observed. 
The list of putrefactive organisms includes various forms of proteus 
VOL. I 
2 M 530 
SYSTEM OF MEDICINE 
(vulgaris, mirabilis, Zenkeri), for which formerly the name bacterium 
termo had to do duty, and also a large number of other aerobic and 
anaerobic bacteria, many of which are still without proper names. 
(c) The phosphorescence observed on the surface of sea-water, or on 
decomposing meat or fish, is due to photogenetic bacteria, of which there 
are many varieties. This curious and beautiful effect depends on active 
oxidation, and the phosphorescence disappears in the presence of CO2. 
Our observations on bacterial products must be concluded here, for 
in a general introduction it would be out of place to enter into matters 
which are either doubtful or of importance rather to the specialist than 
to the physician. The latter will find no difficulty in appreciating 
the excellent warning of Professor Welch, who says that "in fixing our 
attention upon the poisonous chemical products of bacteria we must not 
lose sight of the fact that these are results of vital activities. In the 
case of most infective diseases we can no more dissociate the actual 
presence, multiplication, and specific vital activities of the bacteria 
within the body from the disease than we can substitute any chemical 
substances for the actual presence and growth of the yeast fungi in the 
production of alcohol from sugar. We cannot resolve bacteriology into 
toxicology." 
Variability of Virulence. - As the shape and forms of bacteria may 
vary or may be altered by changes in their surroundings, so likewise 
may their physiological, chemical, or vital activity be greatly modified 
- often to such an extent that in many cases we seem to come very 
near new species. Thus, as said above, many chromogenetic organisms 
lose their power of forming pigment under special conditions; among 
these conditions are absence of oxygen, increased temperature, insola- 
tion, and change in the chemical reaction of the nutrient medium. In 
some cases by such interferences we may obtain varieties which, if they 
do not remain permanently colourless, at any rate have become incapa- 
ble of pigment production for many generations, or - to express it 
differently - show no reversion to the chromogenetic type for a long 
time. Similarly modifications may be brought about in the fermenta- 
tive activity of bacteria by change of soil or by continued growth on 
ordinary laboratory media. Thus organisms which at first liquefy 
gelatine may lose this power permanently; conversely organisms which 
at first were incapable of liquefying gelatine gradually and permanently 
acquire this quality. Lauder Brunton and Macfadyen mention a curi- 
ous instance of adaptation, if such it may be called, while discussing 
the observation that bacteria which form a peptonising enzyme on 
proteid soil can produce a diastatic enzyme on carbohydrate soil. 
Loss of virulence - that is, impaired toxin formation or impaired 
metabolic activity - is not only the most important change, but also 
that most frequently observed. Thus the pneumococcus, if continuously 
grown on ordinary media, very soon ceases to be virulent, and this loss 
of virulence is permanent: similarly the diphtheria bacillus on agar-agar THE GENERAL PATHOLOGY OF INFECTION 
soon becomes less virulent. This loss of virulence is called attenuation, 
and it may be brought about in many ways besides prolonged cultivation 
in or on artificial media, as by heat, evaporation, drying, chemical dilu- 
tion, or the addition of chemical substances to the culture media: these 
methods, however, require no further consideration. Attenuation may 
be temporary or permanent, as in the case of anthrax, where the loss 
of virulence is, moreover, accompanied by loss of spore-formation. It 
is often found also that an organism obtained from a bacterial lesion of 
severe or malignant type soon loses its virulence, or is from the outset 
less virulent than an organism separated from a less severe case of the 
same lesion. The streptococci are in this respect, perhaps, the most vari- 
able of all germs, and therefore the most annoying to the active worker. 
This variability in virulence cannot be satisfactorily explained at present; 
but it must necessarily lead us to be cautious in our attempts to interpret 
vital phenomena by means of test-tube reactions only. 
The virulence of many organisms may also be permanently or tem- 
porarily increased, either by changing the composition of the nutrient 
media in or on which they grow, or by passing the organisms through a 
series of animals (a process which is called "passage "), especially if the 
animals be relatively insusceptible. In some cases, however, continued 
passage will lead to permanent attenuation; an important observation in 
so far as it helps to throw light on the natural decline of many epidemics, 
which may cease by virtue of a gradual attenuation brought about by 
continuous transmission from man to man. 
It would take us too far to discuss the question of natural races or 
varieties; indeed, our observations and premises are not exact enough 
to give us much confidence in so doing. Most writers assume the ex- 
istence of natural non-virulent varieties in the cases of the organisms 
of cholera, typhoid, diphtheria, pneumonia, and traumatic infections. 
These, under special conditions - unknown to us-may acquire viru- 
lence either before or on gaining access to the body, and will then be 
capable of producing the lesion proper to each. This is possible, if not 
probable: it is safer, however, to suspend our judgment for the present. 
531 
IV. Bacterial Activity in Disease 
Having considered the products of bacterial activity in general, we 
can now approach the all-important question of the relation of micro- 
organisms to disease. No one doubts any longer that a number of 
diseased processes are due to bacteria, and the epithet pathogenetic is 
applied to all organisms capable of producing a morbid lesion in the 
animal body. 
The term pathogenetic is, however, a relative one, because - (1) An 
organism quite harmless to one animal may be capable of causing disease 
in another; (2) an organism which, under ordinary conditions, is harm- 
less, under special conditions may give rise to serious lesions; (3) many SYSTEM OF MEDICINE 
532 
organisms, generally regarded as harmless saprophytes, under special 
circumstances of experiment may prove injurious. 
Thus Dr. Klein has shown that the bacillus prodigiosus, which by 
all bacteriologists is considered not to be pathogenetic, when injected 
into the peritoneal cavity of a guinea-pig may cause a fatal peritonitis: 
Buchner, again, has shown that the dead bodies of bacteria, subcuta- 
neously injected into animals, will produce suppuration. We must bear 
such observations clearly in mind; and we must further remember that 
often an organism, unable by itself to initiate any morbid change, may, 
with the assistance of another organism, or in conjunction with it, cause 
most serious mischief: conversely, the pathogenetic pow'er of some or- 
ganisms may be counteracted by the presence of another organism. 
The lesion produced by so-called pathogenetic organisms may be (a) 
local or general; (&) specific or non-specific. If it be local the organisms 
remain in situ, multiplying there rapidly or slowly, and forming their 
toxins, or setting up fermentative processes. The poisons, secreted by 
the organisms or formed by the action, fermentative or otherwise, of the 
organisms on the tissues, are absorbed, and lead to special symptoms and 
constitutional disturbances; or they may react locally on the tissues, 
causing necrosis or destruction. The constitutional symptoms produced 
in such a case may be as serious as, or more serious than, those of a 
general infection. A few examples will illustrate these points. 
In diphtheria and tetanus we have examples of local infections by 
pathogenetic organisms, accompanied by severe general disturbances. 
The bacilli of diphtheria generally, and those of tetanus always, remain 
at the seat of infection, multiplying quickly in the case of diphtheria, 
and slowly and to a limited extent in the case of tetanus. Both manu- 
facture deadly toxins, which, as they are absorbed or enter the circula- 
tion, produce the serious symptoms of the respective diseases. In an 
ordinary suppuration we have, again, an instance of a local lesion pro- 
duced by pyogenetic organisms. Here, however, the general intoxica- 
tion is usually less severe; but the local changes may be extremely 
severe, and end in ulceration or necrosis. 
If the bacterial lesion be a general one, the organisms will be found 
everywhere in the blood, tissues, and lymph channels; that is, a 11 septi- 
caemia " occurs, using that word in its stricter pathological sense, and 
not giving it a clinical meaning. In these cases the poisons and toxins 
are manufactured in the blood itself, and the intoxication may there- 
fore be very serious. At the same time the mechanical presence of 
bacteria in the vessels, leading to vascular obstruction or embolism, 
may act deleteriously. A lesion which is usually a local process, for 
some reason or another may become general. Thus suppuration may at 
any time be followed by a general septicaemia, the pyogenetic cocci cir- 
culating in the vessels; similarly, a pneumonia may be followed by 
infective endocarditis, and this again by a general septicaemia. Tuber- 
culosis also may suddenly become general, often after operative interfer- 
ence. We find that the less susceptible an individual to any particular THE GENERAL PATHOLOGY OF LNFECTION 
microbic lesion, or the greater the toxic power of an organism, the less 
are the chances of a general diffusion. Man, for instance, being com- 
paratively resistant to anthrax, when infected with this bacillus will 
suffer, as a rule, from malignant pustule only. These matters are also of 
some importance inasmuch as they concern both prognosis and diagnosis. 
If, for instance, in the case of pneumonia, diplococci are found in the 
blood, the prognosis is very grave; similarly if, in the course of tubercular 
disease, tubercle bacilli appear in the circulation, or if, after a wound 
infection, pyogenetic cocci appear in the blood, death almost always fol- 
lows. So far as diagnosis is concerned, the presence of microbes in the 
blood in diphtheria, endocarditis, typhoid fever, or other diseases, always 
implies general septic complications. 
A far more difficult question is that of specificity of disease. 
There are certain pathological lesions, characteristic in their appear- 
ance and nature, the symptoms of which stand out so distinctly, that 
they may be recognised at once. If these depend on the presence and 
action of a particular organism, an organism invariably associated with 
them, they are called " specific " ; and they are said to be due to specific 
pathogenetic organisms. Thus tetanus is a specific disease, accompanied 
by unmistakable signs and symptoms, and it is invariably caused by one 
and the same organism, the bacillus of tetanus. Without this bacillus 
there can be no tetanus; and it is only the ignorant who, using a loose 
terminology, still speak of " idiopathic " tetanus. Similarly tuberculosis, 
actinomycosis, leprosy, glanders, anthrax, typhoid fever, gonorrhoea, and 
diphtheria are specific diseases. These lesions are severally due to one 
particular organism, which is essential. Although many, if not the greater 
number, of bacterial diseases are specific in this sense, it is erroneous to 
assume, on the other hand, that all of them are specific. Undoubtedly 
the same morbid lesion may be produced by several different micro-organ- 
isms. Thus, ulcerative or infective endocarditis is a distinct disease, 
characterised by certain pathological and anatomical changes, and often 
therefore regarded as specific; yet it may be produced by a number of 
organisms, among which we may mention the various pyogenetic staphy- 
lococci and the streptococci of suppuration, erysipelas and pneumonia. 
[ Vide art. " Infective Endocarditis."] Strictly speaking, then, there is 
no specific organism of infective endocarditis ; any one of a number of 
cocci may produce a disease, bacteriologically different from, but anatomi- 
cally, pathologically and clinically identical with that produced by another 
member of the same group of organisms. Similarly suppuration may be 
produced by any one of a large number of bacteria; and in the malady 
clinically recognised as erysipelas, instead of the streptococcus of erysipe- 
las, other organisms may often be found. Septicaemia and pyaemia, again, 
may be produced by more than one kind of bacterium, and the same 
applies to pneumonia. We see then that the same pathological process 
may be brought about by various organisms; in other words, we may have 
clinical or pathological identity without bacteriological identity. This ob- 
servation applies especially to those more general pathological conditions, 
533 SYSTEM OF MEDICINE 
534 
such as simple inflammation, cellulitis, suppuration, septicaemia; the more 
specialised the process the more likely are we to find a specific organism. 
These are matters of the utmost importance, because they explain the oppo- 
sition, frequently rather imaginary than actual, which often exists between 
the physician and the pathologist. A particular name is associated with a 
set of phenomena which constitute a certain disease, and this name has 
been applied to the disease before anything was known of its pathol- 
ogy, or anything suspected of its bacteriology. Subsequently it is 
found impossible to adapt the pathological and bacteriological facts to 
the narrower or wider signification of the clinical name. The bacteri- 
ologist finds that a clinical process or set of phenomena may be produced 
by more than one kind of micro-organism; clinically the results may 
be indistinguishable, though bacteriologically diverse. 
Again a specific organism, when it finds access into the animal body, 
will always produce the same lesion; for example, the tetanus bacillus will 
invariably produce tetanus. But we find that the bacteria which are said 
to cause some of the so-called specific diseases are by no means specific 
in their action. Thus the pneumococcus is said to be the specific organism 
of pneumonia, yet we find that in some cases it will produce a fibrinous 
inflammation, in others oedema, in yet others suppuration, ulcerative 
endocarditis, cellulitis, or septicaemia. Similarly the pyogenetic organ- 
isms vary considerably in their action. We must, therefore, be ex- 
tremely cautious in the employment of the term " specific," and must 
adhere to strict definitions. Recent experiences of cholera have taught 
us that the specificity of Koch's comma bacillus was a dream, and that 
a large number of different vibrios are found in this disease. 
The interaction of various organisms is another matter of serious 
importance which has attracted attention during recent years. In 
many infective processes we always find two or more organisms in 
symbiosis; that is, we have concurrent infections by several organisms. 
Thus in pneumonia we invariably find pyococci and the bacillus coli com- 
munis in the company of the pneumococcus. And it has frequently been 
shown experimentally that a non-pathogenetic organism (that is, an organ- 
ism which does not possess the power of producing specific or non-specific 
morbid changes when placed in the tissues) is often rendered deadly when 
another, perhaps equally non-pathogenetic organism is introduced at the 
same time : we also know that the virulence of many pathogenetic or- 
ganisms is often increased or decreased by the concurrent inoculation of 
another organism, which again may be non-pathogenetic. This shows 
how erroneous a popular impression may be, and how relative a term 
" specificity " really is. This interaction of micro-organisms has not as 
yet been sufficiently studied, and here this brief allusion must suffice; I 
shall revert to this matter presently. It is certain that if in certain 
lesions the same collection of organisms is constantly found, we may be 
led astray if we fix on one of them as specific, and neglect the others as 
contaminations. A study of the correlation and interaction between 
the various organisms frequently or almost invariably found together, may THE GENERAL PATHOLOGY OF LNFECT LON 
535 
in future explain many clinical facts and observations which as yet bac- 
teriology has not explained. 
A pathogenetic specific germ must fulfil the following conditions: 
(a) it must be a parasite or a facultative parasite; (6) it must be found 
invariably in the tissues of an animal dead from or affected with the 
disease in question; (c) it must never under any circumstances occur in 
other diseases, nor within the normal tissues; (d) the organism trans- 
mitted from the diseased or dead animal to an unaffected susceptible 
animal must reproduce the lesion, and in this second diseased animal 
the original organism must be found; (e) if the organism can be culti- 
vated outside the animal body, then an artificial cultivation inoculated 
experimentally into a susceptible animal must again produce the disease, 
and this animal must again contain the organism in its tissues or blood; 
(/) these processes must occur in invariable succession under identical 
conditions; (^) the toxins and poisonous substances obtained from the 
artificial cultivations must agree chemically and physiologically with 
those obtained from the diseased animal. 
Unless all these conditions are fulfilled the evidence of the speci- 
ficity of a given organism is incomplete. In laboratory experiments 
considerable research is often required to establish all these points, be- 
cause even the mode of inoculation frequently alters results; moreover 
it is not always easy to find a suitable susceptible animal, or to find the 
method of artificial cultivation most adapted for poison formation; the 
need of some concurrent inoculation may also have to be considered. 
Another difficulty arises when, in the absence of experiments on man, 
it is impossible identically to reproduce the disease in another species. 
This, however, cannot always be regarded as an insuperable objection, 
if it be remembered that the same organism or the same toxin may, 
under various circumstances, produce different naked eye lesions, that 
is to say, different phenomena of a like morbid process. 
It will be well here to give a list of the various infective diseases in 
man, at the same time stating how far their bacterial pathogenesis has 
been proven: - 
1. All the conditions just enumerated have been fulfilled for anthrax, 
diphtheria, and tetanus, chiefly through the brilliant work of Dr. Sidney 
Martin, who was the first of pathologists to establish the toxic specificity 
in addition to the bacterial specificity previously demonstrated. 
2. The bacterial specificity has been satisfactorily settled for the 
following diseases: glanders, tuberculosis, actinomycosis, gonorrhoea, and 
malignant oedema. Specific organisms have been separated and the 
disease has been artificially reproduced in animals. All the conditions 
excepting the chemical agreement of the disease and the organism, have 
been fulfilled. 
3. The next group includes those diseases with each one of which a 
certain organism is always associated, an organism which can be culti- 
vated, and which is restricted to its own disease; the successful animal 536 
SYSTEM OF MEDICINE 
experiment, however, is wanting. In this group we have typhoid fever, 
influenza, mycetoma or Madura disease. 
4. The proof is still incomplete in the case of leprosy and relapsing 
fever, - diseases which are characterised by the invariable presence of 
easily recognisable organisms, which are not associated with any other 
normal or morbid processes. These organisms, however, have not yet 
been grown outside the human body; but so far as relapsing fever is 
concerned, artificial inoculation of human blood into monkeys has been 
successful: in leprosy, on the other hand, experimental infection from 
man to animal, or from man to man, has not been achieved. Arning's 
well-known experiment brought, apparently, the desired proof that lep- 
rosy may be successfully inoculated from the diseased to the healthy 
individual; it has, however, no scientific value, since it was performed 
on a native of an area where leprosy is endemic, and whose relations 
had leprosy; so that before the experimental inoculation was performed 
he must have been freely exposed to the risks of infection. For such an 
experiment to have any value whatever it must be performed on an in- 
dividual clear of taint, living in a country where leprosy does not occur. 
On the other hand, a large number of inoculations with leprous material 
have been practised on man in Europe without a single success. 
Although in the last three groups of bacterial diseases the chain of 
evidence is not quite complete, yet the constant and exclusive associa- 
tion of characteristic organisms with morbid processes equally charac- 
teristic, compels us to believe in their specifically infective nature. 
5. There are a larger number of infective lesions which are not specific 
in the sense defined above,-lesions, that is, which may be produced by 
more than one species of micro-organism, or by several members (varieties) 
of a definite group of organisms. The various organisms in each of these 
cases are pathogenetic and do produce, but do not always reproduce, 
disease in the animal on inoculation. Clinically there is often no differ- 
ence between the disease caused by one organism and that caused by 
another. In this group are the various forms of inflammatory and suppu- 
rative lesions: pneumonia, osteomyelitis, septicaemia, pyaemia, endocarditis, 
meningitis, erysipelas, angina Ludovici, bronchopneumonia, indeed, the vari- 
ous forms of infective inflammatory, suppurative, or septic lesions which 
at present we are unable clinically to distinguish by their bacterial flora. 
6. Cholera is an infective lesion, produced by a number of vibrios 
which differ widely from one another; sometimes several kinds are 
found in the same individual; at other times only one kind, in rare 
cases none at all. The animal experiment, so far as the reproduction 
of a true choleric lesion is concerned, has hitherto failed. In this group 
we may include also various other clinical forms of diarrhoea, which are 
undoubtedly due to infection, but the bacterial setiology of which is as 
uncertain as that of cholera. 
7. Lastly, there are a number of infective diseases, contagious it 
may be in the highest degree, in which no organisms have been separated, 
but which we presume to be due to bacteria. These are syphilis, rabies, THE GENERAL PATHOLOGY OF INFECTION 
537 
yellow fever, dengue, typhus fever, mumps, whooping-cough, small-pox, 
measles, scarlet fever, and other so-called exanthemata. Whether future 
research will prove them to be bacterial lesions it is hazardous to say ; 
for the present they will be included under that heading, since the 
assumption of their bacterial origin constitutes a good enough working 
hypothesis, and one which at the same time can do no possible harm. 
As there is variation in the morphology and chemical activity of 
bacteria, so there is also considerable inconstancy in their activity in bac- 
terial disease. This hardly requires any further elucidation if we admit 
that the same micro-organism may vary in virulence, that it may produce 
highly toxic substances under certain conditions and bodies practically 
atoxic under others, that it may be readily attenuated, and conversely 
that its virulence and infective powers may be greatly increased. Change 
of chemical activity naturally implies change of activity in disease. 
Moreover, I have already pointed out that the same micro-organisms 
may be the cause of various morbid and pathological lesions. What 
this pathogenetic variability depends upon in all cases it is impossible 
to assert; sometimes, no doubt, on the resistance and insusceptibility 
of the individual, often on changes in the micro-organisms themselves, 
which we may guess at, but cannot define. Tuberculosis may appear 
in many forms, which clinically and pathologically are quite distinct; 
again the pyogenetic streptococcus may produce the most dissimilar 
lesions, and no less perplexing are the multiform activities of the 
pneumococcus. We shall deal later with personal insusceptibility. It 
is generally true that the better protected the individual the more likely 
is a bacterial infection in him to be followed by local reactive changes; 
and with regard to changes in the virulence of pathogenetic organisms, 
we find similarly that attenuated bacteria are capable of producing local 
changes only, while virulent ones are apt to be followed by severe general 
infection and disturbance. Enough has already been incidentally said 
on these matters in the previous pages, so that this short recapitulation 
must be considered sufficient. It is important to remember that amongst 
pathogenetic organisms in general, there is as little constancy of patho- 
logical potency as of morphological characters or chemical activity. 
V. INFECTION AND CONTAGION 
A. Infection. - The term infection has frequently been used in the 
previous pages; now we shall fully consider its meaning. The use of 
the word is gradually becoming narrowed down to the signification 
which modern pathology and bacteriology have attached to it. A full 
discussion of older definitions is unnecessary; the time has come for 
uniformity of terminology. The connotation of a scientific term is 
liable to alteration, and it should be sufficiently plastic to adapt itself to 
new requirements. Infection as a clinical or pathological term dates 
from the days before the microbe was dreamt of as an important setio- 538 
SYSTEM OF MEDICINE 
logical factor of disease. Now that the veil has been lifted from the 
mysteries of bacterial disease, if we wish to keep the term, we must adapt 
it to modern ideas. Our ideas of infection and of intoxication are be- 
coming more definite as bacteriological research advances. Formerly 
pathologists understood by infective diseases those which are set up by 
certain poisons, or poisonous substances (whether organised - that is 
living - or non-organised) either entering the body from without, or 
manufactured in and by the tissues of diseased individuals. They dis- 
tinguished between a contagium and a miasma, the former being an 
endogenous virus developed in the diseased individual, while the latter 
was assumed to arise exogenously, that is, outside the diseased organism. 
According to this view contagious diseases can be transmitted only from 
man to man, or from animal to man, or conversely ; while miasmatic 
diseases may be acquired by persons without coming into contact with 
individuals similarly affected. This distinction led to many difficulties. 
Anthrax, for instance, is always transmitted to man from an animal 
suffering from anthrax, yet it appears in animals without previous con- 
tact with similarly diseased animals ; that is, the disease is contagious, 
in the older sense of the term, for man and miasmatic for animals. 
With the advance of bacteriology the microbic nature of almost all 
infective diseases has been recognised, and we have gradually been com- 
pelled to modify our definitions. At the present time we include under in- 
fective diseases only those which are caused by living pathogenetic germs which 
enter the tissues from without, and are capable of multiplying in the same. A 
disease caused by substances not capable of reproduction, as, for example, 
gaseous or other chemical non-organised bodies, is an intoxicative process. 
Though for practical as well as theoretical reasons we must distinguish 
between infective and intoxicative processes, we must remember that the 
chief lesions and symptoms following an infection are caused by the toxic 
products of the infection-carriers. This statement is true for almost all, 
if not for all infective diseases. In several infections we already have 
experimental proof of its truth (for example, in anthrax, diphtheria, 
tetanus, and suppurative infections). We may, then, pronounce the gen- 
eral law that in any infective process due to a vegetable organism the chief le- 
sions are due, not to the mechanical presence of the micro-organisms, but to the 
action of the metabolic products of these organisms. Broadly speaking, we 
have an infection first and an intoxication afterwards ; the latter, indeed, 
it is which gives the disease its specific and characteristic signs. The 
poison is manufactured within the body, and has not been introduced 
as such from without. The real difference then between infection and 
intoxication proper is that in the latter a poison is taken in as such, 
while in the former bacteria, introduced from without, prepare the poison 
or toxin in the tissues. In intoxication proper the effects are generally 
immediate; in an infective process an interval must elapse before a 
sufficient dose of poison has been produced. In the one case we have 
no incubation period, in the other we must have an incubation period 
of varying length. THE GENERAL PATHOLOGY OF INFECTION 
539 
Incubation.-The shorter this period the more the infective process 
resembles an intoxication. Some poisons produced by micro-organisms 
are harmful in comparatively large doses only, others will destroy life 
or give rise to symptoms in extremely small doses. Anthrax is a good 
instance of the more slowly acting poison; tetanus and diphtheria well 
illustrate the class of more active toxins. In tetanus we find that the 
bacilli multiply but slightly at the seat of inoculation; here, therefore, 
the mechanical effect produced by the presence of the bacilli may be 
entirely neglected. In infections such as anthrax, on the other hand, 
the bacilli multiply rapidly in the vessels ; so that in mice, for instance, 
all the vessels of the body are, as it were, injected with pure cultures of 
anthrax bacilli, and the mechanical effect alone of the bacilli must be 
of some, if not of great importance. In diphtheria, also, and in septic 
embolisms the organisms may produce mechanical disturbances, directly 
or indirectly, which materially modify the symptoms caused by the 
toxins absorbed by the blood, lymph and tissues. 
To sum up, then, an infection leads to disease or death, either by intoxi- 
cation alone, or by intoxication aided by mechanical interference caused by 
the presence of the bacilli themselves. 
The effect of such intoxication may be general or local. Examples 
of this we find in tetanus and diphtheria, or in rabies, where the poison 
causes general symptoms; while in other cases, as in certain forms of 
suppuration, the process remains localised. It is, however, extremely 
difficult to draw a hard and fast line between the two, as a local process 
may suddenly become general. I cannot dwell further on these points ; 
the whole matter is extremely intricate, and premature generalisation 
must be carefully avoided. 
The difference between infection and intoxication is well illustrated 
by certain kinds of food-poisoning. Firstly, there are cases where an 
individual, in perfect health, partakes of some article of food and dies a 
few hours later. The chemist succeeds in separating an alkaloidal poi- 
son, and animals fed with the tainted food die rapidly. Here we have 
a true intoxication. In other instances the bacteriologist separates a 
specific bacillus which, introduced by feeding into mice, produces in 
them illness and death after a definite incubation period, varying from 
twelve to twenty-four hours. At first sight both cases seem to be 
examples of food intoxication, for in each instance animals fed on the 
suspected food die. In the first case, however, death was directly due 
to a chemical poison introduced into the animal body as such; while in 
the other the disease did not set in until the second day after feeding, 
that is, not until the bacilli introduced had manufactured sufficient 
poison to bring about illness and death. 
Infective diseases, then, are caused by organised beings, and an 
incubation period is characteristic of them. 
B. Contagion and Contagiousness. - There is much confusion in 
the use of the terms contagion, contagium, contact, and contagiousness. 540 
SYSTEM OF MEDICINE 
By contagion we understand what the German expresses by the word 
Ansteckung ; contagium being the Ansteckung sstoff ; while contact is 
equivalent to Beruhrung, and contagiousness to Ansteckung skraft. " In- 
fective" and "contagious " are attributes which, partly through inaccu- 
racy of expression, have been frequently confused, not only by laymen, 
but unfortunately also by serious writers who are not sufficiently care- 
ful about their terminology. Infection is the general term, and includes 
contagion. It stands to reason that a disease or lesion which is infec- 
tive, as above defined, may be transmitted from the diseased to the 
healthy, since the germs which are responsible for the mischief are 
capable, it may be, of unlimited reproduction within the diseased body; 
but it does not necessarily follow that it is always, or even usually, thus 
transmitted. As instances, pneumonia, typhoid fever, and cholera may 
be mentioned; these are all infective diseases, but are they ordinarily 
contagious ? Relapsing fever, again, is never transmitted from man to 
man; yet modern research has shown that when we transfuse the blood 
of a person suffering from it into the circulation of a healthy man or 
monkey, we may reproduce an attack in the new host. Under extraor- 
dinary, and generally artificial, conditions, therefore, even this disease 
may be contagious. [Tide art. on "Relapsing Fever."] 
Contagion evidently may be either direct or indirect: that is, infection 
may be brought about either by contact directly from A to B, or indi- 
rectly from A to B through a third body C. For want of a better term, 
" contact " is here used in its widest, or at any rate in an extended 
sense, denoting not mere touch only, but also any form of infection or 
inoculation, whether through the broken or unbroken cuticle, the res- 
piratory or alimentary tracts, or in any other possible way. We may 
distinguish therefore direct and indirect contact - diseases directly and 
indirectly contagious. 
Whether a disease be directly or indirectly contagious, or both, will 
depend primarily on the nature of the organism which causes this disease. 
If an infective lesion be due to a strictly obligatory parasite, then it can 
be transmitted only by direct contact, that is, by immediate transference 
from living tissue to living tissue. The less parasitic, and therefore the 
more saprophytic the infective organisms, the greater will be the chances 
of transmitting the lesion by indirect contact; for in this case the organ- 
isms can thrive more or less well for a considerable time outside the ani- 
mal body. This is a matter of some practical importance, because a disease 
which is exclusively directly contagious can be stamped out by isolation 
alone ; while in a disease both directly and indirectly contagious isolation 
alone is of no avail; or, to express the matter in bacteriological terms, 
isolation can only prevent infective lesions due to obligatory parasites, 
and not lesions due to facultative saprophytes, or facultative parasites. 
Arranging the more important infective diseases on this principle we 
find that there are - 
i. Diseases caused by strictly obligatory parasites which readily perish 
outside the living animal body; these must be directly contagious, and THE GENERAL PATHOLOGY OF LNFECTION 
541 
are best prevented by isolation, segregation, or destruction of the individ- 
ual ; assisted, of course, by disinfective measures. Examples are syphilis, 
rabies, gonorrhoea. The organisms, real or imaginary, which cause these 
diseases are of slight resistance, and soon die outside the animal body. 
ii. Diseases caused by obligatory parasites of greater resistance, capable 
of surviving, for a little time at least, outside the animal body, although 
incapable of multiplying under such conditions; these, though generally 
or almost always directly contagious, may occasionally also be indirectly 
contagious. Examples are variola, scarlatina, measles, glanders, diph- 
theria. Isolation and segregation with disinfection are still the best 
means of preventing infection. 
iii. Diseases caused by facultative saprophytes, or parasitic organisms 
capable of thriving outside the animal body; these are obviously either 
directly or indirectly contagious; and the greater the saprophytic faculty 
of the organisms, the greater the chances of indirect contagion. Segre- 
gation and isolation are utterly ineffectual as preventive measures; and 
absolute disinfection is theoretically the only means of prevention: in 
practice, however, this is almost always impossible. Examples are tuber- 
culosis, actinomycosis, pyogenetic infections. It is quite possible that 
with increased knowledge of the biological conditions of pathogenetic 
organisms more than one disease at present included in the previous 
groups will eventually have to be placed in this one. Thus, as evidence 
accumrdates, it seems more and more probable that the bacillus of 
diphtheria is a vigorous facultative saprophyte; and the same perhaps 
may in future be said of the pyogenetic streptococci. 
iv. Diseases caused by facultative parasites, or saprophytic organisms 
capable of acting as parasites; these are hardly ever directly contagious, 
and occasionally not even indirectly contagious. Examples are anthrax, 
typhoid fever, cholera, tetanus. Anthrax is as a rule directly communi- 
cated from the diseased or dead animal to man (that is, directly contagious 
to man); the animal, on the other hand, generally acquires it, with its 
food, from fields or meadows where anthrax spores have been deposited 
from diseased animals (that is, indirectly contagious to animals) : certain 
localities are breeding-places for the anthrax bacillus, and here an animal 
must acquire the disease independently of direct or indirect contagion. 
The more widely these organisms are distributed the less contagious 
will be the diseases caused by them. Tetanus, for instance, is hardly ever 
directly or indirectly contagious; it is generally acquired independently 
of any previous case. During an epidemic of typhoid fever or cholera 
the respective organisms are generally so extensively diffused through 
water that contagion may practically be neglected. 
Diseases caused by facultative parasites are frequently endemic in 
certain areas; thus cholera is constant in certain districts of India, in 
others it appears in epidemics. In the former case the organism must 
be pre-eminently saprophytic, and find the suitable conditions for growth 
in the soil or water. It stands to reason that isolation in such cases 
must be quite ineffectual, and that preventive measures must be directed SYSTEM OF MEDICINE 
542 
to the habitat of the organisms and against their further diffusion, whether 
by means of water-filtration, drainage, cultivation of the soil, or otherwise. 
v. Diseases which are infective but not contagious. - Excluding malaria 
(which is due to plasmodial infection, and is not a bacterial disease), it 
seems that relapsing fever, due to a specific spirillum, is never transmitted 
by direct or indirect contact from one individual to another. It must be 
remarked, however, that our present knowledge of the bacterial pathology 
of this disease is very imperfect. These non-contagious blood diseases 
(relapsing fever and malaria) are always endemic, and can be avoided 
only by change of abode. 
The Natural Mode of Propagation. - The public are always ready 
to assume, because a disease is due to organisms capable perhaps of 
unlimited growth in the body, and can be transmitted by inoculation 
from one guinea-pig or white mouse to another, that it is therefore 
always and under all conditions propagated directly from the affected 
individual to the healthy; which means that its diffusion depends exclu- 
sively on contagion. At once the cry is raised for segregation, separation 
and so forth, instead of pausing to study the natural mode of propa- 
gation of an infective disease. This evidently depends on many factors 
which may in part be deduced from the above statements: - 
A. The germs never leave the animal body, or they do so in a state 
in which they are incapable of setting up a fresh infection. In this case 
there can be no contagion; the germs must have an abode somewhere 
outside the human body (relapsing fever is an example). 
B. The germs as they leave the body retain full possession of their 
infective powers. If they retain both their vitality and virulence, then, 
and then only, can the disease be transmitted from the affected to the 
healthy; that is, it may be spread by contact, direct or indirect: but 
whether it is generally spread in this manner depends on the following 
points: - (a) The saprophytic or parasitic nature of the infective organ- 
isms, which has been sufficiently discussed above. (/?) Their distribution 
and diffusion in space, or the readiness with which they either multiply 
or may be diffused after once leaving the animal body; if a germ be so 
widely distributed as to be almost ubiquitous, then we may practically 
neglect contagion as a means of spreading the disease (y. supra). 
It is well to state here that aerial infection is less common than at 
one time it was supposed to be, and under ordinary conditions this mode 
of infection has been demonstrated only for pyogenetic, tubercular and 
pneumonic lesions; though it must be assumed to exist in influenza, 
(malaria), diphtheria, and some of the exanthemata, such as small-pox and 
scarlatina. For the organisms of typhoid fever, cholera, dysentery, and 
various forms of diarrhoea we must search the water; while the soil is 
commonly inhabited by the bacilli of tetanus and malignant oedema, and 
also of anthrax: pathogenetic pyococci are found likewise in the soil, 
which also absorbs the infective discharges of diseased individuals, dis- 
charges which contain organisms that, under favourable conditions, may 
survive for months. Dust may prove a fertile source of infection for THE GENERAL PATHOLOGY OF LNFECTLON 
543 
tuberculosis, wound infections, tetanus and pneumonia. That some bac- 
terial diseases find their means of diffusion in food is so well known as 
to require no further comment. I may mention more especially tuber- 
culosis, typhoid fever, cholera, diphtheria and scarlet fever. For the 
sake of brevity we must pass over the other possible sources of ectan- 
thropic infections, such as insects, clothes, furniture and the like. 
Seeing, then, that the tubercle bacillus is found in the dust, in the food 
(milk), and in other accessible sources, we must pause before putting 
every fresh case of infection down to contagion, and before we recom- 
mend isolation of the diseased as the one preventive measure. 
(y) The power of the organisms to form spores outside the diseased 
body naturally lessens the importance of direct contagion and increases 
the chances of indirect contagion. (3) The abundance of germs leaving 
the affected individual favours indirect contagion by causing a wider 
diffusion, and by offering more chances of ectanthropic infection. In 
some infective diseases the organisms are never, or but rarely, discharged 
from the body, as for instance in tetanus, where the bacilli are found in 
small numbers at the seat of inoculation; in others the organisms are 
discharged in large numbers, especially in the diseases which affect the 
excretory passages, or organs in direct or easy communication with such 
passages. In bacterial intestinal lesions, - for example, in typhoid fever 
and cholera - thousands of bacilli or vibrios must pass away with the 
dejecta: similarly in pulmonary infections-for example, in tuberculosis, 
pneumonia, influenza - the sputa must swarm with bacteria. From ex- 
tensive ulcerating bacterial skin affections - as, for example, in nodular 
leprosy - myriads of bacilli may be discharged. (The breath, by the 
way, if unmixed with saliva or mucus, is free from micro-organisms.) 
The urine, again, may contain numerous organisms - as in gonorrhoea, 
some forms of puerperal fever, typhoid fever and tuberculosis. When 
the bacteria are incapable of saprophytic existence, or when from the 
nature of the disease the discharges can be more closely guarded, the 
danger of increased diffusion is so far limited. Thus the urine in gon- 
orrhoea and the sputum in acute pneumonia are not dangerous sources of 
infection. On the other hand, consumptives by their expectorations con- 
tribute largely to the wide diffusion of the tubercle bacillus; from the 
chronic nature of their disease they are less easily controlled, and, espe- 
cially in the poorer classes, they are reckless with their expectoration. 
(e) The mode and readiness of infection is naturally of great impor- 
tance, for some organisms will produce disease in whatever way, and 
when they have been introduced into the body in very small numbers. 
Others are virulent when received in large numbers, or only when 
taken in by the stomach, and harmless when injected subcutaneously. 
Thus guinea-pigs succumb to the smallest injection of the tetanus 
bacillus, and white mice are so susceptible to anthrax that almost a 
single virulent spore or bacillus is sufficient to destroy them. Rabbits 
generally acquire a fatal septicaemia when injected with a very small 
number of virulent pneumococci. On the other hand, it requires a large SYSTEM OF MEDICINE 
544 
number of bacilli pyocyanei to bring about a fatal septicaemia in rodents, 
or a large number of pyogenetic staphylococci to produce suppuration. 
To some extent, no doubt, these laboratory observations apply also to 
natural conditions, especially since experiment shows that the result pro- 
duced often varies as the quantity of germs introduced. Thus a small 
number of bacilli pyocyanei will lead to a small local abscess only, 
followed probably by a condition of acquired immunity; a larger number 
will lead to local necrosis, and a still larger number to septicaemia and 
death. The same direct relation between quantity and effect may be 
observed with many pathogenetic organisms. Koch found that white 
mice are resistant to tubercle bacilli inoculated subcutaneously, but suc- 
cumb to subperitoneal inoculations, or when the bacilli are introduced 
by means of inhalation. The same rule applies also to dogs and rats: 
when large quantities of bacilli were used these animals failed to offer 
any resistance, whatever the mode of infection employed. Again, 
Blagovestchewski has demonstrated that, on simultaneously injecting 
the anthrax bacillus and the bacillus pyocyaneus into the anterior 
chamber or subcutaneous tissue of rabbits, no infection but on the con- 
trary immunity against anthrax will result; while on injecting a similar 
mixture into the circulation the animal will die of a double infection. 
Koger, on the other hand, has shown that rabbits, which are naturally 
immune from quarter-evil, will succumb to this disease, if the bacilli be 
injected into the anterior chamber. It is evident, then, that the easier 
and the more general the mode of the infection, both as regards the number 
of germs and the paths of infection, the greater the danger of spreading a 
contagious disease and before we estimate the true risk of contagion, 
we must find out what form of infection is necessary to produce the 
disease, what quantity of bacteria, and how readily such infection can 
be brought about. 
(£) The natural habitat of the pathogenetic organisms greatly affects 
the ordinary risk of contagion. Thus the normal body on its cutaneous 
and mucous surfaces often contains large numbers Of such organisms 
which may suddenly assume infective properties; that is to say, they 
may produce acute infection. In such cases contagion is a factor which 
may be neglected: a good example is pneumonia, (f) The contagious- 
ness of an infective disease further depends on certain social, local, 
climatic and other hygienic conditions which cannot be discussed here. 
(0) The susceptibility or predisposition of the individuals is a factor of 
far-reaching importance. When we test a microbe for its pathogenetic 
property, we always choose a highly susceptible animal - an animal, 
that is, which will acquire the disease under normal physiological con- 
ditions. When studying the contagiousness of any disease in man, we 
should recollect that the healthy body offers unequal resistances to the 
various germs and their poisons. Take, for instance, diphtheria or ery- 
sipelas, inoculate a healthy person with the morbid material, and diph- 
theria or erysipelas will result almost to a certainty. Do the same 
with leprosy or tuberculosis, and probably there will be no specific 
consequences. THE GENERAL PATHOLOGY OF INFECTLON 
545 
Leprosy is not communicable from the diseased to the healthy and 
sound. The experimental evidence on this point is so strong that mere 
opinions to the contrary are of little importance. Many attempts have 
been made to inoculate leprosy from the leper to the non-leper, but never 
has a success been proved. Leprosy cannot be transmitted from the 
diseased to the healthy by means of inoculation - in other words, it is 
not contagious under normal conditions. To transmit the disease some- 
thing else is wanted besides the contagium vivum, which is not sufficient 
of itself to produce leprosy; this something else may be a special pre- 
disposition, a want of resistance. 
Contagion and contagiousness, then, cannot be measured by an abso- 
lute standard, a truth almost persistently forgotten. The scientific and 
the practical aspects of the question must be considered separately. In 
a scientific classification of infective diseases we justly include under 
contagious affections all those which may be propagated by contagion, 
that is by inoculation or any form of infection, irrespective of the fact 
whether they generally, or, indeed, ever are naturally spread in this 
manner. When practical sanitary and preventive measures are contem- 
plated, the natural and epidemiological conditions must be carefully 
considered. 
Summary. - Contagious infective diseases are spread by direct or 
indirect contact or - to put it in symbolic language - from A to B, so 
that B cannot be infected without A; or from A to B through an ectan- 
thropic body X. In the first case, to save B we must remove or destroy 
A. In the second case three courses are open to us, namely, to find out 
whether we can best save B by destroying A alone, or X alone, or both 
A and X. But if we find that to destroy A alone is of no avail, and 
that to destroy X is an impossibility, what are we to do ? Now, it is a 
well-ascertained fact that in many cases an individual has a natural 
resistance against the infective germ, and that the latter cannot exert 
its detrimental effect until this resistance is lost; and this may give us 
the key to action, which will be adapted to restore the resistance, while, 
at the same time, of course, X is kept in abeyance. To this point we 
shall return. 
The micro-organisms responsible for a number of our commoner 
infective diseases belong to the group of facultative parasites, or faculta- 
tive saprophytes, organisms which are capable of multiplying outside the 
human body. These diseases are seldom directly, and occasionally not 
even indirectly, contagious. A good example is cholera. The germs leaving 
the human body are, generally speaking, incapable of setting up an im- 
mediate infection. No doubt direct contagion does occur, but it is a rare 
exception; and sudden outbreaks of cholera are easily explained by assum- 
ing that large quantities of germs grow concealed and unsuspected out- 
side the human organism, or that otherwise becoming diffused they have 
obtained access to a general source of infection, for instance the drinking 
water. The saprophytic nature or phase of the common bacillus, - if we 
assume it to be the contagium vivum of cholera - is of great importance 
2 N 
VOL. I 546 
SYSTEM OF MEDICINE 
in regard to the contagiousness or non-contagiousness of cholera, and to 
the best mode of preventing further outbreaks or diffusion of the disease. 
It has been said above that, if a germ be widely distributed in space, 
we may practically neglect contagion as a means of spreading the disease. 
This may be illustrated by the familiar instance of tuberculosis. Con- 
sidering the large number of consumptives, the immense numbers of 
bacilli in the sputum, and the persistence of these bacilli, the sources of 
infection must be almost ubiquitous, and accordingly the exclusive im- 
portance of contagion vanishes. To go back to our symbols, we cannot 
remove X, or can do so in part only, because it is well known that the 
tubercle bacilli are capable of leaving the animal body and remaining 
dormant outside it for a long time, in the full possession of their infective 
and germinative properties. Dried they retain their virulence for months; 
boiling does not always destroy them, nor does putrefaction. The bacillus 
resists the digestive action of the gastro-intestinal secretions, and it is 
much less parasitic than is generally assumed. Thus, Sander has suc- 
ceeded in growing it on ordinary potatoes and in their juice, on boiled 
macaroni, baked bread, and in ordinary tap water; and it is certain that 
it can be readily acclimatised to changes of temperature. Hence it is 
nearly certain that, within limits, it is capable of a saprophytic existence, 
and we are therefore forced to assume that, in towns at any rate, we 
are surrounded almost everywhere by infective tuberculous material. 
Infection, therefore, is possible in two ways, (a) from the diseased 
directly, or (&) from objects in the immediate vicinity of the affected 
person, or far removed both in time or space from him. To prevent 
further infection we should have to remove both the phthisical individ- 
uals and the bacilli scattered outside the human body. The former 
cannot be done satisfactorily, because phthisis is an extremely chronic 
affection, not always easily diagnosed in its early stages, and what is 
diagnosed as incipient phthisis is often a lesion considerably advanced. 
Isolation and segregation would therefore be followed by so little success 
as to seem unjustifiable. Nor can we entirely remove the ectanthropic 
sources of infection. We know, however, that only those of our fellow- 
creatures will acquire tuberculosis who are disposed to the disease; and the 
question is whether we can alter this disposition when once established, or 
altogether prevent its establishment ? The answer will be supplied later. 
We must understand that in reasoning upon laboratory experiments 
the precepts of logic and common-sense are not to be altogether forgotten. 
Laboratory experience, for instance, has taught us that tuberculosis is 
an infective lesion, due to a bacillus capable of multiplying within the 
body. It is also contagious; experiments on guinea-pigs prove this. 
But we must remember that guinea-pigs are extremely susceptible 
animals, and that the healthiest specimen, if inoculated with the small- 
est quantities of mammalian tubercle bacilli, will succumb. In the 
case of guinea-pigs segregation, destruction, and assiduous disinfection 
of the cages would keep the spread of tuberculosis in abeyance. 
Mankind, on the other hand, is naturally resistant to tuberculosis. THE GENERAL PATHOLOGY OF INFECTION 
This disease is directly or indirectly contagious for all healthy guinea- 
pigs alike; but in man it is contagious only for those who have lost 
their resistance, those, that is, who in some way or other have become 
disposed to the disease. In a well-regulated laboratory we prevent the 
outbreak, or at any rate the spread of phthisis among guinea-pigs by re- 
moving or destroying the diseased animals, and at the same time getting 
rid of the bacilli by disinfection. From our own surroundings, however, 
we can only remove the sources of infection in part; and so long as we 
cannot do so entirely, the destruction or isolation of the diseased subjects 
would be ineffectual. 
The question of predisposition must now be studied more fully. 
547 
VI. Predisposition 
I. Personal predisposition is best defined as susceptibility to a 
disease; it may be either natural or acquired. A natural predisposition 
may be either a property of a species, which as such is transmitted from 
parent to offspring (racial predisposition); or it may be an accidental 
character of one or more individuals of a species (individual predisposi- 
tion), not necessarily transmitted to the offspring. Thus guinea-pigs are 
naturally extremely susceptible to tuberculosis; man to syphilis or diph- 
theria. On the other hand man or animal may be naturally resistant 
against an infective disease, as is a hen against tetanus. In the last case 
the resistance is absolute; that is, so long as we work within the limits 
of experiment, the normal animal cannot be infected; in other cases it 
may be relative and partial, as, for example, in the case of man's resist- 
ance against tuberculosis, leprosy, anthrax, or cholera. We must assume 
that in such cases the disposition is entirely or partly absent. The 
cause of this individual disposition we do not fully understand. 
The predisposition, like immunity, depends on various factors, among 
which the most important are - (1) intrinsic cell properties; and (2) ex- 
trinsic conditions reacting harmfully on the body and its tissue proc- 
esses. Within certain limits every organism has special cellular 
mechanisms to ward off an infection. Thus the acidity of the gastric 
juice, and a proper supply of it, may prove too strong for the cholera 
vibrio; the ciliated epithelium and the sensitiveness of the bronchial 
mucous membrane and the germicidal action of the mucus may protect 
the respiratory organs against an invasion by tubercle bacilli. Again, we 
know from Lbftler's experiments that the age and nature of the epithelial 
lining are conditions of great importance in the case of diphtheria: the 
vaginal mucous membrane of young animals is easily attacked, but that 
of old animals is very resistant. Orth and Wyssokowitsch have shown 
that traumatic lesions at a seat of infection will cause a local predisposi- 
tion to certain infective processes. These investigators produced a well- 
marked malignant endocarditis by first causing a slight injury to the 
cardiac valves, and then injecting a culture of staphylococci: endocar- 
ditis did not result when the valves were intact. Similarly pyogenetic 548 
SYSTEM OF MEDICINE 
cocci will readily produce suppuration in an oedematous rabbit, although 
harmless to rabbits in a normal state. 
The question of predisposition has been more clearly put before us 
during recent times, and a short summary may here be given of the most 
important experiments and observations which show that predisposition 
is a definite quality which can be estimated within the precincts of the 
laboratory, and is not a mere makeshift to explain clinical difficulties. 
II. Acquired Predisposition.-Various means exist by which a re- 
fractory or resistant animal can be rendered susceptible - by which, that 
is, a disposition can be established to any particular infective disease; 
or, to put the case differently, we possess means to make a disease which 
is non-contagious to a certain species of animal extremely contagious to 
certain members of that species. We may reduce the natural resistance 
of an animal against a microbe either by general or special interferences, 
and thus establish an acquired disposition. The former are of more 
interest to us, as they prove how much good can be effected by sanitary 
surroundings in the prevention of disease, and we shall lead off with them. 
General Interferences. - 1. Canalis and Morpurgo have shown that by 
means of starvation we can render pigeons, which are naturally resistant 
against anthrax, extremely susceptible to this infection. They succumb, 
either if we allow them to starve immediately after the inoculation, or 
starve them six days previously and then inoculate them, at the same 
time continuing the process of starvation. But if we feed them regularly 
immediately after inoculation, then, in spite of having previously been 
starved for six days, they will survive. However, if we allow them to 
starve longer than six days before the inoculation, they will succumb, 
whether we feed them or not after the infection. 
Similarly hens, naturally immune, become susceptible to an anthrax 
infection through starvation. White rats, on the other hand, do not lose 
their natural immunity in this manner. Sacchi, by means of starvation, 
succeeded in rendering a local anthrax infection in pigeons a general infec- 
tion. Similar experiments have also been made on artificially immu- 
nised rabbits. Pernice and Alessi proved that dogs, hens, pigeons, and 
frogs can be rendered susceptible to anthrax, by depriving them of water. 
2. Again, fatigue and loss of blood are capable of removing the 
natural immunity of animals. Thus Charrin and Roger have shown 
that the normal white rat, which, as is well known, is very insusceptible 
to anthrax, becomes susceptible to this disease in a marked degree, if it 
is made to work a treadmill in a cage until it is thoroughly fatigued. 
Roger has further demonstrated that rabbits, which are relatively re- 
fractory to quarter-evil, lose their immunity by exhaustion and fatigue; 
and Rodet and others have established an acquired disposition by 
inducing a general ansemia by artificial loss of blood. 
3. An unsuitable diet, as Hankin has shown, may remove the resistance 
of the body against anthrax. Thus refractory rats, fed on sour milk 
and bread, lose their insusceptibility; a pure meat diet increases it. 
Hans Leo administered phloridzin in small doses with the food for some THE GENERAL PATHOLOGY OF INFECTION 
549 
days previous to inoculation, with the result that sugar showed itself in 
the tissues of the animal under experiment: this animal now became 
highly susceptible to a glanders infection, which in its normal condition 
it was able to resist. The same treatment, however, did not increase the 
susceptibility of rats to anthrax and tuberculosis. 
4. Exposure to heat, cold, and moisture has been investigated by 
Pasteur, Petruschky, Fermi and Salsano, and others. Thus on im- 
mersing a hen in water it loses its resistance to anthrax, and the 
same occurs on reducing its temperature by the administration of 
antipyrin. Frogs, if kept at a temperature of 25°-35° C., will easily 
succumb to anthrax. Guinea-pigs and white mice, which are resist- 
ant to avian tuberculosis, can be rendered susceptible by keeping 
them after inoculation in a warm chamber at 33°-35° C. This will also 
increase the susceptibility of white mice to mammalian tuberculosis. 
Cold, on the other hand, does not affect the special disposition of these 
animals. 
We see, then, that it is easy by such general means as starvation, 
fatigue, exposure, and bad diet to reduce the insusceptibility of certain 
animals to infective diseases. Now, if in a community of which the 
normal individuals are insusceptible, a certain number of these, through 
one or other of the above causes, become susceptible, then the disease 
may be extremely contagious for these modified persons, though non- 
contagious for the community as a group. This shows how cautious we 
must be in pronouncing any infective disease to be contagious to a com- 
munity. In many cases it would evidently be absurd to clamour for 
physical or social extinction of the affected individual; we must attack 
the problem differently. Knowing by what processes the disease has 
become contagious for a certain community, while preventing a further 
distribution of the contagium by disinfection and other appropriate 
measures, we must so improve the social and personal hygiene as to 
reverse the direction of modification. 
A consideration of tuberculosis from this point of view will make 
my meaning clearer. We cannot hope to destroy the contagium vivum, 
it is too widely distributed; nor can we destroy the affected individuals 
- such a process would be unavailing, even if free from other objec- 
tions. How, then, can we prevent the spread of the disease ? If, as 
it seems, the disposition to it be due to any or all of the above causes, 
let these be removed. Now we know that a healthy man is relatively 
immune from tuberculosis ; we also know that bad hygiene, exposure, 
and the like, may render him susceptible to it; the rational preventive 
measure, therefore, is to counteract the causes of this acquired suscepti- 
bility, while at the same time we order all consumptives to destroy 
their sputum. That improved personal hygiene and public sanitation, 
and a higher standard of life materially diminish the death-rate from 
consumption is already ascertained; the vital statistics of England 
clearly demonstrate that sanitary legislation has coincided with a con- 
siderable diminution of the number of deaths from phthisis. 550 
SYSTEM OF MEDICINE 
The same reasoning applies to leprosy. This affection, as mentioned 
above, is comparatively, if not quite, harmless to healthy men living 
under sound conditions. Bad hygiene, poverty, insufficient food, and 
so forth, increase the liability to the disease. How is it that the pest 
has died out in England and is decreasing in India ? Certainly not 
merely on account of segregation, for such measures have virtually 
never been taken in Europe, and in India cannot be taken. In Norway 
the disease was decreasing before segregation was enforced. The chief 
cause of the disappearance of the leprosy from these parts is to be 
found in a general improvement of social and personal surroundings 
and a raised standard of living. 
But why shall we not order the compulsory isolation of tubercular 
patients ? Because in tuberculosis we have a chronic, extremely insid- 
ious disease, widely distributed over the world, a disposition to which is 
comparatively easily acquired or inherited; the tubercle bacilli already 
exist everywhere, and compulsory isolation could not be carried out 
rigorously enough to lessen the spread of the disease. Long before we 
have recognised the complaint, our patient, consciously or unconsciously, 
has already disseminated his share of bacilli ready to be taken up by the 
nearest individuals, and to fix upon the susceptible. If there is to be 
any isolation at all, the more reasonable course would be to isolate those 
so disposed. In the wealthier classes this is done, directly and indirectly, 
with good results. In the case of the masses the only thing to be done 
is to counteract the general causes of susceptibility, and to persist in 
disinfection on ordinary common-sense lines. 
The above considerations will also explain the meaning and nature 
of endemicity, or the state, both of the individuals living in a district, 
and of the medium in which they live, which favours a certain infective 
disease. Undoubtedly cholera is a disease for which, if it appears spo- 
radically, a special individual bent is required; and if it appears in 
epidemics, there must be the local predisposition in addition. Now in cer- 
tain parts of India, as, for example, Lower Bengal and Assam, cholera 
is always present or " endemic." Such endemic areas are, for the most 
part, over-populated, poor, or extremely unhealthy. May not these and 
similar factors reduce the resistance of the population, and render the 
existence of the evil a necessary consequence ? This matter gains in 
interest as we remember that in those areas wherein cholera is always 
present leprosy also is most common. This cannot mean that any direct 
causal connection exists between leprosy and cholera, but it is quite 
possible, and perhaps even probable, that those factors which contribute 
to the prevalence of the one have a like effect on the other. 
We should, however, remember that, in contradistinction to this 
individual disposition which applies to certain individuals of a species, 
there is also a racial disposition which applies to all members of a 
species. Negroes are seldom affected by yellow fever, and the same is 
true of the mulatto. There are numerous examples of such phenomena 
in the laboratory. Thus of dogs which are relatively resistant to THE GENERAL PATHOLOGY OF INFECTION 
551 
anthrax, black clogs are less so than white ones. Black and gray rats 
are less susceptible to anthrax than white rats. Field-mice, again, are 
extremely susceptible to mammalian tuberculosis, while white mice are 
practically immune; white mice, on the other hand, easily succumb to 
an infection with the micrococcus tetragonus, while gray house-mice are 
quite refractory to it. 
Again, age is a disposing factor, for young individuals acquire certain 
affections - for example, enteric fever-more easily than adults; this 
fact also is amply borne out by animal experiments. Oemler has shown 
that young pigeons are much less refractory to anthrax than old ones. 
But, strange to say, sucklings appear to be less liable to some infective 
fevers, such as measles and scarlet fever, than to others; this may be 
due to the protective influence of mothers' milk: this matter will be 
discussed later. 
Here we must leave this interesting subject, and direct our attention 
to the effect on predisposition of certain more special and easily defined 
interferences. We shall find that apparently slight causes are capable 
of destroying the balance, and of removing with one stroke, as it were, 
the resistance, whether natural or acquired, of the tissues to a particu- 
lar infection. 
Special Interferences. - 1. It was once thought by Tizzoni and Cat- 
tani that it is impossible to render rabbits immune from tetanus after the 
removal of their spleens, and that the removal of the spleen will destroy 
the natural immunity of dogs from tetanus and anthrax. That, how- 
ever, the acquired disposition does not in all cases depend on the removal 
of the spleen is shown by the experiments of Foa and Scabia and others, 
who worked with the diplococcus of pneumonia and the B. pyocyaneus, 
and proved that, for these infections at least and the immunity from 
them, the spleen is of no importance; for if we allow the animal to recover 
its weight and strength completely, its immunity will persist. The 
Italian authors, on repeating their experiments, have indeed come to this 
conclusion. The temporary loss of resistance is explained, therefore, 
simply by the shock and weakness which naturally follow the operation. 
According to Canalis and Morpurgo, pigeons are rendered less 
resistant to anthrax by removal of the pancreas. This operation also 
predisposes animals to septic infections; and according to Sawtschenko, 
the same happens after section of the spinal cord in pigeons. 
It is true, then, that the destruction or removal of certain organs 
may cancel the insusceptibility of an animal to an infection, either as 
a direct result of the ablation, or indirectly by the production of some 
constitutional change, such, for instance, as the diabetic which follows 
excision of the pancreas. 
2. Again, there are many experiments to prove that bacteria, abso- 
lutely or relatively harmless to animals when injected in pure cultures 
by themselves, become intensely virulent when at the same time we inject 
certain chemical bodies at the seat of lesion. Thus Vaillard and Vincent 
have shown that in animals immune from tetanus a characteristic infec- 552 
SYSTEM OF MEDICINE 
tion can be brought about by injecting lactic acid or trimethylamine 
with the tetanus bacillus. Similarly hydracetin and pyrogallol will 
destroy the acquired immunity of guinea-pigs against hog cholera. 
Bujwid found, on antecedent injection of sugar solution into the sub- 
cutaneous tissue of animals, that an inoculation of the staphylococcus 
pyogenes aureus was in most instances followed by marked suppuration; 
a result not easily achieved by means of the staphylococcus in the absence 
of previous sugar injection. Lastly, hypodermic injections of dextrose 
and lactic acid will render guinea-pigs and white mice susceptible to 
avian tuberculosis, and white mice also to mammalian tuberculosis. 
This was shown by Fermi and Salsano, and it is important to note that 
avian tubercle bacilli, repeatedly inoculated into guinea-pigs rendered 
susceptible by such injections, become virulent for normal guinea-pigs. 
Here we may also mention Klein and Coxwell's experiments, which 
show that in frogs and rats the natural immunity from anthrax may 
be destroyed by means of a chloroform-ether narcosis. 
3. Then, again, the metabolic products of certain, it may be harmless, 
micro-organisms are often capable of rendering a non-pathogenetic germ 
pathogenetic. Examples of this are mentioned by Koger, who has shown 
that rabbits will succumb to quarter-evil, if, simultaneously with the 
bacilli, the chemical products of the bacillus prodigiosus, proteus vul- 
garis, or staphylococcus be administered. Klein and others have given 
further proof of this. Other allied bodies - vegetable ferments, for 
instance - have the same effect. 
On the other hand, many of these chemical products of bacteria 
possess the power of destroying the pathogenetic property of specific 
organisms. I shall only refer to the experiments of Blagovestchewski, 
who showed that a simultaneous injection of anthrax bacilli and the 
products of the bacillus pyocyaneous prevents the lethal effect of the 
anthrax infection, and renders the animal immune. 
4. What has been said of the chemical products of the bacteria 
applies with equal force to the bacteria themselves. Klein and others 
have shown that by means of concurrent inoculations of various kinds of 
organisms we may (1) render non-pathogenetic bacteria pathogenetic; 
or (2) increase or decrease the virulence of pathogenetic germs. A few 
examples must suffice: thus a simultaneous inoculation of anthrax and 
pyocyaneous bacilli, or of anthrax bacilli and erysipelas cocci, or of 
anthrax and prodigiosus or Friedlander's bacilli, protect the animal 
against the poisonous effects of the anthrax bacillus. On the other 
hand, the bacillus prodigiosus and various pyogenetic germs, if simul- 
taneously administered with the bacillus of tetanus, render the latter 
extremely pathogenetic for animals capable of resisting a simple infec- 
tion with the tetanus bacillus. Lastly, the virulence of the bacillus 
diphtheriae is greatly enhanced by means of a concurrent inoculation 
of the bacillus pyocyaneus, as shown by Klein. 
Summary. -We see, then, that the natural resistance of animals is 
easily destroyed by various processes: (1) by such as cause general THE GENERAL PATHOLOGY OF INFECTLON 
tissue disturbances, namely hunger, exposure to heat or cold and wet, 
fatigue, insufficient or inadequate feeding; and (2) by more special inter- 
ferences, such as the removal of organs, essential or not to the animal 
economy, or (3) by concurrent inoculations with chemical or bacterial prod- 
ucts, or with the bacteria themselves. These special interferences do 
not all act in the same manner on the animal organism; some - as, for 
example, the removal of glands - produce general changes in the body; 
but others may, and in many cases do cause a weakening of the tissues 
at the seat of inoculation whereby the local defensive processes are im- 
paired and broken down; thus a foothold is given to the organisms, 
enabling them to grow and to manufacture their toxins. It must be con- 
fessed that our knowledge of the matter of concurrent inoculations or 
bacterial association and interaction is still defective. In the meantime 
these two processes (namely, the interferences which react on the whole 
body and those which react merely locally on the tissues at the seat of 
injury) must be considered apart as much as possible. In the latter 
case writers often speak of a local predisposition produced by tissue 
lesion; this is a misleading expression: it would be more correct to say 
that the predisposition has become evident after certain local changes. 
We cannot tell how far such local changes react on and disturb the whole 
body, although we must admit that in many cases it may not be a mat- 
ter of breaking down an immunity at all, but merely one of soil - one 
of giving the organisms a chance of development by placing them under 
more suitable local conditions of implantation. The whole subject re- 
quires research rather than discussion; for the present it is enough to 
remember that, by means of association of bacterial or chemical sub- 
stances with bacterial infections, we may either break down an existing 
immunity, or establish the existence of a latent predisposition, undetected, 
perhaps, because of the imperfections of our method of inoculation. 
By any of the above methods, then - to express it differently - a 
non-contagious disease can at once be rendered highly contagious. The 
general causes are, in this connection, the more important, because they 
include conditions which are covered by the vague term " unsound hy- 
giene." Before we can approach the question of the prevention of the 
spread of an infective disease, it is, therefore, our duty in all sanitary or 
other inquiries into its contagious nature to ascertain under what condi- 
tions it becomes contagious for a particular community. Contagionists, 
or those who believe in the direct contagiousness of all infective dis- 
eases, ask for some features and characters by which a disposition may be 
recognised. Such a question, while it discloses a want of appreciation 
of the difficulties of the inquiry, is also premature; our knowledge is 
not yet sufficiently advanced to enable us to define the special dispo- 
sitions to given infective diseases. It is easy to scoff at vague generali- 
ties about unsound personal and social hygiene, but their potency in 
establishing a disposition to an infective disease is fully borne out by 
animal experiments; the precise application of this knowledge to a certain 
community can be made only on the historical and epidemiological experi- 
553 554 
SYSTEM OF MEDICINE 
ence, and the scientific evidence obtainable in the particular case. If it 
be found that the removal or abatement of unsound hygienic conditions 
is attended by a concomitant variation of the disease, we may be a step 
nearer to the proof of a correlation between those vague generalities 
about unsound hygiene on the one hand and contagion and susceptibility 
on the other. In many cases - as, for instance, in tuberculosis - we 
have to fight against these vague causes, for we believe that they render 
the disease a contagious one to a special class of individuals; and this 
method, together with personal disinfection, is the only possible way 
of dealing with the problem. That the removal or abatement of unfa- 
vourable hygienic conditions has undoubtedly brought about a decrease 
of phthisis, in England and in the large continental towns, is shown by 
recent statistics. 
Certain writers, such as Baumgarten, deny the existence of a dis- 
position to tuberculosis; our most experienced physicians and ablest 
pathologists, however, recognise its existence; until the days of bac- 
teriology it had never been doubted. Fliigge goes even so far as to say 
that " in tuberculosis we learn from experience that the greater or less 
accumulation of resistant infective agents plays a relatively subordinate 
part in the spread of the disease." (Fliigge's Micro-organisms, trans- 
lated by Watson Cheyne, page 752.) The physician counteracts the 
disposition by removing the susceptible individual from any possible 
risk of infection when sending him to warmer and sunnier climates; 
thus he isolates the predisposed whenever and so far as he can. 
In conclusion, a few words must be said on hereditary predisposition. 
Hereditary Predisposition. - Can an acquired disposition be trans- 
mitted from parent to offspring ? Such a disposition may be called 
" hereditary," or " inherited," and must be carefully distinguished 
from a " congenital " disposition, which the child brings into the 
world independently of parental endowment. Tuberculosis is a disease 
of extra-uterine life, but undoubtedly cases of congenital tuberculosis 
do occur, as shown by Merkel, Landouzy, Rindfleisch, Birch-Hirsch- 
feld and others; and much more frequently than congenital tuber- 
culosis do we find tuberculosis in infants and children during the 
first months or years of life, as shown by Queyrat, Landouzy, Mtiller 
and others. Until recently it was almost universally believed that the 
undisputed hereditary succession of tubercular processes depends, not on 
a direct transmission of the elements of the disease from parent to off- 
spring, but on an hereditary transmission of a proclivity. Baumgarten, 
however, believes that the heredity of phthisis depends on an intra-uterine 
or congenital infection of the foetus with tubercle bacilli from the mother, 
and he supports these views with the following arguments. Besides the 
existence of congenital tuberculosis, Birch-Hirschfeld and others have 
demonstrated that in man, as well as in animals, tubercular infection 
through the placental circulation is not only possible but does actually 
occur. Observations and experiments on animals show: (a) that con- 7'777? general pathology of infection 
555 
genital tuberculosis in the larger susceptible mammals is not very rare 
(Johne); (&) that of the offspring of tubercular guinea-pigs twenty-five 
per cent are born with congenital tuberculosis (de Renzi); (c) that intra- 
uterine tubercular infection is possible in rabbits and mice (Gartner); 
(d) that chickens hatched from eggs inoculated with tubercle bacilli 
manifest tuberculosis, and the eggs of canaries inoculated intra-abdom- 
inally with tubercle bacilli are frequently infected (Mafucci, Baum- 
garten and Gartner). From analogy, therefore, Baumgarten assumes 
that in man also the tubercle bacilli are transmitted congenitally in utero, 
and that if the disease be not apparent at the time of birth the bacilli 
remain dormant in the tissues (of the liver for instance), causing at first 
only small obscure foci, and being for some time impaired in their de- 
velopment ; but that eventually " through some cause or another " they 
awake and produce a manifest tuberculosis. 
It is evident, if we accept Baumgarten's views, we have no longer 
any right to speak of " hereditary " phthisis; such a process as he as- 
sumes and describes is an infection from parent to ovum or foetus, and 
is as much an infection as the transmission of pathogenetic organisms 
from one adult to another. We must then agree with Armauer Hanson 
that no specific infective disease is hereditary, if we use the term hered- 
ity in the sense which Darwin and modern biologists have given to it. 
If it appear congenitally it is simply communicated to the foetus by in- 
fection. It would be absurd, for instance, to speak of an inherited gon- 
orrhoeal infection in cases in which newborn children are unfortunate 
enough to acquire a venereal ophthalmia in their passage into the world. 
Now, if heredity be not a factor in infection, the organisms must have 
been passed on: (a) from the ovary of the mother or the testes of the 
father; or (&) from the mother through the placental circulation; that is, 
infection may have been germinal or placental. Tubercles and tubercle 
bacilli have been found in the placenta, as already stated; and, further, 
there is sufficient evidence, anatomical and histological, to show that the 
bacilli pass from the placenta into the foetal circulation. The evidence 
of germinal infection on the other hand is weak, so that it is safer to 
account for true congenital tuberculosis by placental infection. 
But how are we to account for those cases in which the offspring of 
tuberculous parentage fall into tuberculosis years, often many years, 
after birth ? Baumgarten assumes that in these cases also there is a 
latent infection, the tubercle bacilli having passed through the placenta 
(or from the ovum) into the foetus, as already explained. That there 
may be an obscure tubercular process in many children of tuberculous 
parents must be acknowledged, because swollen and caseous glands con- 
taining virulent tubercle bacilli have been found both in man and animals 
at, or at any rate soon after, birth. Again, Mafucci working on animals 
often found tubercle bacilli in the liver of embryos of tuberculous parent- 
age. Undoubtedly, then, tubercle bacilli may be stored up in the tissues 
of the foetus. But how is it that such offspring often, or indeed gen- 
erally, do not manifest the disease proper until years afterwards ? The 556 
SYSTEM OF MEDICINE 
answer must be because their tissues are sufficiently resistant to keep the 
activity of the bacilli in abeyance, or in some cases sufficiently strong 
even to destroy it altogether. But if later they lose this resistance, the 
bacilli are then placed in the conditions required for successful activity. 
A few bacilli in an obscure focus do not constitute tuberculosis any 
more than does the pathologist's tubercle or wart. We are thus led 
again to assume a proclivity in the cases under discussion. And is it 
not possible that the appearance of this proclivity is favoured by cer- 
tain tendencies transmitted by inheritance ? Hereditary peculiarities 
are often limited to a definite period or age; and we find that in the 
offspring the disease often shows itself at about the same age as it did 
in the parent - a fact of importance in a philosophical consideration of 
hereditary transmission. 
Animal experiments cannot prove much in investigations of this 
nature, for in questions of hereditary transmission we must consider each 
species by itself. Guinea-pigs, rabbits, mice, hens, and canaries - the 
animals generally employed - are naturally highly susceptible to tuber- 
culosis, and hence the predisposition is an inherent property of the parent, 
and therefore also of the ovum or embryo. As the tissues of the normal 
parent offer no resistance, we cannot possibly expect those of the off- 
spring to do so. Baumgarten and his followers should have based their 
arguments and observations on animals of marked resistance - on goats 
and dogs - which cannot be infected without an artificially acquired 
disposition. Animal experiments do, however, make it certain that by 
no means all the offspring of tuberculous animals harbour latent bacilli 
in their tissues, and we have no right to assume that such a condition of 
things commonly exists in man. How then are we to explain the fre- 
quent occurrence of phthisis in the offspring of tuberculous parents ? 
For the present we must assume that in most cases they inherit only the 
proclivity, and subsequently become infected from without. Hence the 
so-called " heredity " of phthisis finds its explanation in the following 
possibilities: - (1) Congenital infection, either germinal or placental, 
followed by immediate results; (2) Congenital infection with inherited 
disposition, followed, after a period of latency, by recrudescence at a sub- 
sequent date; (3) Inherited disposition with infection at a later date. 
Now since in the case of tuberculosis we find some of the characteristic 
features of heredity-for instance that atavism is not uncommon, and 
that the hereditary tendency is often limited to one sex and to a definite 
age-and since it requires great faith to believe in a bacterial sleep lasting 
through many years as a complete explanation, we must incline to Vir- 
chow's doctrine of the existence and influence of an inherited predisposi- 
tion to tuberculosis, even though our modern conception of predisposition 
differs from his. [See article on the " Laws of Inheritance and Disease."] 
The inherited disposition may be either specific or non-specific. The 
parental disposition may have been due to many agents and factors; 
and it is possible that some of these, although not of the same nature 
as the resulting tuberculosis, have been the cause of the congenital bent THE GENERAL PATHOLOGY OF INFECTION 
557 
transmitted to the offspring. This evidently could not be an inherited 
specific predisposition; that is, it is quite within the bounds of possibility 
that a non-tubercular condition of a parent may lead in a child to an 
inherited predisposition favourable to the development of tuberculosis. 
A predisposition can only be specifically inherited in cases in which the 
child was born of tuberculous parents or ancestors. A child born of a 
parent who becomes phthisical some years after its birth cannot with 
certainty be supposed to have inherited a specific tubercular proclivity. 
The eventual acquirement of the disease by the parent cannot make the 
inherited proclivity any more specific; it can prove only that certain 
conditions and abnormalities of the parent which eventually favoured 
tuberculosis have been transmitted to the offspring. For practical pur- 
poses the distinction between a specific and a non-specific inherited ten- 
dency may be unimportant; but in a scientific discussion of heredity it 
is a matter deserving of the fullest attention. 
Germinal infection, though doubtful in tuberculosis, certainly exists 
in the case of syphilis; the contagium being derived either from the 
father or the mother. But since we have no direct knowledge of the 
syphilitic virus we cannot generalise from our observations of this disease. 
Although tubercle and also leprosy bacilli have been found occasionally in 
the testes and ovaries, and even in the seminal fluid of diseased individuals, 
there is no evidence whatever that germinal infection ever does occur: 
in fact Gartner has shown that in animals, even if numerous tubercle 
bacilli are contained in the seminal fluid, it is the mother which is first 
infected, and not the ovum or embryo. This may be said of all infective 
diseases with the bacteriology of which we are acquainted; and for such 
of them as appear congenitally, infection must practically always take 
place through the placental circulation. This is exactly what occurs in 
animals where it can be demonstrated more readily. Placental infection 
in animals has been conclusively shown to occur in congenital anthrax, 
chicken cholera, suppurative lesions, and tuberculosis: in man it is found 
in pneumococcus and suppurative infections, in typhoid fever, anthrax 
(malaria), relapsing fever and tuberculosis; and is assumed to exist in 
measles, scarlatina, and small-pox, diseases the bacteriology of which is 
still obscure. Where placental infection occurs the micro-organisms are 
taken up chiefly by the foetal liver; there, according to Mafucci, a keen 
struggle for supremacy occurs, the embryonic gland as much as the adult 
one being possessed of marked defensive capacity. If the bacteria prove 
victorious, then the foetus may present the characteristic lesions produced 
by the infection - as for instance in many cases of tuberculosis, septi- 
caemia, or pyaemia; or it may present them in a modified form, which 
after birth may assume the ordinary appearance, the embryo being, as 
already explained, apparently endowed in these cases with a more or less 
marked resistance. For instance, although anthrax bacilli, typhoid ba- 
cilli, and pneumococci may pass through the placental circulation, yet, 
as Dr. Welch says, "no instance has been observed in the foetus of fully 
developed anthrax of croupous pneumonia, or of intestinal lesions by the 558 
SYSTEM OF MEDICINE 
typhoid bacillus, although in several recorded instances these bacteria 
have unquestionably invaded the foetus from the mother. The charac- 
teristic lesions have, however, been found so soon after birth as to indi- 
cate positively congenital infection." It is still a debated point whether 
the healthy placenta will allow pathogenetic organisms to pass into the 
foetal circulation; some writers assume that a lesion such as a haemor- 
rhage, for instance, is necessary. It seems, however, that the factor is 
rather one of the time or duration of infection and of the virulence of the 
pathogenetic organisms. The lesson which we derive from these various 
experiments and observations on the foetal infection is one on the use of 
the term heredity in respect of infective diseases; a strict terminology is, 
if possible, the more necessary now that Weissmann's hypotheses have so 
great an ascendency. 
Immunity 
Immunity is the converse of predisposition, and as we distinguish 
between a natural and an acquired predisposition, so must we distinguish 
between a natural and an acquired immunity. Again, as natural resist- 
ance may be racial or individual, so conferred immunity may be merely 
a temporary and personally acquired property, or it may be more per- 
manent and transmissible from parent to offspring. All this follows 
from what has already been said of predisposition. 
It is a difficult task in a few general words to give a clear and 
adequate account of the assumed nature and meaning of immunity, a 
subject which has been made the common fighting ground of pathologists, 
physiologists, biologists, and chemists, and which as yet we are far from 
understanding. Theory has succeeded theory; most of them have been 
but passing opinions, many have been based on the unfounded premises 
of incomplete research, a few bear the stamp of patient work and of care- 
ful observation. Most theories fail in their exclusiveness: the founder of 
a theory selects one phenomenon, which under given conditions occurs 
constantly, and makes it the corner-stone of his creed; but over his 
corner-stone he forgets the bricks. While attempting to peer into the 
mysteries of immunity, we must clearly remember how limited is our 
knowledge of the finer cellular processes, of tissue chemistry, and of 
vital reactions and reactivity. Again, our notions of infection, and of 
the process and mechanism of infection, are changing continually, as they 
become more extensive and move gradually from one field to another, 
touching now on chemistry, now on biology. Endless factors are con- 
cerned which require consideration and reconsideration; but of many of 
these factors, unfortunately, we know as yet but little. 
Acquired immunity will most conveniently introduce us to the study 
before us. A susceptible animal may be rendered resistant against 
subsequent infection in different ways. 
(a) The natural proclivity to an infective disease may be removed in re- 
covery from it. This is Nature's way, and it has given us the key to the 
situation ; individuals who have successfully struggled through an infec- THE GENERAL PATHOLOGY OF INFECTION 
559 
tion become more resistant against future attacks. In some cases this 
immunity is permanent, or at least of long duration; in others it is only 
temporary. Thus recovery from variola, typhoid fever, and the acute 
exanthemata, syphilis, yellow fever, mumps, and whooping-cough implies 
an immunity which lasts for years; while a successful stand against 
pneumonia and diphtheria leads but to a passing security. In some 
instances no immunity is apparent, or it is of extremely short duration, 
as in erysipelas, influenza, and cholera. In a general sense it seems to be 
the rule that recovery from an acquired infection is followed by increased 
resistance against the same. This principle was applied in the practice 
of variolation, which was revived and introduced into Great Britain by 
Lady Mary Wortley Montagu. The intentional inoculation with vario- 
lous matter was generally followed by a mild attack of small-pox which 
conferred on the individual a certain degree of immunity. The obvious 
objections to so dangerous a practice cannot be considered here. 
(b) An artificial resistance may also be brought about by inoculation 
with attenuated virus, meaning by virus not the bacterial products, but 
the living micro-organisms or their spores. Vaccination, whether with 
humanised or calf lymph, is protection by means of inoculation with 
attenuated small-pox virus. There can no longer be any doubt that the 
variola poison becomes attenuated by transmission through calves or 
cows, and that the cow-pock is a modified form of variola vera. [See 
article on "Vaccination."] This method was established somewhat em- 
pirically, but in a strictly scientific manner, by Jenner. It was Pasteur, 
however, who recognised protection by means of attenuated virus as 
a principle. He immunised hens with weakened cultures of the B. 
cholerse gallinarum, as animals are made resistant against anthrax, 
quarter-evil, and swine fever, by inoculating them with attenuated 
cultures of the organisms of these diseases. Against these animal 
infections Pasteur's method of vaccination has proved a successful 
preventive measure. Although in the laboratory animals are easily 
rendered immune in this manner against the various bacterial lesions, 
and although this method of establishing an artificial resistance against 
fully virulent organisms by means of vaccination with less virulent 
organisms is one which has been widely used in experimental work, 
yet in medical as compared with veterinary practice the application 
of preventive vaccination has necessarily been limited. In fact, if we 
except Jenner's system of vaccination against variola, it must be said 
that the only disease against which attenuated inoculation has been 
tried - or rather is being tried - is Asiatic cholera. The principle of 
Haffkine's anticholeraic inoculations is practically the same as that first 
pursued by Pasteur. [See article on " Asiatic Cholera."] 
(c) Instead of using attenuated cultures, small doses of living and fully 
virulent organisms may be employed to produce an artificial immunity. 
Thus 1 c.c. of a fresh broth culture of the B. pyocyaneous will without 
fail produce a fatal septicsemia in a rabbit; but if we inject 0'25 c.c. the 
animal, though it will certainly be ill, will show merely local changes, 560 
SYSTEM OF MEDICINE 
and recover with an acquired immunity. To mention other examples 
would take us too far. In most cases the animal tissues can fight 
against minimal doses of bacteria, and perhaps there is no infective 
process which can be produced by a single unaided bacterial cell. It 
requires a certain minimum dose, which varies with the individual sus- 
ceptibility, to produce a lethal effect; the body can resist the action 
of subminimal doses of living bacteria, so that we must assume that 
the tissues possess defensive or protective mechanisms, primitive and 
slight, perhaps, but capable of further development. Lubarsch has 
shown that mice and guinea-pigs, which are highly susceptible towards 
anthrax, may be fatally infected by a few bacilli, while the tissues of 
rabbits are capable of destroying hundreds of bacilli before their resist- 
ance, slight though it be, is overtaxed. There are, indeed, numerous 
instances of animals possessed of great natural resistance being liable to 
infection when inoculated with large or enormous doses of bacterial cult- 
ures. This explanation may not apply to all cases, but it is sufficiently 
established to justify the opinion that some of the factors of immunity - 
those, that is, which are concerned with the destruction of the bacteria- 
are vital tissue properties; in fact, that some of the germs of immunity 
are innate. The minimal lethal dose, of course, rises and falls with the 
virulence of the culture, and the virulence depends on the activity of the 
toxins, which is to great extent governed by the tissue susceptibilities; 
so that it is difficult, for us from ever-changing premises to draw definite 
conclusions or laws. Judging from experiments, all we can say is that 
an animal is often able to resist living pathogenetic organisms, if injected 
in smaller doses. In all such cases the bacteria die, as mere saprophytes 
would do, in the living tissues, or lead to abortive lesions; while larger 
quantities - often only slightly larger-will readily bring about death, 
whether by means of a general septicaemia or of an intoxication or of 
a toxaemia. But our knowledge of all these processes is so limited that 
we must guard against an ex uno omnes argument; we must penetrate to 
the deeper relations of the facts, and must not be led away by superficial 
similarities. 
(d) One of the most important discoveries in this field for research, 
one which has entirely altered our opinions regarding artificial immunity, 
is that of Salmon and Smith. Until their investigations were made, im- 
munity was attempted exclusively by bacterial vaccination; these authors 
showed, however, that it is possible to protect against an infection by 
means of the inoculation, not only of the living bacteria, but also of 
their metabolic products or toxins, that is, by means of chemical vaccina- 
tion. Salmon and Smith injected pigeons with the sterilised products of 
cultures of the hog cholera bacillus, and thereby rendered them resistant 
against subsequent infection with the bacillus itself. The matter was 
taken up by the various schools, and chemical or toxin vaccination soon 
became the most useful and accepted laboratory method for procuring 
artificial immunity; it is unnecessary, therefore, to give instances of the 
process. THE GENERAL PATHOLOGY OF INFECTLON 
561 
Until this discovery was made immunity was supposed to depend 
on offensive or germicidal influences emanating from the tissues; but 
then it became evident that chemical processes must be concerned in 
the removal of a natural predisposition; that is, either during or after 
the act of protective vaccination, biochemical changes must occur in the 
tissues and their fluids, by which the body is rendered resistant against 
subsequent infection with virulent bacteria. 
In most cases the toxins used are held in solution by the liquid cult- 
ure medium, but it is quite immaterial in what form the metabolic prod- 
ucts are given. They are equally potent in purer forms as albumoses, or 
peptones, or toxalbumins. Indeed, in many cases it suffices to inject 
the dead bodies of the bacteria - that is, the protoplasmic substances or 
proteins of their cells - in order to produce an immunity. There is 
probably no essential difference between the processes of protection by means 
of toxin and protein vaccination. We have some grounds for the assump- 
tion that the toxins which, as we have already seen, are most likely 
secreted by the bacterial cells, must at one time or another exist as such 
in the substance of the bacteria; so that, while injecting these so-called 
proteins, we inject the toxins. To this subject I shall return. 
To render animals immune by means of chemical vaccination we 
generally use either attenuated toxins, or minute doses of the virulent 
poison; and gradually, by repeated inoculations, we accustom the animal 
to withstand larger doses: we aim, that is, at establishing a tolerance 
of the poison, or, as the German expresses it, at making the animal 
" giftfest." The more potent the toxin the more cautiously must we 
proceed: impatience or haste may destroy the careful work of weeks or 
months. By often repeated administration of toxins, beginning with 
minute sublethal doses of fully virulent poisons or with larger doses of 
attenuated toxins, and gradually proceeding with increasing doses of 
highly virulent toxins, the degree of immunity may be greatly and even 
enormously raised. Or in like manner we may begin with attenuated 
bacteria, and gradually continue with increasing quantities of living viru- 
lent cultures. This method of continuous vaccination is the best means 
of obtaining the highest degrees of protection : the more toxin the animal 
absorbs the greater its immunity becomes. If for a time we give sublethal 
doses of bacterial toxins, the animal soon becomes resistant against the 
minimal lethal doses, and even against larger quantities, showing that 
the process of immunisation is " accumulative." Again, although at first 
we must proceed slowly and cautiously with subminimal doses, yet when 
the animal has been once rendered proof against the lethal dose, we may 
proceed more quickly. However, although in this manner we can produce 
extremely high degrees of immunity, there is a limit beyond which the 
acquired resistance cannot be raised. If we persevere with our injections, 
the animal may gradually lose its immunity again, waste, or die acutely. 
Bouchard's Hypothesis. - Although we shall leave the theoretical dis- 
cussion of immunity until we have reviewed, more or less in historical 
order, the various methods hitherto employed, it is well to discuss an im- 
VOL. I 
2 o 562 
SYSTEM OF MEDICINE 
portant doctrine which is associated with Bouchard's name, although 
many other investigators have concerned themselves with it. Because it is 
possible to produce immunity by means of bacteria deprived of their toxins 
or rendered atoxic by means of attenuation, Bouchard and Htippe assumed 
that the bacteria secrete protecting substances besides their deadly toxins, 
and that these protective substances - which either enter into solution if 
the organisms are grown in liquid media or are retained in the bacterial 
cells, and must not be confounded with the bacterial proteins - when in- 
corporated by the tissues bring about the immunity; so that the immunity 
conferring substances and the toxic bodies, though both the products of 
bacterial activity, are essentially distinct. The fact that the highest degree 
of immunity is produced by employing the most virulent toxins or cultures 
in the largest possible dose reduces this notion to an absurdity. We are 
capable of protecting animals against snake venom or tetanus by means 
of continued injections of the respective poisons, beginning with minute 
doses and slowly passing on to large doses, till eventually we render 
them intensely immune. Since, up to a certain limit, the resistance pro- 
duced varies with the amount of poison injected, we cannot logically be- 
lieve that the toxic substances injected into the tissues are combined with 
an immunising substance from the beginning, but we must suppose that 
the changes in the animal organism which result in immunity are pro- 
duced by the toxins. Without the use of highly virulent cultures or of 
toxins of great activity it is impossible to obtain a high degree of immunity. 
Another point of importance, especially for subsequent theoretical con- 
siderations, is the fact that after successful protection the animal is capable 
of resisting both the toxin and the living culture. By means of chemical 
or toxin vaccination it becomes refractory to subsequent inoculation with living 
cultures, that is, to a bacterial infection; and by means of bacterial vaccina- 
tion it becomes refractory to subsequent inoculation with the toxins, that is, to 
bacterial intoxication. Though it is easy to protect an animal by means of 
toxin against the bacteria producing that toxin, we frequently observe that 
it will successfully resist the bacterial infection at a time when it is still 
very sensitive to the toxin itself. But if we persevere it will in time become 
tolerant of the poison as well. Metschnikoff at one time thought that an 
animal vaccinated against a bacterial culture is not necessarily proof 
against the poison produced by that culture. He quotes experiments 
performed by others, showing that by chemical vaccination we may confer 
upon rabbits, in a few days, an immunity from certain infections (vibrio 
Metschnikovii, B. pyocyaneus, bacillus of hog cholera, pneumococcus) yet 
the animals remain as sensitive towards the toxins of these organisms as if 
they had not been vaccinated at all. These observations, however, are 
based on insufficient experiment; for if we only continue long enough with 
the inoculation of toxin we invariably succeed in rendering the animal 
proof against intoxication. Of course we could not expect an animal 
treated with small doses of poison at once to become refractory to large 
doses of the poison; there are proportions in all things. But we do find 
- for instance, in the case of cobra poison - that after a comparatively THE GENERAL PATHOLOGY OF LNFECTLON 
563 
short course of a 0-25 milligramme dose, the animal will successfully 
resist a whole milligramme: it is simply a question of time and patience. 
The same is true of all bacterial toxins whether we use tetano-toxin, 
diphtheria toxin, or other poisons; if the animal has been properly 
treated with gradually increasing doses of a toxin, it becomes proof 
against both infection and intoxication. Immunity, therefore, implies 
resistance against the bacteria and their products. The importance of 
this law, for such it is, we shall grasp more fully presently when we 
come to discuss the theoretical aspects of the subject. 
(e) The experimental study of immunity gradually disclosed remark- 
able properties of the animal serum and the tissue fluids, the recognition 
of which formed the foundation of methods of protection and treatment 
adopted at the present time. Fodor showed in 1887 that the fluids of 
the normal living body, and especially blood, are germicidal, are capable, 
that is, of destroying bacterial life. Buchner, Behring, Nuttall and 
Nissen extended Fodor's observations, and it was soon learned that the 
antimicrobic influences of blood exist also in the serum, and moreover 
that the capacities of various animals are very diverse; that is to say, 
the blood or serum of the various species of animals is not equally 
destructive to all bacterial forms alike : in some animals it either has 
no such power, or it is harmful only to certain micro-organisms, and 
harmless to others. The final outcome of these observations we find in 
one of the greatest triumphs of preventive medicine since Pasteur's 
earlier discovery, in the prevention and cure of infective and intoxica- 
tive lesions by means of the injection of serum derived from protected 
animals. Behring step by step built up the law, that if an animal has 
been artificially protected against a particular infective agent, its blood or 
serum acquires the power, when injected in sufficient quantity into another 
animal, of directly transmitting an immunity from that agent. 
Experimentally this law is so firmly established, that it is now one 
of the articles of bacteriological faith. A few examples may be men- 
tioned : - 
(1) Having succeeded in the artificial protection of rabbits and other 
animals against tetanus, Behring and Kitasato (1890) by injecting highly 
susceptible white mice with serum derived from the protected animals, 
rendered them insusceptible to tetanic infection and intoxication. 
(2) Similarly Behring and Wernicke (1890 and 1891) demonstrated 
that the blood serum of animals artificially vaccinated against diphtheria 
has the power of protecting susceptible animals against an infection with 
the diphtheria bacillus, or against an intoxication with the diphtheria 
toxin. 
(3) Babes and Lepp had already (1889) shown by experiments that 
the blood of dogs vaccinated against rabies, when injected into susceptible 
animals, confers a certain amount of protection against subsequent in- 
oculation, and concluded from their observations that the possibility of 
vaccinating with the fluids and cells of animals which have been rendered 
refractory to the disease must be admitted. 564 
SYSTEM OF MEDICINE 
(4) Ehrlich (1891) clearly brought forward the important fact that 
Behring's law applies not only to bacterial intoxication, but also to 
intoxications with other organic toxins. He succeeded in establishing in 
mice a marked tolerance of ricin (obtained from castor oil beans), and of 
abrin (obtained from jequerity seeds), by administering gradually increas- 
ing doses either under the skin or by the mouth; and he found that the 
serum of ricin-proof animals possesses the power of directly transmitting 
a resistance against ricin, and that the serum of abrin-proof animals is 
capable of producing the same effect with regard to abrin. These obser- 
vations are of far-reaching importance, because they open up a wider 
field for the application of Behring's method; and, as we shall see later, 
they emphasised, from the theoretical point of view, the conflicting opin- 
ions on immunity which at that time were stoutly defended. 
It would take us too far to enumerate all the various bacterial infec- 
tions on which Behring's law has been tested in the laboratory. To 
give a convincing proof, however, to those who may be still in doubt, it 
may be stated that the protective power of serum obtained from animals 
rendered immune from the effects of bacterial inoculations has been 
demonstrated for infections with mouse septicaemia, Friedlander's pneu- 
monia bacillus, Frankel's pneumococcus, the typhoid bacillus, the vibrios 
of Asiatic cholera, B. py ocyaneus, streptococci and staphylococci pyogenes, 
B. prodigiosus, and the B. coli communis. The extensive experiments of 
Calmette, recently confirmed by Professor Fraser, prove that a protec- 
tive serum may also be obtained from animals gradually rendered proof 
against various kinds of animal poisons such as snake venoms, physio- 
logically and chemically closely allied to bacterial toxins. If we arrange 
these facts systematically, we shall find that the lesions for which serum 
protection has been tried, are very diverse. They include - 
(i.) Bacterial infections which are pre-eminently intoxicative, such 
as tetanus and diphtheria, in which the bacilli, in larger or smaller 
numbers, are found only, or chiefly, at the seat of infection, where they 
produce their deadly toxins. 
(ii.) Bacterial infections in which the organisms spread widely into 
the tissues from the seat of inoculation, either along the lymph channels 
or by means of the circulation (hsemic infections). 
(iii.) Direct intoxications with the poisons manufactured by the bac- 
teria, intoxications with other animal or vegetable poisons belonging to 
the group of so-called toxalbumins, and lastly, intoxications produced by 
substances the real nature of which is still unknown, for example, rabies. 
The protective serum is, therefore, in some cases active against the 
bacteria themselves; in others against their products, and in yet others 
equally powerful against the effects of the living organisms and of their 
toxins. No doubt the pathogenetic bacteria call forth the lesions and 
general symptoms of the disease which they produce by means of their 
poisonous activity; so that, although the obvious pathological phenomena 
considered generally appear extremely heterogeneous, yet the common 
principle of intoxication underlies them all. It would almost seem THE GENERAL PATHOLOGY OF INFECTION 
565 
that the stronger the toxic faculty of a particular organism, the less dis- 
posed is the latter to invade the tissues and the blood. This much is cer- 
tain that an animal, whether vaccinated with the living bacteria or with 
their metabolic products, will, when once protected, give a serum which 
is essentially, though perhaps not indifferently, active both against a 
subsequent infection with the living organisms and against a subsequent 
intoxication with the toxins. Since the poisonous products are the chief 
weapons of infection, we must regard the action of the protective serum 
as directed especially against the effect of the poison; hence this serum 
has been called " antitoxin," an ill-chosen name. 
It was further shown by Behring and his pupils, that the protective 
serum can exert its marvellous power even after a preceding infection - 
when the symptoms of disease or intoxication have already appeared; the 
protective serum is therefore also curative. It is obvious that to bring about 
a cure must require larger quantities of serum than are necessary for pro- 
tection ; moreover, the chances of a cure vary directly with the promptness 
of administration. That protective serum is also curative is firmly estab- 
lished, so far as experiment goes, for all the various processes mentioned 
above, including intoxications with vegetable and animal toxalbumins. 
There is a striking difference between immunity produced by the 
inoculation of the bacteria themselves and their toxins - whether attenu- 
ated or not, and immunity produced by serum injections. In the former 
case the animal gains its immunity after an active struggle with the 
disease or lesions following the injection or intoxication; in the latter 
case there is no struggle with disease, and no reaction; the animal 
remains passive, while the immunity-conferring substances are applied 
to its tissues. On account of this essential difference, Ehrlich distin- 
guished active and passive immunity. Passive immunity is effected 
quickly, is less persistent, and varies with the amount of serum used 
and with the degree of immunity of the animal which supplies the 
serum. Active immunity, on the other hand, does not appear for days, 
not until the animal has passed through the reactive stage; then it 
becomes permanent, and is proportional to the intensity of the reaction 
rather than to the amount of vaccine used. 
(/) Within recent years it has also been shown that an artificial 
imm/unity may be produced in animals by feeding them either with the living 
organisms or their products. Ehrlich and Fraser have applied this method 
in the case of the vegetable toxins (abrin and ricin) and the snake venoms. 
An animal can be protected also against tetanus, diphtheria, cholera, 
and other infections in this manner; and what is more, the serum 
obtained from them has acquired preventive and curative powers. 
Although other methods of producing artificial immunity in animals 
have been described, it is more convenient to defer the consideration of 
them; because these six processes, briefly described, form a progressive 
series which much facilitates the theoretical discussion. To this discus- 
sion we shall now pass on. 
Theory of Acquired Immunity. - A number of hypotheses have been 566 
SYSTEM OF MEDICINE 
built up to explain the processes in the animal body by which the 
immunity is gradually developed. Many of these have been but ingen- 
ious speculations, based often upon a single process observed, it may be, 
with brilliant genius and acuity. It must be remembered that a theory 
can take no other foundation than the observation and experience of 
conditions recognised or recognisable at the time; nor can it be tested 
in advance of contemporary knowledge. Retrospectively we now dis- 
card many theories, the discussion of which in the period of their 
ascendency led to much heated controversy; for in the light of new 
discoveries they are seen to be incorrect or insufficient. Many theories 
fail because they attempt to explain a process by selecting a particular 
factor as the cause, instead of recognising in it what it actually is, a 
concomitant variation. As I have given the methods of producing 
artificial immunity more or less in historic order, it will be well to 
consider the theories of acquired immunity in the same manner. 
(a) Pasteur's hypothesis of exhaustion, which was shared by Klebs, 
assumed that the attenuated micro-organisms, which were injected into 
the animal tissues for the purpose of establishing a protection, used up 
and thus removed from the body certain substances of vital necessity 
for the bacteria in question; and that the animal body once deprived 
of these substances remained permanently exhausted, so that if bacteria 
of the same kind subsequently obtain access to the tissues they find no 
suitable soil for further development. This hypothesis was deduced 
from test-tube observations; for evidently a given amount of nutrient 
matter can only offer nourishment to a certain quantity of micro-organ- 
isms, and when the soil is exhausted growth must cease. 
(/I) This hypothesis was doomed to fall, as soon as it became known 
that artificial immunity is better produced by the administration - sub- 
cutaneous, intravenous, or gastric - not of the bacteria, but of their meta- 
bolic products, substances which possess no life and cannot, therefore, 
use up tissue materials. Starting from other observations on the growth 
of bacteria in artificial media, Chauveau and others had already preached 
the theory of retention; according to this theory the bacteria not merely 
deprive the body of material necessary to their growth, but also leave 
products behind which are absorbed, accumulated, and retained. The 
retention of these substances was supposed to make the tissues unsuitable 
for subsequent infection. This hypothesis was apparently supported by 
the facts of protection by means of chemical vaccination, - that is, protec- 
tion with bacterial toxin, - but it is also a test-tube argument; for we 
know that many organisms, especially those which produce active fer- 
mentations, either by primary secretion or secondary fermentation, 
manufacture substances which are deleterious to their own further 
growth and activity. The yeast cells, for instance, by forming alcohol 
compass their own death and destruction. 
Although the retention hypothesis is much nearer the truth than 
Pasteur's cruder notion, there are serious objections to it which compel 
us to abandon it, and these are - THE GENERAL PATHOLOGY OF INFECTION 
567 
(i.) The artificial immunity is frequently of long duration, and we 
cannot possibly assume that such a permanent change from suscepti- 
bility to insusceptibility could be due to the absorption and retention of 
soluble toxins, which, so far as we know, are not retained by the body, 
but, as clinical and pathological observations prove, are readily elimi- 
nated. In many cases the specific toxins can easily be traced in the 
urine during the development of immunity by chemical vaccination. 
(ii.) In most, or in almost all cases, the blood, serum, or tissue 
juices of animals artificially protected by the administration of bacterial 
poisons, form good culture media for the micro-organisms concerned. 
We shall discuss this point more fully hereafter. 
(iii.) An artificial immunity, as shown above, may be readily broken 
down by interferences which can hardly affect the retention of the 
metabolic bacterial products. There can be no doubt that the stability 
of an acquired immunity must be due to reactive virtues acquired by 
the tissues and the cells themselves, and not to something left behind 
by the micro-organisms. 
(iv.) Immunity may be produced by the injection of micro-organ- 
isms which have become so attenuated as to be little more than mere 
saprophytes. 
(y) It is the merit of Metschnikoff to have searched for a cellular 
theory of immunity, and to have formulated the theory of phagocytosis. 
This has already been fully considered in the article on Inflammation, 
where all the important phenomena of phagocytosis are described; the 
matter need not, therefore, be re-opened here. Metschnikoff, who it 
must be remembered built up his theory at a time when chemical vac- 
cination with bacterial products was unknown, assumed that by means 
of inoculation of attenuated micro-organisms the leucocytes and phago- 
cytes, incapable at first of fighting against bacteria possessed of their 
full virulence, gradually acquire, by adaptation and selection of the 
fittest, the power of ingesting and destroying even these. If such ac- 
quired cell properties be transmitted from cell generation to cell gener- 
ation, the animal body becomes protected against future invasions. 
With the discovery of chemical vaccination and serum protection, 
Metschnikoff, reluctant to abandon his theory, had to modify his views 
continually. He assumed that the injection of soluble toxic or protective 
substances into the body has an " educational effect " on the phagocytes, 
by which they are taught to overcome bacteria which previously were 
invincible. Undoubtedly phagocytosis exists, and is perhaps one of the 
commonest phenomena of immunity; but it is not permissible to speak, as 
Metschnikoff does, of an " education of leucocytes to attack and destroy 
bacteria "; let us substitute the real word, and it reads " acquired im- 
munity of leucocytes enabling them to remove the bacteria which come 
in their way." If we do this, then we find that we are little farther than 
before; we have merely thrown the mystery a step farther back, that is, 
from the body as a whole to a small cellular portion of it, the phagocytes. 
Immunity of the body would depend on immunity of the leucocytes and 568 
SYSTEM OF MEDICINE 
their conversion into phagocytes. But how do the leucocytes acquire im- 
munity ? Metschnikoff says they are " educated " to attack, " educated '' 
to conquer; obviously this is no explanation. Furthermore, no pathol- 
ogist who views the animal body as a complex structure, and not merely 
as a congeries of amoebae, and who appreciates the adaptation of the tis- 
sues to diseased conditions, - as illustrated, for instance, by the phenom- 
ena of compensation, - can assume that immunity, a general process, is 
brought about by one specified set of cells. Metschnikoff's observations 
are extremely beautiful and almost dramatic; we admire his zeal and 
penetration; but the advances of recent years, apart from any other con- 
siderations, compel us to give up his theory unconditionally. As soon 
as we realise that the symptoms of infective lesions depend in the first 
instance on the bacterial toxins, and that acquired immunity implies 
protection against the poisons as well as against the bacteria, it becomes 
evident that no theory of artificial immunity can be correct unless it ex- 
plains both processes. Phagocytosis cannot do this, hence it was doomed 
as an exclusive theory to fall. So long as the bacterial poison is not 
neutralised or destroyed in the body, it matters not whether the bacteria 
are eventually killed or not. An animal made immune from a living 
microbe can also resist the toxin of such microbe to varying degrees, and, 
conversely, an animal rendered proof against the toxin will also resist the 
living microbe. Immunity from the toxic effects cannot be explained 
by means of phagocytosis. The proof that the animal body possesses 
other defensive means quite independent of phagocytosis has contributed 
greatly to the decline and fall of this attractive and once dominant theory. 
(3) This proof was first demonstrated by Grohmann in 1884 and by 
Fodor in 1887, who clearly showed that the normal tissue fluids, and more 
especially the blood, possess marked antimicrobic properties. These earlier 
observations were followed up, especially by Nuttall, Behring, and Buch- 
ner, who established further that the offensive action of the blood has its 
source in the albuminous bodies of the cell-free serum, which no doubt are 
primarily derived from the cells, wandering or fixed, phagocytic or non- 
ingestive. Buchner and Hankin took the lead in explaining this action, 
and suggested that the destructive power of serum is due to certain pro- 
teid substances to which, unfortunately, he gave the name of alexins. It 
must not be assumed, however, that the blood of any animal has a general 
antimicrobic action, or even any at all. In some cases it is quite power- 
less, and, moreover, its potency frequently varies in different members of 
the same species. As these observations, however, relate to natural rather 
than acquired immunity, their discussion must be deferred for a while. 
Here I shall make an attempt to explain, if this be possible, the law 
discovered by Behring, that an animal whose resistance to a bacterial 
disease has been considerably increased, possesses a blood capable of 
neutralising an infection or intoxication of the same bacterial origin. 
(e) It was shown by Behring and others that, speaking generally, the 
blood serum of naturally immune animals does not possess any or but slight 
antimicrobic, antitoxic, or protective properties. Thus, for instance, the THE GENERAL PATHOLOGY OF LNFECTION 
569 
serum of a hen, which is naturally refractory to tetanus, cannot protect 
other animals, nor can it " neutralise " the tetanus poison. There are 
instances, it is true, where the serum of naturally immune animals pos- 
sesses a germicidal power; rat's serum, for example, will destroy anthrax 
bacilli, but that of mice, guinea-pigs, rabbits, sheep and cattle, all nat- 
urally susceptible animals, is without effect. There are a few cases of 
such correlation between natural immunity and the antimicrobic power 
of the blood, but they must be regarded as exceptions; we cannot ex- 
plain a specifically acquired immunity by merely assuming that an in- 
crease of a natural pre-existing germicidal power has taken place; it 
must be due to acquired and superadded changes. The best corrobora- 
tion of this opinion is the fact that if tetanus bacilli or their toxin be 
injected into the refractory hen, its serum is thereby rendered active 
against tetanus. Hence, in the first place, it is necessary that even in 
refractory animals reactive changes should be produced before their se- 
rum becomes in any way protective for others. The tissue cells, there- 
fore, are primarily brought into conflict with the bacteria and their 
products, and, if they conquer, it is by virtue of antagonistic substances, 
which are produced by them partly anew, partly out of existing ele- 
ments, are absorbed or dissolved by the body fluids, and are thus dis- 
tributed through the animal organism. By renewing the struggle from 
time to time we can raise the power of these antagonistic substances; 
and the keener the battle, that is, the more susceptible the animal was, the 
stronger this power will be. Further, the action of the protective serum is 
specific, that is, the serum of an animal rendered immune from a par- 
ticular infection will with certainty protect other animals against this 
infection only. Although this assertion must be accepted with certain 
reservations, at present the evidence against it, as a general principle, 
so far as bacterial infections or intoxications are concerned, is not strong 
enough to raise grave doubt or to invite discussion here. There are 
numerous varieties of cholera vibrios which apparently are closely allied; 
yet an animal rendered immune by specific inoculation from the infec- 
tion of one of these will produce a serum active against this variety, 
powerless against others. Again, closely as the pathological effects pro- 
duced by the streptococci and staphylococci resemble each other, yet an 
anti-streptococcus serum is useless against the staphylococci. And yet 
again, although by means of intra-peritoneal injections of the B. pro- 
digiosus it is possible to protect rabbits against intra-peritoneal injec- 
tions of the B. pyocyaneus, nevertheless the serum of an animal protected 
against the B. prodigiosus cannot render another animal immune with 
regard to the B. pyocyaneus, although the serum of animals protected 
simultaneously against both the B. prodigiosus and the B. pyocyaneus will 
protect against both infections. We shall come back to this argument. 
How does the protective serum act ? Does it act (1) as an antidote to 
the toxins, or (2) as lethal to the bacteria ? If we mix in a test-tube a 
certain quantity of diphtheria or tetanus toxin with the necessary amount 
of the corresponding serum, the mixture injected into an animal is harm- SYSTEM OF MEDICINE 
570 
less, the poison appears to be neutralised. Recent observations by Buchner 
and others seem, however, to contradict this assumption, seductive as it 
is on account of its simplicity. A neutralisation, as Behring pictured it 
to his mind, comparable to that combination of an acid with an alkali, 
which, by means of chemical or physiological interaction, leads to a neu- 
tral compound, can hardly be the explanation of the marvellous phe- 
nomena, because it has been found that the apparently neutralised mixt- 
ure, though harmless for less susceptible animals, possesses a highly toxic 
action on more susceptible animals or on weakened individuals of the 
same species. Thus Buchner has demonstrated that a mixture of tetano- 
toxin with tetanus serum, in the exact proportion which renders it impo- 
tent for mice, is still toxic for guinea-pigs which are much more susceptible 
than the smaller rodents; and Roux and Vaillard have shown that a mixt- 
ure of diphtheria toxin and antitoxin, harmless for vigorous guinea-pigs, 
will kill weakened individuals. We cannot then assume that the poison 
has been permanently destroyed by the serum. It has, therefore, been 
thought that the protective bodies do not directly attack the toxins, but 
act by producing a resistance of the tissues so rapidly that on injecting 
the toxin together with the antagonistic serum we have, so to speak, a 
race between immunity and intoxication. Objections may be raised to 
this view also, and with our imperfect knowledge we cannot give a cast- 
ing vote for one theory or the other. Frankel assumes, so far as the anti- 
toxic power of the protective serum is concerned, that the toxin and the 
antagonistic substances (generally called antitoxins), though they do not 
neutralise one another so as to form a harmless stable compound, enter 
nevertheless into a looser combination which results in a temporary sus- 
pension of the poisonous activity of the toxic constituent; a combination 
which may, however, under special conditions be split, and the toxic con- 
stituent once more become free. We have as yet no proof in favour of 
such an hypothesis. Moreover, we must not forget that there is no abso- 
lute standard of virulence or toxic effect, that the toxic coefficient must 
naturally vary for each animal; thus in estimating whether a poison has 
been really rendered inocuous we must use the most susceptible animals. 
We shall then find that a toxin to which serum has been added so as to 
neutralise it for such animals will be harmless for all others. A more or 
less refractory animal is, from its very nature, able to account for a 
greater or less fraction of the poison, so that the protective serum is only 
called upon to neutralise the surplus. This may explain Buchner's diffi- 
culty, that a mixture of tetanus toxin and anti-tetanic serum, though 
harmless to the more refractory mouse, is still harmful to the more sus- 
ceptible guinea-pig. At present it seems more reasonable to accept the 
antitoxic or neutralising power of the protective serum - not indeed as 
an ordinary test-tube reaction, but rather as a vital cellular change. Yet 
since the toxic value is a relative quantity varying with each species of 
animals, the antitoxic value must also be a relative quantity. 
In the next place we must ask (2) whether this serum possesses any de- 
structive action on the bacteria themselves; is it antimicrobic ? Though 
formerly it was assumed to act as a direct poison to the bacteria, after THE GENERAL PATHOLOGY OF INFECTLON 
571 
the manner of a disinfectant; or to contain substances which, when in 
contact with the tissues and their juices, render these destructive to 
microbic life; yet it was soon recognised that acquired immunity can- 
not be explained by the germicidal effect of the serum itself, or by a 
germicidal quality induced in the animal body. 
Experiments show that anti-diphtheritic and anti-tetanic serum form 
by no means unfavourable culture media for the respective bacilli, 
though it is certain that on administering these protective fluids to- 
gether with the organisms, the latter are arrested in their growth or 
eventually even destroyed. Earlier observations made it appear that the 
serum of a protected animal is distinctly germicidal; thus, although the 
vibrio of Metschnikoff, for instance, thrives well in a serum obtained 
from a normal guinea-pig, when this animal has been rendered immune 
its serum will no longer allow the vibrios to flourish. But as in the case 
of natural immunity, it is quite the exception to find a germicidal serum, 
so we find also that the serum obtained from a protected animal seldom 
has this property. So far as the direct destructive power of protective 
serum, measured by test-tube reactions and phenomena, is concerned, we 
find so little correlation between artificial immunity and bacterial de- 
struction, that we cannot look for an explanation of acquired immunity in 
a change of the serum from a nutritive to a destructive one. Yet we find 
that in the animal body the protective serum will prevent lesions essen- 
tially infective, such lesions, for example, as a septicaemia dependent on a 
general overgrowth and diffusion of the bacteria throughout the tissues. 
Bouchard and his school assumed that the process of protection alters 
the serum in such a manner as to render it attenuating; so that although 
it may be unable to destroy bacterial life, it nevertheless becomes capable 
of altering the chemical and toxic activity of the organism concerned to 
such an extent that it ceases to be virulent. Thus anthrax bacilli grown 
in the serum or blood of vaccinated sheep apparently lose their virulence; 
so do erysipelas cocci cultivated in serum of protected animals; and the 
same rule applies to the pneumococcus and B. pyocyaneus. Although 
these observations directly refute the theory which assumes that artificial 
protections lead to the formation of germicidal substances in the blood, 
they would seem to show that these processes endow the tissue fluids 
with a marked attenuating power, so that deadly organisms grown in them 
become capable of producing more than a passing and insignificant lesion. 
Metschnikoff, however, has conclusively demonstrated the incorrectness 
of this supposition. Firstly, this attenuating effect is not a constant 
result of acquired immunity; secondly, it is merely apparent and very 
transitory, while true attenuation is a more lasting change; thirdly, if 
we separate the bacteria from the serum in which they grow by means 
of filtration and washing, we find their virulence restored, so that the 
diminished virulence must be due to the specific action on the animal 
organism of a protective substance hidden in the serum. Artificial im- 
munity, therefore, depends neither on a "direct" germicidal nor on an 
attenuating power acquired by the serum and fluids of the protected animal. SYSTEM OF MEDICINE 
572 
Although, while working in the laboratory with test-tubes and serum, 
we find that the protective serum itself is neither attenuating nor con- 
sistently bactericidal, nevertheless it is certain that the processes in the 
body are very different. There can be no doubt, in spite of Metschnikoff's 
objections, that when we inject cholera vibrios intra-peritoneally into a 
protected animal, crowds of them die in the peritoneal fluid without any 
direct interference on the part of the cells-without phagocytosis. Con- 
versely if we administer the anti-diphtheritic serum to patients and ex- 
amine their tonsillar or faucial membranes from day to day, we shall 
frequently find that legions of diphtheria bacilli die an extracellular 
death. Similarly after the pneumonic crisis, which marks the period of 
acquired immunity, the diplococci die in large numbers without direct 
conflict with the cells. Hence, though our test-tube observations may 
point the other way, we are forced to assume that during the process of 
recovery which ends in acquired immunity the body becomes so greatly 
altered that its tissues and fluids become not only antitoxic, but also 
germicidal. These are two distinct and specifically acquired properties 
which serve to protect the body when its immunity is threatened. 
Hence the secret of an artificial specific immunity must be sought for 
in peculiar vital changes produced in the aniiqal organisms by various 
processes, either actively or passively specific. An active immunity, as 
already explained, is produced by inoculation with living organisms and 
their products, the resistance being acquired after an active struggle 
against the causes of disease; a passive immunity is produced by the 
administration of the specific serum, the resistance being acquired, with- 
out an active struggle, by a peculiar modification brought about under the 
influence of certain specific substances. The chief difference between the 
unprotected and the actively protected animal is that the serum or tissue 
extracts of the latter possess a specifically immunising power. Since 
this change affects all tissues, it is evident that, as the animal passes 
from the susceptible to the immune state, we are dealing not merely 
with a modification of this or the other fluid or cell, but with a general 
reaction. Acquired immunity does not depend on resistance acquired 
by certain cells or elements alone; when once produced it finds expres- 
sion in vital germicidal and antitoxic properties acquired by the tissues 
and their fluids. It is obvious that a struggle against pathogenetic bac- 
teria can only end successfully if these are eventually destroyed, and 
their toxic products rendered harmless. The conception, therefore, of an 
acquired immunity depending on phagocytosis alone, is absurdly narrow 
and incomplete. The toxins being the most dangerous weapons of the 
bacteria, the antitoxic reaction of the tissues is no doubt the more im- 
portant modification; but histological bacterioscopic and clinical investi- 
gations show clearly that with the appearance of immunity and recovery 
the micro-organisms also die. Their death is due (a) to action of the 
cells, or phagocytosis, but also (&) to extracellular destruction. Phago- 
cytosis is therefore merely one factor of immunity, one, indeed, not 
invariably present, nor, when present, equally important in all cases. THE GENERAL PATHOLOGY OF INFECTION 
It may be present although the animal die from the effect of intoxication. 
It is futile then, as we have seen, to enter at the present time into 
further discussion when the advances of our knowledge so clearly indi- 
cate the limitations of the phagocytic theory. 
Artificial immunity, therefore, to state it once more, depends on 
processes which render the tissues capable of (a) destroying bacterial life, 
and (&) of rendering the products of bacterial activity inert; destruction 
of the bacteria themselves is not sufficient to save the animal, unless the 
toxins are also accounted for, or unless the bacteria are destroyed before 
they have time to form their toxins. It is conceivable that an animal 
may survive, if the poison alone be destroyed or rendered inert, but it 
is a matter of experimental as well as of clinical observation that antitoxic 
processes in the body are almost invariably accompanied by antimicrobic 
effects. A protected animal reacts to an infection with local inflammatory 
changes which soon pass off; the bacteria disappear without their prod- 
ucts having had a fair chance of displaying their existence and activity. 
Inasmuch as phagocytosis is a common phenomenon in an inflammatory 
process, leading to resolution and repair, it will also show itself concur- 
rently with immunity; but the essence or cause of immunity it cannot 
possibly be. 
As yet we have no certain knowledge of these antimicrobic and 
antitoxic substances. It seems erroneous to assume that the germi- 
cidal serum or tissue extracts contain these matters in the form in 
which they subsequently appear in the animal body. It is more reason- 
able to assume that they are called into existence by the action of the 
serum, or of substances contained in the serum, on the tissues; this is 
certainly the case so far as the germicidal properties of the immunised 
tissues are concerned, for the protective serum in the test-tube but rarely 
possesses any such properties, while the animal body certainly does. 
Again, by means of chemical vaccination we render an animal refractory, 
so that its tissues are able, both by intracellular and extracellular action, 
to destroy the microbe, and yet this germicidal virtue is rarely trans- 
mitted to the serum. It has also been shown that after heating, which, 
as we know, removes all possible germicidal and antitoxic powers it may 
possess, the protective serum inoculated into an animal is still capable of 
conferring immunity to the tissues and their juices by virtue of which they 
are able to overcome a bacterial infection. With regard to the antitoxic 
effect it is still more difficult to come to a definite conclusion. At first 
sight we might ask why we should require a different explanation here ? 
In almost all, if not in all cases, it takes a long course of inoculation with 
toxins to generate a weak antitoxic serum ; but when the animal is once 
immune its total serum will give much more antitoxin than corresponds to 
the dose of poison against which it has been protected. Roux has further 
shown that the same quantity of toxin given in many small doses leads to 
a greater store of antitoxin in the tissues than when given in a single large 
dose. Lastly, we have the observations alluded to above, that a mixture 
of serum and toxin, apparently neutral for one group of animals, is still 
573 SYS7'EM OF MEDICINE 
574 
toxic for more susceptible animals; or to put it otherwise, " clinically 
cure does not follow the introduction of the serum with the certainty 
and precision of a chemical reaction " (Welch). It is, therefore, in all 
probability incorrect to suppose that the protective serum has a " direct " 
antitoxic and germicidal action which it shares with the tissues; the 
changes, induced by the injected serum, which render the tissues and their 
fluids both antimicrobic and antitoxic, have a specifically vital character. 
Buchner has made attempts to separate the antitoxic bodies from 
serum in a more definite form. All attempts to obtain them in a pure 
state have failed, and in the present state of physiological chemistry 
must fail. The serum may be dried in vacuo and still retain its remark- 
able properties; it may be precipitated by sodium-ammonium sulphate in 
the form of a highly antitoxic powder. Heat destroys the action of the 
antitoxins, but with some difficulty, they are resistant also to light and 
putrefaction, and in many respects they resemble the enzymes. Buch- 
ner's own view is that the antitoxins are substances directly derived from 
the bacterial plasma. There is, however, no definite evidence in favour 
of this assumption, and for the time being we must confess our ignorance 
of the nature of these protective and curative substances. 
Whatever the nature of these so-called antitoxins of bacterial origin 
may be, their action is specific; that is, an anti-diphtheritic serum, from 
whatsoever animal obtained, will immunise against diphtheria alone. 
Most experiments, as I have said, tend to prove this point; and the recent 
attempt made, especially by the French school, to cast doubt on this prop- 
osition, does not as yet carry conviction. It is true that Calmette has 
shown not only that by gradually rendering animals proof against snake 
poison, their serum in this case likewise becomes protective and curative, 
but also that the serum of an animal inoculated against cobra venom will 
counteract the effects of the venom of other snakes; yet this exception is 
but apparent, as it appears from their physiological or pathological action 
that the snake venoms generally employed belong to one physiological 
group. Calmette, however, claims that anti-tetanic serum also works 
antagonistically to snake poison. But recent experiments show that this 
view of the absence of specificity rests on an insufficiently sound basis, and 
applies perhaps more to the antitoxins prepared for poisons of non-bacte- 
rial origin; so that the specificity of antitoxic serum, for infective lesions 
at least, cannot as yet be denied. The most important feature of the ob- 
servations on snake poison is the fact, already demonstrated by Ehrlich, 
that what can be done against the bacterial toxins can also be effected 
against the chemically and physiologically allied animal or vegetable poi- 
sons. Attempts to obtain a protective serum against the vegetable alka- 
loids by means of gradually increasing inoculations have hitherto failed. 
The view that the antitoxins are modified toxins or direct derivatives 
from the mycoproteins is disproved by Roux's experiments, who showed 
that a horse strongly protected against diphtheria toxin, if bled, gives a 
serum of certain value; if bled again a little time later, its serum will 
have the same value as that first removed, although no poison has been THE GENERAL PATHOLOGY OF INFECTION 
575 
administered in the meantime to raise the immunity. Hence, fresh 
antitoxin must have been produced without fresh inoculation with toxin. 
Antitoxin must, therefore, be a direct product of the cells by virtue of 
acquired secretory changes, and its action must also be directly cellular. 
This sketchy and elementary survey of the subject of Acquired 
Immunity must suffice, since the whole subject is one which readily 
invites speculation which may hardly prove profitable, and would at any 
rate fall beyond the scope of a general article. 
Natural Immunity. - While discussing predisposition we have fre- 
quently alluded to natural resistance and immunity, so that here a few 
brief remarks will suffice. Natural immunity, like predisposition, may be 
individual or personal, or may belong to all the members of a species or a 
race. Amongst animals, for instance, we find that Algerian sheep are 
resistant to anthrax, an infection very fatal to other sheep; and we have 
already commented upon the marked insusceptibility of negroes to yellow 
fever and ague, which amounts almost to immunity. Carnivora generally 
are distinguished by a marked degree of resistance to anthrax and septic 
infection, which is almost equivalent to exemption. Racial immunity to a 
great extent must have been acquired by natural selection and inheritance, 
as the more refractory members survive; and since the properties to 
which they owe their survival are of benefit to the species, we may assume 
that they are readily transmitted by heredity. The influence of bacterial 
diseases on the origin of species has not received as yet due attention, nor 
again this influence on the extermination of species. This is not the place 
to consider this question; but I may point out that there is sufficient 
historic evidence to suggest that continued exposure to an infection tends 
to establish a racial resistance, for we find that the commoner infective 
fevers when introduced amongst a population unacquainted with them, 
assume a most malignant and fatal form. 
Natural immunity may be either absolute or relative according to its 
intensity. But few animals are absolutely immune, for in most cases it 
is possible to infect them, without otherwise interfering with them, by 
inoculating excessive quantities of bacteria into their tissues, or by 
introducing the germs in special regions of the body. An animal though 
able to resist large doses injected subcutaneously, may readily succumb 
to intra-peritoneal inoculations; while in other cases intra-peritoneal 
inoculations may be resisted when subcutaneous infection proves fatal. 
This opens up the broad question of local immunity, which at present is 
beyond the reach of an answer. A personal immunity may be merely 
temporary, and then it is often apparent rather than real. When we 
find, for instance, that during an epidemic a certain number of people re- 
main intact, this exemption is not necessarily due to a natural insuscepti- 
bility, but in some cases may be explained by assuming (1) that there 
was no exposure to the contagion, or (2) that certain external conditions 
required for a successful infection were absent. An individual who has 
escaped during one epidemic may become infected subsequently; either 
because his immunity was only temporary, or because in the meantime he 576 
SYSTEM OF MEDICINE 
has acquired the necessary disposition. We must draw a hard and fast 
line between temporary and relative immunity on the one hand, and loss 
of resistance on the other. 
When an animal is naturally immune from a bacterial infection, it is 
also proof against intoxication, an important consideration, as we shall see 
hereafter, for no theory of immunity can be advanced unless it explains 
also this essential factor of natural resistance. The temporary or per- 
manent immunity which some individuals enjoy may be due to the 
intolerance of poisons, especially when pathogenetic organisms find an 
abode in the body without producing an infection, as, for example, is the 
case with the pneumococcus, whose presence is borne with impunity 
by a large percentage of people. It is, however, also possible that such 
organisms while growing in the various secretions and excretions display 
but little or no virulence. Altogether we are on ground so very unsafe, 
and surrounded by so many fallacies, that it is wiser to attack the prob- 
lem of natural immunity in its simplest form. 
We find that some animals are refractory to certain bacterial infec- 
tions, susceptible to others. How are we to explain this ? Various views 
of the matter have been brought forward from time to time. 
Theory of Natural Immunity. - (a) Metschnikoff preached phago- 
cytosis, but we have already seen that in an exclusive form this theory 
is untenable, especially as in most bacterial infections we are dealing with 
the toxins as well as with the micro-organisms themselves. Again phago- 
cytosis may be present to a marked degree, although the animal die (for 
example, diphtheritic infection in guinea-pigs). As in acquired so also in 
natural immunity phagocytosis is merely a phenomenon of natural resist- 
ance. 
(ft) It has been assumed, especially by Buchner and Hankin, that in 
the condition of natural immunity the blood, lymph, and tissue fluids are 
germicidal, and that this property is due to certain albuminous or 
albuminoid substances which may be separated in an impure form from 
the blood, spleen and other tissues of most animals. To these bodies' 
Buchner gave the name of alexins. They are secreted by certain cells of 
the body, according to Hankin more especially by the leucocytes, and 
pass into solution. Certainly, as we have already seen, the serum of 
many animals has some germicidal properties, and from the spleen and 
lymphatic glands albuminous substances capable of destroying or impair- 
ing bacterial life can be removed. These so-called alexins differ from the 
antitoxins in these points : (i) they are very sensitive to light or heat; (ii) 
they have a distinct, though unequal, germicidal power, which (iii) varies 
both in intensity and effects with the species of the animal; in one spe- 
cies they are active against one microbe, in another species against an- 
other. There is in them no uniformity or common principle of action. 
There are many weak points in such a doctrine, of which I may 
mention a few. Thus, the experimental evidence is unsatisfactory, since 
it rests mostly on test-tube reactions which often differ materially from 
those in the animal body. Frequently the serum shows slight antimicrobic THE GENERAL PATHOLOGY OF LNFECTLON 
577 
powers outside the animal body, while the living tissues exert no such 
power. Again, there is no complete correlation between natural immunity 
and this property of the serum, and without it the theory must fall to 
ground. Even in the most refractory animals the destructive power of 
the serum over the micro-organism is too slight to tempt us seriously to 
accept this theory. Thus, we find that frogs' serum in a test-tube will 
destroy but a very small percentage of the anthrax bacilli added to it, and 
that even this slight germicidal power is lost after a short time. There 
can be no doubt that the serum or plasma does contain such substances 
(or alexins, if we wish to use a mystic language); for the germicidal 
power, slight as it is, is readily destroyed by heat or cold. There are 
no doubt destructive substances in the blood of many animals, yet for 
the above reason it seems impossible thereby to explain natural immu- 
nity, especially since it has been found impossible hitherto to produce 
specific cures by means of repeated injections of such bodies. Again, 
the alexins have never been shown to have an antitoxic effect, and it is 
a matter beyond dispute that an immune animal is also toxin proof. 
But we must confess that the serum of certain refractory animals is 
antitoxic to snake poison; yet here again there is no constancy, since 
some venom-proof animals yield no antitoxic serum, while on the other 
hand some susceptible animals yield an antitoxic serum. Natural im- 
munity, therefore, must depend on vital reactions which are called forth 
by the conflict between the tissues and the bacteria with their products, 
the final outcome being death of the micro-organisms and neutralisation 
of the toxins. The destruction of bacterial life is assisted by the innate 
germicidal and antitoxic power of the serum, plasma, or lymph found in 
many animals, and by the phagocytic properties of the wandering cells. 
(y) This reactionary vitality of the tissues and their cells may be 
increased in many ways. Thus, Wooldridge showed that the injection of 
thymus extract may protect rabbits against anthrax, and Kossel, Vaughan, 
and McClintock have rendered animals refractory to bacterial infections by 
the administration of nuclein and nucleinic acid. Since it requires in the 
case of susceptible animals a certain minimal number of micro-organisms 
to produce infection, it follows that every animal possesses the elements 
or the germs of immunity. These will destroy a certain number of bacteria, 
but if we pass beyond the limit, disease' will occur. If now in one way 
or another we increase this innate resisting power by cell-stimuli, the ani- 
mal will be able to resist a larger number; it will appear, that is, to be 
immune, or to have acquired an immunity. We may increase this innate 
resisting power in two directions: (a), specifically against a particular 
infection by administering repeated or increasing doses of the bacteria, 
their proteins, or their toxins; or (&), generally against all infections 
by giving such substances as nuclein, nucleo-albumins, nucleinic acid. 
In either case we increase the reacting powers of the tissues; it appears, 
however, that only when we do so specifically we can obtain a protective 
serum. Thus, Hildebrandt has shown that by means of enzymes of 
various kinds we may alter animals to such an extent that they are 
VOL. I 
2 P 578 
SYSTEM OF MEDICINE 
capable of resisting acute infections; yet if the serum of animals, which 
have been treated with ferments and enzymes, be injected into normal 
animals, it has no antidotal value. The enzyme injections, therefore, 
raise the natural resistance, but do not produce an immunity which can 
be transmitted from one individual to another by means of the serum. 
We stand, therefore, before a question which we are quite unable to 
answer; namely, what is the difference between natural resistance and 
acquired specific immunity ? The former is an innate property of the 
individual or species, one which cannot be transmitted, except by heredity, 
from parent to offspring; the latter is readily transferred from one indi- 
vidual to another by serum injections. Yet we find that by producing a 
specific transferable immunity the natural general resistance is frequently 
raised, for clinically it may be shown that recovery from an infective 
fever often renders the individual less susceptible to other infective fevers; 
occasionally, however, it may render the individual even more susceptible. 
Hereditary Immunity. - An acquired specific immunity may also be 
transmitted from parent to offspring. Numerous experiments prove this, 
butthe most important are those of Ehrlich, and of Tizzoni and his school. 
These observers worked especially with strong toxins, and while Ehrlich 
showed that immunity is exclusively transmitted through the maternal 
tissues, the Italians claim to have demonstrated that the transmission 
may also be through the spermatic fluid. Maternal transmission is 
hardly inheritance, since the foetus is nourished by the blood and fluids 
of the mother; it is rather intra-uterine protection. Ehrlich has also 
shown that an immunity may be acquired through the milk of protected 
animals, so that sucklings may drink to their own protection at their 
mothers' breasts. Needless to say the action of the milk is specific. 
The importance of these observations, both as concerns the individual 
and society at large, will be readily seen. The results of Tizzoni and 
Cattani have not yet been confirmed, and on the other hand have been 
negatived by other observers, so that at present we may doubt the pos- 
sibility of the germinal transmission. As in extra-uterine life immu- 
nity may be acquired through recovery from an infective process, so 
also the embryo or foetus may gain protection after a successful strug- 
gle with a disease contracted in utero. In most cases, however, this 
protection is called into existence, or increased through the protective 
and curative substances developed in the mother. Amongst human be- 
ings an artificial specific immunity may be transmitted to the foetus for 
small-pox and syphilis, which may be due either to a simple transmission 
of the maternal immunity, brought about through the protective circu- 
lation, or may be due to the fact that concurrently with the pregnant 
mother, the foetus, sharing her blood, was impregnated with the anti- 
dotal substances introduced into or developed in the mother. The 
mechanism of immunity conferred by inheritance is as yet in obscurity. 
Indeed the mechanism of immunity, whether acquired or natural, spe- 
cific or general, is still hidden from us; and we cannot as yet lift the veil 
which is interposed between us and the facts. We cannot enter into all THE GENERAL PATHOLOGY OF INFECT/ON 
579 
the seductive hypotheses to which scientific enthusiasm gives expression: 
" from enthusiasm to imposture the path is perilous and slippery." We 
must therefore receive the discoveries of the day with the open and im- 
partial mind of the historian, trusting that the future, perhaps the near 
future, will arrange them in their proper order and proportions, so that 
retrospectively we may learn their lesson. At present the thinker stands 
bewildered before the problem of immunity; and when two recent 
writers (Freund and Grosz) assert that a close relation appears to exist 
between the process of coagulation and serum immunisation, we may 
remember that we are equally ignorant of the inner working of either 
process. It is because of these limitations of our understanding that I 
have passed over numberless observations, such as local immunity, or 
the production of immunity by bacteria or chemical substances not 
specifically related to the disease in question. Yet the recent past has 
revealed so many marvellous facts unto us that we may confidently 
look to the future for more light. 
Serum Therapeutics 
If any arguments be needed to justify those high aims of the patholo- 
gist or bacteriologist which are attained through the sacrifice of animal life 
in carefully devised experiments, we may point with pride to the number 
of lives saved by means of the treatment with curative serum; this treat- 
ment, great even in its present success, and based on sound experience 
and observation, invites us to expect more success in the future than the 
past has already given us. The principles of the new therapeutic method 
have been fully discussed in the previous pages. It is founded on the 
generally established fact that susceptible animals, adequately protected 
so as to reach the highest possible degree of immunity from infections 
with pathogenetic bacteria or from intoxications with their chemical 
products, are capable of supplying a serum which, injected into other 
susceptible animals, will protect them also against like infections or in- 
toxications ; and, even when injected after the earlier symptoms of the 
infection or intoxication have appeared, may determine the cure of the 
diseased animals. Obviously it requires larger doses to remove a lesion 
than to prevent an infection or intoxication. Experimental work has 
further shown that the serum of one animal will display this specific 
activity in animals belonging to widely different species. The practical 
and clinical application of these laboratory observations has opened up a 
new method of treating bacterial and toxic lesions, which consists in the 
injection of curative substances obtained from the blood of highly pro- 
tected animals into the diseased individuals; and since these substances 
are contained in the serum, this therapeutic method is called the " serum 
treatment." These specific substances may be kept in a stable and durable 
form, either in the form of liquid serum, or in the dried state after 
desiccating the serum in vacuo; so that they may be used as quantities 
measurable by weight or volume and constant in potency. 580 
SYSTEM OF MEDICINE 
Behring had first shown that, as far as animals are concerned, this 
method is followed by successful results in tetanus, diphtheria, and the 
various streptococcus infections. Now these lesions differ greatly in 
principle: tetanus is an acute intoxicative process of the most rapid de- 
velopment ; diphtheria resembles it, but is less rapid; the streptococcus 
infections are less intoxicative, and in their severity depend chiefly on the 
distribution and growth of the micro-organisms themselves: these also have 
a marked tendency to infect the blood and the tissues generally, while the 
tetanus bacilli always, and diphtheria bacilli generally remain at the seat 
of inoculation, multiplying to a limited extent and manufacturing their 
more active poisons. Thus we have learned that a curative serum may be 
prepared for intoxicative as well as for infective lesions of bacterial origin. 
The next step was Ehrlich's discovery that Behring's principle may be 
employed also in the treatment and protection of animals against poisoning 
with vegetable toxalbumins, such as abrin and ricin. The field and scope 
of the serum treatment thus at once became, fundamentally at least, 
much wider and more promising. How far-reaching are these earlier 
observations we have now realised on Calmette's demonstration that it is 
possible to render animals proof against snake venoms, and to obtain from 
these animals a serum, capable of protecting other, even highly susceptible 
animals, against the poison; and powerful enough to save them even 
when the first symptoms have already appeared. These toxic bodies are 
not of bacterial origin, but they bear close resemblance to the mycotic 
poisons. Attempts to prepare a serum antagonistic to the recognised 
chemical poisons, inorganic, organic, or alkaloidal in nature, have utterly 
failed, so that there is a near limit to the scope of the serum treatment, even 
in the laboratory; it seems that only certain substances of distinctive 
chemico-physiological action are capable of producing the kind of reaction 
in the animal body which results in the formation of antitoxic substances. 
We have some grounds for suspecting a correlation between chemical con- 
stitution and physiological action in other branches of therapeutics and 
pharmacology; and some such principle, at present obscure, may underlie 
both the changes produced in the animal organism when protected against 
so-called toxalbumins and enzymes, and those which happen in the case 
of the alkaloids which are bodies of entirely different chemical structure. 
The curative value of a serum varies directly as its protective power, 
so that to obtain an active serum the animal must be endowed with the 
highest possible degree of immunity. Since in every animal, according 
to its size and susceptibility, there is a limit beyond which its immunity 
cannot be pushed, the larger animals, such as horses, must be used for 
the purpose of obtaining a curative serum. These must be treated by 
methods which will result in the shortest possible time in the strongest 
resistance obtainable without damage to their tissues. 
Broadly speaking, there are two methods by which the animals may 
be prepared. Firstly, they may be inoculated with gradually increasing 
doses of the toxins; secondly, they may be treated with the living or dead 
bodies of the bacteria, also injected in gradually increasing quantities. THE GENERAL PATHOLOGY OF LNFECTLON 
581 
The increase must be gradual, because the animal acquires resistance 
gradually, and our aim must be to get as near as possible to the maximum 
immunity, and then to keep it at this level. If from time to time we 
remove blood from the animal under preparation, we shall find its serum 
gradually increasing in protective power. Behring and Ehrlich have 
suggested the following as a standard of value. In the case of anti- 
diphtheritic serum, a serum 04 c.c. of which when mixed in a test-tube 
with ten times the fatal dose of diphtheria toxin is capable of rendering 
the latter harmless to a guinea-pig weighing about 300 grammes, is taken 
as the standard, and is called " normal serum." 1 c.c. of such serum is 
the protective unit, so that, for instance, a serum of which 0-01 c.c. suf- 
fices for complete protection possesses ten units. Roux's standard differs 
from that of the Germans. His constant is a toxin solution of which 
04 c.c. kills a guinea-pig weighing 500 grammes in 48 hours. If 1 c.c. 
of this toxic solution be rendered harmless by 0-05 c.c. of serum, then 
evidently 1 c.c. of serum is capable of protecting 100,000 grammes of 
guinea-pig against 04 c.c. of toxin; hence the protective value of such 
serum is 100,000. By his method of protection, which consists essentially 
in injecting toxins, Behring has succeeded in obtaining an anti-diphthe- 
ritic serum of 600-1500 units. During the artificial protection of animals 
it is regularly found that each injection is followed by a marked reaction, 
during which the temperature rises, the weight falls, and the animal is 
ill. During this period of reaction the immunity, and therefore also 
the protective value of the serum, is considerably lowered; but when the 
animal has recovered both are considerably raised. Hence the protective 
inoculations should not be made during these periods of reaction, nor 
should the blood of the animal be taken for therapeutic purposes until 
it is well and sound again. While administering diphtheria toxins to 
horses it has frequently been found that at first the antitoxic value steadily 
ascends, but that when large doses of toxins have been reached this value 
decreases. This would seem to show that in the eagerness of obtaining 
a potent serum the protective substances stored up in the animal organ- 
ism have been overtaxed; or, to express it in other words, the animal 
having been brought to the limit of its immunity, inordinate demands 
have been made on its own antitoxic substances by injecting enormous 
doses of fresh toxin, in the hope of raising its immunity indefinitely. 
There is, however, a point beyond which we cannot go. 
Dr. Klein established an important fact when he showed that an 
anti-diphtheritic serum, obtained after toxin injections, attains to a high 
degree of antitoxic potency, but to a lower degree of protective potency 
than a serum obtained after injections of living cultures. Further, he 
showed that by administration of living cultures the same degree of 
protective power is acquired by horse's serum in a considerably shorter 
space of time than after repeated toxin inoculations. It follows that for 
the preparation of the most useful serum the injection of toxin in in- 
creasing doses should be combined with inoculations of living bacteria; 
for in this way a serum possessed both of highly antitoxic and preventive 582 
SYSTEM OF MEDICINE 
virtues might be obtained. In disease as it appears in man, we have 
to deal both with the poison already produced and with the bacteria 
capable of producing more; it must be our aim, therefore, to attack the 
sources of disease on all sides, at any rate in such lesions as diphtheria 
where the bacilli, although they are generally localised in the membranes, 
are nevertheless extremely numerous; in the case of tetanus and d fortiori 
in snake poisoning we require merely a highly antitoxic value. 
If now we shortly review the scope of the serum treatment, we find 
(1) that every infection requires for its prevention and cure a specially and 
apparently a specifically prepared serum. We have already referred to 
the attempt made by Calmette to shake this law, perhaps too exclusively 
conceived by Behring, and we have seen that, so far as bacterial diseases 
are concerned, the law still holds good. In fact, from a practical point of 
view, this very specificity of the curative serum must limit its application. 
Thus Pfeiffer has shown that although the various vibrios obtained from 
choleraic dejecta are closely allied, and morphologically and biologically 
frequently inseparable, yet each special form of vibrio has its own anti- 
choleraic serum; a protective serum prepared against one variety is not 
necessarily antidotal to another. In cholera the clinical lesions are uni- 
form and characteristic, but they may be caused by several closely allied 
forms of vibrio. Accordingly, we find that it is not possible, in the labora- 
tory at any rate, to obtain a universal anti-choleraic serum. Again, both 
staphylococci and streptococci produce suppuration, septicaemia, erysipe- 
las and pyaemia; and although with our clinical imperfections we are 
unable to detect essential differences, or any at all, between processes 
associated with one or other group of cocci, yet a serum antagonistic 
to an infection by one is useless against infections by the others. It 
seems, then, that in the treatment of infective diseases by this new 
method conditions seem most favourable in those specific cases - such 
as tetanus, diphtheria, enteric fever - which, in their uncomplicated 
form, are due to a single organism. In other cases, such as cholera, 
suppuration, and septicsemic lesions, obvious difficulties must arise in 
the uncertainty and diversity of the bacteria flora. 
(2) Specific curative effects cannot be attained by means of blood of 
refractory animals in their normal state, that is, not specifically pro- 
tected. In this direction laboratory experiments have invariably led 
to failure. Richet and Hericourt, and others, claimed to have dis- 
covered powers curative of tuberculosis in the serum of goats, sheep, 
and dogs, animals almost absolutely refractory to this microbe. Ex- 
perimentally, however, the blood of these animals has been shown by 
Bouchard and others to be devoid of protective power, and it follows 
therefrom that it is devoid of curative power. 
(3) Since the action of the curative serum is specific, we cannot 
expect it also to counteract any secondary infections by other organ- 
isms. Thus, in diphtheria, complications due to the interference of 
pyogenetic cocci, especially streptococci, are not infrequent; against these 
the anti-diphtheritic serum is powerless; it can counteract the effects THE GENERAL PATHOLOGY OF LNFECTLON 
583 
of diphtheria bacilli and their toxins, but of these only. The secondary 
infections must be dealt with by other means, it may be by injections 
of serums specially prepared for these cocci, it may be by vigorous 
means of general disinfection. 
(4) In all cases an adequate dose of antitoxin serum is to be admin- 
istered. Now, as the dose of toxin present in a patient, and the number 
of bacteria settled in his tissues cannot be estimated, it is of importance 
not to use too little of the antidote, and rather to force the treatment 
than to remain more or less expectant. Both in the case of tetanus and 
diphtheria copious dosage at frequent intervals has led to the best results. 
Of course in cases of slight severity less serum and a less energetic 
treatment is required than in graver cases. Many failures in the treat- 
ment of diphtheria have undoubtedly been due to inadequate dosage. 
(5) By the researches of Calmette, mentioned above, the scope of the 
serum treatment has been considerably enlarged. Having succeeded in 
rendering animals so firmly resistant against snake poison as to obtain 
a highly antitoxic serum from them, he further showed that the serum 
active against the venom of one serpent is also potent against that of 
another. Herein he has been confirmed by Professor Fraser of Edin- 
burgh and others. The future must show how far these observations 
are applicable outside the precincts of the laboratory. 
(6) The antitoxic treatment has hitherto been tried in man in several 
diseases, and a short summary of results may be acceptable at this point. 
Its success is so undoubted in diphtheria as to silence all opposition, 
and to lead us to hope for better and better results. It is a specific 
remedy, and it surpasses any other which has ever been employed for 
the treatment of this disease. 
The anti-tetanic serum has, unfortunately, been less successful; chiefly 
because of the extraordinary severity of the disease against which it is 
employed. In acute cases with a short incubation period and a rapid 
onset of spasms it has so far been useless; but chronic cases with a long 
incubation period and a slow onset of spasms seem to be benefited \yide 
art. il Tetanus"]. These latter cases, however, frequently do well under 
other methods of treatment. Again, under ordinary circumstances treat- 
ment is begun too late, and the prospect of success is therefore not very 
hopeful in any really serious case. 
Attempts have been made to cure pneumonia, erysipelas, puerperal 
fever, pneumococcus meningitis, typhoid fever, and also cholera in the 
human subject by means of injections of a specific serum. The facts 
which we possess as yet are too meagre for discussion; yet so much 
has already been achieved by careful observation in the laboratory that 
further triumphs may be confidently anticipated. Success, however, can- 
not be forced: one serum after another has been vaunted as a curative 
agent in tuberculosis; the dog, the goat, and the ass have had false pre- 
tensions thrust upon them; and recently Maragliano has come forward 
with an anti-tuberculous serum, which, however, is evidently not a true 
antitoxic or immunity-conferring serum: it seems rather to act as a 584 
SYSTEM OF MEDICINE 
modified tuberculin, raising the temperature considerably on injection, 
and producing other physiological changes as a rule not observed with 
protective serums. Moreover, Maragliano's observations are not based 
on sound experiments; he fails, at any rate, to record any successful 
preventive inoculation of susceptible animals. Our great difficulties in 
tuberculosis are the protection of the individual from secondary infections, 
and the removal of the latter when they have once made their appearance. 
In conclusion a few words must be said on the dosage and adminis- 
tration of curative serum. Carefully prepared and preserved it is harm- 
less ; and local inflammation or suppuration, if they appear, are generally 
due to a contamination of the serum during its use, or to want of asepsis 
in the injection of it into the tissues. Cleanliness is an imperative 
necessity, although local infections are excessively rare. The serum 
may be obtained either in a liquid or dried state; in the latter case a 
certain weight of it must be carefully suspended and ground up in sterile 
water, or saline solution, or sterile camphor, or thymol water. The dried 
serum will dissolve only in part: after shaking it vigorously it is allowed 
to stand, in order to allow the insoluble matter to fall down. The water 
extracts the active principles and holds them in solution. The skin at 
the seat of injection must be carefully washed and cleansed with anti- 
septic lotion, and the syringe boiled before use; a proper instrument 
which can be readily sterilised must be chosen. 
The injections should be made into the subcutaneous tissues of the 
flanks or buttocks, and as soon as possible; a day's, nay a few hours' 
delay may mean the patient's death: the prompter the treatment the 
greater the chances of success. The quantity of serum to be used, as 
already explained, varies with each case, with the strength of the serum 
and the age and weight of the patient; but as a rule in a severe case it 
is advisable to administer the antitoxin boldly. If, as in the case of 
tetanus, large doses (up to 100 c.c.) have to be injected, the quantity must, 
of course, be distributed over different places; more than 25 c.c. should 
never be injected at any one spot. After use the syringe and needle 
must again be thoroughly cleaned, first with sterile water, then with 
alcohol, and lastly with ether. 
Although we possess in the antitoxin a remarkable therapeutic agent, 
we must not in our enthusiasm forget older established methods. Thus 
in the case of diphtheria local antiseptics and tonics should be employed 
as far as possible; in the case of tetanus physostigmin and other drugs, 
and operative treatment must not be neglected. There is no reason why 
we should disregard measures of a useful kind which may hasten recovery 
by removing the source of infection. 
Rashes occasionally occur after the administration of serum, generally 
of erythematous or urticarial character; they appear either around the 
seat of injection, or they may affect the whole body, or certain areas of 
it, especially the extensor surfaces of the limbs. These eruptions are 
produced by substances in the serum other than the specific antitoxic 
substances, since they may occur on injecting normal horse's serum ; THE GENERAL PATHOLOGY OF INFECTION 
585 
undoubtedly in time they may be eliminated, indeed it appears that on 
using dried serum they are less frequent. 
Joint-pains are also said to occur occasionally; there may be redness 
around the articulation, and even effusion into the synovial cavity, the 
hips, ankles, and wrists being most frequently affected. No ill result 
of these complications has ever been recorded, but they retard recovery; 
it must be our aim, therefore, to obtain a serum free from such contami- 
nation. Serious harm, such as nephritis or suppression of the urine, 
never results, - although statements have been made to the contrary. 
Dr. Caiger speaks emphatically on this point, and we may take it for 
granted that, given a pure serum-supply, care in administration, and 
responsible circumspection, all serious complications can be avoided. 
It has already been mentioned that the protective value of curative 
serum, at least so far as our laboratory animals are concerned, is very 
high, even although the immunity produced is 'only temporary. Fre- 
quent proposals have been made by Behring, Roux, Vaillard, and others, 
to use the antitoxin for purposes of prevention in the case of diphtheria 
and tetanus; so far, however, this suggestion has not had the recogni- 
tion it undoubtedly deserves. Behring, in fact, expects that "by the 
combination of prophylactic and actual treatment with antitoxic serum, 
we piust eventually succeed in abolishing diphtheria and in confining it 
to the pages of history." In local epidemics of diphtheria serum pro- 
tection might be practised; and, although tetanus is a rare disease, pro- 
tective injections are also advisable in cases of wounds contaminated 
with sand, earth, or dust: prevention is frequently easy ; cure may be 
impossible. It is fair to add, however, that the protective value of the anti- 
diphtheritic serum, in man at any rate, does not seem to be considerable. 
A. A. Kanthack. 
Text-Books: - 1. Flugge. Die Mikro-organismen. Leipzig, 1886. - 2. De Baby. 
Morphologic und Physiologie der Pilze. Leipzig, 1866.-3. De Baby. Vorgleichencle 
Morphologie u. Biologie der Pilze, Mycetozoen u. Bacterien. Leipzig, 1884. -4. Nageli. 
Untersuchungen iiber niedere Pilze. Miinchen, 1882.-5. Nageli. Die niederen Pilze. 
Miiuchen, 1877. - 6. Sternberg. Manual of Bacteriology. New York, 1892.-7. 
Huppe. N aturwissenschaftliche Einf 'uhrung in die Bakteriologie. Wiesbaden, 1895. 
- 8. Jorgensen. Micro-organisms in Fermentation. Transl. by A. K. Miller and 
A. E. Lennholm. London, 1893. Variability of Micro-organisms:-9. Adami. 
Medical Chronicle, Sept. 1892.-10. D. D. Cunningham. Scient. Memoirs by Med. 
Officers of Army in India, Part viii. 1894. Thermophile Micro-organisms: -11. 
Mac fad yen. jBriiisA Medical Journal, 1894, vol. ii. Action of Sunlight on Bac- 
teria:-12. P. and G. C. Frankland. Micro-organisms in Water, 332-393, where 
an exhaustive bibliography will be found. London, 1894. Bacteriological Chem- 
istry:-13. Neumeister. Lehrbuch der Physiologischen Chemie. Jena, 1893.-14. 
Brieger. Ueber Ptomaine. Berlin, 1885. -15. Vaughan and Novy. Ptomainesand 
Leucomaines. Philadelphia, 1891. -16. Sidney Martin. Annual Beports of Local 
Gov. Board. Supplement, 1889, 1890, 1891, 1892.-17. Brieger and Frankel. 
Berliner klin. Wochenschr. 1890, p. 1133.-18. Hankin. Brit. Med. Journ. 1889, 
p. 810. -19. Uschinski. Centralb. f. B. u. P. xiv. 10, and Buchner, Milnch. med. 
Wochenschr. 1893, Nos. 24 and 25. - 20. Wesbrook. Ann. de V Inst. Pasteur, 1894, 
p. 138. - 21. A. A. Kanthack and Wesbrook. Brit. Med. Journal, Sept. 9, 1893.-22. 
Klein. " On the Antagonisms of Microbes," Annual Rep. Local Gov. Board. Supple- 
ment, 1892-1893.- 23. Nencki. Ber. d. Deutsch, chem. Gesellsch. vol. xvii. 1884, 
REFERENCES 586 
SYSTEM OF MEDICINE 
p. 2605. - 24. Winogradski. Ann. de I' Inst. Pasteur, 1890.-25. Frankland. Phil. 
Trans, clxxxi. p. 107. -26. Warington. J. of Chern. Soc. 1891, and Chern. News, 
Ixi. 1890.-27. Brunton and Macfadyen. Roy. Soc. Proc. vol. xlvi. p. 542. 
Infection, Contagion, and Predisposition: - 28. Wolters. Centrabl. f. B. u. P. xiii. 
14, 15.-29. Roger. Rev. de med. 1891, p. 169 and p. 500. - 30. Blagovest- 
schewski. Ann. de V Inst. Pasteur, 1890, ii. p. 689. - 31. Sander. Archiv f. 
Hygiene, xvi. No. 3, p. 238. - 32. Canalis and Morpurgo. Fortschr. d. Med. 1890, 
18 and 19. - 33. Sacchi. Centralb. f. B. u. P. 1892, xi. 21. - 34. Pernice and 
Alessi. La Rif. med. 1891, p. 220. - 35. Charrin and Roger. La Semaine med. 
1890, No. 4. - 36. Leo. Zeitschr. f. Hygiene, viL 2. - 37. Fermi and Salsano. 
Centralb. f. B. u. P. xii. 21.-38. Oemler. Arch. f. wissensch. u. prakt. Thierheil- 
kunde, 1877, iii. 4. - 39. Foa and Scabia. Gaz. med. di Torino, 1892, 13, 14, 15.- 
40. Vaillard and Vincent. Ann. de V Inst. Pasteur, 1891. - 41. Bujwid. Centralb. 
f. B. u. P. iv. 19.-42. Klein and Coxwell. Ibidem, xi. 15. - 43. Tizzoni and 
Cattani. Centralb. f. B. u. P. xi. 11.-44. A. A. Kanthack. Centralb. f. B. u. P. 
xii. 7, 8. - 45. Dina Sandberg. Zeitsch. f. Hygiene, ix. p. 376.-46. Bollinger. 
"Ueber Schwindsuchtssterblichkeit," Miinch. med. Wochensch. 1895, 1 and 2.-47. 
Rosenblatt. "Die Lungenkrankheiten in der Schweiz," Deutsche Vierteljahresbr. f. 
bffentliche Gesundheitspflegej xxvi. 1894, 2. p. 292.-48. Baumgarten. Deutsche med. 
Wochenschr. 1891, No. 42. Festnummer, p. 1168; Arbeiten a. d. path. Inst. Tubingen, 
vol. i. 1892, 2. p. 322.-49. Hansen and Looft. Leprosy. Trans, by Norman Walker, 
Bristol, 1895. -50. Mafucci. Centralb. f. B. u. P. v. 7; Rif. med. 1889, 209 and 213; 
Giornale di Anat. Fisiol. e Patologia degli Animali, 1889, fasc. ii. - 51. Gaertner. 
Zeitschr. f. Hygiene, xiii. 1893, p. 101. 
Immunity: - Besides the larger text-books the following special papers may be con- 
sulted: - 52. Metschnikoff's articles in Virchow's Archiv, and in the Ann. de I' Inst. 
Pasteur.-53. Buchner. Numerous articles in the Centralb. f. Bakt., the Archiv f. 
Hygiene, and an important paper in the Miinch. med. Wochensch. 1893, Nos. 24 and 25. 
- 54. Fodor, Deutsche med. Wochensch. 1887, No. 34; Nuttall, Zeitschr. f. Hyg. iv. 
1888, p. 353; Nissen, Zeitschr. f. Hyg. vi. 1889, p. 487. - 55. Behring. Blutserum- 
therapie, i. and ii., Leipzig, 1892; and numerous articles by him and his -pupils in the 
Deutsche med. Wochensch. 1890-1895; and also in the Zeitschr f. Hyg. 1890-1895. - 
56. Ehrlich. Deutsche med. Wochensch. 1891,32 and 34. - 57. Lubarsch. Unter- 
suchungen ii. d. Ursachen der angeborenen und erworbenen Immunitat, 1891; Ueber Im- 
munitat und Schutzimpfung, 1892; also Centralb. f. Bakt. vi. 1889, Nos. 18-20. - 58. 
Bouchard, Les microbespathogenes, 1892; Virchow's Festschrift, 1891. -59. Calmette. 
Ann. de I' Inst. Pasteur, 1894, No. 5, and 1895, No. 4. - 60. Frankel. Schutzimpfung 
und Impfschutz. Marburg, 1895. Further references relating to Phagocytosis and 
Immunity will be found under " Inflammation." 
Serum Therapeutics: - 61. Behring. Blutserumtherapie, i. and ii. Leipzig, 1892.- 
62. Behring. Deutsche med. Wochenschr. 1895, No. 38. - 63. Behring. Bekdmpfung 
der Infectionskrankheiten. Leipzig, 1894. - 64. British Medical Journal, 1895, Aug. 17, 
24, 31.-65. W. H. Welch, "Treatment of Diphtheria by Antitoxin," Trans. Ass. of 
American Physicians, vol. x. 1895.-66. B. Hunt. "The so-called Antitoxic Treat- 
ment of Infective Disease," Trans. Path. Soc. 1894, p. 266. 
A. A. K. 
SEPTICAEMIA AND PYEMIA 
Introduction. - Under this general heading are usually included three 
constitutional affections which, both pathologically and etiologically, are 
quite distinct. Speaking broadly, it may be said that they are due to 
the entrance into the general system either of micro-organisms or of their 
products ; and as a rule they are met with in connection with some wound 
or breach of surface, the discharges from which have become contami- 
nated with bacteria. Three different results may follow the entrance of 
bacteria into a wound, and it is not uncommon to find two or more of SEPTICEMIA AND PYEMIA 
587 
them in combination; indeed, in the great majority of cases the condi- 
tion of sapraemia accompanies that of septicaemia or pyaemia. 
The first of these affections is sapraemia, which is also spoken of as 
septic or putrid poisoning or intoxication. Sapraemia is a general con- 
stitutional disorder exclusively due to chemical poisoning by the products 
of bacteria, and not to the entrance of the bacteria themselves into the 
blood. The poison so introduced cannot increase in the system except 
by the absorption of fresh doses; and the blood of an animal that has 
died of the disease only contains a diluted solution of the amount of 
poison it had received, so that small quantities of this blood, when in- 
jected into another animal equally susceptible, will not set up symptoms 
of poisoning. Hence the disease is in no sense an infective one; more- 
over the poison absorbed is being so constantly and rapidly eliminated 
from the system that, provided the dose already taken up be not a fatal 
one and that all further supplies are stopped, the disease will of itself 
come to a spontaneous and favourable termination. 
The second form of septic disease, septicaemia, or septic infection, is a 
disorder caused not only by the absorption of poisons from a wound, but 
also by the entrance of living micro-organisms into the body and their 
growth and multiplication therein. Although in this case, as in sapraemia, 
it is probable that the constitutional effects are due solely to the chemical 
poisons produced by the organisms, and not to the presence of the organ- 
isms themselves in the blood stream, yet there is this cardinal difference, 
that in septicaemia the poison is being continually produced inside the 
body ; whereas in sapraemia the poison is produced in the wound - that 
is to say, outside the body - and is absorbed from that part. Hence 
it generally happens in the case of septicaemia - in contra-distinction 
to sapraemia-that, if the disease be firmly established, it cannot be 
moderated by the removal of the original source of infection. 
Thirdly, we have to consider pyaemia, an acute, general, infective 
disease, due to the entrance of living pyogenetic micro-organisms into 
the blood, and especially characterised by the formation of abscesses in 
various organs and parts of the body. Here we have not only poisoning 
of the body with the products of micro-organisms which have already 
established themselves in the living body, but we have in addition the 
occurrence of septic emboli, either the result of suppurative phlebitis or 
thrombosis, or formed in other ways which will be afterwards discussed; 
these give rise to the abscesses characteristic of the disease. 
By some authors a second form of pyaemia is spoken of under the 
term Chronic Pyaemia. This is a disease which arises also in connection 
with wounds, which is caused by pyogenetic organisms, and, like pyaemia 
proper, is characterised by the formation of local abscesses in various parts 
of the body. These abscesses, however, are fewer in number than in true 
pyaemia; they chiefly occur in subcutaneous tissues or joints, and appar- 
ently they are not due to embolism. For my own part, I prefer to designate 
this disease by the name " Multiple Abscesses; " for, except that it is due 
to pyogenetic organisms, it differs widely from pyaemia in its pathology, 
and should not, in my opinion, be described as a variety of this disease. 588 
SYSTEM OF MEDICINE 
So much for definition; but, while for this purpose they are described 
as quite distinct from each other, it must be confessed that in practice it 
is not always easy-even at the post-mortem table-to assign definitely 
its exact part to each of the three forms in the production of symptoms; 
for, as I have said, two or more of them very often concur. The sharp 
separation between the three forms depends more on the results of the 
experiments on animals than on clinical observation; it may be interest- 
ing, therefore, to refer shortly to the experiments which have established 
the pathology of these affections. 
Saprcemia.-At the beginning of this century Albert von Haller, 
Gaspard and many others, injected infusions of putrefying meat and other 
putrid animal fluids into animals, and observed the poisonous effects. 
They did not, however, attempt to determine the particular constituents 
on which these effects depended, and Panum was really the first who 
thoroughly studied this side of the subject. He showed that the poison- 
ous properties of putrid solutions were unaltered by boiling, which would 
of course destroy all living elements; further, he found that the poison 
was in solution in the material, and he was able to separate substances in 
the form of a powder from putrefying materials which produced all the 
symptoms that occurred when the raw material was employed. This 
was done in the first place by filtering the fluid, and then adding abso- 
lute alcohol until a precipitate was obtained. This precipitate was 
collected and further purified by repeatedly dissolving it in distilled 
water and reprecipitating it. Finally it was dried at a temperature of 
100° Centigrade. Even this treatment by alcohol, heat and drying did 
not destroy the poisonous products, 0-012 grammes of the powder so 
prepared being sufficient to kill a large dog. 
Selmi attempted to carry the investigation further in order to deter- 
mine the nature of the substances present in this powder; and he de- 
scribed a number of different substances, or more probably groups of 
substances, which he had isolated from putrefying animal tissues. To 
these substances, some of which were harmless and some intensely poi- 
sonous, he gave the name of animal alkaloids or ptomaines, these sub- 
stances being transition products formed by the breaking up of the highly 
complex organic molecule on its way to form simple inorganic substances. 
Brieger has also thoroughly investigated this subject, and has isolated 
and named a number of these ptomaines, such as putrescine, cadaverine, 
neurine, etc. The organisms which produce these substances are not as a 
rule pathogenetic, that is to say, they are not as a rule able to live in the 
animal body. In cases in the lower animals (and also in man) where this 
intense poisoning has resulted, the organisms are not necessarily present 
in the blood during life, unless, indeed, the condition of sapraemia be 
complicated with some infective condition such as septicaemia. 
When a quantity of putrefying material is injected into an animal 
- say a dog - in sufficient quantities to kill the animal, the most 
prominent symptoms are fever, vomiting, and diarrhoea: great restless- 
ness and muscular twitchings may occur at first, but are soon followed SEPTICEMIA AND PYEMIA 
589 
by loss of muscular power; the diarrhoea becomes profuse, serous, and 
frequently blood-stained, and is accompanied by much pain and tenes- 
mus ; the temperature falls, and usually becomes subnormal; the respi- 
ratory movements become very feeble; the pupils are dilated; there is 
marked cyanosis, and death ensues, apparently from cardiac failure. A 
fatal result usually takes place within twenty-four hours, depending 
directly on the dose injected and on the size and susceptibility of the 
animal. Koch describes the symptoms in mice as follows : - " The 
animal becomes restless, running about constantly, but showing great 
weakness and uncertainty in all its movements. It refuses food, respi- 
ration becomes irregular and slow, and death takes place in four to 
eight hours." When a smaller dose is employed the effects are similar 
but less severe, and the animal after a few hours rapidly recovers. 
On post-mortem examination in these fatal cases we find no very 
prominent characteristics. Rigor mortis is transient and slightly marked; 
decomposition sets in early; there is no inflammation of the tissues in 
the neighbourhood of the site of injection. The chief changes occur in 
the blood, which is dark in colour, coagulates slightly and very imper- 
fectly, and stains the lining wall of the veins and endocardium. Occa- 
sionally serous effusions are met with in some of the serous cavities, and 
these are also blood stained. Small, dark extravasations of blood are 
also commonly seen beneath the skin and serous membranes, and occa- 
sionally elsewhere throughout the body; the spleen is greatly swollen, 
often pulpy and dark, from engorgement with blood; there may be 
signs of severe gastro-enteritis with intense inflammation of the mucous 
membrane of the stomach and intestines, and with partial or almost 
complete desquamation of the epithelial lining (Burdon-Sanderson). 
Microscopical examination of the blood shows that the red corpuscles 
tend to form clumps instead of the usual rouleaux; it is found also that 
the staining of the vessel walls depends partly, at least, on the fact that 
many of the red corpuscles are disintegrated, and their liberated hgemo- 
globin is contained in solution in the blood plasma. 
Septiccemia. - Koch, in confirmation of Panum's experiments, found 
that if a considerable quantity of putrefying blood were injected into 
animals, poisoning of the animals advancing to a fatal result was 
brought about; the blood of the animals so killed did not contain any 
bacteria, and was not capable of transmitting the disease. He further 
found that the rapidity and severity of the result were proportionate to 
the amount of putrid material injected; but when small quantities (one 
or two minims) of putrid blood were injected into mice, although no 
immediate symptoms were produced, yet in about one-third of the cases 
evidence of disease appeared within twenty-four hours, and if so a fatal 
result usually ensued. The same events also took place where much 
smaller doses were employed, but in this case the proportion of animals 
affected was still less. 
The symptoms so set up were as follows: - After about twenty-four 
hours greatly increased conjunctival secretion came on which appeared to 590 
SYSTEM OF MEDICINE 
glaze the eye, and ultimately glued the lids together; the animal soon 
ceased to eat, appeared overcome with lassitude, and moved but little; 
soon it sat still with its back bent and its legs drawn up; the respi- 
ratory movements were slow and feeble; the weakness increased, and 
death slowly ensued in forty to sixty hours. On post-mortem examina- 
tion there was slight oedema at the site of the injection; the spleen was 
considerably enlarged, but no other marked changes were found except 
in the blood. Under a high power of the microscope numerous extremely 
minute bacilli were found in the blood, some free, others filling up the 
white corpuscles. The minutest quantity of this blood inoculated into 
a healthy mouse led to the disease, which was therefore a true infective 
one. Koch was subsequently able to cultivate these organisms, and the 
disease resulted from the inoculation of the cultivated organisms in the 
same way as from the inoculation of the blood. 
Since this time a number of organisms have been found which pro- 
duce similar symptoms in various classes of the lower animals; thus, in 
the case of rabbits, at least three different kinds of organisms set up 
these symptoms. This disease in the lower animals is spoken of as sep- 
ticaemia, and is looked upon as the counterpart of septicaemia in man; 
but, in human septicaemia, as will be presently pointed out, organisms 
cannot be demonstrated in the blood in numbers at all comparable to 
those in the lower animals, or indeed in sufficient numbers to account 
for the disease, supposing it to be a simple blood infection. 
Pyaemia. - In the course of Koch's researches on mice and rabbits he 
came across an organism which produced the condition comparable in 
these animals to pyaemia in man; and he found that this condition was 
due to the development of micrococci in the blood. It differed from 
human pyaemia in not being associated with thrombosis and embolism 
of portions of the thrombus, but that similar plugs were formed in the 
vessels in another way, which is also of interest in connection with 
human pyaemia wherein it is possible that something similar may take 
place. He found that this organism grew in the blood, and formed col- 
onies in which masses of red blood corpuscles became incorporated; in 
this way emboli were formed which stuck in the smaller vessels. An- 
other way in which a similar result was produced was that the organ- 
isms seemed to attach themselves to the endothelial cells, and, growing 
there, ultimately filled up the lumen of the blood-vessel and formed a 
plug. It is possible that a similar thing may occur in man, more espe- 
cially in connection with the streptococcus pyogenes. Numerous exper- 
iments have also been made to determine the part which embolism plays 
in the production of pyaemia, but I may leave the reference to these 
until we come to speak of the pathology of pyaemia in man. 
The clinical characters of these diseases as met with in practice 
must next be briefly described. 
They may occur in connection with surgical operations, injuries, or 
diseases. Pure acute sapraemia, as above defined, is rarely found in 
surgical practice, and can only occur in the cases of large wounds or SEPTICEMIA AND PYEMIA 
591 
cavities, such as the peritoneum, which are imperfectly drained; but it 
probably is not uncommonly seen in a milder form, and plays a part 
in the traumatic fever which so usually accompanies a septic wound. 
Hectic fever may be either a chronic sapraemia or a chronic septicaemia; 
that is to say, it is a state in which small doses of septic poison are con- 
stantly being absorbed either from the wound or from the tissues in 
which the organisms are situated. Septicaemia may result from wounds 
of any size, even from mere scratches if they happen to be infected with 
the necessary virus of sufficient virulence. Pyaemia may also result 
from wounds of any kind, or from surgical diseases associated with 
suppuration. Usually thrombosis occurs in the veins leading from the 
affected part, and the emboli resulting from the breaking down of the 
thrombus lodge in the first capillaries at which they arrive; conse- 
quently in most cases, where the systemic veins are affected, the lungs 
are the chief, or, it may be, the only part attacked. Pyaemia following 
acute osteo-myelitis is of the same type and due to the same causes; 
and although commonly described as a distinct variety of the disease it 
presents no special characteristics. The same may be said of the rarer 
cases occurring in connection with cellulitis, local abscesses, etc. 
Puerperal fever, again, can no longer be considered as a separate 
disease. The uterus after parturition or abortion presents a large raw 
surface exactly comparable to that of a recent wound; and any of the 
forms of septic disease, or any admixture of them, may arise as the 
result of the retention of decomposing materials in its cavity, or of in- 
fection of the discharges. It may, however, be here noted that in these 
cases there is a special liability to the retention of a large mass of putre- 
fying material in contact with a large absorbing surface, so that pure 
sapraemia is more often found in this than under any other conditions 
\yide art. on "Puerperal Septic Disease"]. 
Ulcerative, infective, or malignant endocarditis may occur in the 
course of an ordinary pyaemia, or may appear to be the starting-point of 
the disorder. In either case the pathological picture is peculiar, in that 
the primary affection occurs, in the great majority of cases, on the left 
side of the heart; thus the emboli given off from it lodge in the systemic 
arteries or capillaries, and lead to a true arterial pyaemia (Wilks). Be- 
yond this, and the fact that the emboli are usually in great abundance, 
and that the lungs are not affected in the first instance, this disease does 
not differ from ordinary pyaemia [yide art. "Infective Endocarditis"]. 
Suppurative Pyle-phlebitis is a true pyaemia, where the original site 
of infection is situated somewhere in the area drained by the portal sys- 
tem of veins. It is then in the radicles of these veins that thrombosis 
occurs; and the resulting emboli will lodge, in the first instance, in the 
portal veins or capillaries of the liver. It may, in short, be accurately 
described as portal pyaemia. A rare form of this disease is occasionally 
seen in the newly born, and is sometimes described as umbilical pyaemia. 
It results from suppurative phlebitis of the unobliterated umbilical vein. 
Idiopathic or spontaneous pyaemia and septicaemia are names applied SYS FEM OF MEDICINE 
592 
to those cases which present the ordinary clinical features and post- 
mortem appearances of this disease, but in which the source of the in- 
fection cannot be discovered. These cases will be further discussed 
later, but it may be here remarked that most of the published cases 
seem to be examples of multiple abscesses rather than of true pyaemia. 
Infective myositis, an exceedingly rare disease characterised by multi- 
ple abscesses in the muscles throughout the body, has also been classed un- 
der pyaemia, but its pathology has not as yet been properly worked out. 
A. Sapr^mia 
Etiology in Man. - The following conditions may be taken as neces- 
sary factors in the production of this disease in man: (1) There must be 
a large mass of dead material, whether injured tissues, blood-clot or dis- 
charge, which is undergoing putrefactive changes; (2) This putrefying 
material must be in contact with a large, rapidly absorbing surface such 
as would be furnished by a fresh wound, a serous surface, and the like; 
(3) Tension in the wound, keeping the discharges under pressure, and 
mechanically aiding their absorption. 
It may also be accepted that the poisons will produce greater effects, 
or, conversely, that a smaller dose will be required, in persons who are 
debilitated, who are at either extreme of life, or in whom the excretory 
functions, which play so important a part in the elimination of the 
poison, are in any way impaired. 
These demands will be satisfied by such conditions as the following: 
After parturition or abortion, portions of placenta, membranes, or blood- 
clot, if retained in the uterus, are very apt to become infected with 
putrefactive organisms and to undergo rapid decomposition. The in- 
terior of the uterus furnishes a large, raw, rapidly absorbing surface, so 
that a large dose of the poison must be absorbed. In many cases, also, 
the patient may be suffering from a certain amount of physical exhaustion 
or mental distress which renders her more susceptible to the poisonous 
influence [yide art. on "Puerperal Septic Disease"]. In surgical practice 
it may be met with after severe injuries, when a large, deep wound con- 
tains gangrenous tissue, blood, or discharges undergoing decomposition; 
also after operations when large cavities are left, as after the removal of 
large tumours, or the serous cavities of the pleura, peritoneum or large 
joints are laid open, and a quantity of decomposing material is pent up in 
an ill-drained cavity. Again, if a large chronic abscess-such as a psoas 
abscess-be imperfectly opened and drained, and putrefactive bacteria 
gain access to it, sapraemia may occur; and when in these instances it 
does occur, the symptoms set in very shortly after the injury - within 
a few hours. 
It has long been known to surgeons, and especially urged by Sir 
Joseph Lister, that absorption does not take place, or at any rate but 
imperfectly, after a wound becomes completely covered with healthy 
granulation tissue; hence it is that the traumatic fever, the result of SEPTICEMIA AND PYEMIA 
593 
septic absorption, conies to an end about the fourth or fifth day. It may 
be said here that cases of saprfiemia at all comparable to those artificially 
produced on animals, or to those occurring in obstetric practice, are rare 
in surgical practice. In a special report on the subject of septic diseases 
to the Pathological Society of London 156 clinical records are published, 
and in 28 of these there were no metastatic abscesses. Of these 28 
only two are considered cases of sapraemia, and even these are not 
beyond suspicion; it may fairly be urged, however, that these statistics 
do not give a complete view of the facts, for in a large proportion (24 
out of the 26 remaining) septic poisoning, which could not be excluded, 
probably played some part in the production of the symptoms and fatal 
result; and, secondly, the statistics deal only with fatal cases, and this 
disease, as is well known, is overcome by proper treatment in a large 
proportion of cases. 
But while acute and pure cases of saprsemia are rare, mild cases 
are commonly seen; it probably plays a great part in the so-called 
traumatic fever, that is, in fever occurring on the second or third day 
after injuries or operations, where sepsis has been allowed to take place 
in a wound. These mild cases are important from another point of 
view; the poisons irritate and set up an unhealthy state of the wound, 
and from their debilitating action on the patient they so lower the 
resisting powers of his tissues as to make him far more susceptible to 
the graver forms of septic infection. 
Sapraemia, again, is not uncommon in operations on the peritoneum; 
and there can be no doubt that a good many of the cases of death from 
exhaustion, and of those cases where there has been fever but no peri- 
tonitis, are really cases of sapraemia due to the introduction of non- 
pathogenetic saprophytic organisms into the peritoneal cavity. Further, 
the poison being a chemical one, it may readily be absorbed from the 
alimentary canal; and it may be remarked that some of the symptoms 
following strangulation of the gut or intestinal obstruction, usually 
ascribed to collapse or recurrent shock, are in all probability due to ab- 
sorption of poisons generated in the intestinal tract above the obstruction. 
Symptoms. - The symptoms begin suddenly, and usually appear 
within twenty-four hours of the time that the discharges from the wound 
were noticed to be putrid. The temperature rises abruptly to 103°, 
104°, or sometimes even higher, being accompanied, but by no means 
invariably, by a rigor. This initial rigor may be very severe, lasting 
half an hour or more, and usually is not repeated; in exceptional cases, 
however, repeated rigors may occur. At the same time the skin be- 
comes hot, dry and flushed, the patient complains of intense headache, 
the tongue becomes coated with white fur, and there is intense thirst. 
Anorexia is complete; vomiting is common, and may be severe even from 
the commencement. Other common febrile symptoms also appear: the 
pulse is rapid and full; the respirations are hurried ; the urine is scanty, 
high-coloured, and deposits urates on cooling. Locally a sufficient cause 
for the above symptoms is usually obvious. The wound may show 
2 Q 
VOL. I 594 
SYSTEM OF MEDICINE 
signs of inflammatory disturbance, or even appear gangrenous; and in 
all cases there is a considerable amount of very foul smelling discharge. 
If the case be a severe one, and treatment not immediately adopted, 
signs of severe prostration rapidly supervene. There is delirium, es- 
pecially at night, at first noisy but soon assuming the low muttering 
type, and becoming almost constant. There is excessive muscular weak- 
ness as evidenced by tremors. The tongue is now dry, brown and very 
tremulous; the mouth and lips are covered with sordes. Diarrhoea 
may come on, and motions and urine be passed unconsciously. The 
skin may be slightly jaundiced and petechiae may appear. The tem- 
perature may fall, even to subnormal; coma comes on and gradually 
deepens into death. Death usually occurs about the second or third day 
of the disease; but in other cases may be postponed for as long as a 
week, the patient passing into a typical "typhoid state," and dying of 
exhaustion. 
In less severe cases, those most commonly seen in surgical practice, 
the symptoms are similar but less marked. Usually improvement fol- 
lows at once when the wound is freely opened, the putrid material 
removed, and free drainage established; but all fever may not cease 
until granulation is complete, and has formed an efficient barrier against 
further absorption. Even in the most severe cases recovery rapidly 
follows removal of the cause. 
A brief abstract of a case quoted by Dr. Matthews Duncan may be 
given here, as it serves well to illustrate some of the more marked features 
of this disease. It is in every respect a pattern case, and indicates the 
happy result that may be anticipated if treatment be properly carried out. 
" A young woman after a natural labour gave birth to her second 
child. For the first week slight bleeding took place, and on the seventh 
day the discharges were noticed to be putrid. The following day, the 
eighth, rigors occurred, and these were repeated daily until the eleventh 
day after delivery. The patient was then noticed to be very pale, fre- 
quently sick, and there was profuse diarrhoea. The uterus was tender, 
the breath sweet, respirations 44, pulse 146, temperature 104-2° F. The 
lochia were copious and stinking. She had been delirious all the pre- 
vious night. Chloroform was administered, and large pieces of decom- 
posing placenta removed from the uterus, which was thoroughly irri- 
gated. The next day the patient had slept well without delirium, pulse 
100, respirations 36, and the highest temperature 101-4°. Recovery 
henceforth was uninterrupted." Dr. Duncan remarks, " In twenty-four- 
hour s the whole aspect of the case changed from despair to hopeful- 
ness. The woman was at the point of death, it was apparently not 
worth disturbing her by treatment, and yet a few hours afterwards she 
was comfortable, and every alarming symptom had gone." Such re- 
covery as this is only seen in these cases of pure sapraemia. 
In the milder cases recovery, when it occurs, is usually rapid and 
complete; but in the more severe cases convalescence may be accom- 
panied by great anaemia due to the destruction of the red corpuscles 
and haemoglobin. SEPTICAEMIA AND PYAEMIA 
595 
Morbid Anatomy. - The appearances found on post-mortem examina- 
tion of these cases are very similiar to those occurring in animals in 
which the disease has been artificially produced. They are somewhat 
indefinite, and present nothing absolutely characteristic. Kigor mortis 
comes on early and soon passes off, being in most cases but slightly 
marked. Decomposition rapidly sets in, and even in cold weather 
putrefaction of the body prevents proper examination; the organs, 
eight or ten hours after death, are diffluent or distended with foetid 
gases. The blood remains fluid for some time, and gravitates, causing 
marked hypostatic congestion. Coagulation occurs but slowly, and the 
clot formed is soft. 
The lining membrane of the vessels and endocardium is blood stained, 
and there may be extravasations of dark blood beneath the skin, pleura, 
pericardium, in the brain, etc. Occasionally the pleura, pericardium, or 
other serous cavities contain a little blood stained fluid. The liver and 
kidneys are usually swollen; occasionally small hsemorrhages are seen in 
them, and microscopically the glandular cells are swollen and cloudy, 
or coarsely granular. The spleen is almost invariably much swollen, 
deeply congested, and occasionally almost diffluent. Various microbes 
which have been found in the tissues are almost certainly of post- 
mortem occurrence, and in a few hours they swarm in the body. 
Diagnosis presents no difficulty in a ordinary case where we have the 
sudden onset of febrile symptoms in connection with an obvious cause. 
It may not at first be possible to say positively which form of septic 
disease is present, but the effect of treatment and the progress of the case 
will decide the question in a few hours. In doubtful cases of sapraemia 
and septicaemia the test of treatment must be relied on to exclude the 
former, the fact of importance being to determine if septicaemia be present. 
It must also be remembered that certain symptoms of " collapse " 
or " shock," on or about the third day after operation, are commonly 
due to sapraemia. It is probable that large numbers of deaths after 
ovariotomy and other operations on the abdomen which have been 
ascribed to shock and exhaustion are really due to sapraemia. 
As to prognosis but little need be added. In simple cases of sap- 
raemia the prospect of recovery is always hopeful if treatment be imme- 
diately adopted, however bad the patient may appear at the time. In 
the old and debilitated, however, the prognosis must be regarded as 
much more serious. Also the risk of other septic troubles arising in 
connection with the same cause must be borne in mind, and this cannot 
be dismissed entirely until granulation is established. 
Finally it may be said that recovery, when it occurs, is not only 
rapid but complete. 
Treatment is mainly surgical, and needs but a brief allusion. The 
two main points to be aimed at have already been indicated, namely, to 
remove the source of the trouble as thoroughly as possible, and at the 
same time to injure the tissues as little as possible. The first point is 
attained by opening up the part freely, removing any decomposing SYSTEM OF MEDICINE 
596 
material found, and then flushing all the surfaces of the wound thor- 
oughly with a mild antiseptic lotion. Thus if the cause of the trouble 
be blood-clot or pieces of placenta or membranes retained and decom- 
posing in the uterus, the cervix must be dilated as far as necessary, 
the offending substances removed by flushing, or by the fingers, or by 
curetting as gently as possible, and then the whole uterine cavity thor- 
oughly irrigated. If the cause be a wound of one of the large serous 
cavities this must be freely laid open, cleansed in a similar way, and 
means taken to ensure efficient drainage. 
The second point is to handle the tissues as gently as possible, and 
to avoid the use of strong antiseptic solutions for flushing purposes. 
These solutions as applied only act mechanically by washing away 
decomposing material, and cannot destroy all the organisms present. 
On the other hand they act deleteriously on tissues already weakened 
by contact with the poisonous products, so that the wounds allow organ- 
isms to enter, to act on the parts more easily, and perhaps even cause 
their death - thus providing a fresh nidus for the putrefactive bacteria. 
Such fluids as sterilised water, boracic acid, or perchloride of mercury 
(1-6000 or 1 in 10,000) solutions are to be preferred. The best tem- 
perature at which to use them is probably about 100°-105° F., as this 
does not damage the tissues, and it acts as a general stimulant. 
Afterwards the wound must be treated on general surgical principles. 
At the same time the condition of the patient must be carefully attended 
to. The cause being removed, rapid recovery will ensue if the effects 
of the poison already absorbed can be arrested. The collapse of severe 
cases must be treated by large quantities of stimulants frequently admin- 
istered. Brandy must be given by mouth, or per rectum if vomiting 
persist; strychnine seems to be of special value. Carbonate of ammonia 
in two or three grain doses may be given hourly, or sal volatile in half- 
drachm doses. In very severe cases hypodermic injections of ether 
must be resorted to, and repeated as necessary; in a word, every effort 
must be made to keep the patient alive for a few hours until the poison 
in his blood is excreted. 
In milder cases but little medical treatment is required beyond 
attending generally to the excretory functions. A diet consisting 
chiefly of milk with as much fluid as the patient cares to drink may 
be ordered, a large quantity of fluid serving to dilute the poison and 
hasten its excretion. If vomiting persist it may be allayed by a simple 
effervescing mixture, or by small doses of hydrocyanic acid and bismuth. 
As convalescence is established, a liberal diet with general tonics - iron, 
quinine, or strychnine - or perhaps change of air will be beneficial. 
B. Septicemia 
The pathology of this disease is much more difficult than that of 
saprsemia, and indeed it has not as yet been definitely worked out: 
I do not know of any complete solution of it. From my description SEPTICAEMIA AND PYAEMIA 
597 
of the experiments on animals, it would seem to be very simple, 
namely, that in sapraemia we have poisoning with the chemical products, 
in septicaemia we have a blood disease (the organisms growing in the 
blood), and in pyaemia we have in addition to blood disease the forma- 
tion of secondary abscesses; but when we come to the pathology of 
these diseases as they occur in man, we find that it is not so simple as 
would appear from the investigations in animals. As a matter of fact, 
in cases grouped under the name septicaemia, we have not, as a rule, to 
do with a disease resembling the so-called septicaemia of the lower 
animals, in which the organisms are growing freely and in large 
numbers in the blood. True, on examining the blood taken from 
septicaemic patients, pyogenic cocci can usually be found; but they are 
generally in small numbers, are demonstrated with difficulty, and do 
not, as regards their numbers or distribution, in any way resemble the 
septicaemia of mice or rabbits: one is thus tempted to consider septi- 
caemia after all as a chemical poison similar to sapraemia, the organisms 
producing this chemical poison not being in the circulating blood. In 
septicaemia, however, we have one marked difference from sapraemia. 
In the latter case, washing out the decomposing products from the 
wound, or removal of the part which is the seat of decomposition, at 
once arrests the disease ; the explanation being, as before said, that the 
organisms producing the poisonous materials are growing outside the 
body, and that the poisonous materials are absorbed from the surface of 
the wound; on the other hand, it is evident that in septicaemia the 
manufactory of the poisonous products is not necessarily in the wound 
itself, but may be in other parts of the body - in other words, we have 
to do here with an infective disease caused by parasitic micro-organisms 
which are able to live in the body itself. 
As to the place where these organisms live and produce their prod- 
ucts, I believe, as I have just said, that but a slight effect is produced 
by the small numbers of organisms found in the circulating blood. The 
main body of them are at rest in the system, and from the parts where 
they are deposited they pour their poisons into the blood. 
One of the common seats of these organisms is the tissues of the 
wound itself which, in an advanced case of septicaemia, would generally 
be found infiltrated with the cocci. Although they do not grow freely 
in the circulating blood, they get into it, and are carried by it and 
deposited in various parts; after death it is not uncommon to find in 
cases of septicaemia numerous capillaries throughout the body blocked 
with collections of cocci which have not yet led to abscesses. In these 
cases I believe the organisms have become adherent to the endothelium 
of the blood-vessels, and having succeeded in overcoming the resistance 
of these cells they grow there, and form the plug which is found after 
death. 
A few cases where the symptoms are similar, though probably more 
acute, have been found to depend on the growth of organisms in large 
numbers in the blood - usually bacilli; this condition corresponds to 598 
SYSTEM OF MEDICINE 
that found in the lower animals. The organisms which are usually as- 
sociated with septicsemia are, however, the pyogenetic organisms, either 
the staphylococci, or perhaps more commonly streptococci. On post- 
mortem examination careful search generally shows a few organisms in 
the blood, and they may be cultivated from the blood of some of the 
internal organs - more especially of the kidneys, where they are some- 
times in considerable numbers. In cases of bacillary septicaemia it 
seems that the plugs are not uncommon in the heart muscle. The 
organisms are always found in considerable numbers in the wound, in 
the pus, or discharges, in the membranous deposit which is sometimes 
seen on its surface, and deep in the neighbouring tissues; sometimes in 
the lymphatics and the neighbouring lymphatic glands. 
It is difficult to understand how organisms like these pyogenetic cocci 
can at one time cause a simple abscess, and at another a severe and 
rapidly fatal general disease; apparently this depends on the variation 
and virulence of the organisms. These pyogenetic cocci increase in 
virulence when injected into the peritoneal cavity, and we find that 
inoculation from septic peritonitis is one of the commonest causes of the 
very rapid and fatal form of the disease in man. Apart from variation 
and virulence, the initial dose of the organisms which enters the body 
has a great deal to do with the result, while predisposition on the part 
of the body, and the existence of weak points where the organisms can 
settle and develop are also of great importance. It seems probable that 
under the term septicaemia several different septic diseases are grouped: 
but the possibility of making out the state of the case is becoming more 
and more difficult, owing to the spread of the principles of antiseptic 
surgery, and the consequent increasing rarity of the cases - at any rate 
in the hands of those who would be able to investigate their pathology. 
The disease may arise from a simple prick or puncture inflicted 
during a dissection or post-mortem examination. In these cases the 
small size of the wound forbids all idea of poisoning by chemical prod- 
ucts alone, and the disease which establishes itself is usually extremely 
rapid in its course, and accompanied by great fatality. Most commonly 
the disease follows wounds which have not been treated aseptically, and 
where, consequently, the pyogenetic organisms are present. Why it 
should arise in one individual with a septic wound and not in another 
is, as has already been said, not at all clear. 
Apart from the virulence of the organisms and the condition of the 
patient, local conditions no doubt play a very important part, such as 
much bruising in the wounds, especially of the muscular tissues, in 
which the organisms can therefore readily settle; the muscles, more- 
over, are very plentifully provided with lymphatic vessels. Perhaps the 
most important local cause is the retention of the decomposing fluids 
in the wound leading to that amount of pressure which would help the 
entrance of the organisms into the blood or lymph stream. 
In former times the contagious nature of the disease was well shown 
by the severe outbreaks which occurred from time to time in the surgical SEPTICEMIA AND PYEMIA 
599 
wards of hospitals. The disease once introduced spread from patient to 
patient with great readiness; most probably being communicated by the 
surgeons or nurses, especially in the use of the same instruments for 
dressing successive cases without proper disinfection. More dreaded 
still was it in some of the large maternity hospitals, where there are 
records of many outbreaks, especially at the beginning of the century. 
In some cases half or two-thirds of the women delivered contracted the 
disease, and practically all of these died. 
The post-mortem changes which are found in septicaemia (apart from 
the presence of deposits of organisms in various tissues or organs) are 
almost identical with those found in sapreemia. Rigor mortis is as little 
marked; putrefaction proceeds with the same extreme rapidity; there 
are the same blood changes, blood staining, serous effusions, etc. The 
spleen, however, is rarely quite so large, and congestion of the lungs and 
bronchitis are more or less constantly present. 
Symptoms.-In discussing the symptoms, general and local, the 
severer and more typical form of the disease will first be treated, and 
subsequently reference made to the milder varieties. 
General Symptoms. -The disease commences abruptly, often as early 
as a few hours after inoculation, usually within twenty-four hours. 
Accompanying the changes in the wound the temperature is observed 
to be rapidly rising; rigors occur in more than half the cases, and are 
usually repeated and severe. The temperature usually remains high 
throughout (103°-105° F.), with slight remissions. In the severer cases 
the patient's life is rapidly endangered; death may occur as early as the 
second or third day. The pulse is always very rapid, sometimes par- 
ticularly feeble and irregular; the heart sounds weak. The respiration 
is rapid, there may be dyspnoea and cyanosis, accompanied by all the 
signs of catarrhal bronchitis. There is always complete anorexia, some- 
times accompanied by vomiting, more rarely by diarrhoea. 
The cerebral symptoms also vary much. There is usually headache 
more or less severe; in some cases delirium sets in early and is followed 
by coma,-more usually, perhaps, the mind remains clear to the end. 
If the case last longer the patient passes into a typhoid state. The skin 
usually assumes an icteric tint and purpuric spots may occur. The urine, 
besides the .usual febrile characters, frequently contains albumin, and 
micrococci (in cases due to them) can usually be detected in it when 
freshly drawn off from the bladder. The gastro-intestinal symptoms 
become severe, and the patient dies from exhaustion usually within a 
week. 
Although the differences in the symptoms noted above may possibly 
depend to some extent on corresponding differences in the causative 
agent, yet with our present state of knowledge it is impossible to say 
how far this is the case. No trustworthy observations on this point 
have yet been made. 
The symptoms of the milder varieties of this disorder need only 
be alluded to: they are those which ordinarily occur in connection 600 
SYSTEM OF MEDICINE 
with suppuration and septic wounds. There is always fever, but the 
temperature rarely reaches 104° F., and rigors are unusual. The 
patient feels ill, suffers from headache and thirst, the tongue is furred, 
and there is anorexia. Vomiting may occur, and constipation is the 
rule. In these cases also micrococci, if carefully searched for, may be 
found both in the blood and in the urine. As the state of the wound 
improves the fever subsides and the patient becomes convalescent. 
Local Signs. -The changes at the site of inoculation or in the wound 
also vary greatly. In severe cases from a post-mortem prick the finger 
in a few hours becomes greatly swollen and intensely painful; thin red 
lines of inflamed lymphatic vessels may be seen spreading up the arm, 
and the axillary lymphatic glands become affected. Very shortly the 
whole arm may become swollen, oedematous and painful. In rare cases 
the disease is apparently arrested in the glands, and suppuration occurs 
there, and also along the course of the lymphatics. In these cases, the 
abscesses being freely opened, recovery may ensue; but more often the 
infection rapidly passes beyond them. Sometimes a form of gangrene 
spreads rapidly from the site of infection. In other cases no sup- 
puration occurs, but the wound becomes covered with a yellowish 
white adherent membrane. In this membrane* and in the serous flaky 
discharge bacteria can often be demonstrated. In other cases, again, no 
marked changes occur at the site of inoculation. In the milder cases 
the wound is usually in a more or less unhealthy state, suppurating and 
painful, with swollen reddened margins. 
It is probable that some forms of hectic fever may be due to staphy- 
lococci growing in the granulations and the' tissues bordering on the 
wound, and pouring their products into the blood stream. As these 
organisms are thus growing in the living tissues, according to our defini- 
tions as above, some forms of hectic fever must be considered as " chronic 
septicsemia." 
The diagnosis may be made with ease and certainty if the case arise 
in connection with a small wound (an obvious source of infection), or 
if the wound present some characteristic state as above described. In 
other cases extreme difficulty may arise. 
The distinction from sapraemia has already been pointed out; from 
pyaemia it can usually be made by its acuter onset, more rapid progress, 
more sustained temperature, and, later, by the absence of secondary 
abscesses. The possibility of a severe or malignant type of specific fever, 
such as small-pox, may also be borne in mind. The presence of strepto- 
cocci in the blood and urine may be of help in some doubtful cases. 
The possibility of overlooking the severer underlying condition, and re- 
garding the case as one of simple severe bronchitis with cardiac failure, 
must be guarded against. The milder cases with suppurating or septic 
wounds present no difficulty. 
Prognosis in the severer forms, if an absolute diagnosis can be made, 
is almost hopeless. In extremely rare cases, as has been mentioned, the 
disease may be arrested in the lymphatics, and the patient ultimately SEPTICEMIA AND PYEMIA 
601 
recover after a prolonged and severe illness, which often leaves him with 
an impaired constitution. Although persons in apparently robust health 
may be less liable to fall into the disease, yet when once established it is 
as fatal in them as in those of weaker constitutions. 
Treatment. - On first seeing a case, the wound, if a small one, should 
be excised, and the parts freely cauterised with pure carbolic acid or 
the actual cautery. In cases of larger wounds thorough cleansing, fol- 
lowed by application of pure carbolic, may be carried out; or, if they be 
situated on an extremity, the question of immediate amputation must be 
considered. These measures, however, rarely do any good, the disease 
running its course unchecked. 
The most that can be done is to support the patient's strength in 
every way, by administering in small, frequent quantities such nutriment 
as he can absorb, by giving stimulants - brandy and carbonate of 
ammonia - freely, and by combating in a suitable way some of the 
severer symptoms. Thus the temperature may be controlled by tepid 
sponging, vomiting by bismuth or alkalies, and narcotics may be given 
where there is pain. Of other drugs quinine is, perhaps, of as much 
use as any. 
Pyaemia 
When we consider the great interest in this disease, and the terrible 
mortality that it caused among surgical patients up to a recent period, it 
is very remarkable to find so few references to it in older works, and 
to note the little interest which it apparently excited among surgeons. 
Massa in 1559 and Ambrose Pare in 1561 pointed to the occurrence of 
abscesses in the lungs as the result of head injuries; but no precise 
theory to account for this was formulated until Boerhaave published his 
researches in 1720. Boerhaave affirmed that the complications of septic 
wounds were due to the admixture of the pus of the wound with the 
blood; and in spite of many adverse theories and criticisms this view 
received general support and maintained its ground until our own day. 
John Hunter, while apparently adhering to the view that pyaemia was 
due to the admixture of pus and blood, demonstrated the existence of 
supptirative phlebitis, and believed that the walls of the veins secreted the 
pus. The presence of suppurative phlebitis in almost all cases was also 
demonstrated by others, of whom we may mention Dance in 1828. In 
1834 Gunther, and also Castelnau and Ducrest, injected considerable 
quantities of pus into the veins of dogs and cats, and succeeded in nearly 
every instance in producing metastatic abscesses. Virchow, in 1846 and 
later, pointed out that the material in the inflamed veins is not pus, 
but softened and altered blood-clot; and that it is cut off from the cir- 
culation by more recent blood-clot not yet broken down; and he held 
that the alleged mixture of blood and pus is really a leucocytosis. He 
strongly opposed the idea that pus enters the circulation from the veins 
or from the lymphatic vessels; in the latter case he pointed out that the 
glands must stop the corpuscles. In 1826 Cruveilhier drew attention to SYSTEM OF MEDICINE 
602 
the constant association of suppurative phlebitis with metastatic abscesses. 
He injected globules of mercury into the circulation of the lower animals, 
and noticed that abscesses formed where the globules lodged in the vessels; 
and he believed that pus from the veins lodges and acts in a similar manner. 
In 1842 D'Arcet stated that purulent infection consists of two parts which 
are quite distinct from each other, but always occur together, namely, 
poisoning by putrid products and a blockage of the vessels by emboli; 
the first leads to fever and general symptoms, and the second to the 
metastatic abscesses. This theory has been more or less accepted by 
Virchow and others. Virchow further separated septicaemia (which term 
he also applied to cases of septic poisoning) from pyaemia, and showed 
that the two might occur separately. Most of the experiments in support 
of this view were performed with putrid pus: the well-filtered solution, 
when injected into the veins, produced only septicaemia; the unfiltered 
solution containing solid particles led to pyaemia. 
When the importance of bacteriology in connection with surgery 
was recognised these views were carried a stage further, and the causal 
agents were shown to be organisms growing in the decomposing pus. In 
1867 Sir Joseph Lister first published the results which he had obtained 
by adopting the germ theory as the explanation of the occurrence of 
suppuration in septic diseases; and, acting thereon, the brilliant success 
of the antiseptic treatment soon fully confirmed his views, and, in 
spite of criticism, it has constantly gained greater and greater accept- 
ance, till now it is fully recognised and firmly established. The view 
now generally held of the pathology of pyaemia is that the general 
symptoms are due to poisoning with the products of certain pyogenetic 
bacteria, and the abscesses for the most part to plugging of the blood- 
vessels with masses of these bacteria, or with emboli infected with them. 
Pathology. - Many investigations have been made to determine the 
organisms which are associated with pyaemia, and it has been found that 
the organism usually present is the streptococcus pyogenes; though in 
some few instances, more especially in the less severe forms, pyogenetic 
staphylococci have been the only ones present. As I have said, the fever 
and general symptoms of pyaemia may be explained as those of septi- 
caemia ; that is to say, they are due to poisonous products poured into 
the blood stream by pyogenetic cocci growing in the living tissues of the 
body. The formation of the secondary abscesses is, however, not alto- 
gether quite easy to explain at first sight, for many observers have found 
pyogenetic cocci circulating in the blood of patients with septic wounds 
in whom no secondary abscesses were established. Kibbert and others 
have found that the injection of moderate quantities of staphylococcus 
pyogenes aureus into the circulation of rabbits is followed, as a rule, only 
by abscesses in the kidneys, the other organs apparently remaining un- 
affected ; hence other conditions beside the mere presence of pyogenetic 
organisms circulating in the blood stream are found necessary for the 
production of the complete picture of pysemia. 
The almost constant presence in these cases of suppurative phlebitis SEPTICEMIA AND PYEMIA 
603 
has already been mentioned; and there seems no doubt that the second- 
ary abscesses - at any rate in the lungs - are explicable on the view 
that portions of the softened and infected thrombus become detached 
and form emboli in these organs. The sequence of events would then 
be as follows: - (1) Phlebitis occurs in direct connection with the 
wound; (2) a thrombus impregnated with micrococci is formed in the 
vein; (3) the thrombus softens, disintegrates, and portions of it are 
carried into the circulation as emboli; (4) these lodge in the first set 
of capillaries and form infarctions, and then abscesses. 
In support of this view are the following experiments: - Ribbert, in 
experiments on rabbits with staphylococcus pyogenes aureus found that 
he could produce abscesses in the heart and in various organs if the 
cocci were injected into the blood stream attached to particles too gross 
to pass through the capillaries of these organs. He used a cultivation 
of the pyogenetic cocci on potatoes, and took care in removing the cul- 
tivation to scrape off also the superficial layer of the potato itself. If 
this mixture of potato granules and organisms was rubbed up with 
water, so as to form a fine emulsion, and then injected into the circula- 
tion, the result was the production of deposits of organisms in various 
parts of the body, leading to the formation of abscesses. Bonome found 
that by mixing cultivations of pyogenetic organisms with finely pow- 
dered elder pith, and injecting tlie mixture into the jugular vein, he 
obtained similar appearances; but if the fragments of elder pith alone 
were employed no abscesses resulted. 
Various other experiments might be quoted, but these and the path- 
ological facts are sufficient to show that the ordinary pyogenetic cocci are 
able to cause secondary abscesses in the lungs if they enter the gen- 
eral circulation attached to gross particles, and to establish the import- 
ance of thrombosis and embolism as factors in the production of pyaemia. 
The point of difficulty, however, is to account for the abscesses in organs 
other than the lungs in cases where the systemic veins are affected ; or 
than the liver in cases where the portal area is the seat of the primary 
disease. It seems hardly probable that fragments of blood-clot would be 
able to pass through the pulmonary capillaries and stick in the vessels of 
the kidney and other organs, and some other condition must be found 
to account for the presence of these farther abscesses. 
It has already been mentioned, in speaking of the experiments on 
animals, that Koch found micrococci by means of which he could produce 
pyaemia; and that the way in which the deposits of organisms were 
brought about was by their growth in the blood, forming masses of 
organisms, and more especially entangling blood corpuscles. It is very 
probable that something similar takes place in man, and that the strepto- 
cocci growing only in small numbers in the blood tend to form balls, 
which may be increased by the aggregation of blood corpuscles, and 
ultimately attain a size which cannot pass through the capillaries. It is 
possible, also, that in the lungs a fresh suppurative phlebitis may occur 
in the neighbourhood of the secondary abscesses, and thus lead to the SFST'.EJf OF MEDICINE 
604 
passage of emboli into the arterial circulation. While, however, some of 
the tertiary abscesses, as we may call them, may be brought about in this 
way, the view hardly suffices fully to explain the pathology, because 
it is found that these abscesses are more numerous in certain organs, 
more especially in the kidneys; whereas if plugs of cocci were floating 
about in the blood there seems no reason why they should be deposited 
more in one organ than in another. There appears, therefore, to be some 
selective power on the part of the organs, and such an admission clearly 
invalidates a pure embolic theory. It seems probable that most of these 
tertiary abscesses occur in this way - that the organisms floating in the 
blood, in groups not sufficiently large to form emboli, find conditions 
in certain organs more favourable to their deposit and growth than 
in others, and establish themselves in the endothelium of the blood- 
vessels, grow, and form plugs, and subsequently abscesses. Or again, it 
may be that they find a weak spot, caused by an injury or otherwise, in 
which they can settle; or again, there seems evidence in support of the 
view I put forward some years ago, which has since received a certain 
amount of confirmation, that apart from the rupture of blood-vessels 
and communication with the ducts of secreting organs there may be 
an actual secretion of the organisms. For example, in the case of the 
kidney, the organisms may pass from the blood with the water and get 
into the urinary tubules without any lesion of the wall of the blood- 
vessel or tubule; and having reached the tubules they may then find 
conditions; such as rest in a suitable soil, which enable them to develop, 
and there developing, may form masses and subsequently abscesses. I 
found distinct evidence of this some years ago in experiments on the 
lower animals with a certain coccus obtained from wounds, wherein, 
after injection into the blood stream, the kidneys were the only organs 
which showed signs of disease, and the organisms in the kidneys were 
present in the urinary tubules. This is the most probable explanation 
of the occasional occurrence of the abscesses in the parotid and other 
glands sometimes seen in pyaemia. 
The suppurations in joints and serous membranes which occur in 
pyaemia are also probably brought about by a settlement of the organisms 
in the endothelial cells of the capillaries in these membranes, which grow 
there, and then pass into the joint or cavity and set up the infection. 
From what has been said it seems, therefore, that the embolic theory of 
pyaemia must be extended, and that the occurrence of abscesses in various 
organs and in the joints must be farther explained by supposing either 
fresh formation of emboli in the circulating blood, or deposit of organisms 
in the endothelium of the smaller vessels and their growth there; or 
exit of organisms from the blood-vessels into the tissues in connection 
with injuries ; or excretion of organisms and their growth in the tubules 
of the glands, or a combination of these. Various other factors no doubt 
come into play in the production of pyaemia, such as the dose of organ- 
isms, the degrees of their virulence, the general depression of the vitality 
of the body, and so on; but the above are the essential points. SEPTICEMIA AND PYEMIA 
605 
We must now briefly trace the changes which take place in the tissues 
on the impaction of a septic embolus, or on the development of a mass 
of organisms in a small vessel or tubule, which changes result in the 
formation of an acute abscess. If we make a section through a com- 
mencing pyaemic abscess, and stain it appropriately, we shall find that 
in the centre, obviously in the lumen of a vessel, there is a small deeply 
stained mass which, under a high power of the microscope, is seen to 
consist of enormous numbers of cocci. Surrounding this is an unstained 
clear area in which the structure of the tissue is no longer readily dis- 
cernible ; this is an area which has undergone coagulation necrosis [yide 
articles on " Inflammation " and " Retrogressive Nutrition "] as the result 
of the action on it of the concentrated poisonous products poured out 
from the central mass of cocci. Outside this zone, where the poison is 
weaker, the tissues of the part are seen to be undergoing inflammatory 
changes; at a later period the micrococci burst through the wall of the 
vessel, and pass into the dead tissue, and even for a certain distance into 
the inflamed and living tissues; while from the outer part a large amount 
of fluid plasma and a large number of leucocytes are poured into this same 
dead area. Among the properties of these organisms is their power of 
peptonising albumin, and by virtue of this power the necrosed tissues are 
dissolved, while the effused plasma does not coagulate; thus a central fluid 
mass is formed, in which are floating large numbers of dead leucocytes 
and micrococci, and surrounding this mass we have a dense layer of newly- 
formed granulation tissue in which the pyogenetic cocci are present. 
In man pyaemia may originate in connection with any inflammation 
in which the pyogenetic cocci are present; thus it may follow injuries 
and surgical operations where suppuration is allowed to take place, either 
from the use of imperfect precautions to ensure asepsis, or from condi- 
tions of the case preventing absolute asepsis. In former times this disease 
was the great dread of surgeons, and the cause of terrible mortality after 
all operations; but more especially did it follow injuries to veins, bones 
or joints. It was most often seen in hospitals, and especially in war, where 
the hygienic conditions were bad, and many wounded were crowded 
together. It is interesting to note that so late as the first decade of anti- 
septic surgery (1869-1878) there were no less than 903 cases of fatal 
septic disease, chiefly pyaemia, in eight of the large London hospitals. 
Acute suppurative osteomyelitis, or periostitis, is a not unfrequent 
cause of pyaemia, the great tension under which the pus is formed prob- 
ably forcing the septic emboli from the veins into the circulation. It is 
not so common after abscesses, boils and carbuncles; but, in the forms 
of suppuration, such as spreading cellulitis, due to streptococcus pyo- 
genes, and in acute and chronic middle ear suppurations, pyaemia is not 
uncommon. It may also follow ulcers of the skin or of the intestinal 
tract; and in the latter cases the depressed general condition of the 
patient may promote the occurrence of the disease. 
As to age, statistics point to pyaemia being more common between the 
years of 30 and 40; but this is probably due to accidental causes: no age 606 
SYSTEM OF MEDICINE 
is exempt. Its frequency lias also been found to vary with the seasons, 
being more common in damp and cold weather; probably because of the 
increased neglect of hygienic precautions prevailing at such periods. 
Symptoms. - The ordinary form of pyaemia will be first considered, 
and later the distinctive features of the other varieties. The disease 
usually commences within the first week of an injury or operation. The 
wound generally becomes unhealthy, any granulations which have formed 
disappear, the previously sealed inter-muscular planes open up, and the 
discharge becomes thin, watery or sanious pus, often so scanty that the 
wound may appear dry. Phlebitis of the veins leading from the affected 
part may be made out, forming at first tense cords, accompanied later 
by surrounding thickening and tenderness; and, if superficial, by oedema 
and redness of the skin. In other cases, as in thrombosis of the lateral 
sinus, severe pain and tenderness along the course of the vessel may be 
the main local indication of phlebitis; or again we may have to draw 
an inference from oedema of the area drained by the vein. In rare cases 
the wound may appear healthy and even heal, and thrombosis, even if 
present, may be overlooked. 
The general symptoms are usually ushered in by a severe rigor and a 
rapid rise of temperature to 104° or 105°. For a few days before this 
there will probably have been some general malaise and loss of appetite, 
accompanied by more or less fever. The rigor is followed by profuse 
sweating, and the temperature rapidly falls to 102° or 101°, or even 
lower. The rigors are usually repeated throughout the course of the 
disease; rarely are they absent for more than 24 hours at a time, 
although they occur quite irregularly, and two or more may occur in the 
course of a few hours, or even in connection with a single rise of tempera- 
ture. The temperature is always high during the rigors -104° F.- 
105° F.; even 110° F. has been certainly registered; in the intervals of 
the rigors it may be 100° F.-1O10 F., normal or even subnormal. The 
rigors are always followed by most profuse and exhausting sweats, 
and, together with the course of the temperature, are fairly characteris- 
tic ; they may, however, occur with such daily regularity that the chart 
resembles that of a case of quotidian ague, or again the temperature 
may be more continuously high and rigors absent. Profuse sweating 
is in any case an almost constant symptom. 
Usually there is anorexia and sometimes vomiting; but occasionally 
the appetite remains good until near the end, and the digestive func- 
tions may be but slightly affected in the earlier stages of the less severe 
cases. This may be accounted for by the periods of apyrexia or com- 
parative apyrexia, which give the patient time to recover from the effects 
of the fever. In other cases there may be severe and frequent vomit- 
ings, or, more rarely, persistent diarrhoea. The tongue is usually furred, 
but cleans in the afebrile intervals; later, it becomes brown and dry, 
and the teeth and lips are covered with sordes. The breath is often said 
to have a sweet smell. Excessive thirst is common, and the patient 
will- consume a large amount of fluid. SEPTICEMIA AND PYEMIA 
607 
From the beginning the pulse is very rapid and soon becomes soft; 
later, it becomes very feeble, running, irregular or uncountable. The 
first sound of the heart is usually weakened, and may become almost 
inaudible. Various cardiac murmurs may also be heard; they are usually 
functional in origin, but in these cases the possibility of ulcerative 
endocarditis must always be borne in mind. Examination of the blood 
shows that the white corpuscles are increased in number, relatively and 
absolutely; and in some cases pyogenetic cocci have been seen in the 
blood, or obtained from it by cultivation. The respirations are increased 
in frequency; sometimes there is marked dyspnoea and cyanosis, but 
this usually occurs only in connection with some bronchial or pulmonary 
affection, of which, however, it may be almost the only clinical manifes- 
tation. The urine usually contains a small amount of albumin, but acute 
nephritis is very rare. The amount passed is usually about normal as 
a large amount of fluid is taken in the diet. The urea and urates are 
increased, and there is a diminution in the amount of inorganic salts. 
If blood and pus be present they point rather to a renal abscess. The 
patient rapidly loses muscular power, the muscles become flabby and 
waste rapidly, and all movements are very tremulous. 
For a long time the patient's mental faculties are retained, or he may 
perhaps be delirious during the fever, and completely conscious during 
the intervals. Towards the end of the disease low muttering delirium 
is common, and the patient usually sinks into a comatose state. In other 
cases marked cerebral symptoms are present. Wild, noisy delirium and 
prolonged periods of unconsciousness are seen, and very severe headache 
is not uncommon. These symptoms are usually the result of the fever: 
cerebral abscess or meningitis cannot be recognised in the absence of 
direct localising symptoms. 
The skin is often slightly tinged with yellow, but rarely much jaun- 
diced, except in some cases of liver abscess. Occasionally an erythem- 
atous rash is seen much resembling scarlet fever in general appearance, 
but differing from it in its distribution; it chiefly occurs on the parts 
around the axillae and groins, and spreading down the limbs, is rarely 
pronounced on the chest: more rarely still a pustular rash occurs. In 
the later stages of the disease petechiae are not uncommon, or extensive 
cutaneous haemorrhages may occur. Death usually ensues about the end 
of the first or during the second week; very few cases live more than three 
weeks. The patient may die of exhaustion, with all the symptoms of the 
typhoid state, and coma usually precedes death. Or the patient may die 
from the direct effects of a secondary lesion, such as cerebral abscess or 
meningitis, extensive pulmonary disease, heart affection, etc. In rare 
cases death occurs suddenly from impaction of a large embolus in the 
pulmonary artery. 
The local symptoms, consisting of secondary abscesses in various organs 
and other parts of the body, and suppuration of the serous membranes, 
must now be considered. These usually appear about the sixth to the 
tenth day of the disease; and, in the ordinary form of pyaemia, the em- 608 
SYSTEM OF MEDICINE 
boli originate in the systemic veins, and consequently are most usually 
arrested in the lungs. The lungs rarely escape secondary deposits in 
cases of pyaemia arising from disease of bones, such as osteomyelitis or 
periostitis from compound fractures, amputations, or other wounds in- 
volving bones ; and in these cases the lungs only may be affected. In 
other cases, however, it is more usual to find abscesses in other parts 
with or without abscess of the lung; these arise either from the emboli 
being sufficiently minute to enable them to pass through the compar- 
atively wide pulmonary capillaries, or from emboli formed in some of 
the other ways above discussed. 
Many abscesses may form in the lungs and yet give rise to no very 
definite symptoms. The dyspnoea is increased and there are general 
signs of bronchitis. If an abscess form near the surface of the lung it 
will set up a localised pleurisy ; then we have the characteristic pleuritic 
pain, cough, etc., and on auscultation the friction sound. Soon fluid is 
poured out into the pleura, at first commonly serous, but later becoming 
purulent; or the lung abscess may burst into the pleura. In either case 
a localised empyema is formed with or without pneumothorax, and may 
be recognised by the usual signs. Occasionally an abscess near the 
surface of the lung is sufficiently large to cause dulness on percussion 
and the other signs of consolidation. 
Pleurisy may also occur apart from pulmonary abscess; and this has 
been more commonly noted in cases of pyaemia arising in connection with 
middle ear disease. The spleen, kidneys and brain are the other organs 
most commonly attacked in this form of the disease. In the spleen 
some pain and enlargement accompanied by great tenderness may be 
detected, and the abscesses bursting into the general peritoneal cavity 
may cause acute general peritonitis. Multiple abscesses in the kidneys 
usually give rise to some pain and tenderness with albuminuria; occasion- 
ally all symptoms are absent; or again there may be acute nephritis with 
pus and blood in the urine. The last symptoms are the only trustworthy 
ones on which to base a definite diagnosis, and they are but rarely seen. 
Abscesses in the brain and purulent meningitis can only be diagnosed 
definitely when some definite localising symptom is present; general 
symptoms, such as headache, vomiting, optic neuritis, coma and the rest, 
may occur apart from particular cerebral lesions. Abscesses in the liver 
also occur, especially it seems after head injuries. They arise in con- 
nection with the branches of the hepatic artery, and thus differ from 
those of portal pysemia. The symptoms will be discussed later under 
this heading. 
The eyes may also be affected in a very important manner: optic 
neuritis may occur with haemorrhages scattered in the retina; the arteria 
centralis retinae may be plugged by an embolus; this causes sudden 
blindness of the affected eye, followed by suppuration of the eyeball - 
panophthalmitis. The latter result will also follow if an embolus lodge 
in the ciliary region or iris. 
Suppuration in the joints is one of the commonest lesions of pyaemia, SEPTICEMIA AND PYEMIA 
609 
and may occur in any joint. There is usually intense pain at the onset, 
rapidly followed by purulent effusion, and then the pain often subsides 
more or less completely. The joint shows all the signs of acute suppura- 
tive arthritis, but if the affection be treated early by free evacuation of 
the pus, it is remarkable how little permanent damage may follow. 
Suppuration in the peritoneal cavity also not uncommonly occurs; 
and may be primary, or secondary to an abscess of one of the viscera 
which may burst into it. It is very common in puerperal cases, in some 
probably due to direct extension. It is usually general, but may be localised 
at the outset. Pain at first is severe and accompanied by all the symptoms 
of acute peritonitis; later, however, pain and tenderness are often both 
absent; excessive tympanites from paralysis of the intestines is present; 
and, the purulent effusion being distributed throughout the abdomen, but 
nowhere in large quantity, dulness or fluctuation may never be obtainable. 
In this absence of signs the affection is commonly overlooked. 
Purulent effusion in the pericardium may also occur, sometimes pre- 
ceded by signs of pericarditis, friction sounds, etc., but often coming on 
very insidiously. 
In the cellular tissue of the body large abscesses may form and burrow 
extensively. There is usually severe pain at the outset, but afterwards 
this may subside; the swelling is often very diffuse, and tenderness may 
not be very marked. Transient patches of oedema and redness of the 
skin and subcutaneous tissues, subsiding without suppuration, are also 
described (Erichsen). Abscesses in the muscles are very rare. In the 
heart they are also rare. The symptoms are indefinite, but the cardiac 
action is greatly impaired, and death is liable to occur from rupture of 
the heart wall. In rare cases abscesses are seen in the parotid gland, 
thyroid gland and testicles. Their possible pathology has been discussed. 
Morbid Anatomy. - After what has already been said this may be 
dealt with very briefly. The general blood and tissue changes are exactly 
similar to those already described in septicaemia, but are usually some- 
what less marked. They are the effect of the fever and general blood 
poisoning. 
The wound will be found as already described; and if careful search 
be made, a thrombosed vein will often be found leading from it. Such 
veins are filled with soft adherent clot, in some places breaking down, in 
others replaced by pus, which*is always shut off by clot from the general 
circulation. Around the vein there is a certain amount of periphlebitis, 
or even a periphlebitic abscess. Cases have also been seen (six cases, 
Path. Soc. Reports) in which thrombosis followed by embolism has oc- 
curred in a vein remote from the seat of infection. 
In the lungs signs of bronchitis and broncho-pneumonia are almost 
constantly found. Haemorrhagic infarctions are rarely seen, but scattered 
throughout are abscesses varying in size from a pea upwards. In the 
kidneys and spleen also the abscesses are commonly multiple. In the 
brain it is not uncommon to find a large area of acute softening, the re- 
sult of an embolus, with only a drop or so of pus in its centre. Pyogenic 
VOL. I 
2 R 610 
SYSTEM OF MEDICINE 
organisms of one or more varieties can be demonstrated in large numbers 
in the original site of infection, in the emboli and thrombosed veins, and 
in the secondary abscesses; but rarely in the blood. 
Suppurative Pylephlebitis or Portal Pyaemia. - This form of pyaemia 
is extremely rare. The commoner causes of it are suppurative appen- 
dicitis, ulceration of the intestine, especially dysentery, malignant ul- 
ceration of stomach or intestines, chronic gastric ulcer, and ulcerative 
diseases of the rectum. Suppuration of the gall-bladder, ulceration from 
gall-stones, or suppurating hydatid cysts, may also cause it. Cases of a 
foreign body which has been swallowed and has penetrated to a branch 
of the portal vein are on record; and we have already mentioned cases 
in the newly born following phlebitis of the umbilical vein. 
The result of the suppurative phlebitis of the portal system is the pro- 
duction of pyaemia similar in all its general symptoms and pathology to 
that already described, but differing from it in that the chief secondary 
deposits occur in the liver. Numerous abscesses are always seen through- 
out the liver, obviously arising in connection with branches of the portal 
vein. The liver is uniformly enlarged - sometimes very large - the 
capsule may be normal or covered with patches of peritonitis, and the 
abscesses may show on the surface. The clotting may occur throughout 
the portal vein, and even spread through into the hepatic vein. These 
abscesses must be distinguished from those arising from gall-stones and 
the like, where the infection spreads up directly by means of the bile 
ducts; from abscesses in ordinary pyaemia, which arise in connection with 
the hepatic artery, and are usually fewer in number; and also from the 
large tropical abscesses. In none of these is portal thrombosis present, 
and the mode of origin is usually obvious. 
Only the special symptoms due to the implication of the liver will 
here be referred to. The disease is always of a severe type, and runs a 
rapidly fatal course. There is intense pain in the right hypochondrium, 
and the liver rapidly enlarges. It is very tender on palpation, with an 
ill-defined, soft margin. Signs of gastro-intestinal irritation, especially 
vomiting, are common. Two characteristic symptoms are ascites and 
marked jaundice, but they are by no means constant. Ascites occurs when 
a considerable extent of the portal vein is blocked, but it may also be due 
to peritonitis. Jaundice occurs when a large bile duct is pressed on or 
involved in an abscess, but there is always some bile passed in the faeces. 
The diagnosis may be completed by placing the patient under an 
anaesthetic, and thoroughly using a large exploring needle or trocar, but 
even then an abscess may be missed. 
General peritonitis may be caused by rupture of an abscess into the 
peritoneal cavity. The spleen is always much enlarged. 
So-called Chronic Pyaemia or Multiple Abscesses. - This disease arising 
under similar conditions to true pyaemia, and leading to the formation of 
secondary abscesses, has long been confounded with pyaemia. It differs, 
however, essentially from true pyaemia in that embolism apparently plays 
no part in it. Pyogenic organisms reach the blood stream by a wound, SEPTICEMIA AND PYEMIA 
611 
or the like, and, owing to the depressed vitality of the patient, continue 
to live there, but produce only slight disturbance. Then if some spot be 
weakened by the result of a slight injury, the organisms fix on that spot, 
develop in it, and produce an abscess. The injury producing the abscess is 
usually slight, such as a strain, too long or too great pressure on a part, 
and so forth. The abscesses are consequently few in number, often only 
one or two, and are situated in the subcutaneous tissues or in the joints. 
The disease may last for months, the general symptoms not being severe; 
elevation of temperature, pain, etc., occur at the commencement of each 
fresh abscess, but subside in the intervals. 
A case is recorded in the Pathological Society's Transactions, in which 
a compound fracture of the lower jaw was followed by suppuration occur- 
ring at the site of other fractures sustained at the same time. The 
fracture of the femur was noticed suppurating nearly a month after the 
injury, and ten days later the fractures of the humerus and rib were 
affected. Numerous experiments on animals have shown that the simple 
injection of small numbers of pyogenic cocci into the blood stream will be 
followed by no ill effects, but that if simultaneously an injury be inflicted 
on any part of the body a local abscess will result. 
Diagnosis of Pyaemia. - Difficulties mainly arise in cases where the 
source of infection is unusual or obscure; it must also be borne in mind 
that a patient with a suppurating wound may contract a fever, such as 
typhoid. In all suspected cases such sources of infection as osteomyelitis, 
chronic middle ear suppuration, ulcerative endocarditis, suppuration in 
the nose or in connection with carious teeth, ulceration of the mouth, 
throat, or alimentary tract, rectal diseases, gonorrhoea, and so forth, 
must be very carefully inquired into. 
Of the diseases more or less resembling pyaemia typhoid fever is the 
most important; indeed, pyaemia has been called wound-typhoid. In both 
we find a similar temperature, and in both an enlarged spleen; similar 
abdominal symptoms may also be present; in both the typhoid state 
supervenes, and there may be an absence of other definite symptoms. To 
distinguish typhoid we must inquire into a possible source of infection ; 
the rose-coloured rash and peculiar stools are decisive; haemorrhage from 
the bowel is extremely suggestive; the abdominal symptoms may be 
prominent, and the fever is usually more regular. Moreover, in very 
rare cases pyaemic infection may arise in connection with the typhoid 
ulcer. On the other hand pyaemia is indicated by the discovery of a 
probable source of infection, by the irregular course of the temperature, by 
the recurrent rigors and profuse sweating, by petechiae in the skin, by 
optic neuritis and retinal haemorrhages, and, lastly and conclusively, 
by the formation of multiple abscesses. 
Typhus fever, now extremely rare, also closely simulates pyaemia. 
The abrupt onset, high fever, and cerebral symptoms, are common to 
both. The diagnosis between them must rest on the mulberry rash of 
typhus, or on the secondary abscesses in pyaemia. In acute tuberculosis 
the temperature may be similar, and there may be no decisive symptoms. 612 
SYSTEM OF MEDICINE 
We must look for other signs of a tubercular disease and a tubercular 
history. Later, the slower onset of the disease, its protracted course, 
signs of tubercle in the choroid, and the absence of local signs of abscess, 
show the true nature of the disease. 
Pyaemia may closely simulate malaria in the course of the fever and 
sweatings. The history of exposure to malarial influences, or previous 
attacks of it, the absence of local abscesses, and above all the effect of 
quinine, will decide the question. Acute rheumatism and pyaemia have 
in common a similar course of temperature, profuse sweats, inflammation 
of serous membranes and joints, and perhaps endocarditis. In acute 
rheumatism the sweat has a very peculiar sour odour; the inflammation 
of the joints often subsides suddenly and attacks other joints, and there 
is no jaundice or sign of embolism. 
With regard to ulcerative endocarditis it must be remembered that 
the murmur varies much and may be absent, and that the disease is 
most common after pneumonia. 
The differences between the rash of scarlet fever and a skin affection 
sometimes seen in pyaemia have already been pointed out, and these 
diseases have few other symptoms in common. 
The diagnosis from septicaemia is not important, and rests entirely 
on the presence of secondary abscesses. 
Pyaemia may have to be distinguished from meningitis when head 
symptoms are very prominent, or from uraemia in cases of acute nephritis. 
In the prognosis of pyaemia the varieties of the disease must be 
separately noticed. Cases of ulcerative endocarditis and suppurative 
pylephlebitis are invariably fatal. 
In ordinary surgical pyaemia the prognosis is very grave and recovery 
extremely rare. The majority of the patients die in the first week, and 
very few survive more than two weeks. The worst cases are those 
associated with high continuous fever, extreme vital depression, and the 
early formation of visceral abscesses. In the cases which recover, as a 
rule only external abscesses have occurred; and even then an impaired 
constitution, stiff joints and tendons usually remain. In cases of 
chronic pyaemia, on the other hand, recovery is not infrequent, but after 
months of suffering and with the deformities above mentioned. 
Treatment. - The preventive treatment may first be considered. This 
is purely surgical, and consists in the thorough adoption of the antiseptic 
methods wherever possible. In other cases every precaution, and es- 
pecially free drainage, must be adopted to keep the wound as healthy 
as possible. At the same time the patient's general health must be 
carefully attended to, a good supply of fresh air provided, and over- 
crowding especially of patients suffering from suppurating wounds, must 
be avoided. Even where thrombosis of a vein has occurred in connec- 
tion with suppuration the pyaemia may be cut short by freely opening 
up, purifying, and draining the source of infection, and at the same 
time cutting off from the circulation and cleansing, or, much better, 
excising the whole of the thrombosed vein. ER YSIPE LAS 
613 
The disease once established nothing but symptomatic treatment can 
be attempted. The fever, if very high or continuous, may be controlled 
by antipyretics, or better still by such means as tepid sponging. Quinine 
in five grain doses two or three times a day may also be tried. Cardiac 
failure must be mainly combated by stimulants, of which brandy or 
whisky are the best, and these may be given in large quantities. If 
vomiting be present champagne may be tried. Severe vomiting may be 
allayed with bismuth or small doses of hydrocyanic acid. Morphia is 
required in many cases to relieve pain. The patient's general health 
must be supported by abundance of such light nourishment as he can 
digest; and an unlimited quantity of fluid, such as barley water, 
" imperial drink," milk, and soda-water may be allowed. Special care 
must be taken in the nursing to avoid bed-sores. Secondary abscesses 
must be promptly opened and drained. 
W. Watson Cheyne. 
ERYSIPELAS 
Definition. - A contagious disease characterised by a peculiar spread- 
ing inflammation of the skin, or more rarely of a mucous membrane, 
due to a specific micro-organism, and associated with general febrile 
symptoms. 
The contagious nature of the disease was not recognised until about 
1850, and apparently first in England. Later Velpeau pointed out 
this fact in France, and showed, as Trousseau had previously done, 
the frequency of its origin in connection with a wound or abrasion. 
In Germany Wernher in 1862 adopted these views, and Volkmann in 
1869. This contagious nature has now been conclusively proved, and 
that the disease originates almost invariably in connection with slight 
wounds or abrasions is generally admitted; but there is even yet much 
dispute as to the exact limits of the name. The older authors applied it 
to a large number of distinct skin affections (such as eczema, etc.), and 
also to diffuse phlegmonous inflammations of internal organs and serous 
membranes. The skin affection known as erysipelas is now sharply 
distinguished, and the name is not applied to internal inflammations ; 
though some authors, following Nunneley (1841), still describe as ery- 
sipelas spreading diffuse forms of inflammation affecting the subcuta- 
neous tissues with or without associated skin affection, and even such 
diseases as whitlow. 
It has also been held that erysipelas can give rise by contagion to 
pyaemia, puerperal fever, and other septic diseases, and vice versa. 
There is, however, no sufficient evidence in favour of these views, and 
the statistics of a report to the Pathological Society of London tend to 
disprove any connection between them. 614 
SYSTEM OF MEDICINE 
It seems more in accordance with the present state of our knowledge 
to regard inflammation of the subcutaneous cellular tissue as a distinct 
(although a closely allied) affection due to a separate cause; and when the 
two affections occur simultaneously and run concurrently, to regard the 
disease as due to a mixed infection. This subject must be further con- 
sidered when the specificity of the causative micro-organism is discussed. 
A distinction has also been drawn between surgical erysipelas, or that 
complicating wounds, and medical erysipelas, which latter mainly attacks 
the face and is supposed to arise idiopathically. Usually, however, it 
arises in connection with some slight injury of surface, and there is no 
essential difference in the two diseases. Although typically a skin affec- 
tion and limited to the cutis vera, the disease may attack mucous mem- 
branes, either spreading to them by direct extension from the skin, or, 
originating on a mucous membrane such as that of the throat, it may 
spread to the skin, or possibly even remain limited to the mucous surfaces. 
Etiology. - The causes of this affection may be either general or local, 
some perhaps act both generally and locally. The disease is widely spread, 
and usually occurs in an endemic form; rarely distinct epidemics of it 
have been noted. Women are more liable to it than men, and people 
between the ages of 35 and 55 are chiefly attacked. Season seems to 
exert a decided influence on its prevalence, the disease being most common 
in spring and autumn, much less so in summer and winter. February 
and November are the months in which the disease is more especially 
prevalent, - months, that is, usually associated with considerable changes 
of temperature, but on the whole cold and damp. This may be in part 
accounted for by the overcrowding in unhealthy, ill-ventilated rooms, 
and the want of proper exercise, which commonly occur at such seasons. 
Erysipelas formerly was not uncommon in the surgical wards of 
hospitals, and especially in those which were ill ventilated or defective in 
sanitary arrangements. In these wards, if once introduced, the disease 
was extremely difficult to eradicate, and nearly every patient with a 
wound would be attacked, the contagion being probably conveyed by the 
hands of the dressers, etc. Where the hygienic arrangements are good, 
and efficient means are taken to prevent direct conveyance of the con- 
tagion by the hands or instruments, the disease shows but little tendency 
to spread; the poison is never widely diffused through the air. It clings 
closely, however, to furniture, bedding, clothes and the like, and may 
be conveyed by a third person. The disease is not uncommon in patients 
debilitated by recent acute diseases such as typhoid fever; and in gen- 
eral it is more common among the poor and weakly, whether from im- 
proper food, bad hygiene, or the exhaustive effects of chronic disease, 
especially perhaps of albuminuria and diabetes. 
Certain persons show a marked disposition to the disease, and suffer 
from many attacks of it throughout their lives: the attacks sometimes 
show a kind of regularity, returning every spring or sometimes even more 
often, and this disposition has been said to be hereditary. It may be in 
part a general disposition, but many cases may possibly be explained by ER YSIPELAS 
615 
the constant presence of a chronic disease producing a weak spot or slight 
abrasion from which the disease originates; in favour of this view it is 
found that the same spot is attacked time after time. Thus such persons 
may be found to suffer from an irritating discharge from the nose or ears 
which excoriates the surrounding skin. It is probable that one attack 
confers immunity for a very short time; it has been found impossible to 
inoculate successfully a patient who had had an attack five weeks pre- 
viously ; a second attack, however, may occur after three or four months. 
The most important predisposing condition is a wound, which may be 
of any size ; the smallest abrasion, by removing the epidermis, seems suf- 
ficient to allow the organisms to gain a foothold. This advantage may 
be given not only by trauma, but by irritating discharges from ozsena, 
otorrhoea, or even a common cold; or by chronic eczema, lupus, and the 
like. It has frequently been asserted that a small wound, such as one of 
these, is invariably the starting-point of the disease, and that, as Volk- 
mann says, erysipelas is a true traumatic infective disease. This view 
is most probably correct, for if very careful search be made, some wound 
or abrasion will be found in the large majority of cases; for the others 
it must be remembered that the wound may have healed during the 
incubation period of the disease, and that if the disease be not seen at its 
commencement, the swelling, etc., that occurs will soon mask it. The 
fact that the disease on the face generally starts at the margins of skin 
and mucous membranes, or near the external auditory meatus, where 
excoriations are so common and so easily overlooked, lends much support 
to this view. In searching for wounds it may be remembered also, as 
Fehleisen has shown, that the disease may first appear at some little 
distance (3 cm.) from the point of inoculation. 
The immediate cause has been most conclusively shown by Fehleisen 
to be a streptococcus very closely allied to, if not identical with the 
streptococcus pyogenes. Micrococci of various kinds had been previously 
recognised in the blood and lymphatic vessels of the skin of the affected 
part, chiefly at and just beyond the spreading margin of the disease, by 
such observers as Lukomsky, Von Recklinghausen, Koch and Billroth. 
They also described the cocci as occurring in the subcutaneous tissues and 
in the internal organs; indeed, there is a great probability that most of 
their observations were made on cases of erysipelas complicated with 
cellulitis or pyaemia. Fehleisen was the first to describe accurately and 
to isolate a specific streptococcus, to cultivate it in pure cultivations 
outside the body, and to demonstrate its direct causal relationship with 
the disease. 
On examining sections of skin taken through the margin of the spread- 
ing redness, he observed numerous micrococci growing in chains in the 
lymphatic vessels and spaces of the corium, not in the blood-vessels as 
other observers had stated; these he found to be most numerous at and 
just beyond the spreading margin of the disease, but in parts where the 
redness is passing or has passed off, the lymphatic vessels and spaces 
become infiltrated with leucocytes and the cocci rapidly die out. A few 616 
SYSTEM OF MEDICINE 
cocci were also seen in the neighbouring subcutaneous tissues; the ap- 
pearances were the same in all of thirteen cases examined. Pure cul- 
tivations were obtained on various nutrient media, - blood serum, jellies, 
and on potatoes. Fehleisen asserts that their growth in these media is 
characteristic, but most observers have failed to detect any difference 
between this growth and that of streptococcus pyogenes. 
Experiments were made by inoculating the ears of rabbits with pure 
cultivations. A definite disease followed, characterised, as in man, by a 
sharp spreading margin of redness without suppuration. On making 
sections of the spreading margin the cocci were found in the lymphatic 
vessels and spaces presenting the same appearances as in man. Other 
organisms may, however, produce similar results in rabbits. But, further, 
Fehleisen, by inoculating persons the subjects of incurable tumour with 
pure cultivations of the cocci, has absolutely proved that these organisms 
are the cause of erysipelas in man. Of seven individuals so inoculated, 
six presented the disease in every way typical; the seventh case failed 
even after repeated inoculation, but he had suffered two or three months 
previously from an attack of erysipelas, and was probably immune. It 
was shown in some of the other six cases that immunity was conferred 
for at least a short time, as repeated inoculations failed to reproduce the 
disease. The method he employed was to make superficial scarifications 
over the part, and then to rub in the pure culture. The incubation 
period in these cases varied from fifteen to sixty-one hours, and it is also 
noted that the disease did not always start exactly at the punctures, a 
fact which has also been noted in cases occurring spontaneously. 
It had long been noted that various malignant diseases - especially 
sarcoma and such chronic skin diseases as lupus and chronic eczema - 
were markedly improved or even cured by an attack of erysipelas; and 
many observers had endeavoured with more or less success to set up in 
such cases a curative erysipelas. It was for this reason that Fehleisen's 
experiments, which at first sight might appear unjustifiable, were under- 
taken ; considerable benefit occurred in most of the cases, although prob- 
ably none were cured. This treatment, almost abandoned because of 
its danger, has lately been revived in an improved form for the cure of 
some forms of malignant disease, the toxins of erysipelas obtained by 
sterilising a pure cultivation of the cocci being employed as a hypodermic 
injection. 
An important question has been raised by a number of observers, who 
have asserted, and many still assert, that the streptococcus of erysipelas is 
identical with the streptococcus pyogenes, and that the different results 
depend on differences in other conditions, such as variation in the viru- 
lence, dose, seat of inoculation, susceptibility of the host, and so forth. 
Fehleisen asserted that in cultivations under similar conditions there were 
marked differences in the modes of growth of the two forms, and also 
that the inoculations in rabbits gave rise to similar but distinctive proc- 
esses. Other observers, however, have totally failed to confirm these 
results. There is no doubt that the two organisms are very closely ERYSIPELAS 
617 
allied species, but that they are absolutely identical seems difficult to 
reconcile with clinical experience in man. On the one hand, there is no 
sufficient evidence to show that the erysipelas cocci can cause suppuration 
in man - this result has never followed experimental inoculation with 
pure cultivations - and, on the other hand, inoculation into the skin of 
streptococcus pyogenes has produced suppuration, but not erysipelas. 
Thus, in opening abscesses which not infrequently contain streptococci, 
the skin is necessarily inoculated; and in one definite case (Rosenbach) 
a dense inflammatory induration appeared round the incision, but ery- 
sipelas has never been shown to result in such cases. The balance of 
evidence, therefore, seems to be in favour of the specific nature of the 
erysipelas coccus, but the point is still under discussion. 
Some further experiments illustrating the mode in which the disease 
is spread may be alluded to. It has been found extremely difficult 
to transmit the disease directly from patient to patient, and pre- 
pared plates exposed to the air of wards containing cases of erysipelas 
have very rarely yielded cultures of the organism. They have been 
most successful when the patients were freely desquamating, when the 
scales thrown off have been shown by cultivation to contain living- 
organisms. Thus it is probable that these scales are the most usual 
means of carrying the disease. 
Pathology. - The minute anatomy of the local lesion has already been 
described, and as it will be further discussed under the symptomatology, 
but little need be said in this place. The redness of the skin disappears 
after death, but some of the swelling remains; blebs and effusion into 
the lax subcutaneous tissue are also seen. These blebs usually contain 
serum more or less turbid; they rarely contain organisms. The loose 
tissues of the eyelids, larynx, etc., may also be seen distended with 
serum, and the tension of the effusion may have been so great as to 
cause gangrene of these parts. 
In patients dying of erysipelas, besides those dying of laryngeal 
stenosis, the characteristic appearances of the more fatal complications 
will also usually be found. Thus in many cases diffuse cellulitis will be 
seen, and often a resultingpycemia. Disease of the kidneys must also be 
looked for. In such cases organisms are commonly found in the internal 
organs, but this is probably not so in simple cases of erysipelas. Pneu- 
monia or bronchitis may also be found, more rarely meningitis ; the latter 
has been said to arise from the inflammation passing directly inwards 
from the scalp to the meninges, or from the face along the trunks of the 
fifth nerve, but it is more probably a pysemic symptom. If a person die 
of simple uncomplicated erysipelas, the internal organs simply show the 
usual signs of a septic disease or those common to the typhoid state, 
namely, swollen congested spleen, enlarged liver, and kidneys with 
cloudy degeneration of the glandular epithelium, etc. 
Symptoms. - The incubation period of erysipelas has been variously 
estimated at from three to seven days. We have already seen that it is 
fifteen to sixty-one hours when the disease is experimentally produced. 618 
SYSTEM OF MEDICINE 
The general symptoms commence somewhat abruptly, simultaneously 
with, or just before or after the appearance of the local lesion. The 
temperature rises rapidly; there is often a more or less severe rigor, the 
patient feels ill, is languid, and often has intense headache, anorexia or 
even vomiting. The fever and constitutional disturbance are usually in 
direct proportion to the extent of the local lesion. Herpes labialis is 
not uncommonly seen, and, apart from cases of erysipelas of the fauces, 
there is soreness of the throat accompanied by general congestion. The 
fever, with varying remissions, usually remains high while the skin 
affection is spreading, and often terminates suddenly with the cessation 
of the spread. The skin is hot and dry, but sweating occurs during the 
remissions of the temperature. Other febrile symptoms, such as rapid 
pulse, frequent respirations, febrile condition of urine, are also present, 
usually in direct proportion to the degree of the fever. In some cases 
after apparent cessation of the symptoms a recrudescence of the disease 
takes place, a fresh rise of temperature, etc., accompanying a fresh local 
outbreak. In the chronic cases of wandering erysipelas the temperature 
takes a very irregular course; it may become normal while the disease 
is still spreading, but usually a fresh spread is accompanied by»marked 
but brief constitutional disturbances. 
In the milder uncomplicated cases the general disturbance may be 
and usually is very slight; in other cases, more especially in debilitated 
constitutions, the gravest symptoms may supervene. The severity of 
the fever and its duration may bring on the typhoid state, and the 
patient sink of exhaustion. In other cases severe gastro-intestinal dis- 
turbances may be present - complete anorexia, obstinate vomiting ac- 
companied by constipation or profuse diarrhoea - and these symptoms 
persist and exhaust the patient. Of albuminuria I shall speak later. 
In other cases, again, and especially in drunkards, nervous symptoms, 
such as intense headache and great restlessness accompanied by violent 
delirium, may be very prominent from the commencement. The delir- 
ium may pass into the low muttering type as the patient sinks into stu- 
por, coma, and death. In most of the severer cases the spleen may be 
made out somewhat enlarged, and the skin is more or less jaundiced. 
Locally, the disease as it attacks the face and head will be alone de- 
scribed. A sharply-defined patch of redness appears on the cheeks - or 
more usually at the junction of the mucous membrane of the nose and 
skin - at the margins of the lips, near the external auditory meatus, 
or near the margin of the hairy scalp. The affected portion of skin 
becomes red, hot, swollen and shiny, and is accompanied by a feeling of 
tension or burning pain; the patch spreads by direct continuity to sur- 
rounding parts. Extension usually occurs unequally in different direc- 
tions, and the disease is very apt to be arrested by a fold in the skin or 
at the margin of the scalp. Where it is spreading there is always a 
sharply-defined, raised red line, separating the healthy from the affected 
tissues, which may be both seen and felt. Behind this line the redness 
and swelling gradually shade off until the parts become normal again. ER YSIPELAS 
619 
The disease lasts in a particular spot about four or five days, so that it 
may still be spreading in another place while the part first attacked has 
become normal. Where the disease spreads over loose tissues much 
serous effusion oozes into them; thus the eyelids become enormously 
swollen, and the eyes are closed, the ears are greatly thickened, the 
wrinkles of the face obliterated, and the features quite unrecognisable. 
Blebs more or less large may also appear on the skin in the severer 
cases and add to the deformity. They contain serum, often turbid, or 
a sticky gelatinous fluid, and soon burst and dry up, leaving adherent 
crusts. Very rarely local gangrene may occur from the intense viru- 
lence of the inflammation and the tension of the effusion in such tis- 
sues as the eyelids, ears, etc. In such cases the eye may be destroyed. 
The glands in the neck are always enlarged and tender. 
Definite abscesses occurring in the skin or subcutaneous cellular tissue 
are most probably the result of a mixed infection, and this is not un- 
likely to be the case when they occur, as is not very uncommon, in the 
eyelids. 
When the disease spreads to the scalp there is usually increased head- 
ache accompanied by much local tenderness and oedema, but without 
redness. The disease may spread from the face to the neck and body. 
In some cases it assumes a chronic form, spreading from place to place 
until nearly the whole body has been attacked, and one part may even 
be affected twice. These cases are more common in children; the consti- 
tutional disturbance varies, but, as a rule, is mild, and recovery may take 
place after many weeks; in infants, however, recovery may be incom- 
plete, and death occur later from marasmus. In these cases also the 
spreading margin of the disease is no longer distinct, but diffuse patches 
appear, often not in continuity. 
Where the disease spreads over a joint, effusion takes place into its 
cavity. This is serous, perhaps turbid, but probably in simple erysipelas 
never purulent. Wherever the skin has been attacked considerable 
desquamation follows, and this, as has already been shown, is the chief 
means of dissemination of the disease. 
I have already said that the various mucous membranes may also be 
attacked by erysipelas; the frequency with which this occurs varies in 
different epidemics. The disease may begin on the skin and spread by 
direct continuity to the mucous membranes of the nose, mouth, etc., or 
conversely ; or, beginning at the junction of skin and mucous membrane, 
may extend simultaneously in both directions. There is also good reason 
to believe that some of the cases described as acute oedematous laryngitis 
and pharyngitis are really examples of erysipelas limited to that region. 
The disease always spreads from the throat to the skin, or vice versa, by 
direct continuity; and cases have been described which illustrate the four 
paths by which this extension may take place. In order of frequency 
they may be enumerated as follows: (1) from the lips by the mucous 
membrane of the mouth, tongue, etc.; (2) by means of the nostrils, na- 
sal mucous membrane, etc.; (3) by the Eustachian tube and auditory 620 
SYSTEM OF MEDICINE 
canal; (4) from the eyes by the lachrymal canal to the nose, etc. The 
mouth, ear, nose, tongue, palate, pharynx, larynx and trachea may all 
be affected. Cornil records eighteen cases in which the throat was 
attacked; in nine of these the affection spread inwards from the skin, 
in seven it originated in the throat. In the former case the throat 
was generally attacked on the third to the fifth day of the disease. In 
all these cases the general symptoms are much more severe, and gastro- 
intestinal disturbances are common. The throat is extremely painful, 
preventing sleep, and causing great pain and difficulty in swallowing. 
When the larynx is attacked there is the further danger of suffocation 
from laryngeal stenosis; or the disease may spread down the trachea, 
and broncho-pneumonia may be set up. 
The local appearances on the palate and fauces are most characteristic. 
The whole part is uniformly dark, shiny, red, and feels dry and burning 
hot. Much oedematous swelling also occurs, especially affecting the 
uvula; the tonsils share in the process, but are not nearly so enlarged as 
in quinsies, and sometimes the sharp spreading margin of the disease 
may be distinctly seen. Bullae, small or large, are frequently seen; at 
first they are well formed and contain turbid serum, but in a few hours 
they burst, leaving yellowish white, membranous-looking patches which 
persist some days. After the disease has subsided dilated veins are 
observed on the part. 
When the nose is attacked the swelling of the mucous membrane 
entirely occludes it. In the mouth erysipelas gives rise to marked 
purplish red swelling and profuse ptyalism. In all these cases the 
glands at the angles of the jaw are markedly swollen and tender, 
causing great pain and difficulty in mastication. 
When the larynx is attacked there is deep red congestion and swelling 
of the whole mucous membrane, and great oedema, especially affecting 
the epiglottis, aryepiglottic folds, and arytenoids. This oedema always 
comes on very suddenly, and may rapidly destroy the patient's life un- 
less urgent means of treatment be adopted. In rare cases the inflam- 
mation goes on to gangrene: this usually attacks the oedematous parts, 
or arises in the membranous patches above described. All the symptoms 
are then aggravated, there is intense prostration, the breath is extremely 
foetid, and septic forms of bronchitis and pneumonia may set in. 
Two other forms of the disease may be briefly mentioned. In infants 
the disease may start in connection with the navel, and, though commonly 
fatal from the feeble resisting power of the patient, it presents no other 
peculiarity. Also in infants or young children the disease is not un- 
commonly seen to start from the vulva. Intense swelling and oedema 
of these parts occurs, with pain and great difficulty in micturition; not 
very uncommonly it results in gangrene. 
Complications and Sequelae.-The most serious local complication of 
erysipelas is diffuse cellulitis; this it is which gives rise to local suppura- 
tion, to pleurisy, pericarditis, meningitis, and the other pyaemic symptoms 
usually described as complications of erysipelas. Apart from septic in- ERYSIPELAS 
621 
fection, pneumonia and bronchitis are occasionally seen, especially if 
the throat be affected. 
Albuminuria is very commonly present as a symptom of erysipelas, 
and acute nephritis is not very rare. In drunkards delirium tremens 
may arise. Still more rarely by implication of the conjunctiva, the nu- 
trition of the cornea may suffer, leading to sloughing and destruction of 
the eye; if the disease spread along the ear and Eustachian tube acute 
suppuration of the middle ear with all its evils necessarily ensues. 
Among sequelae may be noted increased liability to the disease after 
a brief period of immunity; and repeated attacks not uncommonly leave 
a greatly thickened, unsightly condition of the skin. When the scalp is 
attacked there is usually a falling off of the hair, which, however, soon 
grows again, unless the attacks be repeated. Chronic skin diseases - 
eczema, lupus, etc. - are often much reduced or even cured by an attack 
of erysipelas; in many cases after single attacks it has been noticed that 
the skin is finer and softer, and the complexion much improved. 
The diagnosis of erysipelas of the skin is usually quite easy; the 
abrupt raised margin of redness, spreading by direct extension, and 
accompanied by constitutional disturbance, is characteristic. 
Diffuse cellulitis is accompanied by more brawny swelling, and the 
superjacent redness of the skin is more diffuse. The redness accompany- 
ing lymphangitis is also more diffused, and, at least in parts, the thin red 
lines of the larger inflamed vessels may be made out. 
Erythema of the skin occurs in bright red diffuse patches, and spreads 
by the formation of fresh distinct patches. It chiefly resembles the 
migratory form of erysipelas, but is not accompanied by pain or any 
constitutional disturbance. 
Acute eczema spreads by the formation of tiny, pin-point lesions, 
usually minute vesicles; it has a weeping surface, and never anywhere a 
distinct raised margin. Other skin affections - such as herpes, pemphi- 
gus and urticaria - need scarcely be mentioned. 
In the throat, also, erysipelas presents characteristic points apart from 
its general association with skin affection. The pharynx is more acutely 
painful, the constitutional disturbance greater, the local signs of swelling 
and oedema more marked, and the parts of a deeper red than in simple 
acute pharyngitis. The tonsils are not nearly so large or inflamed as in 
quinsy. Herpes of the palate is not associated with so much general 
congestion or swelling, and the constitutional disturbance is slight. 
When the larynx is attacked reliance must chiefly be placed on the ac- 
companying severe bodily prostration to distinguish it from other forms 
of acute oedema. Scarlet fever may simulate both the throat and skin 
affection; but the scarlet rash never appears first on the face and is more 
diffuse and punctiform both on the skin and throat. The pultaceous 
throat sometimes met with in scarlet fever may, however, be indistin- 
guishable from that following the formation of vesicles in erysipelas; 
the diagnosis must then be made by the concomitant symptoms. 
The prognosis of erysipelas, as it occurs in healthy adults, is very 622 
SKS'ZLE'AZ OF MEDICINE 
favourable; but some epidemics are much more severe than others. Mild 
cases last two or three days; the severer ones five to ten days: the 
migrating form may last for weeks, and in any case after apparent ces- 
sation relapses may occur. 
Erysipelas attacking surgical or puerperal patients is apparently 
much more fatal than the kind above described; but the mortality for- 
merly occurring in such cases was probably due in part to the lowering 
treatment (bleeding, and so forth) too often adopted in patients already 
depressed; and in part to other complications of the wound. The 
disease is more fatal in the aged; and in infants it tends to assume the 
spreading form which not unfrequently leads to marasmus and death. 
In patients suffering from chronic renal disease the prognosis is 
extremely bad; it is also grave in the subjects of chronic alcoholism 
or of any wasting disease such as diabetes, phthisis, malignant disease, 
chronic suppuration, and the like. 
Cases in which the throat is attacked are more dangerous than those 
in which the skin is affected alone; and those cases in which the disease 
spreads inwards from the skin are said to be much more dangerous than 
those in which the extension takes places in the opposite direction. 
When the larynx is involved the case becomes extremely grave, apart 
from the special danger of suffocation. Gangrene of the throat is almost 
necessarily fatal. 
In most cases the severity of the general disturbance, the pulse, tem- 
perature, gastric and mental symptoms will give trustworthy data on 
which to base a prognosis. 
Treatment. - The disease being contagious the patient must be 
isolated as soon as possible; especially must he be kept away from all 
communication with patients suffering from wounds, and from puerperal 
cases. The attendants on the sick must also be very careful of any cuts, 
cracks or abrasions on their hands, and these attendants must not at the 
same time look after other patients, especially not those suffering from 
wounds. If these precautions be rigidly carried out, and other cases 
treated aseptically, there is little harm in the patient remaining in the 
same ward with them. On recovery the patient's bed, clothes, and other 
articles must be thoroughly purified, and the walls and furniture around 
well washed. During convalescence, when desquamation is in prog- 
ress, increased care must be taken; if the patient's skin be affected it 
should be well greased with vaseline or olive oil, or, if the area be small, 
with carbolic oil (1-40), and the part sponged with a weak solution of 
permanganate of potash many times a day until the process has come 
to an end. 
In the ordinary milder cases seen in adults no active medicinal treat- 
ment is required. A light, nutritious diet, with possibly a little stimu- 
lant, is prescribed; the action of the bowels should be attended to in 
conjunction with some of the local means of treatment about to be 
described, and the disease will get well of itself. 
In severer cases more active treatment is required, and, the disease ER YSIPELAS 
being essentially adynamic, no lowering methods must be adopted. The 
diet must be chiefly fluid, milk, eggs and the like, with a liberal allow- 
ance of stimulants. If vomiting be present it may be met by effervescing 
mixtures or bismuth, and the regular action of the bowels must be ensured. 
The worst cases require a very large amount of stimulants; and carbonate 
of ammonia and strychnine may be prescribed in addition. Should the 
temperature remain persistently high, or hyperpyrexia be present, the 
effect of large doses of quinine may be tried; but as a rule tepid sponging 
or the cold bath will prove a more efficient method of treatment. Other 
antipyretics are less to be trusted, and have too great a tendency to depress 
the patient. For great restlessness, want of sleep or delirium, spong- 
ing may be employed, or an ice-bag applied to the head. If these fail 
morphia is probably the best drug to use, or bromides with chloral may 
be given. 
In addition to the above symptomatic treatment two drugs may be 
mentioned, which at different times have been considered to act almost 
as specifics. Of these the best known is perchloride of iron, which is 
given in very large doses (nf 40-60 of the tincture) every four hours. 
This drug is certainly well tolerated in these cases, and by maintaining 
the patient's strength probably does good in many. The other drug is 
camphor, recommended by Striimpel, but is of more doubtful value. 
Camphor is given in three grain doses every two or three hours, and at 
the same time the patient is encouraged to drink large quantities of hot 
tea, so that he soon perspires freely. Quinine was also at one time con- 
sidered a specific. 
Numerous methods of local treatment have been recommended at 
various times, the very number showing their general inefficiency. It is 
probable that the simplest are the best; such are dusting the affected 
part with powdered boracic acid, zinc oxide, or a mixture of these with 
starch, and covering the part with a thin layer of cotton wool. This in 
part relieves the painful local sensations, is cleanly, and does no harm. 
For the face, it is a good plan to cut a mask of lint with holes for the 
mouth, nose, and eyes, and to keep this moist with evaporating lead 
lotion. This is very soothing, but must never be applied to any part 
where there is the least tendency to gangrene. Where the pain is great 
tinct. opii (2^-oz. to the pint) may be added to the lotion. These two 
methods are better than simply dusting the part thickly with flour, or 
applying plain water dressings. The dry powders are also much better 
than the various pastes which are sometimes recommended, and better 
than the ointments, at least at this stage. Painting the affected part 
with collodion usually does harm. If there be very great tension in the 
affected part, or gangrene threaten, free incisions must be made into it 
at once, and antiseptic fomentations applied. 
Formerly it was much the fashion to apply nitrate of silver over the 
healthy skin - just beyond the spreading margin of the erysipelatous 
redness-care being taken not to destroy the whole thickness of the skin; 
it was asserted that in a considerable number of cases the erysipelas came 
623 624 
SYSTEM OF MEDICINE 
to a standstill when it reached the line so made. Unfortunately, however, 
it very often crosses at some part or other and spreads on as before. In 
place of nitrate of silver some surgeons use iodine. At first sight the 
value of this method of treatment is not very obvious, and many have 
asserted that in the cases where the disease was arrested at this line they 
had to do with mere coincidence. From recent work on the pathology of 
the disease, however, we can see that the plan was not so foolish as may 
appear. As previously mentioned, the erysipelas cocci spread in the 
lymphatic vessels of the skin, and it has been found that while, on the 
one hand, when we have to do with an acute, rapidly-spreading erysipelas 
there is very little cellular infiltration in the part, yet on the other hand, 
when the process is mild, or when it is coming to a standstill, a large 
number of cells are found forming a barrier against its further progress. 
Now the application of nitrate of silver to the skin in so strong a solution 
as to cause slight ulceration will lead to a rapid exudation of leucocytes 
which may fill up and block the lymphatic vessels of the part; and thus 
when the cocci in their spread reach that line, they may find their path 
barred by a collection of leucocytes. 
Not very long ago, when the parasitic nature of the disease was first 
understood, attempts were made to arrest its spread by the injection of 
weak antiseptic solutions - such as 2 per cent carbolic acid solution, weak 
perchloride of mercury lotion, etc. - into the healthy skin just beyond 
the spreading margin. This method proved untrustworthy. More 
recently, however, it has been improved by Krause, whose method of 
treatment is highly spoken of by those who have experience in erysipelas. 
This plan is to make numerous scarifications in the healthy skin beyond 
the spreading margin, the scarifications crossing one another and com- 
pletely surrounding the disease, as did the old nitrate of silver line. In 
order to carry out this plan efficiently the patient must be placed under 
an anaesthetic. When the scarification is complete, a steam spray-pro- 
ducer, containing 1 to 20 carbolic acid, is made to play on the part for 
some considerable time (an hour or two); it is subsequently dressed with 
carbolic compresses. I cannot speak personally of this method, as my 
experience in the treatment of erysipelas is insufficient. 
When the mouth is affected it should be constantly washed out with 
simple gargles of boracic acid, Condy's fluid, or sanitas; and if the nose 
be attacked it should be gently syringed with similar solutions. When 
the throat is attacked the gravity of the affection must be borne in mind, 
and in spite of opposition on the part of the patient, a considerable 
amount of fluid nourishment and stimulants must be administered. The 
pain of swallowing may be considerably mitigated by the simple plan 
recommended by Mr. Hovell: an attendant standing behind the patient 
makes firm pressure during the act of deglutition over the ears and 
part of the neck below by the palms of the hands, the fingers being 
directed upwards. Locally the patient may be directed to suck ice con- 
stantly, and to use weak antiseptic gargles frequently. Sometimes, on the 
other hand, frequent gargling with a hot saturated solution of bicarbonate ERYSIPELAS 
625 
of sodium will give most relief, and at the same time hot fomentations may 
be applied around the angles of the jaw. If these measures fail, free 
scarification of the palate, and especially of the uvula, will always afford 
relief. When the larynx is attacked the special danger of suffocation is 
added, and treatment must be mainly directed to prevent this. All food 
must be given cold, and all hot or steam inhalations scrupulously avoided. 
Formerly great reliance was placed on leeches, six to twelve being applied 
over the larynx, and they certainly give temporary relief. But their 
tendency is to exhaust the resources of the patient, and usually they 
have to be repeated. Other means of counter-irritation are useless. 
The best plan of all is to keep the patient constantly sucking ice; at the 
same time he should keep quite quiet, and avoid all use of the voice. In 
some cases this treatment will be all that is required. Where, however, 
in spite of this the swelling increases, we must either perform tracheo- 
tomy or freely scarify the larynx. The effect of the latter may be first 
tried in adults, where the patient is not too intolerant of the necessary 
manipulations, and where the dyspnoea is not so extreme as to render the 
method dangerous from the reflex spasm it excites. The method recom- 
mended is as follows: -cocaine is not used, its application wearies the 
patient, excites spasm, and does no good - guided by the laryngoscope a 
long, deep incision is made into each ary-epiglottic fold, most efficiently 
by an open knife like Heryng's, rather than by a guarded instrument 
like Mackenzie's scarifier; it is better to make the incisions into the 
outer side of these folds, so that the blood may have less tendency to 
trickle into the larynx, and thus to cause much discomfort or even 
serious danger to the patient. The bleeding is promoted by gargling 
with hot fluids, and afterwards the patient continues to suck ice. 
If this fail to relieve the dyspnoea tracheotomy will be required, and 
this should be done as soon as its necessity is foreseen, so as to give the 
patient his best chance of recovery. Where scarification is out of the 
question, as in children and adults who cannot tolerate the necessary 
manipulations, tracheotomy offers the sole hope of relief; for all other 
methods of scarifying-by the finger nail, or by a guarded bistoury 
guided by the finger touch - are to be strongly condemned as unscien- 
tific and dangerous. 
When the parts around the vulva or anus are attacked much relief 
may be obtained by immersing the child's body in a warm bath to which 
small quantities of tincture of iodine may be added. The child is swung 
in a sheet and properly supported, and may be allowed to remain in the 
bath twenty-four to forty-eight hours at a time. 
Finally, in addition to the general and local treatment above described, 
the presence of complications must be carefully sought or watched for, 
and especially must the state of the kidneys be investigated, and appro- 
priate treatment adopted in the respective cases. 
W. Watson Cheyne. 
VOL. I 
2 s 626 
SYSTEM OF MEDICINE 
REFERENCES 
1. Bristowe. Article " Pyaemia," Reynolds' System of Medicine, 1862.-2. Burdon- 
Sanderson. " Septicaemia," etc., British Medical Journal, 1877, vol. ii., and 1891, vol. ii. 
- 3. Bonome. Fortschritte d. Med. 1886, No. 1; Deutsche med. Wochenschrift, 1886.- 
4. Cheyne, W. W. Suppuration and Septic Diseases, 1889 (which contains full refer- 
ences down to 1889).-5. Cornil. "Erysipelas," Archives de me'decine. Paris, 1861 
and 1862. -6. Duncan*, Matthews. " Sapraemia," Lancet, 1880, vol. ii. -7. Erichsen. 
Principles and Practice of Surgery.-8. Eiselsberg. V. Langenbeck's A.rchiv, vol. 
xxxv. -9. Emmerich. Fortschritte der Med. vol. v. 1887. -10. Fehleisen. Aetiologie 
der Erysipels. Berlin, 1883; Micro-organisms in Disease, New Sydenham Society, 1886. 
- 11. Gaspard. " Memoire physiologic sur les maladies purulentes et putrides," Jour- 
nal de Majendie, 1822. - 12. Hamilton. Textbook of Pathology. -13. Jeannel. 
L'inf'ection purulente ou pyrhemie. Paris, 1880. -14. Koch, Robert. Aetiologie der 
Wundinfectionskrankheiten; and Traumatic Infective Diseases, New Sydenham Society. 
-15. Knoor. "Identity of Streptococcus Pyogenes and S. Erysipel," Berl. klin. 
Wochens. xxx. 1893, p. 699. -16. Klein. " Behandlung der Erysipels," Berliner klinische 
Wochenschrift, 1891, No. 39. -17. Lockwood. "Traumatic Infection," Lancet, 1895, 
vol. i. -18. Metschnikoff. Arch. f. Path. Anat. cvii. 1887. -19. Nunneley. On 
Erysipelas. Lond. 1841. - 20. Ogston. British Medical Journal, 1881.-21. Osler. 
" Goulstonian Lectures," British Medical Journal, 1885, vol. i. - 22. Paget. "Pyae- 
mia," Lancet, 1886, vol. ii. -23. Panum. " Zur Lehre von der putriden oder septischen 
Infectionen," Schmit's Jahrbiicher, 1855.-24. Ribbert. Deutsche med. Wochen- 
schrift, 1884, 1885.-25. Rosenbach. Mikro-organismen bei d. Wundinfectionskrank- 
heiten des Menschen. Wiesbaden, 1884; Micro-organisms in Disease, New Sydenham 
Society.-26. Sternberg. Manual of Bacteriology.-27. Transactions of the Patho- 
logical Society of London, vol. xxx. 1879. - 28. Vacher and Braidwood. "Report 
to the Scientific Grants Committee," British Medical Journal, 1882, vol. i.-29. 
Vaughan and Nouy. Ptomaines and Leucomaines, 1894.-30. Virchow. Gesammelte 
Abhandlungen zur wissenschaftlichen Medicin, 1862. - 31. Wilks. "Arterial Pyae- 
mia," British Medical Journal, 1882, vol. i. - 32. Ziegler. Textbook of Pathology, 
(translated by D. Macalister). 
w. w. c. 
INFECTIVE ENDOCARDITIS 
Synonyms. - Ulcerative Endocarditis, Malignant Endocarditis, Arte- 
rial Pyaemia, Mycosis Endocardii. 
For some time two forms of acute endocarditis have been distin- 
guished- the simple, benign or verrucose, and the malignant or ulcera- 
tive endocarditis. There now is abundant evidence that in both forms 
of acute endocarditis micro-organisms are formed; and though in some 
cases the same organisms have been found in the two forms, yet as the 
malignant type very frequently implants itself on the chronic form of 
benign endocarditis, and produces a new and often fatal train of symp- 
toms, it is desirable that the two affections, so different in their charac- 
ter and principle features, should be considered separately. 
Various names have been suggested for the malignant type, none of 
which, however, is quite unobjectionable: ulcerative and malignant endo- 
carditis are those now most frequently used. Against the name ulcerative 
endocarditis it may be urged that occasionally no distinct ulcerations are 
found; whilst on the other hand the ulceration which may result from INFECTIVE ENDOCARDITIS 
627 
degenerative changes in chronic endocarditis or in the arterio-sclerotic 
form-the so-called atheromatous ulceration-is not associated with 
the symptoms of malignant endocarditis. Against the name malignant 
endocarditis it may be urged that some cases recover; and again, that 
even the verrucose form may sometimes run a rapid and fatal course (29). 
Infectious or infective endocarditis (E. infectieuse, E. infectante, E. 
vegetante of French authors) is perhaps the least objectionable name, 
but as yet it has not been generally adopted by English writers. 
As there is now clear proof that the cause of malignant endocarditis 
is a microbe, and as in many cases the organisms occurring in septic and 
pysemic diseases have been found in it, we think that the proper place for 
infective endocarditis is amongst the septic diseases ; in deference, how- 
ever, to habit and convenience we propose to consider now only the 
etiology and general pathology of this form of endocarditis: the symptom- 
atology, morbid anatomy, diagnosis and treatment will be dealt with in 
one of the articles on diseases of the heart. 
History and Etiology of the Disease. - Bouillaud (1824-1832) is said 
to have been the first to indicate a form of acute endocarditis which occa- 
sionally began with pysemic symptoms; but he did not recognise the rela- 
tion of the endocardial lesions to the general symptoms: Stenhouse Kirkes 
was the first to comprehend the malignant form of endocarditis; he looked 
upon the general or typhoid symptoms as due to an altered condition of 
the blood produced by the granular masses detached from the diseased 
valves. Virchow not only pointed out the embolic nature of the blocks 
found in the small arteries in cases of valvular lesions of the heart, 
but, in a case of puerperal perimetritis, with peritonitis and diphtheritic 
deposits in the large intestines, he also described coagula with granular 
masses, like diphtheritic deposits on the mitral valve; and he looked 
upon the process as possibly due to a parasitic cause. 
The pyaemic character of malignant endocarditis was also early noted 
by Dr. Wilks who afterwards suggested the name of arterial pyaemia for 
this affection (52) ; he was followed by J. W. Ogle, Murchison, Moxon, 
Bristowe, and other English writers. Bamberger and Friedreich laid 
stress on the similarity of the symptoms in some forms of endocarditis 
and in pyaemia; and of the early French observers we may note Char- 
cot and Vulpian and Lancereaux, who described the clinical characters 
of malignant endocarditis. Not a few observers, such as Hayem and 
Dugues, and Desplats, looked upon the valvular lesions and the le- 
sions in the other organs as local manifestations of a general infectious 
disease. 
Winge was the first to describe microbes (which he spoke of as chains 
of small rods or round granules like chains of leptothrix) both on the 
valves and in the secondary infarcts in a case of infective endocarditis; 
and, as the patient had suffered from suppuration of a toe, he thought 
the microbes, which he regarded as the cause of the disease, were derived 
from this source: he accordingly proposed for the disease the name 
mycosis endocardii. 628 
SYSTEM OF MEDICINE 
Heiberg found microbes similar in character to those seen by Winge 
in a case of infective endocarditis in a puerperal case. He inserted 
particles from the affected valves into the peritoneal cavity of a rabbit, 
but with negative results. 
Nevertheless Heiberg's observations formed the starting-point of a 
series of similar publications all of which made for the existence of 
microbes in the diseased valves: some of the cases, like that of R. Meier, 
were primary infective endocarditis ; in others (Wedel (50)), the primary 
source was septic endometritis, whilst in others again (27), the primary 
disease was pneumonia with empyaema. 
Birch-Hirschfeld not only found numerous micrococci, in zoogloea 
masses and in chains, in the diseased valves and in the metastatic in- 
farcts, but he also succeeded in producing panophthalmitis in three rab- 
bits by inoculation with fragments from the valve deposit. Klebs made 
some important contributions to this subject: from an examination of 
twenty-seven cases of endocarditis he came to the conclusion that all 
forms of this malady are of mycotic nature; the verrucose form being 
due to cocci (monadines), the other (which he calls the septic endocar- 
ditis) to a somewhat different organism (a capsulated coccus). Koester, 
by a series of observations, confirmed the opinion of Klebs that every 
endocarditis, whether malignant or benign, is caused by microbes ; find- 
ing, moreover, that many of the vessels of the affected valves were filled 
with thrombi consisting of cocci, he came to the conclusion that the 
endocarditis was produced by these microbic emboli which rupture the 
walls of the vessel and reach the free surface of the valve. About this 
time Cayley, who suggested the name infecting endocarditis (6), and 
Purcer published malignant cases of endocarditis in which they de- 
scribed the presence of microbes. Litten confirmed the observations of 
Klebs and Koester. In the meantime the clinical features of infective 
endocarditis, and its relation to the simple or rheumatic endocarditis, 
were made the subject of further study by many pathologists and 
clinicians, some of whom will be referred to in the clinical section; at 
present I will mention only the papers by Goodhart (17) and Osler (37). 
With the progress of bacteriology, our knowledge of the organisms 
found in this disease has become more definite; pure cultures of them 
have been obtained, and their behaviour when injected into animals defi- 
nitely followed. A series of important observations were published 
between the years 1885 and 1888, amongst others by the following ob- 
servers : -Wyssokowisch, Cornil and Babes (9), Ribbert, Senger, Bram- 
well, Netter (35), Prudden, E. Frankel and Saenger, Stern and Hirschler, 
Weichselbaum, Dreschfeld, 0. Rosenbach. Of the papers treating on 
the etiology of this disease published since 1888 I may cite those of 
F. Taylor, Gilbert and Lion, G. Lion, Roux and Josseraut, and Dessy. 
If we summarise the results of these and some other observations we 
arrive at the following data: - 
1. That in nearly all the cases of infective endocarditis, whether 
ulcerative or not, microbes were found. INFECTIVE ENDOCARDITIS 
629 
2. That in most cases only one organism was found, but in a few 
(Weichselbaum, Stern, Hirschler, Frankel, etc.) more than one. 
3. That the organism found was not the same in all. In many cases 
an organism was found which occurs in other infectious diseases, whilst 
in some an organism occurred not hitherto found in other diseases. 
The organisms belonging to the first group were: the streptococcus 
pyogenes (including the streptococcus of erysipelas) ; the staphylococcus 
pyogenes aureus, the staphylococcus pyogenes albus; the pneumococcus 
of Frankel and the pneumobacillus of Friedlander; the typhoid bacillus 
(16); the bacillus of tuberculosis (25, 8, 20) ; the bacillus of diphtheria 
(21) ; the gonococcus (29). 
The organisms belonging to the second group were bacillus endocardi- 
tis griseus (Weichselbaum and Netter); micrococcus endocarditis rugatus 
(Weichselbaum) ; bacillus endocarditis capsulatus (Weichselbaum); ba- 
cillus immobilis et foetidus (Frankel and Sanger), and the bacillus of Gil- 
bert and Lion (besides a few others with less definite specific characters). 
4. In most cases the microbe found in the diseased valves was also 
met with in such secondary deposits as infarcts and metastatic abscesses. 
5. The organisms most frequently found were the streptococcus pyo- 
genes, the staphylococcus pyogenes aureus, and the pneumococcus. The 
first two were found chiefly in cases in which the endocarditis was pri- 
mary, in cases of puerperal diseases, of pyaemia and septicaemia (wounds, 
abscesses, osteo-myelitis, etc.), and especially in those cases in which 
the infective endocarditis had attacked valves already affected with 
chronic rheumatic endocarditis. 
The pneumococcus has been found mostly in cases where croupous 
pneumonia was present, and in some of meningitis without pneumonia. 
As streptococci and staphylococci have also been found in the diseased 
valves when the primary disease was enteric fever, diphtheria, gonor- 
rhoea, and so forth, it is evident that sometimes the endocarditis is due 
to a mixed infection. 
6. Experimental investigations on animals have led to diverse results. 
Particles of the diseased valves inserted into the subcutaneous tissue, 
into the peritoneal cavity, or into the anterior chamber of the eye, have 
sometimes produced no effect; but often they have given rise to local 
abscesses. Injections of pure cultivations into the peritoneum or under 
the skin sometimes produced no results; at other times they gave rise 
to marked septic symptoms and lesions. 
Endocarditic lesions have been produced by the injection into animals 
(rabbits and dogs have most frequently been used for this purpose) of 
pure cultivations of the organisms found on the diseased valves in 
cases of malignant endocarditis. Some observers - Ribbert, Perret and 
Rodet, Bonome, Dreschfeld, Mannaberg, Gilbert and Lion, Roux and 
Josseraut, and Vaillard - by injecting pure cultivations into the jugular 
vein of rabbits, succeeded, without previously injuring the valves, in 
producing inflammatory changes with or without ulcerations in the 
aortic valves, and often also on the mitral and tricuspid valves; and in 630 
SYSTEM OF MEDICINE 
the valvular deposits masses of the organisms of the pure culture were 
found both on the surface, in the deeper layers of the deposits, and, in some 
few cases also, inside the capillaries and small arteries of the inflamed 
valves. Other changes found in the animals experimented upon were: - 
Enlargement of the spleen, metastatic infarcts, and haemorrhage into the 
brain. These various lesions, though evidently the result of the mi- 
crobes, were, however, by no means uniformly found. Gilbert and Lion, 
by the injection of a peculiar bacillus found in a case of infective endo- 
carditis into a vein of the ear in rabbits, produced marked endocarditis 
with many secondary changes (softening and haemorrhages in the central 
nervous system). 
The majority of experimenters, however (Rosenbach, Orth, Frankel and 
Saenger, Weichselbaum, etc.), only succeeded in producing endocarditis 
by injuring the aortic valves shortly before injecting the cultures into the 
jugular vein. The aortic valves were injured by introducing a sterilised 
stylet through the carotid into the left ventricle, a method first made 
use of by Rosenbach (43). Secondary or metastatic deposits of microbic 
origin were also found in these animals, together with other changes such 
as enlargement of the spleen, fibrinous deposits in the pleura, etc. 
7. The examination during life of the blood of persons suffering 
from infective endocarditis has shown in a few cases, especially on the 
application of certain methods which will be given in the clinical sec- 
tion, the presence of microbes of the septic kind. 
As regards the nature of infective endocarditis the conclusions which 
we may draw from the above data are: - 
(i.) Infective endocarditis is a disease due to micro-organisms. 
(ii.) This disease is not produced by one specific microbe only; other 
organisms, separately or together, may give rise to it. 
(iii.) The organisms which most frequently are the cause of the 
disease belong to the septic and pyogenetic type (streptococci and 
staphylococci. 
(iv.) Of other organisms, the diplococcus of pneumonia often gives 
rise to infective endocarditis; the specific organisms of enteric fever, 
gonorrhoea, diphtheria, tuberculosis do so very rarely: infective endo- 
carditis occurring in the course of any one of these affections, or found 
in valves already the seat of chronic endocarditis or atheroma, is due 
to septic organisms, and must be looked upon as a mixed infection com- 
plicating these diseases. 
(v.) The organisms more readily attack valves weakened or altered 
by disease. 
(vi.) Some of the microbes found in infective endocarditis are also 
found in the rheumatic or verrucose endocarditis. 
Etiologically we may distinguish the following types of infective 
endocarditis: - 
(a) Primary infective endocarditis. 
(6) Infective endocarditis as a complication of septic disease (pyse- 
mia, septicaemia, puerperal affections, traumatism). INFECTIVE ENDOCARDITIS 
631 
(c) Infective endocarditis as a complication of pneumonia or menin- 
gitis, and due to the diplococcus pneumoniae. 
(d) Infective endocarditis as a mixed infection due to septic organ- 
isms secondary to acute infectious fevers, or secondary to rheumatic 
endocarditis or sclerotic conditions of the valves. 
Remote Causes. - 1. A debilitated state of the system. Though 
infective endocarditis occasionally attacks persons of sound constitution 
and in good health, it is more often noticed in debilitated persons, in 
drunkards, in persons suffering from nervous depression and the like, or 
suffering from such chronic exhaustive diseases as cirrhosis of the liver 
(45a). 
2. The presence of an infectious disease. This point I need scarcely 
dwell upon again. Besides the various affections, septic and non-septic, 
already mentioned, we may note also dysentery, malaria, small-pox, scarlet 
fever, epidemic influenza (Fiessinger) as diseases which, by lessening the 
resistance of the body, favour the entrance and growth of the septic 
organisms. Syphilis does not appear to enter into the causation, and the 
endocarditis accompanying it is more of a sclerotic and fibrous nature 
with fibrous deposits in the myocardium. 
3. During pregnancy and the puerperal state infective endocarditis 
has repeatedly been observed, especially in the presence of a septic or 
pysemic affection of the uterus or its appendages. 
4. Acute rheumatic arthritis, though much more commonly associ- 
ated with rheumatic or verrucose endocarditis, occasionally gives rise to 
malignant endocarditis. Dr. Ogle recorded three cases, and others have 
been mentioned by Osler, Peter, Burkart, Fernet. 
5. Chronic valvular affection of the heart, the result of chronic 
endocarditis or produced by sclerotic changes, commonly enters into the 
causation. Of sixty-nine cases of infective endocarditis, Dr. Coupland 
noticed sixty-one in which the valves had been previously affected, and 
Osler states that in three-fourths of his cases sclerotic changes persisted 
in the valves. (To avoid repetition, I will give the results of my own 
analysis when, in a later article, I consider the clinical aspects of this 
form of endocarditis.) 
6. Gallstones, with or without suppuration in the biliary passages, 
have occasionally been known to give rise to infective endocarditis. As 
yet seven cases only have been published, but I may mention another 
which occurred in a patient under the care of my colleague Dr. Steell. 
Murchison had already noticed this association in his work on Diseases of 
the Liver. Other cases have been described by Jaccoud, by Mathieu and 
Malibran, by Netter and Martha, and more recently by Leva, who gives 
the literature on this subject. Netter and Martha (36) found a small 
bacillus in the biliary abscesses, and also in the endocarditic deposits. As 
the bacterium coli commune is occasionally found in calculous affections 
of the biliary apparatus, the connection between cholelithiasis and infec- 
tive endocarditis, even when there is no suppuration, is easily understood. 
7. That chorea, which is so closely connected with rheumatic endo- 632 
SYSTEM OF MEDICINE 
carditis, may be associated with infective endocarditis, is shown by the 
following case which came under my care about two years ago. A boy, 
aged 11, was taken into the Manchester Infirmary suffering from chorea; 
there was no history of rheumatism, and, on admission, there were no 
signs of endocarditis. A week after admission he began to be feverish, 
and a loud mitral systolic bruit appeared; a fortnight later he showed 
signs of a cerebral affection (severe headache, delirium, optic neuritis, 
hemiparesis). At the post-mortem examination infective ulcerative endo- 
carditis of recent date, and a small abscess of the brain with suppurative 
meningitis, were found. The valves showed no signs of chronic disease. 
Barkley (39) gives a case of chorea, terminating fatally, in which 
endocarditis, abscess of the parotid, and broncho-pneumonia were found; 
the endocarditis in this case may possibly have been secondary to the 
pneumonia. 
8. Traumatism, apart from external wounds and injuries, may give 
rise to infective endocarditis in another way, namely, by an injury 
causing rupture of a heart valve. Biggs gives a case in which the 
aortic valves were ruptured by a fall, and infective endocarditis super- 
vened. A similar and very interesting case came under my notice. A 
gentleman, a patient of Dr. Stott of Haslingden, had been under obser- 
vation for several years on account of slight albuminuria, for which he 
periodically consulted Sir William Roberts. He met with a severe bodily 
strain, and shortly afterwards, not feeling well, consulted Sir William 
Roberts again, who then for the first time detected a loud aortic diastolic 
bruit. He returned to Haslingden and, some short time after whilst 
out shooting in the month of September, he began to suffer from symp- 
toms of malignant endocarditis (repeated rigors, which recurred almost 
daily, intermittent pyrexia in which the temperature rose to 105° F., 
and eventually embolism of the posterior tibial artery): from this state 
after a time he recovered. He is now in the enjoyment of good health, 
though the loud diastolic aortic bruit is still present. 
9. Climatic conditions appear to me to have some influence in this 
matter. I have noticed that cases of infective endocarditis occur more 
frequently during the autumn; and in several cases the patient before 
the attack had spent some time in a swampy or marshy district. De- 
caying vegetable matter may have something to do with the outbreak 
of the disease in these cases. 
10. Infective endocarditis occurs especially between the ages of 20 
and 40. It is very rare in older people, and, according to Osler, it is 
also very rare in children (3 to 4 out of 209 collected cases). From my 
own observations infective endocarditis in children would appear not 
to be so rare as this estimate would indicate. Men are more frequently 
affected than women. 
The paths of entrance of the microbes, as in other septic diseases, 
vary in the different groups of cases. We may notice as the chief 
portals : - 
(a) The skin and subcutaneous tissue. Many of the septic cases, INFECTIVE ENDOCARDITIS 
633 
following abrasion or ulceration of the skin, belong to this group; and 
likewise the cases of infective endocarditis following furuncles, carbun- 
cles, gangrene, erysipelas, and the like. Considering how slight an ab- 
rasion may sometimes be followed by septic infection, it is possible that 
in some cases of the so-called "primary" infective endocarditis the germs 
may have entered the system in this way. 
(&) The osseous system, as in osteomyelitis and otitis media. 
(c) The mucous membranes of the digestive tract. Ulceration of the 
intestines explains the occurrence of septic endocarditis after enteric fever 
and dysentery. In several of the recorded cases, besides the ulceration in 
the intestines, there was an old lesion of the valves. Gangrenous stomati- 
tis and ulcers on the tongue and lip are occasionally quoted (Brissaud, 
Gilbert) as primary channels of entrance. Probably the tonsils, which 
are so often affected in rhuematic endocarditis, may occasionally serve as 
the means of entrance, and thus again some of the so-called " primary 
cases " may be explained. 
(d) Of the biliary passages we have already spoken. 
(e) The genito-urinary organs. The frequent occurrence of infective 
endocarditis in puerperal disease and after abortions has been noted; the 
channels along which the infection travels are the uterine lymphatics and 
veins. In men the mucous membrane of the urinary tract may form the 
starting-point, as in gonorrhoea, or bladder and kidney affections, which 
have sometimes been followed by infective endocarditis. 
(/) Respiratory tract. We know that many infective germs may 
pass into the blood through the respiratory passages, often after having 
caused such changes in the epithelium as facilitate their entrance into the 
blood. But it may also be admitted that germs may pass through the 
lungs, and find their way into the circulation without any previous 
injury. 
The frequent association of infective endocarditis with pneumonia 
need scarcely be mentioned again: the disease has also been noted in 
bronchiectasis by Thiroloix. The microbes, having reached the blood, find 
access to the valves (where they produce more or less extensive lesions to 
be described hereafter under the pathological anatomy of the disease) 
either on their free surface by deposition from the circulating blood - a 
view first set forth by Virchow - or by way of the vessels of the valves 
in which they form small emboli, and thence penetrate into the tissue and 
to the surface - a view already attributed to Kbster. Most observers are 
inclined to adopt Virchow's opinion, one strongly supported by experi- 
mental pathology (seeing that infective endocarditis so often attacks 
valves already diseased), and by argumentsbasedupon the paucity of blood- 
vessels and capillaries in the valves even when inflamed. On studying 
the distribution of the micro-organisms in sections of the diseased valves, 
I have been struck by the gradual diminution in their number from the 
surface of the valve inwards; but this may well be due to the more favour- 
able conditions on the surface of the valve for their growth. 
Several observers, however (Cornil and Babes, Koster and others), 634 
SYSTEM OF MEDICINE 
have described numerous emboli, consisting almost entirely of microbes 
in the vessels of the inflamed valves. There is no reason why we should 
not accept both views of the processes. 
Chemical Pathology. - On this subject, which is sure to become an 
important one in all bacteriological diseases, we have to record the 
observations of Sidney Martin, who, in connection with his important 
researches on diphtheria, studied also the action of the chemical poisons 
in malignant endocarditis and in anthrax. A chemical examination of the 
blood and of the spleen (by his method) from a case of infective endo- 
carditis, in which a staphylococcus, which could be cultivated, was found 
in the diseased valves, showed the presence of two bodies-aproteid(proto- 
and deutero-albumose) and a non-proteid product of strong acid reaction. 
The albumoses when injected into animals produced fever, and retarded 
the coagulation of the blood; and the fever increased with the quantity 
injected: the albumoses from anthrax were more toxic, and caused greater 
loss of weight in the animal. The post-mortem examination of the an- 
imals that died, or were killed, showed that no pathogenetic organism 
was present; when a large single dose of the albumoses was injected into 
the animal fatty degeneration of the heart was found after death. 
Julius Dreschfeld. 
REFERENCES 
1. Bamberger. Lehrbuch der Krankheiten des Herzens, 1857, p. 157. - 2. Biggs. 
Soc. of the Al. of Bellevue Hosp. 1890. - 3. Birch-Hirschfeld. Arch.f. Heilkunde, 
1876, vol. xvii. p. 208. - 4. Bonome. Arch. Ital. de biol. 1887. - 5. Bramwell. 
The American Jour, of Med. Sci. 1886.-6. Cayley. Med. Times and Gazette, 1877, 
p. 509. - 7. Charcot and Vulpian. Gaz. med. de Paris, 1862.-8. Cornil. Abeille 
med. 1884.-9. Cornil and Babes. Les Bacteries et leur role, etc. Paris, 1885.- 
10. Desplats. " De la nature de 1'endocardite ulcereuse," Thes. Inaug. Paris, 
1870. -11. Dessy. Lo Sperimentale, 48, 1894; and Virchow und Hirsch's Jahresb. 
1894, vol. ii. -12. Dreschfeld. Brit. Med. Jour. 1887, vol. ii. p. 998.- 
13. Frankel, E., and Saenger. Virch. Arch. vol. cviii. p. 286.-14. Fried- 
reich. Virchow's Arch. f. path. Anat. 1861. -15. Gilbert and Lion. Compt 
rend, de la Soc. de biologic, April 1888 and Jan. 1889; and Soc. des sciences 
med. Lyon, 1891. -16. Girode. Soc. de biol. 1889, Nov. 9. -17. Goodhart. 
Path. Trans, vol. xxxiii. p. 56. -18. Hayem and Dugues. "Note sur un cas 
d'endopericardite ulcereuse a forme typhoide," Soc. de Biol. 1865. -19. Heiberg. 
Virchow's Arch. f. path. Anat. vol. Ivi. 1872, p. 407. - 20. Heller. Centralbl. f. 
Bacterial. 1887. - 21. Howard. Johns Hopkins Hospital Bulletin, 1893, iv. - 22. 
Kirkes, Stenhouse. Edin. Med. and Surg. Journal, vol. xviii. 1853, p. 119. - 23. 
Klebs. Archiv f. experim. Pathol, vols. iv. and ix. p. 52. - 24. Koester. Virchow's 
Archiv, vol. Ixxii. p. 257. - 25. Kundrat. Wiener med. Wochen. 1883. - 26. 
Lancereaux. Soc. de Biologie, 1862.-27. Lehmann and Van Deventer. Week- 
blad von det. Nederlandsch Tidjschr. 1875.-28. Leva. Deutsch, med. Woch. 1892, 
p. 228. - 29. Leyden. Deutsche med. Wochen. 1893, No. 21; 1894, p. 913. - 30. 
Lion, G. " Essai sur la nature des endocardites infectieuses," These de Paris, 1890. 
- 31. Litten. Zeitsch. f. klin. Med. vol. ii. p. 378. - 32. Mannaberg. Soc. des 
sciences med. de Lyon, 1891. - 33. Martin, Sidney. Local Government Report for 
1891-92, p. 147. - 34. Meier, R. Virchow's Archiv, vol. Ixii. p. 145.-35. Netter. 
Arch, de Physiol, norm, et path. 1886, vol. viii. p. 107; and Arch. g finer. de med. 
1887.-36. Netter and Martha. Arch, de Phys, normal et path. 1886. - 37. 
Osler. " Goulstonian Lectures," Brit. Med. Jour. 1885, vol. i. p. 467. - 38. Perret 
and Rodet. Arch. Ital. de biol. 1887. - 39. Petit (quotes Barkley). "Endo- 
carditis," Traite de medicine, vol. v. p. 148. - 40. Prudden. The Amer. Jour, of PUERPERAL SEPTIC DISEASE 
635 
Med. Sci. 1887. - 41. Purcer. Dublin Jour, of Med. Science, 1877, p. 553. - 42. Ribbert. 
Fortsch. der Med. 1886, No. 1. - 43. Bosenbach, O. Arch.f. exper. Path. vol. ix.; 
Deutsche med. Wochensch. 1887, Nos. 32, 33; article " Herz Krankheiter " in Eulenberg's 
Real encyclopaedia ; and Breslauer iirztliche Zeitsch. 1881.-44. Roux and Josseraut. 
Soc. des sciences med. de Lyon, 1891; and Arch, de med. exper. No. 3, 1892. - 45. 
Senger. Arch.f. exp. Path. vol. xx. p. 389; and Deutsche med. Wochen. 1886, No. 4.- 
45a. Steell. Med. Chronicle, 1892. - 46. Stern and Hirschler. Wien. med. Presse, 
1887, Nos. 27, 28.-46a. Taylor, F. Guy's Hospital Reports, 1891, p. 169. - 47. Thiro- 
loix. Soc. Anat. Mar. 1891. -48. Vaillard. Soc. med. des hopitaux, Fev. 1890.-49. 
Virchow. Gesammelte Abhandlungen, Frankfort, 1856, p. 505; and Arch, fur path. 
Anat. und Phys. 1856.-50. Wedel. "Mycosis Endocardii," Dissertation. Berlin, 1873. 
- 51. Weichselbaum. Wiener, med. Wochen. 1885, No. 41; Med. Jahrb. 1886; and 
Ziegler's Beitrdge zur path. Anat. 1888, vol. iv. p. 127. - 52. Wilks, Dr. Guy's Hosp. 
Reports, 1870, vol. xv.-53. Winge. Nordisk. Med. Arkiv, vol. ii. 1870. - 54. Wysso- 
kowisch. Centralbl. f. med. Wissensch. 1885, No. 33; and Virchow's Archiv, 1886, vol. 
ciii. pp. 301, 333. 
J. D. 
PUERPERAL SEPTIC DISEASE1 
History. - Before the comparatively recent recognition of the influence 
of infective germs in the causation of puerperal septic disease, the views 
entertained of the nature of this terrible scourge of obstetric practice were 
most chaotic and puzzling. Of course the frequency of the disease in 
practice had ensured attention to the subject from the earliest times, and 
explanations were almost endless; generally some prominent symptom 
was supposed alone to indicate the origin of the malady. For instance, 
Hippocrates, Galen, and many of the older authors, who distinctly 
recognised the disease, supposed it to be caused by suppression of 
the lochia, - an opinion which was maintained by many later obstetri- 
cians, such as Smellie, Denman and others. In France the view of 
Puzos that the disease was due to milk metastasis was generally accepted. 
This opinion was obviously derived from a mistaken theory of the 
nature of the peritoneal exudations so frequently observed after death. 
Similar errors prevailed in this country, where the disease was attrib- 
uted to local inflammation; thus one attributed it to peritonitis, another 
to metroperitonitis, to metritis, or to inflammation of the veins and 
lymphatics. Other authors contended that puerperal fever was an 
acute specific fever, occurring in lying-in women only; this view was 
stoutly maintained by Fordyce Barker in his well-known work on The 
Puerperal Diseases. 
It is not surprising that in the face of such various and contradictory 
views our knowledge of this fatal malady was narrow and unsatisfactory. 
Various observers, however, from time to time came to have inklings 
of the true nature of the disease, although these truths are now 
1 It seemed well to include this short article in the System of Medicine, as the general 
physician has often to treat cases of puerperal septicaemia. - Ed. 636 
SYSTEM OF MEDICINE 
only recognised in the light of our recent knowledge. The analogy of 
the interior of the uterus after delivery to the stump of an amputated 
limb (first pointed out by Harvey, and subsequently insisted upon by 
Van Swieten, Cruveilhier and others) was an approach at least to a rec- 
ognition of the identity in this respect of a puerperal and a surgical 
patient, which is the essential fact in the interpretation of septic disease 
in childbirth; but the still more important lesions of continuity about the 
cervix, vagina and vulva, through which the absorption of the infectious 
materials so readily occurs, were not then noted. Some, however, suggested 
that the disease was due to the introduction of animal poisons into the 
system after delivery, and a subsequent vitiation of the blood; as, for 
example, Kirkland, who in 1774 wrote, " It sometimes happens that coag- 
ulated blood lodges in the uterus after delivery, and putrefying from 
access of air, forms an active poison, is in part absorbed, and brings on 
putrid fever." But such passing surmises attracted little attention. 
The enormous mortality occurring in Lying-in Institutions, both in 
this country and abroad, could not fail to startle and shock those who 
knew the facts. When we look back on what occurred it seems almost 
incredible. It will probably be now generally admitted that it is safer 
for a lying-in woman to be delivered in a well-conducted Lying-in Hos- 
pital than in the most luxurious house, of which the hygiene and ar- 
rangements are not thoroughly within our control. Yet not very long 
since in these very same buildings the mortality was at times so great 
that every woman entering them held her life in her hand, and ran a 
risk not less than that of some grave surgical operation. This is 
no exaggerated statement; the history of obstetrics is full of accounts 
of these so-called epidemics of puerperal fever, now happily unknown, in 
which the disease spread from one case to another, or rather was conveyed 
from one case to another, with appalling frequency. Thus in the years 
1760, 1768 and 1770, it prevailed in London to such an extent that in 
some of the Lying-in Institutions nearly all the patients died. Of the 
Edinburgh Infirmary it is said that " almost every woman, as soon as 
she was delivered, or perhaps about twenty-four hours after, was seized 
with it, and all of them died." In the large Maternity Hospitals of the 
Continent the mortality was equally great, and outbreaks of puerperal 
disease occurred in them all, even down to comparatively recent times, 
when they were checked by the general introduction of antiseptic pre- 
cautions. The history of medicine records no such triumph as this. 
The starting-point of our present estimate of the nature of puerperal 
septic disease was the well-known, but at the time little appreciated 
work of Semmelweiss who, in 1847, was the first to show clearly that 
puerperal septic disease was directly conveyed to the patient by hands, 
sponges and the like, defiled by decomposing animal matter; and was 
the first also to point out the influence of cleanliness and antisepsis 
in destroying puerperal contagion, by showing that students who washed 
their hands in solutions of chloride of lime after handling infective 
matter, did not convey the disease in anything like the same measure as PUERPERAL SEPTIC DISEASE 
637 
those who neglected such precautions. After years of calumny and 
neglect his epoch-making observations are now estimated at their proper 
value. The practical identity of surgical and puerperal septicaemia was 
very clearly pointed out by Sir James Simpson in his interesting paper 
" On the Analogy between Puerperal and Surgical Fever," which was far 
in advance of the teaching of the day. It is interesting to note how he 
foreshadowed the enormous gains both to surgery and midwifery which 
have followed the general adoption of the principles of antisepticism. 
"I do believe," he says, " that if any man should ever have the good 
fortune to detect, or suggest any simple and practical measures to avert 
and prevent, or to mitigate and cure surgical and puerperal fever, he 
would, in doing so, confer one of the greatest of all possible benefits 
upon the advancement of surgery and midwifery, and be the means of 
saving numerous lives in operative and obstetric practice. Nor does it 
seem utterly hopeless to expect the possible detection of some such 
measures in the way of prevention, at least, if not in the way of cure." 
Happily the man has been found, with the results, as regards the 
mortality of public Lying-in Institutions, which Simpson predicted, and 
all the world knows. 
Unfortunately, as Dr. Boxall has clearly shown, as yet there is no 
corresponding improvement in the general puerperal mortality of private 
practice. It takes a long time for the paramount importance of the 
somewhat irksome details of antiseptic midwifery to be generally ap- 
preciated. To the bulk of the practitioners educated before the new 
doctrines were taught in the schools, such notions probably appear new- 
fangled and useless, and the uneducated midwives practising all over 
the country probably never even heard of them. In a decade or more, 
when the students of to-day are in active work, there is good reason 
for hoping that the general decrease in the mortality and morbidity 
of childbirth which has followed the introduction of strict clean- 
liness and asepsis into Lying-in Hospitals will be apparent in general 
practice also. 
The recent development of bacteriology, and the recognition of the 
existence of infective germs which may be conveyed to the lying-in 
woman in various ways, have entirely altered the views formerly held 
of the nature of the puerperal fevers, whose identity with the septic 
diseases following surgical operations is practically conceded. The risk 
now seems to be, not that the influence of bacteria in producing puerperal 
diseases should be insufficiently recognised, but that causes of puerperal 
disease difficult thus to explain, but of which there is strong clinical 
evidence, should be discredited or disbelieved because they do not readily 
accord with the new views. In this there is grave danger, since it may 
lead us to overlook sources of disease which might otherwise be guarded 
against or removed. 
Etiology. - It is generally conceded that puerperal septic disease is 
strictly analogous to surgical wound fever [vide art. " Septicaemia"]. It 638 
SYSTEM OF MEDICINE 
may be well, however, to indicate very briefly the present state of our 
knowledge of some special questions concerning the puerperal form of 
the disease. 
First, as regards bacteriology, it seems to be pretty clearly proved 
that as yet no one microbe has been identified as a specific cause of puer- 
peral fever. In the majority of cases of puerperal septic disease, how- 
ever divergent in symptoms, the infection appears to be caused by the 
streptococcus pyogenes, which is found in great quantities, and is prob- 
ably introduced from without, on the hands of the medical attendant 
or nurse, or by infected sponges, instruments and the like. Other micro- 
organisms, such as staphylococci, gonococci, and (as has been shown in 
one case) the bacterium coli have, however, been detected, and may be 
effective either alone, or in combination with streptococci, in causing 
febrile processes in lying-in women; and it seems probable that other 
varieties of pathogenetic micro-organisms may have like effects. Diseases 
originating in this way correspond to those which were formerly described 
as " heterogenetic," the sources of infection being external. It is to 
be noted that these same varieties of micro-organisms are found in 
erysipelas, certain sore throats, and surgical wound fever. There is, 
indeed, an important class of puerperal diseases, originating in the 
decomposition of portions of organic matters in the genital tract (such 
as blood-clots, detached portions of placentae, membranes, and the like), 
which were formerly described as" autogenetic "; it is pretty clear, how- 
ever, that this term is not strictly applicable to cases of this kind, for 
had not these retained matters themselves become infected from without, 
no septic mischief would have resulted. It has been supposed that 
cases of this kind are " sapraemic," the mischief arising from the absorp- 
tion of poisonous ptomaines resulting from their decomposition: it is, 
however, recently contended that sapraemia of this kind is not by any 
means so common as has been supposed; pure cultivations of strepto- 
cocci are generally to be made in these cases, and they are probably due 
to infection from ordinary pus producing organisms. 
Whether strictly " autogenetic " poisoning may occur in puerperal 
women, from pathogenetic organisms existing in the genital tract before 
delivery, is a question which has been hotly discussed. It is supposed 
that such organisms, having no effect during pregnancy, may become 
dangerous when absorbed through the lesions of continuity occurring 
during labour. A large number of observers have examined the vaginal 
and uterine secretions in women after delivery, and those of the vagina 
during pregnancy. The general result is that both before and after 
delivery micro-organisms, generally streptococci, are to be found in the 
vaginal secretions, which do not exist after delivery in the uterine dis- 
charges unless febrile symptoms be present, when they are found in 
abundance. This being so, auto-infection is theoretically possible. It is 
probable, however, that it is of rare occurrence, since Leopold and others, 
on abandoning the use of antiseptic douches before and during labour, 
found that the number of febrile cases in their practice was lessened con- 
siderably. PUERPERAL SEPTIC DISEASE 
639 
That strict antisepsis of hands, instruments and the like is of 
primary importance in midwifery practice has been clearly proved by 
the remarkable results which have followed its introduction into Lying-in 
Institutions in all parts of the world. No satisfactory explanation, 
however, has as yet been offered of the extreme susceptibility of 
puerperal women to the influence of pathogenetic micro-organisms. It 
is clearly not their absorption through lesions of continuity in the gen- 
ital tract which is alone at fault; such lesions continually occur in 
women who have undergone operations about the vagina and uterus, 
when micro-organisms must be present as they are after delivery, and 
yet nothing analogous to puerperal fever occurs. There must, therefore, 
be something besides the mere presence of micro-organisms, something 
which is special to the lying-in woman, which predisposes to this type of 
infection; what is it which causes her structures to afford so favourable 
a soil for the growth and development of such micro-organisms as may 
have gained access to them ? In the answer to this question the explana- 
tion of the proclivity of lying-in women to septic disease will no doubt 
be found, but as yet no very satisfactory answer can be given. The 
hydraemic condition of the blood existing during pregnancy, and the fact 
that immediately after delivery a quantity of excrementitious matter is 
absorbed into the circulation during the process of involution, suggest 
themselves as possible factors in this susceptibility; but further investiga- 
tions in this direction are still much needed. 
Of late years there has been a tendency on the part of obstetricians 
to limit the causes of puerperal infection to pathogenetic matter conveyed 
directly on the hands, instruments and the like, and to minimise the 
influence of contagion conveyed in any other way. There appears to be, 
however, strong clinical evidence that infective material suspended in the 
atmosphere may reach the patient by some other means than by direct 
conveyance. Dr. Amand Routh, in a discussion on this matter at the 
Obstetrical Society, referred to a case occurring in the wife of a butcher 
who was confined over the shop. I have myself been called in to no 
less than three such cases in butchers' wives. In some of these the odour 
of meat permeated the whole house. Is it not probable that infective 
germs, similar to those which convey the contagion in the case of students 
engaged in dissection, were widely diffused, and that no lying-in woman 
is safe in such an atmosphere ? 
A number of cases have been brought forward by myself to prove the 
origin of puerperal disease in defective sanitary surroundings. Similar 
cases have been published by Gueniot and many others; and it appears 
beyond doubt that here is a fertile source of a dangerous kind of illness 
in lying-in women, which has never yet been clinically distinguished 
from puerperal septicaemia due to manual and like conveyance. Is it 
to be assumed, as some seem inclined to assume, that this illness is some- 
thing entirely different from septicaemia, merely because they do not 
admit that pathogenetic microbes can be suspended in the atmosphere 
as well as attached to examining fingers ? It has been suggested that 640 
SYSTEM OF MEDICINE 
as the air of sewers has been proved to be bacteriologically pure, these 
cases may be explained on the supposition that sewer air alone does not 
cause septicaemia, but produces, possibly by some unrecognised ptomaine 
contained in it, a condition peculiarly favourable to the growth and 
absorption of pathogenetic germs after delivery. This hypothesis would 
account for cases, otherwise difficult to explain, in which women, who 
have been exposed for a length of time to sewer emanations without ap- 
parent mischief, show signs of septic disease as soon as labour has taken 
place. 
There is also good clinical evidence that a form of puerperal disease, 
hitherto not distinguished from septicaemia, may arise from the con- 
veyance of the poison of such zymotic diseases as scarlet fever or 
erysipelas, in which the characteristic symptoms of these diseases re- 
spectively are not present. It is impossible in a paper of this description 
to bring forward this evidence, but it exists in abundance. It has been 
supposed that Dr. Boxall's excellent researches disprove this position. 
What Dr. Boxall has proved, and very conclusively, is that scarlet fever, 
and presumably erysipelas and other forms of zymotic disease, frequently 
breed true in lying-in women, and run a normal course. This, so far as 
I know, no one has ever denied. He has not, however, proved, although 
the inference has very generally been drawn, that such diseases always 
breed true. There is, indeed, strong evidence to the contrary; and it 
seems impolitic and illogical to shut one's eyes to recorded facts, and 
to say - as many do - because they do not fit in with certain opinions 
on the causation of puerperal septic disease, " This is a mere coincidence, 
and in these special cases the infection must have been conveyed from 
some other source." It is not very easy to explain why the poison of 
zymotic disease should in one lying-in woman produce a typical case of 
the originating disease, and in another an illness indistinguishable from 
septicaemia. It may be that in the latter case the channel of entry is 
through lesions of continuity in the genital tract. All I can now say is, 
that the evidence of the origin of certain forms of puerperal disease in 
this way is very weighty, and as yet has never been shaken. 
Pathology. - The post-mortem signs in cases of puerperal septicaemia 
are so various as to render any complete description impossible. In the 
most intense form the patient may succumb before definite pathological 
changes, such at least as are evident to the naked eye, have had time to 
appear. There may then be little more to observe than a thin altered 
condition of the blood, and traces of commencing inflammation in the 
veins and lymphatics of the uterus. Microscopically signs of diffuse 
mischief may be found in almost all the tissues, as shown by granular 
infiltration and disintegration of cell elements. 
In the more chronic cases extensive pathological changes are found 
in many organs. The genital organs themselves are largely implicated. 
The vagina will generally be found inflamed and oedematous, and any 
lacerations about the perinaeumor cervix swollen, especially at their edges, PUERPERAL SEPTIC DISEASE 
641 
and covered with a dirty yellowish membrane. This membrane is chiefly 
formed of pus cells and necrosed tissues, and, in the event of recovery, 
is thrown off, leaving a healthy granulating surface beneath. The tissues 
of the uterus show signs of oedematous infiltration, and become soft and 
swollen. The endometrium is covered with a purulent debris; or it may 
become necrotic, and the underlying tissues bared or partially destroyed 
in portions. The lymphatics are especially enlarged, and their dilated 
cavities filled with a yellowish fluid consisting of pus and masses of 
cocci. From them inflammation spreads into the para-metritic connective 
tissues all round the uterus, between the folds of the broad ligaments, 
and even into the iliac fossae; and this may eventually resolve or may 
terminate in abscess. Salpingitis and ovaritis are generally met with, 
and the canals of the tubes may also be filled with infected pus. 
Some form of peritonitis is almost always present. This may be 
limited to the neighbourhood of the pelvis, and then the folds of the 
peritoneum are matted together with exudation. Diffuse general peri- 
tonitis is of very common occurrence, the pathogenetic matters being 
conveyed through the inflamed uterine lymphatics, or along the tubes to 
the peritoneum. Then follow very various results of the peritonitic 
affection. The cavity of the peritoneum is filled with an offensive serous 
fluid, the surfaces of the intestines are covered with a fibrinous exuda- 
tion, their muscular tissues are swollen and oedematous, and they are 
often enormously distended with flatus. 
Other serous cavities are often attacked, probably through the 
lymphatics wrhich have been found full of bacteria at great distances 
from the uterus; and marked inflammations of the pleurae, the peri- 
cardium, and even of the larger joints are common. 
Thrombi in the veins may play an important part in the pathology 
of the disease, as they may become infected by bacteria conveyed to 
them in the blood. In the course of the changes naturally occurring in 
these blood-clots they soften, and minute infective emboli detached from 
them may be carried to distant parts of the body, and there, becoming 
impacted, may give rise to multiple abscesses, pneumonia, and other 
complications of the septic process. 
Symptoms. - As puerperal and surgical septicsemia are due to like 
causes, so are the resulting symptoms much alike. 
The first symptom to be observed is an initial rigor, which may be 
so slight as to escape notice; but on inquiry it will generally be found 
that the patient had complained of chilliness, which attracted little 
attention at the time. This may occur as soon as twenty-four hours 
after delivery, more commonly on the third or fourth day, and rarely, 
if ever, after a week. Puerperal illnesses commencing later are of doubt- 
ful septic origin, as in cases in which the distinct influence of sewer gas 
emanations are traced; or, it may be, that the initial symptoms were 
so slight as to escape observation, until some secondary complication, 
such as pelvic inflammation or phlegmasia dolens, appeared. During a 
2 T 
VOL. I 642 
SYSTEM OF MEDICINE 
protracted septic process fresh rigors may from time to time occur, due 
to the absorption of more poison, as in cases in which putrefying organic 
materials remain undisinfected in the passages; or in the pysemic type 
of disease, in which coagula formed in the veins soften and break down, 
and infective emboli, becoming thus detached, are carried to and arrested 
in distant parts of the body. 
Following the initial rigor, fever, indicated by elevated temperature, 
is always present, and continues until death or convalescence. There is 
no very definite period of the pyrexia, which varies according to the 
nature of the case, the intensity of the poison, the occurrence of second- 
ary complications, and the like. In the accompanying Charts, copied 
from my Treatise on Midwifery, these variations are well shown. 
Sometimes (as in Charts 7 and 8), it remains uniformly high - from 102° 
up to 104° or 105° - even during a protracted illness, until convalescence 
or death; at other times (as in Charts 5 and 6), it shows marked remis- 
sions and exacerbations, the latter probably being caused by fresh 
absorption of septic materials. With fever the pulse is always frequent, 
Chart 2. PUERPERAL SEPTIC DISEASE 
643 
ranging in bad cases from 120 to 140, and becoming thin, compressible, 
and even imperceptible. 
The other symptoms of septicaemia vary considerably with the type 
of disease which is present. 
In the most intense cases' (such as were formerly so often seen in 
Lying-in Hospitals, but now happily rarely met with), the patient may 
Chart 3. 
be overwhelmed from the first by the intensity of the disease. The 
temperature ranges from 104° upwards, with little or no remission (as 
in Chart 8) the pulse is rapid, small, compressible, running up to 140, 
or it may even become uncountable. The countenance is sallow and 
anxious, and the tongue dry and furred; the intelligence as a rule is 
unimpaired, although towards the end there may be low muttering 
delirium. 
In a type of disease which is not so intense, but analogous in char- 
acter, and in which the septic poison is probably absorbed through the 
lymphatics, the symptoms are of the same kind, but not so severe. The 644 
SYSTEM OF MEDICINE 
illness generally commences within three days; in Charts 2, 6, and 8 it 
will be seen to have begun on the second day. The fever runs high, 
even to 105°, and it may continue elevated for three weeks and up- 
wards, as in Chart 7. More frequently the disease ends in one way or 
another within a fortnight. The pulse is rapid, thin and compressible. 
The tongue may be clean, or even dry and cracked, but this generally 
occurs when too much stim- 
ulant has been given. In 
such cases extreme disten- 
sion of the abdomen is usu- 
ally a marked symptom, not 
due to peritonitic effusion, 
but to paralysis of the intes- 
tinal muscles, and to exces- 
sive flatulent distension. It 
is not, as a rule, tender on 
pressure, and generally, even 
when the illness is intense, 
the patient makes no com- 
plaint of suffering. The 
bowels may be constipated; 
but sometimes, and as the 
disease makes unfavourable 
progress, uncontrollable di- 
arrhoea supervenes. Vomit- 
ing of dark, grumous, coffee- 
colouredmatter is sometimes 
present. The respiration is 
often hurried and panting, 
and if the pleurae or pericar- 
dium become affected, char- 
acteristic friction sounds 
may be heard. The skin is 
at first dry and burning, and 
frequent mottled red septic 
rashes, of an erythematous 
character, may be seen about 
the chest and abdomen; later in the disease profuse perspirations are of 
frequent occurrence. The intelligence as a rule is not much affected: the 
patient may be dull and heavy, and she is generally unconscious of the peril 
in which she is placed; but her faculties may otherwise be clear to the end. 
At other times delirium, but never of a very intense type, may be present. 
The cases in w'hich the venous system is more especially affected 
are, as a rule, more protracted in their course, and more marked in the 
remissions which may occur; the temperature falling nearly to normal, 
and again rising, after a fresh rigor, from the causes already described. 
When the septic process leads to perimetritis or parametritis the 
Chakt 4. PUERPERAL SEPTIC DISEASE 
symptoms are modified accordingly. Much more abdominal pain is felt, 
and there are always characteristic local signs depending on exudation 
in and about the pelvis, involving the peritoneum or the connective 
tissues. This may be absorbed if the case run a favourable course, or 
the inflammation may run on to suppuration, and end in pelvic abscess. 
In the more purely pyaemic cases we may have prolonged elevation 
of temperature of a hectic type, with morning remissions, and the 
645 
Chart 5. 
eventual formation of multiple abscesses in various parts of the body ; 
or suppuration may occur in the larger joints. Occasionally there may 
be general peritonitis instead of the localised form of the disease: then 
the symptoms are much more intense; there is acute pain and general 
tenderness, and the abdomen soon becomes greatly distended from gaseous 
expansion of the intestines. Very constant and distressing vomiting is 
usually present, and such a case will generally end fatally in a few days. 
It is needless to say that these symptoms may all, or some of them, 
be very variously mixed in particular cases. Hence the paramount 646 
SYSTEM OF MEDICINE 
importance, when in attendance on any case of septicaemia, of carefully 
watching day by day for the various complications that may occur. 
Treatment. - If there be one disease more than another in which the 
time-honoured adage, "Prevention is better than cure" should be inces- 
Chabt 6. 
santly borne in mind, it is surely puerperal septicaemia. To enter into 
the details of preventive treatment, however, would involve a recapitu- 
lation of the whole subject of practical attendance on lying-in women, 
especially of antiseptic midwifery, to the importance of which all students, PUERPERAL SEPTIC DISEASE 
practitioners, and nurses are now, it is to be hoped, thoroughly alive. 
Briefly, absolute cleanliness of hands and instruments; the disuse of 
sponges; the thorough washing of the hands, first with soap and water, 
then with antiseptic lotions (such as the 1 in 1000 solution of perchloride 
of mercury); the judicious use of antiseptic douches before and after 
647 
Chart 7. 
delivery and during convalescence; the avoidance of needlessly-repeated 
vaginal examinations; the closure with aseptic ligatures of all attainable 
breaches of continuity in the genital tract, such as lacerations of the 
perinseum; attention before delivery to such questions of hygiene as 
drainage, the avoidance of contagion, and the like, form the main head- 
ings of this all-important topic. 648 
SYSTEM OF MEDICINE 
When once the conflagration has begun, it may now and again be 
possible to extinguish it soon by removing any obvious source of mis- 
chief, such as by washing away decomposing materials in the genital 
tract, the removal of the patient to a fresh and unvitiated atmosphere, 
and so on; but more generally our aim must then be to watch the 
patient until the septic process has burnt itself out, to minimise its 
ravages, and to keep her alive until the imminent danger is over. 
Chart 8. 
On the first advent of threatening symptoms the possible pres- 
ence of any removable cause of septic infection should be carefully 
investigated. 
It will be well to make a thorough local examination to see whether 
there be any sloughing surfaces about the vulva, or a lacerated peri- 
naeum, which, if lacerated, should be disinfected as completely as possible 
by scraping, dusting with iodoform, and the like. One or two irriga- 
tions of the uterine cavity, which should be administered by the practi- 
tioner himself, may cut short a threatened attack by washing away PUERPERAL SEPTIC DISEASE 
649 
infecting organic matters. Tincture of iodine dropped into warm water 
until it is of a dark sherry colour, a solution of creoline in water, or a 
1 in 2000 solution of perchloride of mercury, are amongst those which 
are most effective. Subsequently antiseptic vaginal douches should be 
given night and morning. The value of such antiseptic irrigation of the 
uterine cavity cannot be exaggerated in any case in which decomposing 
portions of membranes and the like are retained in utero. It is not 
uncommon under such circumstances to see very threatening symptoms at 
once cut short (Chart 4), and there are few cases in which they should 
not be administered. To be effectual, however, the irrigation must be 
thorough, and it is useless to trust it to the nurse, as is frequently done. 
Two or three intra-uterine douches should be sufficient, and as the process 
is often painful, and always annoying to the patient, it is rarely needful 
to continue it. Of late, especially in Vienna, curettement of the uterine 
cavity, followed by swabbing with linimentum iodi, has been much rec- 
ommended. It is likely to be very useful when there are portions of 
retained placenta in the uterus; and in skilled hands it is a very effec- 
tive way of thoroughly disinfecting the uterine cavity, but it requires a 
certain aptitude and experience, and the procedure is not free from risk. 
The sanitary condition of the house should be investigated and, if 
found defective, the patient should be removed at once to another room, 
or even to another house, if practicable. In any case it is often use- 
ful to remove the patient from the lying-in chamber, the atmosphere 
of which must generally be unwholesome from long occupation, even 
if it be not otherwise tainted. It is impossible to exaggerate the impor- 
tance of thorough ventilation, and of a plentiful supply of pure fresh 
air. I have frequently been struck with the improvement following 
this simple procedure. 
The general treatment resolves itself into measures for supporting 
the strength of the patient during the progress of the disease, and into 
the administration of such drugs as are likely to alleviate the symptoms 
and to lessen their intensity. 
The former indication is best met by administering an abundance of 
easily assimilated nourishment at frequent intervals, say every second or 
third hour, such as strong beef tea, Brand's essence, milk, eggs beaten up 
with milk, and the like; and nowhere is the value of trained and efficient 
nursing more apparent than in the conduct of this important part of the 
treatment. In a disease in which there is generally a marked tendency 
to prostration stimulants will sooner or later be required. It must be 
admitted that they have often been given in needless excess, an error 
which it is necessary to guard against; nevertheless, in bad cases their 
use in moderate quantities (such as a tablespoonful of good old brandy 
or whisky every four or six hours) will be very valuable, strictly pro- 
portioning the quantity to the degree of debility and prostration. In 
very severe cases, in which the pulse is rapid and thready, and there is 
much low delirium, tympanites and sweating, their free use in larger 
quantities may be necessary to save the life of the patient. 650 
SYSTEM OF MEDICINE 
Medicinally drugs which lower the temperature are most useful. In 
an early stage probably antipyrine in doses of 20 grains, combined 
with 30 minims of sal-volatile to counteract depression, answers best; 
or in its place 2 or 3 grains of salicylic acid, or salicylate of soda, may 
be given. These cannot, however, be continued more than a day or two, 
and later it is best to trust to the antipyretic action of quinine. Quinine 
is not uncommonly given in small doses of 5 grains thrice daily, but I 
much prefer to administer it in full doses of 20 grains night and morn- 
ing ; this will often reduce the temperature two or three degrees. It 
may be advantageously combined with 15 or 20 minims of tincture of 
perchloride of iron, with a drachm of glycerine, thrice daily. The iron 
is unquestionably a valuable drug, and the glycerine, by its antiseptic 
properties, seems to lessen the distressing tympanites which is frequently 
present. In a protracted case it is often advisable to change the drug; 
and, not rarely, when other antipyretics have failed, two or three doses 
of Warburg's tincture have proved very efficacious in reducing the 
temperature (Charts 5, 6 and 7). 
In cases marked by hyperpyrexia, with a temperature reaching 105° 
and upwards, cold may be advantageously tried to bring down the body 
heat. One of the best ways of applying it is a Thornton's ice-cap, by 
means of which a current of iced water is kept running continuously round 
the head. It is comforting to the patient, and often relieves the throbbing 
headache from which she suffers. When in use it often brings down 
the temperature two or three degrees. The external application of 
cold, by sponging or by the use of towels soaked in ice-water, may be 
tried in very severe cases; but this treatment is troublesome, and as it 
is palliative and not curative, it is not often called for. 
The only other remedial means specially calling for notice is the use 
of aperients, formerly much employed. In the early stage of the disease 
one or two doses of calomel (of 4 or 5 grains each) certainly seem to act 
well, and may generally be administered with advantage. It is to be 
remembered, however, that as the disease progresses diarrhoea, often 
uncontrollable, is very apt to supervene, and aperients should therefore 
be employed with caution. 
It is to be hoped that further research will give us some means of 
counteracting the septic state of the blood; and it is not unreasonable to 
look for some valuable aid in this direction from the advances now being 
made in sero-therapeutics. 
Abdominal section has been much discussed of late years in connec- 
tion with puerperal septicaemia. The successful cases have been chiefly 
where localised collections of pus were present, as in pelvic peritonitis, 
or in diffuse general peritonitis occurring six or seven weeks after the 
commencement of the disease. Although septic in origin, such cases 
can scarcely be called true cases of puerperal septicaemia. In the acute 
form of the disease, with great abdominal distension, laparotomy would 
not only be a most difficult and hazardous operation, but since the 
septic infection is general and not local, would promise little or no 
hope of benefit, even if practicable. FURUNCLE 
651 
In every case special events and complications may present themselves 
for which no exact rules of management can be laid down, and which 
must be dealt with on general principles as they arise 
W. S. Playfair. 
REFERENCES 
1. Barker, Fordyce. The Puerperal Diseases. - 2. Black, J. Watt. Inaugural 
Address on the Bacteriology of Puerperal Fever, Obstet. Trans, vol. xxiv.- 3. Boxall, 
" Fever in Childbed," Obst. Trans, vol. xxxv.; "The Mortality of Childbirth," Lancet, 
1st July 1893; " Scarlatina during Pregnancy," Obst. Trans, vol. xxx. - 4. Doederlein. 
Arch.f. Gynsek. 1891, xl. 99. - 5. Gueniot. "Du Mephitisme de Fair comme cause de 
Septicaemie Puerperal," Bui. de I'Acad. de Med. 1892.-6. Kirkland, Thos. On Child- 
bed Fevers. London, 1774. - 7. Leopold and Goldberg. Arch.f. Gynsek. 1891, xl. 
439. - 8. Playfair, W. S. " On Defective Sanitation as a Cause of Puerperal Disease," 
Lancet, 5th February 1887; " A Lecture on a case of Puerperal Septicaemia with Hyper- 
pyrexia treated by the continuous Application of Cold," Brit. Med. Journ. 1877, v. 2, 
p. 687.-9. Semmelweiss. Der Aetiologie, der Begriff, und die Prophylaxis des kind, 
bet Fiebern. Wien, 1861. -10. Simpson. "The Analogy between Puerperal and Sur- 
gical Fever," Edin. Month. Journ. of Med. Science, November 1850. -11. Weiss. " On 
Curettement in Puerperal Septicaemia," Amer. Journ. of Obstet. 1st August 1892. -12. 
Williams, J. W. Eridge. " Puerperal Infection considered from a Bacteriological 
Point of View," Amer. Journ. of Med. Science, 1893. 
W. S. P. 
FURUNCLE 
(boils) 
A Furuncle is accompanied, by intense inflammation of the entire 
thickness of the skin, and of the underlying connective tissue. It com- 
mences with thickening and induration of the dense tissue immediately 
surrounding a sweat gland or hair follicle, and produces a slight eleva- 
tion of the skin, which rapidly increases until the third or fourth day, 
when it attains its full development. The area which it now occupies 
depends upon the density of the skin and the facility with which infiltra- 
tion has occurred. Sometimes it has a diameter of one inch, at other 
times of more than five inches. The central portion is a dusky red and 
surrounded with an intensely congested zone of a bright red colour; 
beyond this, again, is an area which is less congested, but often contains a 
considerable quantity of oedema fluid. The induration about the centre 
is sometimes so great that the part feels like a piece of cartilage set in 
the softer tissues round it. Very soon a small orifice appears at the 
most prominent part of the swelling, and through this orifice a small 
quantity of purulent fluid, and later the characteristic slough, escape, 
leaving behind a small cavity, with ragged, shreddy, and readily bleeding 
walls. The slough consists of a network of coarse connective tissue, 
containing in its interstices a quantity of pus cells and micro-organisms. 652 
SYSTEM OF MEDICINE 
With the escape of pus and separation of the slough the tension and 
pain are greatly diminished. The healing process .commences in the 
usual manner, and finally a permanent scar results. 
Situation. - Furuncles may occur on any part of the body, but the 
favourite seats are those parts which are subject to dirt or friction, such 
as the nape of the neck, the nates, the outer surface of the thighs, the 
auditory meatus and nostrils. They are very rare, however, on the palm 
of the hand and sole of the foot, and are not common upon the abdomen or 
scalp. They are unusual in infants and in persons over thirty, but are 
most common during the period of life when severe and irregular exercise 
is taken. This is especially noticeable in schoolboys and young men. 
Etiology.-Women are much less frequently attacked than men. 
Persons whose general tone is impaired by poor living, or by a severe 
illness, are very prone to these affections; they are extremely common 
in persons who suffer from diabetes, and not uncommon in albuminuria. 
On the other hand they occur in young people while training for certain 
sports, more especially in rowing men, who are apparently in good health 
and are carefully fed. 
Whatever part constitutional states may play, it is certain that the 
occurrence of a furuncle is impossible without the intervention of pus 
micro-organisms. Staphylococcus pyogenes aureus or albus, or both 
together, are invariably present, and pure cultivations of these organisms 
can be readily obtained by transferring a little of the pus to any of the 
nutrient media which are commonly used for such purposes. When 
inoculated into man, either in the form of pure culture or directly from 
a furuncle, they give rise to similar circumscribed suppurative inflamma- 
tions. This has been repeatedly demonstrated by good observers. The 
occurrence of furuncles in successive crops is due to reinoculation from 
the surface, and has nothing to do with the circulation. The impetigo 
or scrum-pox of Rugby football players, described by Mr. Armstrong of 
Wellington College and other authors, seems to be traced to chafing 
by jerseys infested with pyogenetic cocci. Frequent washing and stov- 
ing of flannels is, therefore, very important in all such cases [yide art. 
" Impetigo "]. If the micro-organisms were carried to the capillaries of 
the skin by the blood stream, we should expect to find evidence of 
abscesses localised in internal organs. Moreover, if the skin round the 
furuncle be kept perfectly clean no such crops occur. 
In a simple furuncle the struggle between the micro-organisms and 
the tissues is confined to the abscess wall; and, though inflammation and 
oedema may exist for a considerable distance round it, it is not possible 
to obtain a culture from the oedema fluid of this area. Sometimes, how- 
ever, when a furuncle is large, or is rapidly followed by the appearance of 
others in its vicinity, the first barrier is transgressed, and the organisms 
travel along the lymphatic channels, causing enlargement of the glands 
which drain them. At other times, when the inflammation is yet more 
severe, this second line of defence is also broken through, and the 
organisms gain access to the general circulation, thus producing septi- FURUNCLE 
653 
ceemia which may be complicated by the formation of localised abscesses, 
and even terminate fatally. 
Treatment. - In order to prevent the further formation of furuncles 
the whole of the skin should be thoroughly cleansed with soap and 
water, and the parts around them with sublimate lotion; the furuncles 
must be covered with moist, warm, antiseptic compresses frequently 
changed, and the underclothing boiled or stoved. The patient must be 
warned not to touch the affected part lest he inoculate himself elsewhere. 
A furuncle may often be induced to abort by injecting a few drops 
of carbolic acid into its centre. If pus is already formed, an artificial 
opening may be made by the application of several small crystals 
of carbolic acid in succession over the most prominent part of the 
swelling. The surrounding skin should be protected with vaseline and 
the excess of acid mopped up as the crystals liquefy. The crystals 
may be applied with a heated needle to which they readily adhere. This 
plan, though painless, is a little tedious. Incisions are extremely painful, 
and few people will submit to this treatment. There is, however, no 
other method by which such rapid relief may be given, especially when 
the boil is large and the tension great; and in those extremely painful 
forms which occur in the auditory meatus and nostrils. 
After the escape of pus an attempt may be made to disinfect the 
cavity by thrusting into it a few more crystals of carbolic acid by means 
of a probe. The dressings are now to be applied and changed every four 
hours. The double cyanide gauze, which is both absorbent and anti- 
septic, is the best; poultices, however, retain their heat longer, and are 
far more effective in relieving pain, especially when there are a number 
of furuncles, many still in an early stage. Unfortunately poultices 
are not absorbent, and the discharge is apt to collect beneath them 
and reinfect the neighbouring skin. This risk of reinfection can be 
overcome by making the poultices antiseptic. For this purpose two 
drachms of pure carbolic acid should be added to half a pint of boiling 
water together with or immediately before the addition of the linseed 
meal. The poultice will contain roughly 1 in 45 of carbolic acid, and 
will be found to destroy pus micro-organisms; and although certain 
spore-bearing bacilli found in the linseed, and at times on the skin, are 
not destroyed by it, yet their growth is entirely arrested. Children are 
soon irritated or even poisoned by the use of carbolic acid on the skin; 
less must be used for them, and a fresh poultice should be applied every 
four or five hours. Before applying it the skin should be freed of all 
discharge and well disinfected. 
It is well to bear in mind that although a furuncle is a comparatively 
insignificant lesion, it may at times and in unhealthy persons give rise to 
serious trouble. Its proper treatment should, therefore, not be neglected. 
The urine should be tested, and if sugar or albumin be found the 
recognised treatment for these conditions should at once be adopted. If 
the general health is good, and the furuncles few in number, no drugs are 
required; good plain feeding and fresh air are all that is necessary. If, 654 
SYSTEM OF MEDICINE 
however, the furuncles are numerous and the strength failing, large 
doses of iron should be given. The various drugs alleged to have spe- 
cial healing properties in these affections are, so far as we know at the 
present time, quite useless. w s> Melsome. 
The relation between a furuncle and a carbuncle is a simple one. 
Their etiology and pathology are the same; clinically, however, they are 
somewhat different. A furuncle has one suppurating focus which results 
in the formation of a single orifice; a carbuncle consists of a number of 
furuncles grouped together upon a larger area, it gives rise to a flattened 
rather than a conical elevation, and results in the formation of several 
orifices or in the sloughing of a large portion of skin: a carbuncle is 
often attended with very serious consequences. 
It occurs more often in advanced life, and is especially common in 
those who suffer from diabetes or Bright's disease. It begins as a firm, 
painful swelling which rapidly spreads. Its colour, at first red, soon 
changes to purple or varies in different parts so as to appear mottled. It 
is accompanied by a rise of temperature and considerable depression of 
spirits. Extensive infiltration, cartilaginous firmness, and pain are the 
prominent symptoms. It may attain enormous dimensions; sometimes 
it occupies an area as large as a dinner plate, and extends deeply into 
the subjacent tissues. The constitutional symptoms are correspondingly 
severe. It is indeed in these progressive forms of the disease that death 
from exhaustion and septicsemia are to be feared; even in those which 
are more limited and less rapid in their progress, thrombo-phlebitis and 
localised abscesses are by no means uncommon. 
Treatment. - Bearing in mind the exhausting effects on the constitu- 
tion and the liability to such serious consequences, it will be understood 
that the treatment of carbuncle must be energetic. A conical or crucial 
incision should be made under strict antiseptic precautions, and the in- 
fected tissues scraped with a sharp spoon. The cavity is then dried as 
thoroughly as possible and disinfected by carefully swabbing the whole 
raw surface with pledgets of cotton wool soaked in pure carbolic acid; 
but before deciding on this step we must carefully consider the size of 
the carbuncle and the age and vitality of the patient, remembering 
that, unless the incision be made early, severe hsemorrhage may occur. 
If we decide on incision it must be done at once. Every delay adds to 
the danger, not only by increasing the liability to haemorrhage, but also 
by reducing the strength of the patient. During the last few years good 
results have been obtained by injecting carbolic acid at several points 
round the circumference of the carbuncle. This plan has been especially 
advocated for checking the advance of facial carbuncles, which are excep- 
tionally dangerous owing to the close connections between the veins of 
the face and those at the base of the brain. For those who refuse 
operation we have to decide between hot and cold applications. If the 
CARBUNCLES EPIDEMIC PNEUMONIA 
655 
carbuncle be in an early stage, frequent poulticing is without doubt the 
best form of local treatment. It increases the vascularity and local 
reaction, which at the present day we know to be powerful factors in 
bringing about the termination of localised diseases. If, however, the 
carbuncle be large and shows signs of spreading, and especially if the 
general health be poor, ice compresses should be applied continuously 
in the hope of diminishing the activity of the disease, and thus lessening 
the quantity of poison which is absorbed into the system. It is just 
possible that by this means we may for a time give the body a rest, so 
to speak, from a burden which is proving too severe for it, and by 
allowing it to recover a little strength enable it finally to overcome the 
disease. Meanwhile the general surface should be kept very warm and 
opium given to ally pain. 
Great care should be taken to support the strength by careful feed- 
ing, and large doses of some easily-digested form of iron should be pre- 
scribed. For old and weakly persons alcohol is essential, and, in the 
absence of special indications, such as glycosuria, they may be allowed to 
choose the drink they like best. The bowels should be carefully attended 
to, and the examination of the urine for albumin and sugar never omitted. 
The occurrence of thrombo-phlebitis must be carefully watched for, 
and when detected the limb should be slightly elevated, surrounded with 
several layers of cotton wool, and kept absolutely at rest. Excision of 
the thrombosed vein is a very serious undertaking in old persons whose 
vitality is already much reduced. Ligature of the vein on the cardiac 
side, a less severe operation, may be performed if some such step seem 
desirable. 
W. S. Melsome. 
EPIDEMIC PNEUMONIA 
Apart from its occurrence as a sequela of certain zymotic diseases, 
croupous pneumonia is met with not only in sporadic cases, but also 
in groups, and occasionally in more or less extensive epidemics, with 
clear evidence of infection from person to person. The proof of infec- 
tiveness is strengthened by the discovery that the tissues and sputa 
of pneumonic patients contain specific micro-organisms which can be 
cultivated, and have the power of reproducing the disease when inocu- 
lated into lower animals: moreover, Dr. Klein has found that animals 
so inoculated become centres of infection to others kept near them. 
Pneumonia of this kind is to be regarded not as an affection of the lung 
simply, but rather as a constitutional infection - a " pneumonic fever " 
- of which pulmonary and pleural lesions are only the local, and not 
necessarily constant manifestations. Perhaps it would be more correct 
to speak of pneumonic fevers in the plural, for it seems that more SYSTEM OF MEDICINE 
656 
than one kind of microbe can give rise to infectious pneumonia. At any 
rate some of the sporadic cases are of like nature, as bacteriological 
examination proves, notwithstanding the frequent absence of any clue 
to the source of infection and of extension of the malady to other 
persons. Similar obscurity often surrounds the etiology of enteric 
fever, diphtheria, and other diseases of the mobile and more or less 
saprophytic class. It is more than possible that such diseases may 
occur in forms so modified or attenuated as to be distinguishable with 
difficulty, if at all; or that their continuity may be maintained in lower 
animals, or even in external media such as soil. 
Although epidemics have been recorded in this country for nearly 
two centuries much of our present knowledge of infectious pneumonia 
dates from 1888, when an outbreak of unusual extent and severity 
occurred at Middlesborough, and was carefully studied by Dr. Ballard. 
The ordinary clinical history, in attacks admittedly of the infective 
kind, may perhaps best be gathered from his observations, which were 
briefly as follows : - 
The incubation was short, not exceeding five or seven days; and 
here it may be remarked that in other epidemics the latent period has 
seemed to be shorter still, sometimes not more than one or two days. 
The onset of the symptoms was sudden, with rigors, pain in the side or 
epigastrium, and rapid rise of temperature, often accompanied with 
vomiting and diarrhoea. The temperature sometimes reached 104° 
within a few hours; the highest point recorded was 105° on the 
morning of the third day. Delirium almost invariably set in, occasion- 
ally as early as the first day, but more commonly on the second or 
third. As a rule the physical signs of pleuro-pneumonia were observed, 
in one or both lungs, on the second day; but in many cases they were 
delayed and of slight intensity; generally speaking " the constitutional 
disturbance was out of all proportion to the evidence of local pulmonary 
disease." There was not much cough, but the sputa presented the 
characters usual in pneumonia. The tongue, in fully-developed attacks, 
was dry and brown, with moist white edges. Fatal cases for the most 
part terminated on the third, fourth, or fifth day of illness, or, at all 
events, within a week. Convalescence usually began by a crisis on the 
seventh to the tenth day. Three or four days after the crisis a relapse 
sometimes occurred, which often coincided with commencing pneumonia 
in the other lung. Among the occasional phenomena to which Dr. Ballard 
directed attention were haemorrhages (especially epistaxis, which some- 
times appeared to be critical), and painful swellings of the knees, ankles, 
shoulders, and other joints. By other observers, and in other localities, 
similar arthritic complications have been found to be due to the specific 
pneumococcus. In only one of the cases seen by Dr. Ballard was there 
any herpetic eruption about the mouth. The mortality was very high. 
Out of 682 attacks which came under observation, 143 (21 per cent) 
were fatal. In the workhouse the proportion was over 40 per cent; 
and it was exceptionally high also in certain portions of the town. EPIDEMIC PNEUMONIA 
657 
Two years later an epidemic on a smaller scale occurred at the vil- 
lage of Scotter, in Lincolnshire, and was investigated by Dr. Parsons. 
Here the more severe cases, which were practically limited to adults 
and aged persons, corresponded closely with the above description; but 
at the same time there was among children a wide-spread prevalence of 
a slight and ill-defined form of sickness, marked principally by headache, 
vomiting, diarrhoea, and some rise of temperature. Proof is wanting 
of the identity of these slight attacks with true " pneumonic fever," but 
the probability seems to lie in that direction. 
Several other village epidemics of severe type have been recorded 
in recent years: one, for example, in the spring of 1893 at Yeadon, 
reported by Dr. Russell McLean, where the non-fatal cases ended by 
crisis between the third and eighth days, usually on the sixth. As early 
as 1875 Mr. Wynter Blyth called attention to the infectious character 
of the pneumonia then prevalent in certain North Devon villages. 
Sometimes the prevalence has been limited to particular streets, or 
to certain industrial sections of the population. Still more localised 
epidemics have occurred in barracks, schools, hospitals, workhouses, 
prisons, and on board ship; usually in association with unwholesome con- 
ditions which may be thought likely to offer maximum facilities for the 
transmission of infection, and to lessen the resistance to disease. And, 
lastly, both in epidemic and in non-epidemic times, groups of cases are 
met with in single households, often without any clue to importation of 
infection from without, and here the type is frequently most fatal, and 
the indication of infection from person to person most convincing. 
Etiology. - The incidence of attack, and case-mortality too, increase 
with advancing years, from childhood onwards. Thus at Middlesborough 
Dr. Ballard found the following relation to age, in cases which were 
fully recorded: - 
Years of 
Age. 
Attacks. 
Deaths. 
Estimated 
Attack-Rate 
per 1000 
Population. 
Case Mortality. 
M. 
F. 
M. & F. 
M. 
F. 
M. & 
F. 
M. 
F. 
M. & F. 
0 to 41 
123 
84 
207 
13 
4 
17 
10-8 
10-6 
4-8 
8-2 
15 to 45 
263 
58 
321 
55 
12 
67 
16-3 
20-9 
20-7 
20-9 
45 to 65 
88 
36 
124 
37 
9 
46 
34-3 
42-0 
25-0 
37-1 
Over 65 
18 
12 
30 
5 
8 
13 
53-4 
27-8 
66-6 
43-3 
All ages. 
492 
190 
682 
110 
33 
143 
16-7 
22-4 
17-4 
21-1 
The usual experience is that attacks of pneumonia are less fatal, but 
much more common in men than in women, the net result being a 
higher death-rate among the former. Tn the Middlesborough epidemic, 
however, the case-mortality was lower among females, except at ages 
above sixty-five. 
2 u 
VOL. I 658 
SYSTEM OF MEDICINE 
Debility, especially if due to habits of intemperance, must be 
counted among the most important of the conditions which dis- 
pose to infection and lessen the chance of recovery. Wherever the 
opportunity for comparison has arisen, the fatality has been found 
excessive among intemperate persons, and also among the poor and 
aged. Most observers agree with Hirsch in classing infectious pneu- 
monia with the filth diseases, in the sense that its incidence and severity 
tend to be greatest where insanitary conditions exist, whether drainage 
defects, effluvia from foul accumulations, overcrowding, insufficient 
ventilation, or unhealthy surroundings of other kinds. Striking in- 
stances are on record in which localised outbreaks of so-called " pytho- 
genic pneumonia" have followed closely upon exposure to air from 
foul drains. The effect of climatic conditions is not always clear, but 
it seems that cold, and especially sudden and frequent changes of tem- 
perature, are important disposing conditions; and the same may be 
said of absence of rain and low level of subsoil water, which connote 
dryness of air and soil. The Middlesborough epidemic, after extending 
during a period of comparative drought, appeared to be arrested by 
heavy rain. The seasonal curve is probably not very different from that 
of the aggregate of fatal " pneumonia " of all kinds, as recorded in the 
Registrar-General's reports, which is above the mean from November 
to April. Epidemics have occurred in the summer and autumn, but 
by far the greater number take place in the winter and spring. Oc- 
casionally there is some indication of endemic localisation, repeated 
epidemics following each other at intervals in the same community. 
The geographical distribution of epidemic pneumonia is not without 
interest in this connection. Hirsch recounts many epidemics in the 
several countries of Europe, from the sixteenth century onwards, nearly 
all of them presenting in a very marked degree the fatal typhoid or 
asthenic type which characterises these outbreaks in general. In some 
of the higher Swiss valleys it recurs almost annually, in the spring, and 
is known as the Alpenstich. In Italy and France and adjacent countries 
it has more than once attained pandemic diffusion, but although 
epidemics have been frequent in Europe during the nineteenth century 
" they have been mostly far apart and confined within narrow limits." 
North America has suffered severely, especially from 1812 to 1825; 
but here again the seasonal curve was strongly marked, and the 
prevalence was to a great extent limited to the winter and spring 
seasons. Both in America and in Africa the negro races have been 
found to be specially susceptible to pneumonia. 
As already stated, the infection is probably not always of the same 
kind. At least three different microbes have been regarded, on ap- 
parently conclusive evidence, as pathogenetic in infectious pneumonia: 
an oval capsulated micrococcus, described by Friedlander ; a capsulated 
diplococcus, by Frankel and Weichselbaum; and a bacillus, found by 
Klein in the Middlesborough and Scotter epidemics. Each of these can 
be cultivated and inoculated upon lower animals. Miniature epidemics EPIDEMIC CEREBRO-SPINAL MENINGITIS 
659 
have occurred among monkeys, guinea-pigs, and mice, when some of 
their number had been inoculated with Klein's bacillus. The same 
bacillus was found in several samples of bacon obtained in Middles- 
borough during the epidemic, and in all which came from infected 
houses; but the proof that infection was actually imparted to man in 
this way was necessarily incomplete. Evidence is also wanting as to 
the possibility of water or milk conveying infection; no recorded out- 
break of pneumonia has been traced to such a source. 
It may safely be assumed that the infection is given off, or tends to 
be given off, in the breath and sputa, and possibly in other modes also; 
and that it is acquired by inhalation and perhaps by swallowing. The 
facility of transmission from person to person is largely determined by 
lowered vitality on the part of the recipient, and by close and prolonged 
contact with the patient, especially if in a confined atmosphere. Whether, 
apart from this, the transmission requires an exceptional intensification 
of the virus, or is of frequent though unobserved occurrence in series 
of cases too slight and indefinite in character to be recognised as pneu- 
monia, cannot be decided by the light of present evidence. Nor is it 
at all clear what is the true relation of epidemic pneumonia to other 
infective diseases with which it is not infrequently associated in locality 
and time, and even in sequence of attack in the same individual; such 
diseases are enteric fever, influenza, and malarial fevers [wide art. on 
" Cerebro-spinal Meningitis"]. It has been suggested that there may 
be an underlying identity, that the pneumonic fever may be in truth 
only a variety of one or other of those zymotics, but the bacteriological 
aspects of well-marked epidemics of pneumonia lend little support to 
this view. Dr. Klein has found the Middlesborough bacillus in two 
out of five cases examined in which croupous pneumonia followed 
influenza, so that the occasional sequence of the two different infections 
must be admitted. 
The recognition of the infective character of croupous pneumonia 
at once suggests the application of ordinary preventive measures of 
isolation and disinfection. Treatment will be considered in another 
section. 
Arthur Whitelegge. 
EPIDEMIC CEREBRO-SPINAL MENINGITIS 
Synonyms. - C er ebro-spinal fever, Malignant purpuric fever. 
Cerebro-spinal meningitis, in its epidemic form, is a disease of which 
we in England have had very scanty experience. Yet there are many 
reasons why we should not neglect to consider it; its historical and 
geographical interest is great; its exact etiology is yet undiscovered; 660 
SYSTEM OF MEDICINE 
and a country, hitherto immune, cannot expect always to escape out- 
breaks in the future. 
This disease was unknown, or at least undistinguished, till the pres- 
ent century; within the nineteenth century there have been two wide- 
spread epidemics of it in Europe, and three in the United States. 
Professor Hirsch, upon whose exhaustive writings I must largely 
draw, divides the history of epidemic cerebro-spinal meningitis into 
four periods (1). 
The first of these periods ranges from 1805 to 1830. In Europe 
the outbreaks were then isolated and not very extensive; as at Geneva 
(1805), at Grenoble and Paris (1814), Metz (1815), in the province of 
Genoa (1815), at Vesoul (1822), in Westphalia, and possibly at some 
other places, as for instance, in Sunderland (1830). But in the United 
States this period was characterised by a wide-spread epidemic, includ- 
ing the New England states (1814 to 1816), and other more westerly 
states as far as Kentucky and Ohio (1808). Nor was Canada altogether 
exempt. 
The second period is from 1837 to 1850. France was first attacked; 
in 1837 the disease began in two separate districts of the south of 
France - namely, Bayonne and the valley of the Adour on the one hand, 
Foix and Narbonne on the other -and thence spread through towns of 
S. W. and S. E. France respectively. In many instances the epidemic was 
limited to the garrison of a town; and an epidemic at Versailles appeared 
to be produced by the transference thither of soldiers from an infected 
spot. Other independent foci appeared in N. E. France, as at Metz 
(1839 to 1840), and N. W. France, as at Laval (1840), Brest, Caen, and 
Cherbourg, whence the disease also spread mainly, but not wholly, 
among garrisons. These outbreaks continued till 1842 and then abated, 
but from 1846 to 1850 a fresh series appeared, chiefly in garrison towns 
of N. E. and S. E. France, but also in Orleans and Paris. Throughout 
this French epidemic the central parts of France were the least affected. 
Coincidently, and doubtless in connection with the French epidemic, 
there occurred an epidemic in Algiers (1840 to 1847). 
Southern Italy and Sicily were severely attacked between 1840 and 
1845, the disease spreading widely among the villages. In Denmark 
also and Iceland the disease was widely prevalent between 1845 and 
1848. 
In no other European country was there a severe and extensive 
pestilence, though minor outbreaks were reported from various places, 
as from Gibraltar in 1847 (2). In Great Britain certain cases appeared 
in Irish workhouses in Dublin, Bray, and Belfast (1846), and some at 
Liverpool. 
The United States were again the theatre of a wide-spread epidemic, 
which manifested itself in the western and southern states, " at places 
as remote as possible from Transatlantic communication, and hundreds 
of miles distant from each other" (3). Somewhat later it appeared in 
Pennsylvania (1848), and at New Orleans (1850). EPIDEMIC CEREBRO-SPINAL MENINGITIS 
661 
The third period, 1854 to 1874, exhibited quite a different distribu- 
tion of the disease in Europe. The countries of South and West Europe 
(except for a somewhat wide epidemic in South Italy, an outbreak in 
Portugal and one in Ireland) were spared; Sweden, Germany, and some 
parts of Russia were the chief sufferers. 
Beginning at Gothenburg in 1854, and reinforced from other foci in 
the south of Sweden in the following year, the disease spread through 
Sweden in a northerly direction. The outbreaks, which proved extremely 
fatal, appeared in winter or spring time, and gradually extended north- 
wards till in 1858 the latitude of 63° N. was reached. After that year 
the pestilence gradually declined. The neighbouring countries of Nor- 
way and Denmark did not wholly escape. 
In 1861 to 1862 there were outbreaks in Portugal. 
Next Germany was widely ravaged. The disease appeared in North 
Germany, namely, in the eastern districts of Silesia (1863), Posen, 
Pomerania, East and West Prussia; and also in Brandenburg, Saxony, 
Hanover, etc. Southern Germany was severely attacked; beginning at 
Erlangen and Nuremburg (1864), the disease spread over the bulk of 
Bavaria, and appeared also in Hesse and Baden. The acme of the Ger- 
man epidemic was in 1864 and 1865; after 1866 the outbreaks became 
limited and scanty. 
Austria and Hungary largely escaped. Russia suffered at various 
points, and notably in the Crimea (1867 to 1868). 
At Dublin and in some other parts of Ireland (1866 and 1867) there 
was an epidemic which affected both the troops quartered there and the 
civil population. There were some scattered cases in England, namely, 
in Rochester and South London, and a small epidemic at Bardney in 
Lincolnshire. 
The United States witnessed a third great epidemic. This began in 
North Carolina and in New York State (1856 to 1857), spread widely 
during the War of Secession (1861 to 1863), and afterwards covered 
nearly the whole area of the States, and did not subside till 1874.1 
Hirsch's fourth period, namely, from 1876 to 1884, to which we may 
fairly add the next ten years, is one of quiescence. There have been no 
great epidemics, though limited outbreaks have been reported at inter- 
vals from divers countries. In Great Britian we may mention sundry 
minor attacks, as at Dublin (1885 to 1886), Birmingham and its neigh- 
bourhood (1876), Galston near Kilmarnock (1884), and certain villages 
in the eastern counties (1890). 
Epidemic cerebro-spinal meningitis may be regarded in a twofold 
light: (1) as an acute specific fever; (2) as a disease which, like many 
other specific fevers, is characterised by certain definite local lesions. 
Morbid Anatomy. - This consists essentially in an acute inflammation 
1 Stille's table (1883) of the annual deaths from this cause in Pennsylvania showed 
that although the numbers dropped from 246 in 1873 to 82 in 1874, they still remained 
high, ranging from 56 to 90 per annum. Pepper's continuation of this table shows a 
sudden rise in 1884 to 124 deaths, then a decrease to 23 in 1891. 662 
SYSTEM OF MEDICINE 
of the pia-arachnoid, both of the brain and cord, usually manifesting 
itself by a purulent effusion into the sub-arachnoid space. In some few 
cases, indeed, where death has taken place at a very early stage, no 
effusion may be perceptible to the naked eye, nothing more being evi- 
dent than mere hyperaemia, or (it may be) cloudiness of the membranes. 
Even then, however, the microscope may show that they are infiltrated 
with cells. But most commonly the effusion is visible. This when 
quite recent may appear serous or simply cloudy, or it may be blood- 
stained, or again it may be transparent and gelatinous in consistence; 
but most commonly it is purulent, either yellowish and semi-solid like 
butter, or a purulent liquid. Such purulent effusion has, indeed, been 
found where death took place only five hours after the onset (4). The 
pus is in the sub-arachnoid space, and thus remains in situ after removal 
of the dura. Upon the brain it is distributed either at the base only 
or over the hemispheres, or in both places, and also upon the cere- 
bellum. It may occur in streaks and patches along the line of the vessels, 
or in the recesses of the fissures and sulci, or in a more or less continuous 
sheet covering the whole brain. Of the cord it affects by preference the 
posterior aspect, and the dorsal and lumbar regions and cauda equina, 
rather than the cervical region; but the whole cord may be covered by it 
and the nerve roots as well. An effusion, though less frequently purulent, 
may take place into the ventricles of the brain, resulting from inflamma- 
tion of the choroid plexus. There is therefore nothing to distinguish 
acute meningitis of the epidemic type from that due to any other consti- 
tutional cause, tubercle excepted. 
The effusion consists, according to von Ziemssen, of pus cells, 
granules, fibrin, and mucin. Micrococci have been found in it - to 
which point we shall return later. 
Dr. Burdon-Sanderson says the cells bear a general resemblance 
to pus cells, but are less uniform in size and character. They may form 
almost a continuous layer, or may be embedded in a granular amorphous 
interstitial substance. 
In the two cases examined by Flexner and Barker they found three 
varieties of cells, namely, small round cells with one large nucleus (lym- 
phocytes), large and more irregularly shaped cells with several nuclei 
(leucocytes), and larger cells of epithelioid type with vesicular nuclei, 
and some red blood-cells. There was an amorphous intercellular sub- 
stance staining deeply with logwood; a little fibrin in one case and 
none in the other. 
The subjacent nerve centres are also involved in the morbid process. 
This may be recognised to a certain extent from their naked-eye appear- 
ance - the surface of the brain being either congested, or, perhaps more 
commonly, sodden, soft and pale - but it is more definitely ascertained 
by microscopic sections. These show that the cell infiltration spreads, 
as we might expect, by contiguity into the superficial layers of the brain 
and cord, and further that it penetrates still more deeply along the 
sheaths of the vessels that dip into the nerve substance. Microscopic EPIDEMIC CEREBRO-SPINAL MENINGITIS 
663 
abscesses and haemorrhages may thus arise, and sometimes these are 
large enough to be visible to the naked eye.1 
There is little to be said about the other organs of the body. The 
skin may exhibit the remains of eruptions. There may be marked 
post-mortem lividity, fluidity of blood, and ecchymoses of internal organs, 
as in other acute blood diseases. The skull-bones and dura are often 
highly congested. The spleen may or may not be enlarged. Bronchitis, 
broncho-pneumonia, and hypostatic congestion of the lungs may be 
present (the patients often dying from pulmonary embarrassment). Some- 
times there is lobar pneumonia or acute pleurisy; sometimes endo- 
carditis or pericarditis. But the meningitis is the only essential lesion. 
Any description of the symptoms and course of this disease must be 
prefaced by the statement that they are liable to much more variation 
than is usual in specific fevers, both in different epidemics and in 
different cases of the same epidemic. Nevertheless there are certain 
cardinal symptoms; namely, on the constitutional side - fever of sudden 
onset, with depression of the vital powers, with or without rash; on 
the nervous side - pain in the head and neck, retraction of the head, and 
oftentimes delirium and coma: and out of the commonest symptoms 
and their most frequent association authors have endeavoured to con- 
struct a " simple type " of the disease. 
In this type there may be prodroma, such as chills, malaise, 
headache, vague pains in the back and limbs; or the disease may 
commence suddenly with a rigor, fever, severe vomiting, vertigo, and 
above all with pain in the head, chiefly at the occiput. This pain is 
intense, and accompanied or soon followed by stiffness at the back of the 
neck, or actual retraction of the head. The pain is apt to spread down 
the spinal column and to radiate into the limbs and abdomen. Along 
with it there may be tenderness of the skin of the trunk. The eyes are 
suffused, the pupils (at this stage) are often small, the face pale, and 
the mind clear; an extreme restlessness is common, a lethargy is less 
frequent. 
In mild cases the disease may stop short here and the symptoms 
pass off; in severe cases they become worse, the pain increases, the 
rigidity of the neck spreads down the spine, producing perhaps actual 
opisthotonus, the mind begins to wander, or downright delirium sets in, 
which may pass into furious mania. At such a stage, after only a few 
days' illness, the patient may die, apparently from the mere violence of 
the nervous symptoms. 
But if neither death nor abatement of the disease take place the 
delirium is often succeeded by coma. The two conditions may alternate, 
or the coma may be persistent and eventually deepen into death. But 
should the coma also clear up, the patient, after a varying interval, 
1 Striimpell, who has drawn special attention to this process, believes that the in- 
flammation thus set up is by no means limited to the surface of the hrain. He also 
thinks that a large localised abscess may arise after, and in consequence of an attack 
of epidemic cerebro-spinal meningitis.- Deutsches Archiv f. klin. Med. xxx. pp. 523 foil. 664 
SYSTEM OF MEDICINE 
and in an extreme condition of emaciation and enfeeblement, enters on a 
tedious convalescence. 
Other common events are- (1) cutaneous eruptions, notably herpes, 
and petechial spots; (2) affections of the eye and ear, which too often 
prove irremediable. 
The duration of the attack varies greatly - from two or three days 
to three or four weeks or more. Death may occur, or recovery set in, 
at variable stages, and such recovery may be complete, or may leave 
the patient with persistent headache, or crippled in limb or special 
senses. 
Numerous other types are described. The most important of these 
is the " type foudroyante " of French authors, which may also be called 
the fulminant, siderant, apoplectic, or malignant type. The character- 
istics of this are extreme suddenness of onset, severe collapse, and early 
coma, which may prove fatal ere diagnostic symptoms have appeared. 
Cutaneous haemorrhages, often extensive, are common in this form of 
the disease. Recovery is a rare event. Such cases are comparable to 
the malignant forms of measles and of other specific fevers, in which the 
patient, overwhelmed by the poison, dies early. They are said to be 
most common at the commencement of epidemics, and obviously this 
must render the diagnosis of their true nature more difficult. 
The abortive type is that in which the patient suffers for a short time 
and in a limited degree from vertigo, headache, occipital pain and the 
like, but recovers rapidly without any serious illness. Similarly during 
cholera epidemics cases of simple diarrhoea are often prevalent; and 
during epidemics of scarlet fever or diphtheria cases of sore throat. 
The intermittent type is a curious variety. In this there appear 
alternate remissions and exacerbations of the symptoms. Sometimes 
these appear to have the periodicity of true ague; but according to von 
Ziemssen the regular use of the thermometer shows that the periodicity 
is more apparent than real. This peculiar tendency may be observed 
in any stage of the disease, even in the prodromal period where such 
exists. 
The clinical features of the disease must be considered more in 
detail; and first, the general features. Acuteness of onset and violence 
of local symptoms are dominant facts. Yet the temperature does not 
necessarily run high. All authors agree that the temperature is not 
characteristic, it neither corresponds to the type of any other fever, nor 
has it a type of its own. Maintained elevation of any high degree is 
exceptional; 101° to 103° appears to be about the average. But, as in 
other diseases of the nerve centres, sudden rises may take place, which 
are either transitory or prolonged into veritable hyperpyrexia. Neither 
can any rule be laid down about the pulse rate; it is rarely much 
accelerated, except it be towards the end of a fatal coma; it may vary 
greatly from time to time. But in character the pulse is compressible 
and of low pressure, not hard or bounding; in this respect corresponding 
to the general loss of strength, prostration, and tendency to collapse EPIDEMIC CEREBROSPINAL MENINGITIS 
665 
which from, the outset form a striking feature of the disease.1 There is 
no constant increase in the respiration rate; the character of the respira- 
tion in the early stages may be simply indicative of pain, but in the 
graver conditions it becomes embarrassed and 11 suspirious," marked, that 
is, " by a slow, laboured inspiration followed by a quick expiration and a 
long pause " (5). When in deepening coma there is a steady rise in the 
pulse rate, respiration rate and temperature, with blueness and a clammy 
skin, a fatal pulmonary paralysis is indicated. The tongue, except in 
very severe cases or towards the later stages, when a so-called typhoid 
condition has appeared, may give no indication that the patient has a 
grave constitutional disease. The bowels are usually confined. There is 
neither burning heat of skin nor profuse sweating. The conjunctiva may 
present a diffuse pink suffusion upon which some authors lay much 
stress (3) ; the face is usually pale, and till stupor or delirium intervene 
the expression is not dazed and heavy, but indicative of pain, restless- 
ness and irritability. 
The urine is normal, but sometimes contains albumin, and in 
haemorrhagic cases blood; glycosuria has been observed rarely (8, 9). 
The blood, as obtained by venesection, shows, according to Stille, 
the characters indicative of inflammation; while from microscopic ex- 
amination Flexner and Barker conclude that there exists in the early 
stages of the malady a well-marked leucocytosis, associated with certain 
other changes, not peculiar to this disease, which may exist in any kind 
of local inflammation with exudation. 
The nervous symptoms must evidently be similar to those which occur 
in other forms of meningitis, but their acuteness and severity are 
greater. 
The headache is not a mere dull aching, but an intense and often an 
intolerable pain. Without definite localisation at first, it soon concen- 
trates itself upon the occiput and back of the neck. Pain, too, may 
affect the spinal column, and may radiate thence into the limbs and 
round the trunk, and into the abdomen particularly; so that in some 
cases abdominal pain becomes quite a leading symptom. The pain is 
aggravated by all movements. 
Cutaneous hyperalgesia is common. This probably originates, like 
the pain, in irritation of the sensory nerve roots. Numbness and 
anaesthesia may follow as the nerve irritation gives place to paralysis. 
The pain is accompanied or soon followed by another symptom, so 
common as to be almost pathognomonic, namely, retraction of the head. The 
head is thrown backwards (in extreme cases so far that it appears to lie 
between the scapulae), the patient generally lying on his side with the 
legs drawn up. Dr. Burdon-Sanderson thinks this pose of the head is 
assumed in order to mitigate the pain in the muscles of the nucha; but 
most authors regard it as due to a tonic muscular spasm. Sometimes the 
11 do not find that authors lay much stress on slight irregularity of pulse, such as 
is common in tubercular meningitis, though Ziemssen remarks that irregularity in 
rhythm is not uncommon. 666 
SYSTEM OF MEDICINE 
extensor muscles of the whole back are implicated, so that there is actual 
opisthotonus. The limbs also may become rigid,1 or the face may be 
drawn into a risus sardonicus, or in bad cases there may be trismus. 
All these muscular spasms are more continuous than those of tetanus, 
not presenting such perfect alternations of paroxysm and remission as 
does that disease. 
Vomiting is another early symptom; it is of more common occurrence, 
more severe and intractable than in most other fevers. It may occur 
independently of food, without furring of the tongue or other sign of 
gastric disturbance, and is therefore to be ascribed to the irritation of 
the nervous system. Vomiting in the later stages of the disease, especially 
when associated with coma and convulsions, is indicative of distension of 
the ventricles by effusion, and is of bad import (7). 
There may be distressing vertigo, particularly when the patient lifts 
his head from the pillow; this may be sufficiently accounted for by the 
derangement of the cerebral centres, but it must be remembered, too, 
that sometimes the auditory apparatus is specially involved. 
Twitching s of the limbs are very common, general convulsions may 
occur, but (except in children) are less frequent than we might expect, 
considering the amount of cortical irritation. Prolonged convulsions 
are a bad sign, particularly when they occur late in the disease. 
Paralysis of the ocular nerves, causing squint (possibly due sometimes 
to muscular spasm), ptosis, dilatations and inequalities of the pupils, 
are as common as in other forms of meningitis. Nystagmus is some- 
times seen. Facial paralysis may also occur. Paralyses of the limbs 
do not appear to be common; still they may occur, and particularly 
in the later stages: they may be of very Various type (hemiplegic, 
paraplegic, monoplegic), as is evident from the wide distribution of the 
lesion; and may be transitory or permanent, according to the degree of 
damage to the nerve roots and centres. 
The tendon reactions, according to Strumpell, may vary. Thus, in 
thirty-two cases examined by him in Leipzig in 1879, the knee-jerks 
were absent in five; in three they disappeared, to reappear during con- 
valescence, which change was probably due to varying pressure on the 
nerve roots; sometimes they were lively, sometimes much increased. 
Optic neuritis was found by Randolph of Lonaconing, Maryland, six 
times in forty cases examined ophthalmoscopically. 
The mental condition we have already noticed. Extreme restlessness 
is often a characteristic of the early days of the disease. Delirium very 
commonly supervenes, whether it be a mere wandering at night, or a 
kind of rambling stupor from which the patient can be aroused by 
sharply speaking, or an active and often violent delirium. The access of 
coma is always a grave sign, though recovery from it is by no means 
impossible; the more deep and persistent the coma the worse the 
1 Kernig pointed out that by putting the patient into a sitting posture (or flexing 
his thighs as he lies) a certain spasm is induced in the flexors of the knee, so that this 
joint cannot be completely straightened out (10). EPIDEMIC CEREBROSPINAL MENINGITIS 
667 
prognosis. It must not be supposed that these mental states always 
succeed each other in regular order; delirium may occur at the outset, 
and the worst type of case, the " foudroyante," is marked by early coma. 
There are symptoms which cannot be wholly referred to the disease 
of the nervous centres, and of these the most striking are the rashes. 
These are by no means constant. In some epidemics there has been no 
rash ; in others very various rashes have been described, as for instance 
erythema, urticaria, rose-spots like those of typhoid, measly eruptions, 
vesicular and bullous eruptions. But the most common are herpetic 
and haemorrhagic rashes. 
Herpes of the lips and face is so frequent that it has been called 
characteristic of the disease.1 Tourdes observed it in two-thirds of his 
cases. Von Ziemssen says that in no other disease has he observed 
facial herpes to spread so widely. It commonly occurs within the first 
five days of the illness, but sometimes later than this; and, indeed, there 
may be several crops of herpes coming out at various dates. It has no 
prognostic significance. Eruptions of herpes may come out on the limbs 
and trunk, and are often symmetrical; they have been referred, there- 
fore, to the nervous lesion as a cause. According to Klemperer, herpes 
labialis stands on a different footing to herpes zoster. He finds micro- 
cocci in the vesicles of herpes labialis, and thinks that this eruption 
indicates some acute inflammatory affection. Petechiae were so common 
and so abundant in the early American epidemics that the name " spotted 
fever " was applied to the disease - a name peculiarly unfortunate; 
first, because of the confusion thereby created between epidemic men- 
ingitis and exanthematic typhus; and secondly, because in many other 
epidemics petechiae have not been seen at all. This rash, like herpes, 
may appear early, and has little relation to the gravity of the disease. 
Cutaneous haemorrhages other than mere petechiae are a more serious 
matter, as they generally indicate a severe form of the disease. In the 
Dublin epidemic of 1866-67 such haemorrhagic rashes were particularly 
common, so that the name " malignant purpuric fever " was then pro- 
pounded. Dr. Samuel Gordon, describing the condition of the skin in 
this epidemic, notes that there may be - (1) a coldness or blueness of 
the extremities or whole body like that of cholera; (2) bruises and ecchy- 
moses like those of typhus or scurvy ; (3) a haemorrhagic eruption com- 
ing out all over the body, but chiefly in the lower limbs, dark in colour, 
being brown, purple, or black as ink; some spots small and round, others 
larger and irregular, others like large spots of very black purpura, but 
more mottled and more irregular in colour and shape, others raised 
above the level of the skin. These may be gradually absorbed, or may 
in some cases become gangrenous. Haemorrhages from the mucous 
surfaces, for example, of the nose, stomach, bowels, kidneys, may also 
take place. t 
1 Yet Stille says of the Massachusetts epidemic: - " Herpes labialis was noticed in a 
few instances . . . it is certainly much less common as a symptom of epidemic meningitis 
than either the roseolous or petechial spots " (3). 668 
SYSTEM OF MEDICINE 
There are other important possibilities, which are perhaps best 
reckoned as complications and sequelae. 
Foremost amongst these are affections of the special sense organs. 
The eye may be attacked, even in the early stages of the disease, 
by severe conjunctivitis, or by iritis or keratitis leading to corneal 
opacities. Still more to be dreaded is inflammation of the deeper parts, 
such as a purulent infiltration of the choroid, leading to detachment of 
the retina, or (still worse) to inflammation and disorganisation of the 
whole eyeball. It is possible that this deep-seated inflammation is prop- 
agated from the meninges along the sheath of the optic nerve to the 
structures at the back of the eyeball. Other ophthalmic complications 
are optic atrophy, secondary to optic neuritis; thrombosis of the retinal 
veins; amaurosis without obvious cause. 
Disease of the auditory apparatus is even more frequent than that of 
the eye. The onset of deafness may be difficult to time in the presence 
of a severe constitutional disease, particularly when there is delirium or 
stupor. But in some cases, at any rate, it is an early symptom. Deaf- 
ness may be due either to purulent otitis media, or to disease of the 
labyrinth (15). In the latter case it is probable that the meningeal 
inflammation spreads along the auditory nerve to the cochlea and semi- 
circular canals. If these parts are destroyed total and hopeless deaf- 
ness must result; and in little children this means deaf-mutism.1 
With this is sometimes associated a staggering gait.2 
Of less importance are anosmia and loss of taste, which have also 
been described. 
Chronic hydrocephalus is a very serious sequela. This has been 
particularly studied by von Ziemssen (7). It would appear that in 
cases which survive the acute stages of the disease the meningeal exu- 
dation gradually degenerates, and is absorbed; but the pia-arachnoid 
becomes thickened and shrunken, and the ependyma ventriculorum hy- 
pertrophies. The ventricular effusion, probably in consequence of these 
cicatricial changes, either remains unabsorbed or increases in amount, 
albeit now less purulent and more passive in character; while the 
cerebral substance becomes pallid and atrophied from pressure. The 
symptoms of such hydrocephalus show themselves during the period 
of convalescence, a distinct interval having elapsed since the acute 
stage of the meningitis; they consist of headache and pains, vomitings, 
coma, convulsions. Sometimes they have a paroxysmal character, and 
may thus last for weeks. The onset of such symptoms at this late 
1 How frequent these aural complications may be is shown by the observations of 
Moos, who found that out of 64 convalescents from epidemic cerebro-spinal meningitis, 38 
were deaf-mutes; 20, absolutely deaf; 5, partially deaf; 1, not at all deaf; and 32 had a 
staggering gait. And von Ziemssen found that, in an institution for deaf-mutes, contain- 
ing!^ children, every one had become deaf-mute after cerebro-spinal meningitis, while in 
another of 32 inmates the number due to this cause was 22. , 
2 Voltolini's disease, the symptoms of which are deafness, deaf-mutism, and stagger- 
ing gait coming on after a short feverish attack, perhaps accompanied with severe cere- 
bral symptoms, which Voltolini ascribes to primary inflammation of the labyrinth, is 
thought by many physicians to be a meningitis spreading to the ear. EPIDEMIC CEREBROSPINAL MENINGITIS 
669 
stage of the disease must give rise to serious alarm, for though recovery 
from hydrocephalus may take place it is very rare. 
Joint disease is not unfrequent; it is mentioned both by the older 
writers and by several recent authors. Sometimes the joints are painful, 
red and swollen, as in gout or acute rheumatism; sometimes there is a 
simple serous effusion, sometimes they contain pus. This last fact seems 
to point to the general blood state as the cause of the joint disease, 
rather than to a perverted trophic influence of the nerve centres. The 
appearance of joint affections has in some instances coincided with 
amelioration of the meningeal symptoms. Nonpurulent arthritis has 
been treated successfully by salicylates. 
Pulmonary congestion and collapse are frequent, as is natural in the 
course of an exhausting acute disease; broncho-pneumonia may occur, 
and sometimes acute lobar pneumonia. It will be remembered that con- 
versely acute pneumonia may be complicated by meningitis; this occur- 
rence, rare on the whole, is said to be more frequent after an epidemic 
of meningitis than at other times (16). 
Other complications, apparently of a pycemic nature, may be men- 
tioned ; such as ulcerative endocarditis, pericarditis, pleuritis, peritonitis, 
parotitis with abscess, and diffuse abscesses in the connective tissues of the 
limbs and trunk. Sometimes, instead of the usual constipation there is 
an enteritis, which causes a dysenteric diarrhoea. 
Lastly, a rapid and great emaciation accompanies the disease, which 
may take long to amend. 
As to treatment, it must be admitted at once that we have no 
specific to arrest the morbid process. In the earlier epidemics free 
blood-letting was employed, not with much success: but local depletion 
by leeches or cups, or blisters to the temples, nucha or spine, have been 
much used. Such remedies are suitable only for the early stages of 
the disease, when they are said to relieve symptoms, and possibly 
to modify the local inflammation of the meninges. Cold in the shape 
of ice-bags is recommended for the same purpose. Mercurial purga- 
tives have been freely given, and mercury has been used so as to 
produce its constitutional effect. One author writes: - " The jugular 
vein was opened, and blood drawn in a full stream as long as the boy's 
strength would permit. This was followed up by relays of leeches to 
the temples and mastoid processes. The mercurial plan was at the same 
time most energetically pursued, and blisters with mercurial dressings 
were applied to the head and along the spine. Yet all was of no avail, 
my patient died in convrdsions on the fourth day." All such heroic 
measures in the way of bleeding, purgation, emetics, mercurialisation, and 
the like, are contra-indicated by the tendency to depression and collapse 
which may exist from the very outset. Such tendency, when present, 
must be met by alcohol, used sparingly in ordinary cases, liberally in 
those which are of the malignant type. The diet must necessarily be 
light at first, while vomiting and other acute symptoms prevail, but 
it may be increased earlier than in most fevers, as there is seldom any 670 
SYSTEM OF MEDICINE 
gastric or intestinal lesion, and severe emaciation is common. The 
importance of carefully feeding comatose patients, by the rectum or by 
the nasal tube if necessary, need hardly be insisted upon. There is 
an almost universal testimony in favour of one drug, namely, opium or 
morphia. Burdon-Sanderson says that its advantages in calming rest- 
lessness and relieving pain after the initial symptoms have subsided seem 
unequivocal (in doses of to | grain of opium by the mouth, or better 
as morphia hypodermically). Von Ziemssen says, il Morphia may be 
regarded as one of the most indispensable remedies in the treatment of 
epidemic meningitis." Stille, going further, gave one grain of opium 
every hour in severe cases, or one grain in moderately severe cases 
every two hours, under the conviction that it is not merely a palliative, 
but also influences favourably the whole condition of the patient, and 
that the opium treatment is most useful when it is begun early in the 
attack. 
In the later stages of the disease, for such symptoms as may depend 
upon meningeal thickenings and deposits, iodide of potassium is the best 
accredited remedy, with tonics to restore the exhausted strength. But 
for secondary hydrocephalus, von Ziemssen says, little can be done. 
Local paralyses must be treated by massage and electricity. For the 
severe disorganisations of eye and ear nothing can be done. 
Prognosis. -The course of the disease, as already mentioned, is very 
variable, but the outlook is always serious. In the fulminant or malig- 
nant cases, where the patient is stricken down suddenly and rapidly 
passes into coma, recovery is very rare. In mild cases, at the end of 
the first few days, after the irritative stage of headache, vomiting, and 
perhaps even delirium, the disease may take a favourable turn and 
convalescence begin. Such convalescence is sometimes rapid, but more 
often slow. " The disease is distinguished by the slowness of its cure 
and the rapidity of its fatal issue," says Tourdes. But death may oc- 
cur during the stage of delirium, or still more commonly during coma, 
in any case comparatively early; Simon and Sanderson say, "generally 
from the fifth to eighth day; " Hirsch says, " commonly within the first 
eight days, and as a rule between the second and fourth day." Nor are 
the later stages free from danger, looking to the risk of hydrocephalus 
and to the extreme exhaustion and emaciation. 
The prognosis is influenced: - 
1. By the character of the epidemic; Hirsch's tables of forty-one 
epidemics give all grades of mortality from 20 to 75 per cent (17); 
and by the duration of the epidemic, for rapidly fatal cases are most 
frequent at the commencement of an outbreak, mild cases towards its 
close. 
2. In the individual case by the following circumstances: - 
Absence of prodroma, sudden and severe onset, early appearance of 
coma, depth and prolongation of coma, wideness in the distribution of the 
local nervous symptoms (showing brain and cord to be alike involved), 
trismus, complications involving other organs - especially the lungs, the EPIDEMIC CEREBRO-SPINAL MENINGITIS 
671 
reappearance of grave cerebral symptoms (vomiting, convulsions, coma) 
in the stage of convalescence; all these things are unfavourable. 
As to age, Hirsch says that children and people over forty run 
greater risk than those of middle age. Concerning a Dublin epidemic 
Grimshaw says that of the children admitted to Cork Street Hospital 
many recovered, while the recruits admitted to Steeven's Hospital mostly 
died. 
The diagnosis should in general be aided by two considerations: - 
1. The knowledge that an epidemic prevails. 
2. The appearance of meningeal symptoms early in the illness. 
There are not many epidemic diseases with which confusion is likely. 
Typhus may resemble it in the rash, the prostration, and the coma; 
and true typhus may be complicated by meningitis: but the attack of 
epidemic meningitis is more sudden, there is no regular upward march 
and maintenance of temperature, the initial headache is more severe and 
persistent, and the meningeal symptoms come on early. Influenza pre- 
sents similarities in the sudden onset with fever, headache, and pains in 
the back and limbs, and in the prostration to which it gives rise. Given 
coincident epidemics of the two diseases, it might indeed be difficult to 
distinguish severe influenza from mild meningitis; but in general the 
shorter course, the less serious character of the nervous symptoms, and 
the absence of retraction of the head, and of positive signs of organic 
nerve disease (such as squint, etc.), would point to influenza rather than 
to meningitis. Should an epidemic of meningitis begin with fulminant 
cases, which prove fatal before nervous symptoms set in, it may be 
impossible to recognise their true nature at the time. The opposite 
difficulty may occur when an epidemic is characterised by many mild 
or abortive cases; in that case minor complaints, such as rheumatism 
of the neck, migraine, hysteria with opisthotonus, may be taken for 
meningitis, and particularly febrile diseases in children beginning with 
convulsions, vomiting, nervous irritability, and perhaps with retraction 
of the head. 
Tubercular meningitis (in children, at any rate) has generally a more 
gradual onset, a less violent headache, and a more regular course than 
the epidemic disease. 
In acute meningitis of the ordinary type diagnosis is aided by the 
presence of a recognised cause, for example, suppurative disease of ear 
or nose, disease of bone, injury, pyaemia, or other acute illness; more- 
over, spinal symptoms are less commonly present. 
Isolated cases of cerebro-spinal meningitis occur without obvious 
causation, and the recognition of them before death may be very difficult. 
Whether such sporadic meningitis is essentially the same as the epidemic 
or no, we can hardly say till we have attained more certain knowledge 
concerning the etiology of the two varieties. The rash which is so 
striking a feature of many epidemics, and which seems to assimilate them 
to acute fevers in general, is absent in most sporadic cases, but not 
invariably. It is said that sporadic cases crop up particularly in places 672 
SYSTEM OF MEDICINE 
which have suffered, from the epidemic disease, as in the Franco-Prussian 
war (19) ; if this be so, it points to the identity of the two varieties. 
Etiology. - Cold contributes to the outbreak, but cannot be the sole 
cause. Most epidemics have begun in winter or spring, and further the 
attack seems in individual cases sometimes to be determined by exposure 
to cold. But, on the other hand, in many of the severest winters there 
have been no epidemics, and recrudescences of epidemics have begun 
during spells of mild weather. Neither is the disease known in Arctic 
climates, but only in the temperate and sub-tropical zones. Hirsch 
gives its limits in W. hemisphere from 45° N. (Montreal) to 30° N. 
(Mobile) ; in E. hemisphere from 63° N. (Sweden and Russia) to 30° N. 
(Jerusalem, Persia, Algiers). 
It is independent of malaria, and of local peculiarities of soil and 
situation: this is shown by its very wide distribution over manifold 
countries, altitudes and soils. 
It has no special predilections for race or sex; as to age, it selects 
principally children and adults in the prime of life. As to conditions 
of life, it may be that privation, overcrowding, bad sanitation,-in 
short, the circumstances of the very poor, - favour its outbreak, but 
they have never been shown to form an essential cause thereof. It has 
been seen alike in town and country. One fact, however, is most promi- 
nent, namely, that soldiers are especially obnoxious to it, and particularly, 
as it would appear, during garrison life. Recruits, too, suffer more than 
seasoned troops. Particular battalions or regiments, or again particular 
barracks, have sometimes been picked out by the disease. The counter- 
part to this has been seen in civil life, when a particular workhouse or 
school has been selected by it. 
The manner of its appearance and spread is peculiar. It spreads 
from no one centre of origin or of activity either by contiguity or on 
special lines, whether lines of traffic or other mode of distribution;1 but it 
breaks out at diverse and apparently disconnected foci, in separate towns, 
villages or tenements; and it spreads in a similar discontinuous way. 
In point of time, an epidemic of meningitis does not steadily mount 
to a maximum and then decline, but proceeds by fits and starts, crops 
of fresh cases appearing at irregular intervals. 
Its ordinary methods of propagation are not known. It has not been 
traced to food2 or water-supply. Direct propagation from one patient to 
another is certainly not the rule, albeit there are a few instances of this. 
There may be a certain infection of locality, as already said, it may hang 
about places where it has once appeared; and it has been transferred 
from place to place by human beings. 
I find no statements bearing on the question of immunity, as to 
whether one attack protects against another. 
1 There are a few exceptions to these statements, for example, the transference of the 
disease when troops have been moved from place to place, and the Swedish epidemic 
which spread steadily in one direction (vide supra). 
2 The surmise of Sir Benjamin Richardson, that it is due to diseased grain has not 
been generally adopted. EPIDEMIC CEREBROSPINAL MENINGITIS 
673 
Although epidemics of meningitis have coincided with or followed 
epidemics of other specific fevers, such as typhus, cholera and others, 
it has no constant relation with any one of them, and its history and 
clinical features are sufficient to stamp it as specifically different from 
them and probably dependent on a virus of its own. 
Can we go further, and say what this virus is ? 
We naturally look to bacteriology for an answer. But bacteriologists 
are at this disadvantage, that since their science has established itself, 
there have been no large epidemics of meningitis, and therefore their 
researches have been limited to certain minor outbreaks. Taking these, 
however, as a basis, a somewhat surprising conclusion is indicated, namely, 
that the organism associated with epidemic meningitis is identical with 
or closely related to that which is responsible for croupous pneumonia. 
Now, inasmuch as these two diseases appear clinically to be utterly 
dissimilar, it may be well to state some of the facts which seem to 
support the alleged connection. The micro-organism of croupous 
pneumonia was originally supposed to be a bacillus, discovered by 
Friedlander and named after him. But this bacterium has been de- 
throned in favour of a micrococcus1 which bears, it is true, just 
sufficient resemblance to Friedlander's bacillus to allow us to suppose 
that the two were originally confounded. This micrococcus, which we 
may briefly term the pneumococcus, usually occurs in pairs (diplococcus), 
surrounded by a transparent, easily-disintegrated capsule. The individual 
cocci of each pair, when seen in the blood or in pneumonic exudate, are oval 
or lance-shaped (like a grain of wheat or of barley); but in most cultivation 
media they are round. They stain with aniline colours, but are not (like 
Friedlander's bacilli) decolorised by Gram's iodine solution. They grow 
in most cultivation media provided these are not acid. They are sen- 
sitive to temperature, so that they do not grow at the ordinary tem- 
perature of a cool room, nor at higher temperatures than 42° C. In 
cultivations they rapidly lose vitality, and changes may be wrought - 
(1) in their form, so that the cocci become more rounded and are asso- 
ciated not so much in pairs (diplococci) as in chains (streptococci); (2) 
in their virulence, so that they lose their power of generating disease 
till they have been passed de novo through the living tissue of some 
susceptible animal. Rabbits and mice are extremely susceptible to 
inoculation with the pneumococcus, so that a subcutaneous injection 
thereof produces at the point of injection an acute oedema or cellulitis 
followed by rapidly fatal septicaemia. Dogs and sheep have more resist- 
ing power, so that a subcutaneous injection produces little effect on them. 
But injection into the pulmonary tissue of dogs, sheep or rabbits, which 
have been rendered impervious to the septicaemic effect, produces a 
characteristic croupous pneumonia. This last fact, and the fact that 
the micrococcus is found in pneumonic sputum, in pneumonic exudate 
1 Described by Frankel in Germany, Talamon and Pasteur in France, Sternberg in 
America; and often called Frankel's diplococcus, or the micrococcus lanceolatus. The 
description in the text is mainly taken from Sternberg's Manual of Bacteriology. 
VOL. I 
2 v 674 
SYSTEM OF MEDICINE 
drawn by a syringe from the chest during life, and in hepatised lungs 
post-mortem, are held to justify its claims to be the cause of pneumonia. A 
most remarkable fact is that this micrococcus is often present in normal 
human saliva, and inoculation of rabbits with such saliva has produced 
a characteristic septicaemia [yide article on "Epidemic Pneumonia"]. 
Now it would seem that when a pneumonia affects tissues other than 
the lung proper, this micro-organism may be found in such diseased parts; 
not only in the lymph upon the pleura and pericardium, which are so 
commonly inflamed in acute pneumonia, but in rarer complications also, 
such as ulcerative endocarditis; and even in disease of organs beyond 
the chest, as in peritonitis and (what concerns us mostly) meningitis 
(20, 21). 
Again, diseases such as these may occur without demonstrable 
pneumonia. Most physicians have seen cases of acute pleurisy, the 
clinical course of which has been indistinguishable from that of a 
pneumonia, but in which post-mortem the lung is not found hepatised. 
In these it is not surprising to learn that the pneumococcus has been 
found in the pleural lymph by Dr. Washbourn (67). But it has been 
found also in ulcerative endocarditis (without pneumonia), idiopathic 
peritonitis, otitis, encephalitis, meningitis after injury, and, lastly, in 
acute purulent meningitis which has no obvious cause (21, 22, 23, 24). 
Not that in all cases of purulent meningitis this identical organism 
is present. For in some there has been found a micrococcus bearing a 
general resemblance to it, but presenting some slight points of difference 
(25, 26); in others the ordinary streptococcus pyogenes; in others, again, 
where the meningitis occurred in connection with some acute infectious 
disease, such as typhoid, the organism proper to that disease (27, 28). 
Yet the fact that in most cases of idiopathic meningitis which have 
been investigated the pneumococcus has been found, and that its intro- 
duction into the cranial cavity of animals produces meningitis, as its 
introduction into the chest produces pneumonia, seems to show that it 
may be at least a frequent cause of that disease. 
From sporadic to epidemic meningitis is no great step; the bacterio- 
logical observations on this latter are as follows: - 
(a) Jaffe, studying an epidemic in Hamburg (1879), could find no 
micro-organisms in the meningeal lymph. 
(6) Giuffre, in a Sicilian epidemic of 1882, found oval cocci in the 
meningeal lymph, not in the blood nor in the spleen. Attempts at cul- 
tivation and inoculation failed (30). 
(c) Ughetti, in Sicily, 1883, found micrococci in the meningeal 
exudation and the blood; inoculations failed (31). 
(d) Marchiafava and Celli found diplococci, both free and within the 
cells in the meningeal exudation; cultures were negative (32). 
(e) Netter states that, in an outbreak at Blois and Orleans in 1886, 
the micrococcus lanceolatus was found in the spinal and cerebral exuda- 
tion by Widal. 
(/) Friis, at Copenhagen, 1886, isolated and cultivated a bacterium EPIDEMIC CEREBRO-SPINAL MENINGITIS 
675 
in the shape of short thick rods, not unlike an oval coccus; inoculations 
failed. 
0) Four cases from an epidemic at Turin, 1888, were investigated 
by Foa and Bordone-Uffreduzzi; they found a micrococcus which they 
identified with Frankel's, cultivated it and experimented with it; injec- 
tions into the cranial cavity produced acute general sepsis with cerebral 
and spinal meningitis. Two of their four cases had pneumonia. 
(7z) At an epidemic near Padua in 1890, Bonome obtained from the 
meningeal exudation a micrococcus resembling in some degree the pneu- 
mococcus, but differing from it in the peculiar tangled growth which it 
forms on agar, in its inability to grow in blood serum, and in some of 
its effects on animals. This he believes to be the specific micrococcus 
of epidemic cerebro-spinal meningitis. There was no pneumonia in his 
cases. 
(i) Mirto in 1891 (37), as quoted by Flexner and Barker, discovered 
in some epidemic cases the typical micrococcus lanceolatus. 
(J) Herwerden (1893) (38) gives the case of a woman who died of 
this disease in an advanced stage of pregnancy. Caesarean section was 
performed, the child lived five and a half days, and then died of menin- 
gitis complicated with pleurisy. In the meningeal exudations both of 
mother and child, and in the blood, the liver and the kidneys of the 
child, pneumococci were found. The virulence of these appeared at first 
to be slight, but it was increased by submitting them to the action of 
hydrogen and oxygen, so that injection of them into rabbits produced 
meningitis. 
(k) Leichtenstern (39), writing in 1893 of epidemics in Cologne and 
the neighbourhood in 1885-1892, says that he found the pneumococcus 
in cases where there was pneumonia, but not in other cases. The special 
micro-organism he considers to be not the pneumococcus itself, but a 
variety or " specific derivative " of it. 
(I) Lastly, Flexner and Barker, in an epidemic at Lonaconing, Mary- 
land (1893), found lanceolate diplococci in the meningeal exudation, both 
free and enclosed in their cells; but their cultures and inoculation experi- 
ments did not succeed well. 
Such are the primd facie grounds for supposing that the pneumo- 
coccus, or some allied organism, is the cause of epidemic cerebro-spinal 
meningitis; but there are certainly difficulties in the way of a final 
conclusion. 
For (1) some of the observations, especially the earlier ones, are 
admittedly imperfect; and some are not quite harmonious in detail with 
respect to the characters of the micro-organism described. We hardly 
know what importance to attach to small variations of this kind. 
(2) It has been suggested that sometimes the pneumococcus, some- 
times bacteria of other diseases, may produce epidemics of meningitis. 
But to admit this is to give up the notion that the disease is specific at all. 
(3) As to the pneumococcus theory there are general reasons both 
for and against it. The wide-spread dissemination of that organism, 676 
SYSTEM OF MEDICINE 
which, seems to exist even, in normal human saliva, certainly harmo- 
nises with the wide dissemination of the disease, and with the sudden 
appearance of it at isolated foci, without recognisable sources of infection. 
The variability, under different conditions, of the virulence, and perhaps 
of the morphology of the micrococcus, which seems to be recognised in 
the laboratory, may explain the paroxysmal appearance of the disease, 
and why it is not always with us. But this only puts the inquiry a 
step farther back. The question then would be, What are the external 
influences which, either by augmenting the virulence of the micrococcus 
or by reducing our resisting power, render us obnoxious to its attack ? 
And of these we are profoundly ignorant. 
And, it may be objected, if identical or closely-related organisms pro- 
duce the two diseases, pneumonia and meningitis, why do they not more 
commonly co-exist ? 
Doubtless such co-existence has been observed, but chiefly, I believe, 
in the later and more limited outbreaks; it does not seem to have struck 
the observers of the older and more extensive epidemics, who would have 
been disposed to identify the virus of this disease with that of typhus 
or cholera. 
We cannot then consider the question of etiology as yet settled. 
APPENDIX 
It may be of interest to English readers if I refer briefly to the outbreaks 
of this disease which have taken place in the United Kingdom. Many of these 
(though the Irish epidemic of 1866 and 1867 constitutes a notable exception) 
can scarcely be called epidemics, and some indeed are merely groups of two or 
more cases occurring at the same time and place. Yet their essential identity 
with the epidemic meningitis of the Continent and America is, in some instances, 
hardly to be doubted, and in others is very probable. 
1807.-In 1807, at Blackaton, a small village on Dartmoor, a peculiar 
group of cases was observed by Gervis, the nature of which, in the absence of 
a post-mortem, remains somewhat uncertain, but they may possibly have been 
instances of this disease. There were five cases, four of them in one family, 
and four of the five died very rapidly. Headache, vomiting, collapse, slight 
convulsive movements, sore throat, and an hsemorrhagic rash are mentioned as 
symptoms, but no retraction of the head. 
1830. - In the autumn of 1830, at Sunderland, several cases occurred, in 
one of which meningitis was found post-mortem (41). 
1846. - The first Irish outbreak occurred in the first half of 1846; there 
were cases in the workhouses of Belfast, Bray, and Dublin, mostly in boys under 
twelve years old; and two fatal cases in the Hardwick Hospital, Dublin (42). 
During the same year Whittle records cases in Liverpool, some of which he 
distinctly ranks with epidemic meningitis as seen in Ireland and on the Conti- 
nent. Of nine such cases three were fatal. Some, on the other hand, were of 
a milder type. 
In 1846, also, a case was seen at Haslar Hospital (44). 
1846-1850. - It would seem from the statements of M'Dowell that from EPIDEMIC CEREBROSPINAL MENINGITIS 
677 
the time of the first Dublin outbreak mild cases presenting symptoms of menin- 
gitis continued to appear in Dublin till 1850 at least. 
Three cases of somewhat doubtful nature are mentioned at Rochester in 
1850 (44). 
1864-1868. - At Rochester, also, in 1864 and 1865, some four or five cases 
occurred, one of which was examined post-mortem (46). 
During 1865 it appears that there were further cases in Dublin (47); while 
the succeeding years (1866 and 1867) saw the second Irish epidemic, the most 
severe manifestation of the disease which has yet appeared in these islands (48). 
This epidemic raged principally in Dublin, but also affected other parts of 
Ireland, attacking both military and civil population. It was marked by great 
fatality, and by the prevalence of haemorrhagic rashes, so that the name of 
"Black Death" was at one time proposed for it, and also that of "Malignant 
Purpuric Fever." 
In England about the same time there were some isolated cases: two in 
London which were rapidly fatal (49), and one at Devizes (50) (May and June 
1867). 
At Bardney, a Lincolnshire village, there was a small epidemic - over nine- 
teen cases, with one death (51). 
Somewhat later, namely, March 1868, we read of four cases within three 
weeks at Shorncliffe Camp (52). 
In 1867, too, there was a fatal case with petechial rash at Stafford, where 
there formerly had been two similar cases, namely, in 1865 and 1859 respec- 
tively (53). 
1876-1878. - The Irish epidemic of 1866 and 1867, with the minor out- 
breaks which we have just mentioned in England, evidently corresponds to the 
great wave which had just passed over the Continent. 
The next notice of the disease is in 1876, in the Midlands. Two cases 
occurred among the militia at Oxford (54), and an epidemic in and round 
Birmingham; fourteen cases were admitted to the Queen's Hospital in nine 
months, and there were others in the neighbourhood (55). 
In the winter of 1877-1878 a good many cases were seen at Dundee, several 
of which had a roseolar rash, or an haemorrhagic rash like typhus. There 
seems to have been evidence that the disease was contagious. One case died 
with rupture of the spleen (56). 
At Dublin, in the commencement of 1878, there were three fatal cases 
within two months (57). 
1884-1886. - In the spring of 1884 two cases occurred at the Seaman's 
Hospital, Greenwich (58), and two at the London Hospital (59); but as three 
of these patients were sailors the local character of the outbreak cannot be 
insisted upon. 
In Dublin, again, during 1885 and 1886 a somewhat serious outbreak took 
place, largely in the suburban districts, and amongst comparatively well-to-do 
people (60). There were fifty-two deaths during 1885. Rapidly fatal cases 
with purpuric spots were not wanting (61). 
In 1884 a small but very fatal outbreak took place at Galston near 
Kilmarnock. Out of seven cases five were fatal, some with extreme rapidity. 
Personal intercourse was traced between the various patients, so that contagion 
seemed probable (62). 
At Aberdeen, in 1885, Ogston examined the body of a child which died of SYSTEM OF MEDICINE 
678 
acute cerebral meningitis; this he referred to disease of the nasal bones, but he 
notes that another child of the family died of meningitis, and that the father 
had symptoms of the same disease. 
Similarly, near Faversham in 1886 two deaths occurred in one family from 
meningitis (64). 
1890. - In July, August, and September 1890 (65), there was an outbreak 
in five neighbouring villages on the border of Norfolk and Suffolk (Oakley, 
Broome, Scole, Kenton, Bressingham); the symptoms appear to have been typi- 
cal ; there were twenty cases and two deaths: one post-mortem was made, in 
which evidence of meningitis was found. No cause could be assigned for the 
disease. In a village thirty miles away, Great Horkesly, near Colchester, there 
was another case. Near Malden, in Essex, some obscure and rapidly fatal cases 
of fever had been seen that same autumn. In certain Lincolnshire villages 
scattered cases possibly of a similar nature occurred; thus at Willingham, near 
Gainsborough, a gipsy boy died apparently from pneumonia and meningitis; at 
Holbeach, near Spalding, a woman died with symptoms of meningitis; and a 
severe though non-fatal case occurred at Gedney Hill, about ten miles from 
Holbeach. Two cases are said to have occurred in the preceding year near 
Oundle, in a village distant about twenty miles from Gedney Hill. 
In March, April, May and June 1890 four cases of idiopathic cerebro-spinal 
meningitis were examined post-mortem at St. Bartholomew's Hospital (66). 
J. A. Ormerod. 
1. Hirsch. Handbook of Geographical and Historical Pathology. New Syd. Society 
Trans, vol. iii. p. 347 foil. - 2. Gilkrest. London Medical Gazette, 1844.-3. StillIl 
On Epidemic Meningitis. Philadelphia, 1867.-4. Gordon. Dublin Quarterly Journal 
of Medical Science, 1867 (Case I.). - 5. Burdon-S anderson. Eighth Report of Medical 
Officer of Privy Council, 1865, p. 286.-6. Flexner and Barker. American Journal 
of Medical Science, February and March 1894. - 7. Von Ziemssen. Cyclopaedia of 
Medicine (American translation), vol. ii.-8. Mannkopf. Ueber Meningitis Cerebro- 
spinalis Epidemica. Brunswick, 1866.-9. Klebs. Virchow's Archiv, vol. xxxiv.- 
10. Kernig. Neurolog. Centralblatt, 1884, p. 391. -11. Randolph. Bulletin of the 
Johns Hopkins Hospital, iv. 32. -12. Strumpell. Deutsches Archiv f. klin. Medic, xxx. 
-13. Tourdes. Hist, de I'tpidemie de meningite, etc., a Strasbourg. Paris, 1842. -14. 
Klemperer. Neurolog. Centralblatt, 1893. -15. Moos. Ueber Meningit. Cerebro-spin. 
Epidemica. Heidelberg, 1881. -16. Immermann and Heller. Deutsches Arch. f. klin. 
Medicin, 186$.-17. Hirsch. Die Meningitis Cerebro-spinalis Epidemica. Berlin, 1866. 
-18. Grimshaw. Brit. Medical Journal, 1886, vol. i. p. 1216. -19. German Army 
Medical Reports as abstracted in Neurolog. Centralblatt, 1886, p. 235.-20. Frankel. 
Deutsch. Med. Wochenschrift,1886. - 21. Weichselbaum. Wiener klin. Wochenschrift, 
1888, i. 28-32.-22 Leyden. Centralblatt f. klin. Medicin, 1883, March 10.-23. Kan- 
thack. Pathol. Soc. Transactions, vol. xlv. p. 230. -24. Kanthack. St. Bartholomew's 
Hospital Journal, vol. i. p. 67.-25. Weichselbaum. Fortschritte die Medicin, 1887, 
vol. v.-26. Goldschmidt. Centralblatt f. Bakteriologie, ii. 649.-27. Neumann. 
Virchow's Archiv, cix. 477.-28. Adenot. Des meningites microbiennes. Paris, 1890. 
- 29. Jaffe. Deutsches Archiv fur klin. Medicin, vol. xxx. p. 372.-30. Neurolog. 
Centralblatt, 1886, p. 184 (original pamphlet published at Palermo, 1885). -31. Neurolog. 
Centralblatt, 1886, p. 184, and as quoted in Hirsch's Handbook. Original article in 
Giorn. della Societa ital. d'igiene., October 1883. -32. As quoted by Hirsch. Original 
article in Gazzetta degli Ospedali, 1884. -33. Netter. Archives Generates de Medecine, 
1887. - 34. Friis. Virchow's Jahresbericht, 1887, vol. ii. p. 12.-35. Foa and Bordone- 
Uffreduzzl Zeitschrift f. Hygiene, 1888, p. 67.-36. Bonome:. Ziegler's Beitrage, 
etc. 1890, p. 377. - 37. Giaro della Assoc. Napoli di Medic., etc. 1891, No. 2, 129. - 38. 
Schmidt's Jahrbiicher, 1893, vol. iv. p. 227. - 39. Schmidt's Jahrbiicher, 1893, vol. iv. 
REFERENCES INFLUENZA 
679 
p. 153.- 40. Gervis. Medico-Chirurgical Transactions, vol. ii.-41. John Scott. 
Medical Times and Gazette for 1865, vol. i. p. 515. - 42. Mayne. Dublin Quarterly 
Journal of Medical Science, vol. ii. p. 90. - 43. Whittle. London Medical Gazette for 
1847, p. 807.-44. F. T. Brown. Trans. Epidem. Soc. vol. ii. p. 391.- 45. M'Dowell. 
London Journal of Medicine for 1851, p. 850. - 46. F. T. Brown. Ut antea, and in 
Privy Council Reports, 1865.-47. Kennedy. Medical Press and. Circular, June 1867, 
p. 551. - 48. Dublin Quarterly Journal of Medical Science (various writers), vols. xliii. 
and xliv.; Mapother and Marston, Trans. Epidem. Society, 1874.-49. Crisp and 
Clarke. Lancet for 1867, vols. i. and ii.-50. Clapham. Medical Times and Gazette, 
1867, vol. i. p. 709. - 51. Lowe and Woolley. Lancet for 1867, vols. i. and ii.-52. 
Medical Times and Gazette for April 4, 1868. - 53. Day. Clinical Histories and Com- 
ments.- 54. Lancet, 1876, vol. i. p. 812. - 55. Neville Hart. St. Bartholomew's 
Hospital Beports, vol. xii. p. 105. Foster : Lancet, 1876, vol. i. p. 849. Johnston and 
Russel: British Medical Journal, 1876, vol. ii.-56. Maclagan. Edinburgh Medical 
Journal, Aug.-Dec. 1886; also Lancet for 8th June 1878, and Brit. Med. Journal, 1878, 
vol. i. p. 276.-57. Hayden. British Medical Journal, 1878, vol. i. p. 740. - 58. Car- 
rington. Pathol. Society's Trans, for 1884, p. 51.-59. Turner. Ibid. p. 63. - 60. 
J. W. Moore. Brit. Med. Journal for 1886, vol. i. p. 1216. - 61. Hayes. Ibidem. 
- 62. Frew. Glasgow Medical Journal, 1884, p. 21.-63. Ogston. British Medical 
Journal, 16th May 1885. - 64. J. Irvine Boswell as quoted by Bruce Low (infra).- 
65. Bruce Low. Loc. Gov. Board Beports 1890-1891, p. 117. - 66. Ormerod. Lancet, 
1895, vol. i. p. 735. - 67. Washbourn. Med. Chir. Trans, vol. Ixxvii. p. 179. - For 
a complete Bibliography the reader is referred to Hirsch's Handbook of Geographical 
and Historical Pathology. 
J. A. 0. 
INFLUENZA 
In attempting the description of a disease we are often in doubt how 
best to set about the task. Influenza offers no exception to this rule, 
but happily, so to speak, it has overreached itself, and by the very width 
of its range of action over the human body has simplified matters in 
a way that may not at first be apparent. Clearly the only possible 
presentation of a disease so multiform in its character as influenza, is 
to describe it first of all, in as full a manner as space permits, on its 
clinical aspect, and thereafter to discuss its pathology and treatment. 
It is not well to pay too much attention to the disease as it has 
appeared in other countries. After all it is the disease as it appears 
here in England which concerns us; and it is too often forgotten 
that, although the whole world is kin, yet there are racial and climatic 
influences that must make some difference in the picture of disease as 
it has occurred here or there, - a difference which may well come in 
to throw light upon some of the obscure points in the natural history 
of a malady, but which is of less importance from the practical stand- 
point of its management as we have to deal with it amongst ourselves. 
As a matter of fact, however, the disease has departed little if at all 
from certain broad characters, whatever the affected area. 
Description.-To present the disease at all adequately it is neces- 
sary to describe groups of cases. In actual experience all groups must 680 
SYSTEM OF MEDICINE 
necessarily blend somewhat, nevertheless each is sufficiently distinct to 
demand separate mention. 
All cases present, more or less, certain features in common; it will 
be convenient, therefore, to describe first of all what we may call com- 
mon influenza. A healthy person is suddenly, one may say without 
exaggeration that many are instantaneously attacked with violent 
aching of the head and eyeballs; with a pain in the back, perhaps so 
severe as to resemble the onset of variola; with racking in the bones 
that could not be worse if they were being broken; with a general dis- 
tressful soreness; sharp fever without any corresponding acceleration 
of the pulse, and a hard dry cough, sometimes with coryza as from a 
bad cold. Often enough there is some little delirium during the first 
day or two, and not a few cases have even been ushered in by an acute 
maniacal delirium. The tongue is thickly coated with a white creamy 
fur, it is flabby, indented by the teeth, and tremulous. The breath has 
often a peculiarly offensive odour, and the patient suffers from a sudden 
prostration, both mental and physical, altogether out of proportion to 
the duration or apparent severity of his illness. The spleen has been 
found enlarged in some cases. 
The fever lasts, perhaps, three, four or five days and then subsides, 
leaving the patient weak and much depressed, and with a feeling of 
having undergone a serious illness in a short space of time. To add to 
the discomfort, after a day or two chills are apt to recur, usually down 
the back. These are followed by profuse sweats, which may be repeated 
again and again, and perhaps only slowly disappear some time after the 
more essential symptoms have entirely passed away. 
The first case of influenza that I recognised occurred on December 
24,1889. The disease had not then declared itself in epidemic form in 
England. But, as other observers have stated, cases had occurred at 
any rate in the two or three weeks previously. A strong healthy man 
went to Manchester to play a football match. He went with a bad cold 
upon him, and there he became so much worse that he returned home 
again, by which time he was so exceedingly ill that his brother, a 
medical man, became much alarmed. He was delirious, prostrate, 
restless, with a temperature of 102°, a very distressing dry cough, a 
generally tremulous condition of the muscles, and a thickly furred 
tongue. His lungs gave no evidence of pneumonia, but the air entered 
badly, and there were plenty of sibilant rhonchi and rales, a state of 
things that indicated that the bases were engorged - " congested," as I 
should prefer to say. These various symptoms, combined with a little 
diarrhoea, gave the case the appearance of typhoid fever, but the tem- 
perature, falling almost at once to normal, led to a correct diagnosis, 
and he rapidly convalesced. 
Of the simple catarrhal form, with its prostration and pulmonary 
congestion, this is an ordinary case of moderate severity; but there are 
cases in which the poison is apparently much more virulent, and where in 
consequence the disease assumes still more of the characters of typhoid INFLUENZA 
681 
fever. A striking example of this occurred also early in the epidemic of 
1889. A young healthy man came to town to spend Christmas with his 
relatives who were in an hotel. Within a short time from his arrival he 
was seized with an overwhelming drowsiness and fever. His drowsiness 
was indeed so great that he could by no means be kept awake, and in 
this respect the case corresponded to a mild attack of the sleeping form 
of influenza as it has occurred in this epidemic, and has been recorded as 
"nona" by Braun and others (1). He was removed to a nursing home 
because of some slight roseola which suggested scarlatina, but within a 
few hours he was so prostrate, with so much subsultus, and a tongue so 
dry, brown, and cracked, that he presented the appearance of some 
severe form of continued fever. There was somewhat of the dusky 
appearance of a case of typhus, the engorgement of lung either of that 
or of enteric fever, the pulse about the ordinary rate of typhoid; but 
the pyrexia did not run the course of either of these, and in five or six 
days the fever had spent itself and the man was convalescent. 
Another group may well be styled " pulmonary influenza," for the 
violence of the disease expends itself chiefly upon the respiratory tract. 
There is the same sudden attack, with the aching head and limbs, the 
fever, the thickly-coated tongue. But the cough is more troublesome, 
there is more obvious impediment to the respiration, and the posterior 
parts of the lungs are full of sharp, sticky rales of a quality quite 
peculiar to the disease. This condition will often slowly increase, and 
extend over the lung, the fever continuing, and the condition of the 
patient becoming more and more embarrassed. Delirium supervenes, 
the pulse at last mounts up, and the case terminates fatally, without, so 
far as the physical signs go, any evidence of consolidation being at any 
time present. Sometimes in the course of the bronchial catarrh patches 
of solid lung will appear here and there, or an acute pleuro-pneumonia 
will suddenly light up. In some of these the influenza bacillus has been 
found, thus showing the disease in truth to be influenzal pneumonia; 
in others, again, only the pneumococcus, giving support to another con- 
tention that the consolidation is in some cases a sequel or complication, 
and not the primary disease. 
When pleurisy occurs it often runs on into an empyema. In most 
cases, happily, the catarrh, though slow in taking its departure, gradu- 
ally becomes of a less glutinous quality, and the expectoration more 
and more free, until the amount of the purulent discharge expectorated 
becomes so excessive that one wonders where it can all come from, see- 
ing that there are seldom any physical signs adequate to so profuse a 
flux. Sometimes the pulmonary affection leads to haemoptysis, occa- 
sionally profuse, and to hoarseness, and may thus have much superficial 
likeness to tuberculosis. Into this - the pulmonary form - the simple 
or common influenza often passes. There is often, indeed, a much 
quickened respiration, even when there are no physical signs of any 
pulmonary disease, and Graves (quoted by Thompson (10)) describes 
a dyspnoea which is not to be explained by any stethoscopic signs. SYSTEM OF MEDICINE 
682 
Over and. over again, too, there is the history of three or four days of 
fever, then a return to a normal temperature and apparent convales- 
cence ; and then, after perhaps twenty-four or more hours, a relapse, 
not infrequently ascribed to some indiscretion in uncovering or what 
not, but which, in most cases, is probably a part of the disease. And 
with the relapse come more pulmonary symptoms - more cough, more 
expectoration, more fever, a gradual and too often uncontrollable inva- 
sion of the lung by the glutinous bronchitis already described, and in 
too many cases death eventually by the delirium and the exhaustion of a 
gradually asphyxiating bronchitis, or of a pneumonia that knows no crisis. 
Even when the disease clears up it is very slow in its progress; the 
expectoration remains profuse and purulent; the lung is slow in expand- 
ing to its full extent again, and, until it has completely recovered, is 
very prone to temporary recurrences of the old physical signs. 
Influenza that spends itself primarily and chiefly upon the heart is 
not a common occurrence, but it is a very grave matter when it does 
happen. The symptoms are a frequent and alarming tendency to 
syncope, and a feeble, irregular, and often a very rapid pulse. 
A waiter, set. thirty-five, who had drunk freely, was suddenly taken 
ill with influenza. He kept at his work as long as he found himself able 
- a matter of a day or two only - and then sent for his doctor. His 
state was as follows: He was a well-nourished man, sitting half upright 
in bed, with a short, panting respiration and slight lividity of the lips. 
His pulse at the wrist was hardly perceptible, though regular, 120 in the 
minute. His general condition reminded me most of cases of severe peri- 
cardial effusion, but there was no evidence of any increase of the precor- 
dial dulness, nor were the sounds muffled in any way. The impulse was 
diffused and palpable beyond the nipple, the first sound was metallic 
and flapping in character, but there was no murmur. The other viscera 
were in good order. The only conclusion that seemed possible was that 
an acute dilatation of the heart had taken place, and the man was so ill 
that he appeared likely to die. As a rather forlorn hope strychnia was 
injected subcutaneously with much apparent benefit, and he recovered. 
The signs of cardiac failure are for the most part a ready tendency 
to fainting, a feeble, irregular pulse, sometimes pallor, precordial dis- 
tress or pain, and sweating. There are records of a fatal issue under 
such circumstances, sometimes sudden, like the paralysis of diphtheria; 
at other times deferred for a few days, after the manner of acute dila- 
tation of the heart. For example, a middle-aged man of very nervous 
temperament was taken ill with influenza. He was kept in bed and 
had no alarming symptoms, but as he flagged and was depressed he was 
told to get up. In the exertion attendant upon the effort he was seized 
with most alarming faintness, from which it was difficult to rally him 
-indeed, he never did rally thoroughly, for his hands and feet remained 
cold, his face was a dusky gray, his pulse beat 140 per minute, and was 
very feeble, the first sound of the heart was so feeble as to be hardly 
audible, he was constantly sick, and he died in about thirty-six hours. INFLUENZA 
683 
When recovery takes place from attacks of this kind the heart may 
yet be long in returning to a natural action, the pulse remaining feeble, 
intermittent, irregular, or easily disturbed; and Dr. Sansom has re- 
corded cases of persistent tachycardia. The pulse is sometimes unnat- 
urally slow as well as intermittent or irregular - 40 to 50 per minute 
only - in this also showing a striking likeness to one of the ominous 
symptoms in diphtheria. 
As an affection of the circulation thrombosis of one or other of the 
larger veins of the extremities may here be mentioned. I have seen 
seven cases of this complication which occurred in all the cases before 
convalescence had set in, but in some, probably in all, the fever was a 
long one; this feature, occurring in the second or third week of the dis- 
ease, helped in two or three cases to determine the real nature of an 
otherwise indeterminate fever. 
Passing next to the more strictly'nervous phenomena of influenza 
we are confronted by the most bewildering as it is the most interesting 
feature of the disease. And surely of these the suddenness of onset is 
both the earliest and most striking. A medical man went to bed in his 
usual health, as he thought, and getting up during the night to void 
urine, he fell to the ground, and was so weak that he was unable to get 
into bed again without assistance. Another man was out in his dog- 
cart driving and quite well. He suddenly fell out insensible. He was 
picked up, got into the cart and drove himself home; but although he 
had broken a rib he remembers nothing about the drive, and when he 
arrived was so dazed that he wanted to get into bed with his boots on, 
and was thought to be intoxicated. Many similar and even more strik- 
ing instances might be given of the extraordinary rapidity with which 
strong men were instantaneously laid low; but these must suffice. 
Then there is the intense headache; the extreme prostration, quite 
out of proportion to the severity of the fever; the occasional maniacal 
delirium of the onset, or it may be, even definite symptoms of menin- 
gitis ; the marked mental depression that marches with the disease or 
follows it. Neuralgia, too, is very common, sometimes mapping out 
the distribution of certain nerves, and followed by paralysis or other 
evidence of neuritis; sometimes attacking organs and producing, for 
example, pain in the eyeball, chest pang, nephralgia, neuralgia of the 
testis. Then there are the racking pains in the bones - pains indeed 
almost anywhere; subjective sensations of all sorts and in all parts, for 
this short summary is bald indeed in comparison with the multitudinous 
effects described by the many who were affected. 
Of the disease as it spends itself upon the abdominal organs, it will 
suffice perhaps to say that in one of the later recrudescences of the 1889 
to 1895 epidemic, there were a fair proportion of cases in which the chief 
symptom w*as of choleraic character - the attack being ushered in by a 
profuse watery diarrhoea. A gentleman who lived upon a well-appointed 
flat, and who, therefore, had everything handy to his convenience, re- 
lated that his attack was so sudden, so urgent, and so profuse, that it SYSTEM OF MEDICINE 
684 
was impossible for him to retain his control over his sphincter, and that 
in the few yards between his room and the water-closet a stream of fluid 
poured from him. Dr. Simon of Birmingham has put on record (2) 
a series of similar cases, abdominal pain and collapse being added to 
the liquid discharges in true cholera fashion. Of other less common 
modes of onset it is less necessary to speak, for it is quite impossible to 
mention all the vagaries of the attack of this most searching disease; 
but I have heard of a series of cases all of which presented haematuria; 
and many cases have commenced with sore throat, or acute pain, swell- 
ing and abscess in the ear. 
And now before dismissing the primary disease and passing on to 
conditions that may with some propriety be called sequelae, there is good 
reason for taking the leading phenomena of the attack as here enumer- 
ated, and considering them a little more in detail. 
Of the suddenness of onset enough has perhaps been said. It was so 
sudden in some cases as to be instantaneous, and the completeness of 
the prostration by which it not only, as it were, flung strong men down, 
but kept them down, was a thing that appears to be almost peculiar to 
the disease. Only in Cholera Asiatica is the collapse anything like so 
sudden and continuous, and herein it is due, perhaps, not so much to 
physical weakness as to retardation of the circulation and the mental 
hebetude entailed by it. 
The headache was of an unusually severe character. Descriptions 
of it varied, but it was mostly frontal or orbital, and of that terrible 
kind that forbids sleep and goads the patient into delirium. It was 
very like the bad headache that ushers in many a case of typhoid fever; 
but it seldom lasted so long, and usually subsided after two or three 
days, often earlier. 
The aches and pains in the bones and general soreness, in like man- 
ner, were very severe; sometimes they were like the pain of a breaking 
bone; sometimes they resembled not a little the lightning pains of 
tabes dorsalis; sometimes there was a more general ache and soreness 
in head, in shoulders, loins, thighs, that forbade ease in any position 
and gave rise to an indescribable unrest. Fortunately, as with the 
headache, the pains did not usually last in any severity over two or 
three days. 
The appearance of the tongue was quite characteristic. With occa- 
sional exceptions, such as have been mentioned, it was tremulous, large, 
soft, indented by the teeth, moist, and uniformly coated with a thick, 
perhaps rather dirty, creamy fur. This was usually associated with a 
peculiarly offensive fetid odour of breath, which one cannot attempt to 
describe. Indeed, who should attempt to describe a smell unless there 
be an easily recognisable odour with which to compare it ? The chief 
characteristic of this influenza smell was its overpowering nastiness. 
The odour of the sweat of influenza has also been described as peculiar 
- peppery, mousy, fusty, or mouldy (3). 
Of the pulse, the most distinguishing characteristic seemed to me to INFLUENZA 
685 
be that for the severity of the illness it seldom underwent any propor- 
tionate acceleration. A sharp fever with a pulse of only 80 or 90 was 
quite a usual occurrence. 
Coryzal symptoms were sometimes severe, but they were not a pre- 
dominant feature in this epidemic. Probably they were more often in 
evidence in the earlier part of the outbreak than in its later years. 
The cough no less had features of its own. It was hard, dry, and 
racking. It did not ease itself by its occurrence. It often came on in 
violent paroxysms, suggestive, as some have said, of whooping-cough, and 
with the headache, often existing meanwhile, would give rise to the most 
intolerable disquiet. It was not accompanied by any expectoration to 
speak of, and it was exceedingly intractable to remedies. From one to 
another went the question - What is the best remedy for the cough of 
influenza ? and the common experience seemed to be that no drug could 
be relied upon. 
Passing next to the fever, it had no very definite type, and unless 
disturbed by any complication, pulmonary or other, it did not usually 
run to any unusual height. Its duration was variable; in many cases 
not more than three or four days; but in many also it would run ten or 
twelve, or even more. In not a few it ran the twenty-one-day fever of 
typhoid very close. It might be said by some that the fever was also 
very liable to relapse, but this would not perhaps be strictly true, for 
this relapse was almost always associated with the occurrence of some 
complication, even though, as I should certainly contend, such com- 
plications- pneumonia, for example - by their frequent occurrence 
showed themselves to be a part of the disease. It has been asked by 
some whether influenza is ever an apyrexial disease. There can be no 
doubt that it is so sometimes, as virulent forms of other infectious 
diseases may be. A lady in the height of one of the outbreaks came 
to feel so exceedingly ill that she was obliged to take to bed. She 
had excessive headache, and neuralgic pains in various parts of the 
body, and was ill for many days, and much depressed for some time 
afterwards. Her temperature was below normal all the time. My 
colleague, Dr. Wilks (4), records, amongst several others, the case of a 
gentleman, with whom he is well acquainted, who suffered severely, and 
was many weeks ill with influenza, yet who had no fever at any time. 
A very well-known and able practitioner of my acquaintance in the 
provinces even contends that " typical influenza " has no fever. It 
is not possible to accept such a statement of influenza in general, 
but it is possible that it may be true for a special locality or a special 
period of an outbreak. At any rate the observation is of importance 
as bearing upon the general question, and the point cannot be con- 
tested. And why should it be? Contagious diseases are by no 
means wanting which show a similar peculiarity. Cholera is one; but 
the most comparable is diphtheria, a disease mostly associated with 
pyrexia, but in which pyrexia may be quite absent, and that without 
allowing thereby of any more hopeful forecast. Any poison specially 686 
SYSTEM OF MEDICINE 
noxious to the nerve centres may so alter the natural heat-regulating 
processes as to appear upon occasion as an apyrexial disease. That 
influenza is a malady that expends its force largely upon the nervous 
centres cannot at this date be denied, and it is equally certain that it 
may strike, and strike hard, and yet the sufferer be free from fever all 
the time [yide arts, on other Infections]. 
Another common and characteristic symptom, at any rate after two 
or three days had passed, was the occurrence of drenching sweats. 
They were variable in severity - to judge from the descriptions of the 
sufferers - from a peculiarly unpleasant feeling of cold down the back 
up to the most profuse sweats. Moreover, as with other features of the 
disease, they were very obstinate in their tendency to recurrence, and 
many were the cases in which this symptom outlasted all the others, 
and, indeed, only gradually died out after many weeks, or even 
months. 
The occurrence of rigors is another characteristic that may be 
coupled with the sweats, because it emphasises the likeness of this dis- 
ease to those of malarial origin - a likeness that has shown itself from 
the earliest days of the history of the disease when ague and influenza 
appear to have been considered in common. So far as my own experi- 
ence goes, I think it may be said that hitherto, and until the occurrence 
of the late epidemic, those of the present generation were unfamiliar 
with severe and repeated rigors, except as the heralds of acute disease or 
of true ague, or of localised suppuration in this part or that, for example, 
in the cellular tissue or liver. But influenza introduced us to another 
common cause of rigors, and severe and repeated shiverings which, before 
1889, would certainly have been taken to indicate the formation of pus, 
have now to be considered from a wider point of view. I have several 
times known of rigors so severe and so repeated, and the patient to be 
so ill, as to give the appearance and the subjective sensation of impend- 
ing death; that one could not but surmise the case to be one of virulent 
septic poisoning, or of the local formation of pus; and yet, after pro- 
voking this diagnosis, the symptoms have disappeared again without 
any such untoward result. I have also known of three cases, at least, 
in which daily recurring rigors lasted over several weeks. 
Yet one more symptom may be insisted upon, because I have repeat- 
edly found it of value in diagnosis, namely, the extensive diffusion over 
the bases of the lungs of characteristic sharp, sticky rales. It is a pity 
that no verbal description can convey an idea of the peculiarity of 
this feature of the disease. It will occur to many that the bronchitis 
of typhoid cannot be very different, and yet any one familiar with the 
pulmonary sounds in the two diseases would surely bear out the 
statement that the two conditions are distinguishable by the ear. In 
typhoid fever the abnormal sounds are chiefly sibilant and musical 
wheezings, with no great amount of rale. In influenza the rales were of 
medium size, sharp in quality, and conveying the idea of a peculiar 
viscidity of the contents of the smaller bronchial tubes. And the INFLUENZA 
687 
clinical course of the pulmonary affection was quite in accord with this 
presumption of the nature of the diseased product. For in many cases 
the mucus could not be expelled, and it was long before there was any 
expectoration. And for the same reason the lung was long in returning 
to its healthy state. In many cases, indeed, here was one of the chief 
dangers of the disease; the mischief crept from some small area at the 
base of one lung over a larger and larger area of that lung, and then to 
the other lung, without showing any sign of giving way: in not a few 
cases the patient was slowly choked by the spread of an exudation or 
secretion, with the formation or expectoration of which medicine was 
quite powerless to deal. 
And now to pass to the after effects of influenza: I can hardly do 
better than set out with the words of a layman who, in describing its 
effects, said: " It hit me hard, for it ridged my nails." As with the 
initial symptoms of the disease, so with the sequelae, the general pros- 
tration may well take precedence of any other more definite nerve 
lesions. For of all the complaints that are made there is certainly none 
more common than this: " I had the influenza, and have never been 
well since." It may be that the sufferer complains of frequent head- 
ache ; but more often of a feeling of constant " good-for-nothingness," 
an everlasting sense of fatigue, both of body and mind: to move is an 
exertion that is almost insupportable, and is followed by profuse sweats; 
all power of sustained thought is gone. Dr. Gowers has well de- 
scribed this state of things. " It is," he says, " an intense feeling of 
inertia. Every action, physical or mental, requires an effort of the will 
to initiate and maintain it that is almost painful. Immobility of mind 
and body alone seem possible, and yet even rest has to be endured, for 
it brings no freedom from the sense of prostration. So strange and 
unfamiliar is the state that it seems at first as if it be only transient, 
and would be gone to-morrow; but the mistake is realised when day 
after day, week after week, pass without relief. In perhaps the majority 
it is only after some months that the natural freedom of untrammelled 
effort is regained." To this may be added that even now, five years after 
the original outbreak of this the latest epidemic, there are many who 
still suffer more or less from sensations such as are here described. 
Again, frequent is the case where peculiar " all-overish " attacks have 
repeatedly seized the man or woman; sometimes flushings, sometimes 
indescribable internal sensations, but in all cases associated with such a 
dread or panic of impending death that, as several persons have told 
me, they would far sooner die outright and have done with it. 
Of more definite disease of the nervous system I have myself seen 
several cases of temporary mental aberration, and Dr. Althaus has col- 
lected many cases of all kinds, from simple hypochondriasis to melan- 
cholia, mania, and general paralysis. Suicidal temptations seemed 
especially to follow influenza. Cases of this sort are observed after other 
severe febrile affections - typhoid fever, for instance - but after no one 
can it be said that such an occurrence is anything like so common as 688 
SYSTEM OF MEDICINE 
has been our experience in influenza. But we are not dependent upon 
what may be called functional maladies such as these, for there have 
been cases of acute meningitis, for example, during the recent epidemic 
which have afforded presumptive evidence of being related to influenza. 
Or if such cases as these allow of doubt, there are other acute lesions 
of spinal cord and nerves which have been recorded in considerable 
number. Neuralgia, of one distribution or another, has been noted in 
any number of cases; and of still more serious lesions, Dr. Buzzard, 
in a later volume of this work, will record a case of acute multiple 
neuritis that came under the cognisance of Professor Clifford Allbutt 
and himself, which terminated fatally. Dr. Gowers alludes to cases of 
neuritis, and also to the curious circumstance that disturbances of 
sensation appear to be less common in this form than in that produced 
by other toxic agents. Dr. Gowers also notes that influenzal neuritis 
appears more prone to attack the face than other forms. A case is 
quoted from Westphal, where a man aged twenty-five, on the eighth day 
of convalescence from a sharp attack of influenza, found that his limbs 
were becoming weak. The loss of power rapidly increased, included all 
his limbs, and extended to both sides of his face. The nerve trunks and 
muscles of the trunk were tender, and the muscles quickly lost faradaic 
irritability, but preserved voltaic - the reaction characteristic of nerve 
degeneration. There was but slight disturbance of sensation. When 
the loss of power had reached a considerable degree it was accompanied by 
the peculiar oedema of the extremities, often met with in multiple neuritis. 
Then the palsy ceased to increase, and after two weeks more began 
to lessen - at first slowly, and then rapidly; and went on to complete 
recovery. Dr. Clifford Allbutt tells me of a case of peripheral neuritis 
of the lower extremities, in which the gait resembled a case of loco- 
motor ataxy; the knee jerks however remained. I have myself seen two 
cases of paresis of the lower extremities associated with muscular wast- 
ing, and have seen or heard of many cases of local wasting of groups of 
muscles that indicated a localised neuritis. A very interesting group 
of this sort are the ophthalmoplegias. Of the external group the 
external recti appear to be the most often affected. Of internal ocular 
palsies loss of accommodation has been described, and is said by Althaus 
to be very common: this is one of the several points of resemblance 
between this disease and diphtheria. Many other ocular troubles have 
been described in influenza; chief of them is neuritis of the optic 
nerve or of its sheath, followed by optic atrophy and amaurosis. 
Ulceration of the cornea was not very uncommon (Higgens), and, in thus 
mentioning the loss of sight, one may link with it also a loss of smell 
sometimes complained of, and still more often a loss of taste that 
lingered long after the disease had subsided. 
Besides these conditions changes have been recorded, both at home 
and abroad, that have not usually been attributed to any toxic agency 
such as we suppose this disease to be. Of these is acute myelitis, 
occasionally localised, but more usually disseminated through more INFLUENZA 
689 
or less of the spinal cord. Even more chronic changes still are said to 
have followed it, such as locomotor ataxy, spastic paralysis, and so on. 
It is said that these serious lesions are more likely to occur in the later 
of repeated attacks than in the first, and it is certain that they bear no 
relation to the severity of the attack. The post-influenzal, like the post- 
diphtheritic nerve lesions, may be just as severe after mild as after 
severe attacks. Dr. Wilks, in respect of this very point, contends that 
we have no right to call many of these nervous phenomena " sequelae," 
for, inasmuch as in many cases they are the only symptoms, they are 
the essential disease. As another sequela diabetes may next be men- 
tioned, not because it has been common, but because of its nervous 
origin: Dr. Saundby has described post-influential diabetes, so also has 
Eischel, and I have seen a case. Sir T. Grainger Stewart asserts that 
a considerable number of cases took origin after influenza, and that in 
a considerable number of those already diabetic coma supervened as the 
result of the intercurrent malady. 
Of Van pulmonary sequence pneumonia was the most frequent. That 
it is, often, an integral part of the disease has already been said, but in 
many it was probably rather a sequela, the influenza bacillus being 
absent and the pneumococcus present. It is necessary, therefore, to 
suppose, as I shall presently say of typhoid fever, that the influenza in 
some cases laid its victim open to an attack of pneumonia. 
In another large number of cases this seemed certainly true as re- 
gards pulmonary tuberculosis. Many a case seemed to start from an 
attack of influenza, and many a case of phthisis was certainly sent on its 
way with an alarming increase in the rapidity of its progress. Asthma, 
though in nothing like the same degree, is another malady that has in 
some cases been definitely traced to an attack of influenza ; and in two 
instances I have known it to be the initial symptom of the epidemic 
disease. There is also no doubt, too, that empyema is unusually prone to 
follow upon the acute pulmonary inflammations that arise in influenza. 
Probably the same may be said of pyo-pericardium. I met with four 
cases in the height of the epidemic, and I shall also state my strong 
belief that ulcerative endocarditis was no uncommon outcome; at any rate 
it seemed to me to be disproportionately frequent during the epidemic. 
Quite recently a woman with mitral disease in Guy's Hospital took influ- 
enza, and thenceforward remained feverish and died after several weeks 
of malignant endocarditis with infarctions in the spleen and pneumonia. 
The mention of unhealthy inflammations of this sort may well lead 
on to the next sequela that was very common, namely, the formation of 
abscesses in various parts of the body. Many were glandular abscesses, 
but not all. Abscesses in the brain, in the lungs, in and about joints, 
in the neck, axilla, groin, have all been met with, and, at one period of 
the epidemic, otitis of the middle ear and abscess following upon influ- 
enzal sore throat was quite a common occurrence. Suppuration in the 
antrum of Highmore is a distressing and possibly fatal sequela which 
for a time may escape diagnosis. 
2 Y 
VOL. I 690 
SYSTEM OF MEDICINE 
These are the main results of this strange and terrible disease. 
But the list is by no means exhausted. There would appear to be no 
organ or tissue that may not become the subject of its attack. Dr. 
Boulting tells me of four cases of myxoedema that he believes to have 
been consequences of attacks of influenza, and acute thyroiditis was 
twice recorded (in the British Medical Journal) during the year 1895 as 
a complication of influenza. Purpura hoemorrhagica deserves mention. 
Dr. Sansom has recorded a case associated with acute pemphigus, and 
Professor Allbutt tells me of another that occurred in a severe case of 
influenza with pneumonia and recurrent attacks of mild mania. The 
patient was a gentleman of forty-five, over the trunk of whose body, 
though chiefly towards the back whereon he lay, were very black, close 
set petechise, that took many weeks to fade. A variety of erythematous 
eruptions upon the skin have been noticed; and albuminuria and haema- 
turia were not uncommon with nephritis as an occasional result. Orchi- 
tis has been noticed in one or two cases. 
Lastly, one may notice the persistence, long after the disease has 
spent itself, of a subnormal temperature, a condition that may be taken 
to mean either the long-lasting influence of the disease upon the ner- 
vous centres, or no more than the dyspepsia, the neuralgia, the general 
"good-for-nothingness" which are expressive of the severity of the illness 
the sufferer has passed through. And in this regard maybe mentioned 
two other curious results of the disease that are to be explained, one 
may suppose, in the same way: one is the development in some people 
of an unnatural appetite. A friend tells me that for a long time after 
the attack, though habitually a small eater, and taking next to no food 
in the middle of the day, he would eat four enormous meals; and if 
from stress of work he was unable to get food, he would suffer such 
intolerable agony in his stomach that he would rather have died. The 
other point is the toleration of alcohol that followed the disease in 
some persons. A young man told me that he was so weak after his 
attack that he daily took a quart of stout at his lunch and another at 
dinner, and " it never seemed to go anywhere," nor did he experience 
any ill effect. An old lady, who in ordinary circumstances was a small 
eater and seldom took alcohol in any form, had a mild attack of influenza 
and then a relapse with diffuse phlegmonous cellulitis of one leg. 
She now took food in large quantities, enough, it was said, for three 
men, so as to be the astonishment of her friends; and she took twenty- 
five ounces of brandy, two-thirds of a bottle of port, and a pint of cham- 
pagne in the twenty-four hours for ten days or more consecutively and 
made a good recovery. 
Etiology and Pathology. -It is a matter of doubt when the disease 
that we now call influenza first appeared in England. In the sixteenth 
and seventeenth centuries ague and influenza were not adequately 
distinguished. The notion of ague, as Creighton remarks, was upper- 
most, and there were no means of distinguishing one disease from the IN FL UENZA 
691 
other. In the eighteenth and nineteenth centuries the idea of catarrh 
has been the more prominent. 
But it would seem probable that since 1650, or thereabouts, a disease 
of the same characters as our visitant of recent times, or approaching 
thereto, has now and again appeared in this country. This, however, 
would hardly be supposed from the various appellations given to it. 
Some of these, as narrated by Creighton, are as follows: In 1562, " the 
new acquaintance; " in 1580, " the gentle correction; " and at later 
dates "the new delight," "the jolly rant." There can be few indeed, 
having had experience of our recent epidemic, who would not rather 
subscribe to the propriety of the term " knock-me-down fever " (applied 
sometimes to dengue), than speak of it thus tenderly as "the gentle 
correction," and still less as " the new delight." Happy are we, if with 
our recent and vivid memory of such a scourge, we can yet smile at the 
conceits of a bygone day. 
So far as the attack itself is concerned, the description of the 
epidemics of earlier times are wonderfully accurate now. Subjoined is 
a description by Huxham of the disease as it appeared to him in 1733 
(5) : " It began with slight shivering, followed by transient erratic heats, 
headache, violent sneezing, flying pains in the back and chest, violent 
cough, a running of thin, sharp mucus from the nose and mouth. A 
slight fever followed, with the pulse quick, but not hard or tense. The 
urine was thick and whitish, the sediment yellowish white, seldom red. 
Several had racking pain in the head, many had singing in the ears and 
pain in the meatus auditorius, where sometimes an abscess formed; 
ulcerations and swelling of the fauces were likewise very common. The 
sick were in general much given to sweating, which, when it broke out 
of its own accord and was very plentiful, continuing without striking in 
again, did often in the space of two or three days carry off the fever. 
The disorder in other cases terminated with a discharge of bilious matter 
by stool, and sometimes by the breaking forth of fiery pimples. It 
was rarely fatal, and then mostly to infants and old, worn-out people. 
Generally it went off about the fourth day, leaving a troublesome cough, 
often of long duration, and such dejection of strength as one would 
hardly have expected from the shortness of the time. The cough in all 
was very vehement, hardly to be subdued by anodynes; and it was so 
protracted in some as to throw them into consumption, which carried 
them off within a month or two." 
This description, except in the statement that the disease is rarely 
fatal except to infants and old, worn-out people - and it is still em- 
phatically true, that to the free liver and the aged the risk was largely 
increased - would include many of the main features of the disease 
now. Moreover, there are those still living who experienced an attack 
in the epidemic of 1847-48, and who having suffered again now, were 
able to identify their old enemy without any hesitation. Its prevalence 
has been that of sudden, sharp, short outbursts, mostly exhausting them- 
selves after a few weeks of virulent fury, and then several recurrences 692 
SYSTEM OF MEDICINE 
at longer or shorter intervals, until at last it has disappeared altogether 
for ten, twelve or twenty years. In times gone by the suddenness of 
its invasion, the rapid way in which numbers were attacked almost, one 
might say, at a definite hour, certainly upon a definite day, and the 
alleged fact that the disease attacked not only those on land, but also 
appeared upon ships far away from land, and therefore out of all possible 
contact with sources of contagion, have led to the belief that the disease 
is one that owns some atmospheric origin. But in the last attack the 
observation that has been brought to bear upon this point has made it 
certain that the incubation is very short, that the disease is contagious 
from man to man, that the contagion is carried about by fomites, and 
that it is by these means chiefly that the disease is spread. For in- 
stance, the invasion of a country or district when examined into is 
clearly not so sudden as has been thought. In the first outburst of the 
disease in the winter of 1889, the disorder befell us, apparently, almost 
upon a particular day in the last week in December. But, as I have 
already said, cases had occurred for several weeks before; and this is 
certainly true, for on looking over notes of cases at that period I find 
several in the preceding month or five weeks that puzzled me at the 
time, but which I know now to have been influenza. So also when the 
outbreaks on vessels far from land come to be inquired into, not one, in 
the opinion of Dr. Parsons, is free from the suspicion that there may 
have been less complete isolation than has been currently reported. 
Again, the few towns or villages that have escaped have been remark- 
able for remoteness of situation or natural inaccessibility, curtailing, 
therefore, within the narrowest possible limits the intercourse between 
those within and those beyond their borders. On the other hand, in 
instances too numerous to mention, the disease has apparently started 
and spread rapidly from the date of a person going from an infected 
area to either a healthy house, village, or public institution. 
The permanent home of influenza, if one there be, is not yet 
absolutely certain. The west of Russia seems on the whole to be its 
most likely source, for it would appear that " La Grippe " figures largely 
as a disease in Russia in ordinary years (6). It has been thought by 
some that the disease is really dengue fever under another name, but 
this cannot be. The two diseases are no doubt strikingly alike in some 
general features, but there are also striking differences (vide art. on 
" Dengue The natural habitat is an important one. Influenza seems 
to spare no climate, whereas dengue is a disease of hot seasons only. 
There are regions, again, where outbreaks of the one and the other have 
followed each other at such short intervals (3) that if the one disease 
has offered no protection against the other the occasion has yet offered 
an opportunity for skilled observers to watch the one disease with the 
other fresh in memory, and to contrast the two. Perhaps the most 
marked difference between the two is that dengue is almost invariably 
associated with a rash, and is often-followed by desquamation in large 
flakes, whilst influenza is but rarely accompanied by an eruption. INFLUENZA 
693 
The incubation is probably short. From two to five days is ap- 
parently the limit: usually two or three days, though this cannot be said 
to be substantiated with any degree of certainty, and a still shorter 
period has been alleged. Not only is the incubation short, but the 
infective power of the disease develops early, as might be expected from 
a disorder so distinctly catarrhal in character; for a like reason it is 
not surprising that instances are on record where the infective power 
appears to have remained for many days after the onset of the affection. 
It is obvious that if the infective agent be largely present in the bronchial 
secretion as well as in that of the nasal passages, the duration of possible 
infective power might need to be measured by the continuance of the 
catarrh, whether it relapse in the particular case or not. In this respect 
it may be that pertussis and influenza show a resemblance to each other. 
In making this comparison, however, it is necessary to remember that 
pertussis is prone to relapse again and again long after the primary dis- 
ease, and that there is no evidence that the relapses are infective in 
their nature. It may perhaps be thus with influenza - at any rate in 
those common cases in which certain individuals are said to have had 
the disease time after time. 
The shortness of incubation and early activity of the infecting agent 
are of paramount importance when considering the next question, namely, 
the epidemic character of the disease. A short period of incubation 
must enormously increase the rapidity of the spread of any disease that 
is contagious. But scarlatina is a disease that has a similar period of 
incubation, and no such sudden outbreaks are known ■with it. But two 
important qualifications have to be considered in this comparison. In the 
first place, scarlatina exhausts the soil and protects its subject against 
recurrence; secondly, it is more or less always with us. Influenza does 
not render its subjects immune - not, at any rate, to anything like the 
same extent, certain persons seem indeed to be attacked, preferentially, 
as it were, again and again - and even allowing that, as some insist, the 
catarrhal conditions that are more or less always present at certain 
seasons are influenza in posse, influenza cannot be said to be always with 
us in any such sense as is scarlatina. It may be asserted, then, 
that influenza when it comes finds a soil prone to it instead of proof 
against it, and finds such conditions over a very wide area of the earth's 
surface. No previous epidemics have prepared man to resist it in any 
way, even if they have such a power; like a familiar guest, it finds us 
with open house everywhere. And if to such ready access be added 
the other factor that, like measles, it infects actively so early that it is 
at work for this purpose long before it can be recognised, we have a 
combination of circumstances that, as Dr. Parsons insists, explains the 
extraordinary rapidity of the diffusion of the disease, and one that must 
be carefully considered and appraised before any attempt be made to 
estimate the nature or the power of epidemic influence. 
What additional influence or influences make for an epidemic are 
still unknown. It cannot be doubted that some such are needed, and 694 
SYSTEM OF MEDICINE 
that, speaking generally, they must be of atmospheric order. We have 
knowledge of epidemics of voles, of locusts, of wasps, of certain cater- 
pillars, of the Colorado beetle, of certain blights, depending no doubt upon 
the conditions of environment of these lower orders of life by which 
their reproduction has been extraordinarily facilitated. There seems 
no adequate reason against some assumption of the kind in the present 
case. Short incubation, early activity of infecting power, and absence 
of immunity, would all seem to forecast an endemic rather than an 
epidemic disease; whereas influenza sweeps over the world and it is 
gone. We can see it afar off, and trace its progress, but can do nothing 
to stop it; and it smites the sanitarily pure with a severity on the whole 
much the same as it shows to the rest of the world. 
Atmospheric influences no doubt vary considerably within limits, 
else why should some suffer headache when thunder is in the air, or the 
corns of others shoot when dry weather breaks into wet? And as in 
all zymotic diseases, even endemic ones, there are times when the disease 
is violently active, times when it sleeps and seems almost to disappear, 
the conditions of its life history remaining constant all the time, there 
is no need to labour the proof of epidemicity. We know nothing what- 
ever, and are a long way off the discovery of subtle influences of this 
kind, but none the less they certainly exist. 
The main point, however, that has been made in the present epidemic 
is -that the influenza is contagious; this being so, it becomes probable 
that it is of microbic origin, and investigations in pursuit of a specific 
germ have resulted in the discovery of a bacillus that has distinguishing 
characteristics. This bacillus, according to Klein, was first found by 
Canon, and being found in the blood was supposed by him to cause the 
symptoms by circulating in that medium. But so many subsequent 
observers have failed either to cultivate the germ or to produce the 
disease by inoculation, that Dr. Klein suggests that such bacilli as are 
found in the blood are mostly dead. Pfeiffer about the same time 
described the influenza bacillus independently of Canon, and stated that 
the home of the active germ is in the gray mucus of the respiratory 
tract, where the bacilli exist in such numbers, that by care in selecting 
the specimen almost a pure culture may be obtained. This is corrobo- 
rated by Kitasato and others. 
As regards cultivation of the bacillus, Pfeiffer has produced by inoc- 
ulation in monkeys symptoms similar to those of influenza. Dr. Klein 
(7) has made numerous experiments by inoculation of the pure culture 
upon rabbits and monkeys; in only one monkey was any success obtained, 
but the juices from this animal when injected into other monkeys pro- 
duced the disease in some of them. This difficulty of reproducing the 
disease by inoculation is of importance, because it is believed by some 
that human influenza exists also in horses, dogs, and cats. There is 
some evidence in support of the belief, but it is meagre and equivocal. 
Pfeiffer's bacillus, as it is now called, is very minute - 04 m. in thick- 
ness, 0-8 m. in length (7). It occurs in masses, or singly, or in twos and INFLUENZA 
695 
threes. In stained specimens it has a peculiar appearance, the proto- 
plasm being segregated into a stained granule at each end, while the 
middle portion remains unstained, and shows only the outline of the 
sheath. Thus the bacillus looks like a diplococcus, and where two are 
placed end to end, they look like a chain streptococcus of four spherical 
cocci. They are found in quantities in the bronchial secretion, and, in 
severe cases, in the peribronchial and subpleural lymphatics. 
The bacillus stains with difficulty. My colleague, Dr. Washbourn, 
to whom the three foregoing paragraphs have been submitted, states 
that the best method is to use a solution of carbolic fuchsin diluted 
with water. The smeared cover-glass is dried and then stained for 
ten minutes, afterwards washed with water, dried, and mounted in the 
usual way. The cultivation of the bacillus, a matter of some difficulty, 
is favoured by the presence of haemoglobin in the medium. The best 
method is to remove blood from the blood-vessels of pigeons with 
aseptic precautions, and allow it to clot upon the surface of agar 
sterilised in a test-tube. The sputum is sown upon the surface of the 
blood, and the tube kept in an incubator at blood heat for twenty- 
four hours. By this time the influenza bacilli will have formed 
minute transparent colonies hardly visible to the naked eye. This 
bacillus is characteristic of the disease. So far it has not been dis- 
covered in the blood or secretions from patients suffering from other 
diseases. 
Thus much of the bacillus. It is consistent with all that is known 
of most of these minute organisms that their presence in the secretions 
of one part or another should be associated with a specific state of 
pyrexia in the individual attacked. But we have yet to consider the 
relation of the germ to the after effects of the disease, and the explana- 
tion of these is by no means free from difficulty. Influenza in its sudden 
and severe prostration is very like typhus fever; in its disturbance of 
the nervous centres and tracts it is more like diphtheria. The diffi- 
culty in both is that the after effects may come on when and indeed long 
after the primary disease appears to have spent itself. Up till recent 
times no explanation of this phenomenon has been at all satisfactory; but 
now the theory of the production of toxins during the growth of the 
bacillus adapts itself reasonably and it would seem adequately to the 
peculiar explanations of such cases. Upon this hypothesis the life and 
growth of the bacillus leads to the production of poisonous material in 
the juices upon which it thrives: this is carried into the circulation, 
and gradually works out the distributed effects which characterise the 
sequelae of each. 
Morbid Anatomy. -The mortality of influenza was so large that much 
information might have been expected under this head. But indeed 
our knowledge has not been greatly extended. In all sudden epidemics 
of the kind the disease is so distributed that comparatively few deaths 
occur in public institutions where such opportunities can be utilised; 
moreover, the outbreaks are so overwhelming that it is impossible to 696 
SYSTEM OF MEDICINE 
turn aside from the living to the dead. Indeed we have not yet arrived 
at that certainty which will enable us always to distinguish between the 
changes in tissues or organs that are due to this acute process or the 
other. 
Thus, speaking generally, the changes in the lung, for example, are 
those of bronchopneumonia, of acute lobar pneumonia, or of acute 
bronchitis; yet there are no obvious morbid characters by which, apart 
from the history of the case, we can recognise such changes as belong- 
ing to influenza. It is true in the main that the morbid changes of 
influenza are the result of certain secondary processes: influenza opens 
the door, as it were, to various other poisons, which we have already 
indicated in the clinical description - the streptococcus with the conse- 
quent production of pus, the pneumococcus with the production of 
pneumonia, and so on. 
Certain changes, which appear to be peculiar, have, however, been 
described in the lungs, not only in the more recent, but also in several 
of the earlier visitations. I may quote, in particular, from an account 
of the epidemic of 1837, as recorded by Graves upon the authority of 
Dr. George Green: "The bronchial mucous membrane was found in 
every case more or less congested and inflamed. . . . The inflammation 
in most cases occupied the trachea and the bronchial tubes of both 
lungs. ... A sanguinolent frothy mucus occupied the area of the tubes, 
and increased in quantity as they were traced to their minuter divisions. 
The parenchymatous tissue of the lung was invariably discoloured, and 
it did not crepitate, or very feebly so, when pressed between the fingers. 
The surface of its section was not rough to the touch, and when pressed 
in the hand a quantity of the mucus described was driven out. . . . 
When the torn surface of such lungs was examined it did not appear 
granulated. . . . The signs of recent pleuritis were rare." 
Dr. Louis Hayne, writing of the morbid anatomy of the lungs in the 
recent epidemics (11), agrees very closely with this description. He notes 
the frequency of lobar pneumonia and its tendency to attack the upper 
lobe. Dr. Ribbert of Berlin is quoted to the effect that " the hepatisa- 
tion on section has a peculiarly smooth aspect, differing from the ordi- 
nary granular aspect of acute croupous pneumonia. Sometimes there 
is marked interstitial inflammation, explaining perhaps the tendency to 
abscess and pulmonary gangrene. This peculiar smooth aspect has been 
frequently observed in the deaths from recent epidemics, as has also the 
association with it of areas of bronchopneumonia. Often the solid lung 
looks as though it were composed of a number of patches of broncho- 
pneumonic consolidation, these patches having run together and involved 
the whole lung, suggesting the appearance of a confluent bronchopneu- 
monia rather than that of the croupous variety of pneumonia. . . . This 
is often found in conjunction with red hepatisation. ... In some cases 
pale patches of bronchopneumonia are scattered throughout the lung so 
as to suggest at first sight the existence of miliary tubercle. As regards 
the bronchi, inflammation of the larger tubes is very common, besides the INFLUENZA 
697 
capillary bronchitis, the bronchi being congested and covered with thick 
mucus. The tubes are generally filled even to considerable dilatation 
with muco-pus. The whole thickness of the bronchial wall is softened. 
Sometimes the contents of the bronchial tubes are not mucopurulent, 
but fibrinous." 
I cannot myself attribute much significance to this smoothness of 
surface. I am quite familiar with it as, at any rate, an occasional feat- 
ure of irregular forms of pneumonia; and it has seemed to me some- 
times to be due to a want of intensity in the exudative process, sometimes 
to the occurrence of mixed forms of inflammation, particularly in the 
direction of interstitial changes and nuclear proliferation, associated 
with collapse of the spongy structure of the lung. 
Little more can be said, and this little is scarcely distinctive. 
Probably as much could be said of an epidemic of measles. The 
peculiarity of the changes lies mostly in the fact that acute broncho- 
pneumonia, a rare disease in the adult, is the common morbid change 
found in the bodies of those who die of influenza, but that it is often 
associated with patches in which the microscopical changes are those 
of lobar pneumonia. 
Before now quitting the etiology and pathology of the disease, I am 
tempted to say that epidemic disease has a valuable bearing upon a very 
interesting question, namely, that of the " change of type " of disease. 
In diseases that are ever with us, that grow old as we do and with 
us, it is difficult, though it might seem easy, to express any opinion 
upon such a point. For it may easily be with disease as it is with the 
face of a familiar friend. How easy it is to think that face has altered 
in little or nothing since the days of our boyhood together! Yet what 
havoc does the fashion of the day, with its photographs of the individual 
at various stages of his existence, make with any such fond idea ! In 
influenza, however, we have a disease which only visits us at considerable 
intervals, and thus it affords a favourable opportunity of eliminating 
this possible source of fallacy; and it would appear from evidence 
already quoted that there is no material alteration in the symptoms; 
as they were in former times, so they are now. 
But it is possible that if the causes be the same the individual may 
have altered. Is there any evidence upon this head? Without answer- 
ing this question in any decisive way, it may be worth while to point out 
that there is no record in former times of the long series of post-influ- 
enzal nerve disorders with which we are now but too familiar, and 
which will be found by our successors when in the heat of epidemics 
yet to come they study as we do to-day the recorded experience of 
the past. The difference in this respect that can be noticed between 
the past and present may indeed be due to a simple imperfection 
in the medical record, and the question must be left an open one ; 
but it may well be considered a chief object of the chronicle of to-day 
to put clearly on record, that as a disease influenza has shattered 
the nervous systems of a large number of its victims, in some 698 
SYSTEM OF MEDICINE 
cases permanently, in many for several years after it has run its 
course. 
Whether this disorder has the power of modifying the course of 
other diseases may more conveniently be considered under the head of 
diagnosis now to come. 
Diagnosis.-The general symptoms have already been sufficiently 
considered. All observers have insisted upon the extreme prostration 
as the typical feature of this disease. This has probably led us into 
some neglect of one or two other features that are probably not less 
weighty as means of diagnosis. Chief of these I would place the thick 
coating of a moist, dirty, creamy material upon a large, flabby, and often 
tremulous tongue. To this characteristic tongue must be added the ten- 
dency to profuse sweats, a pulse but little accelerated, and a pyrexia, if 
present, of indefinite type. In the great majority of cases the key to 
the diagnosis rested upon the accurate fitting or otherwise of one or 
other of these pieces into the mosaic - in such, at any rate, as presented 
any difficulty; and these were many. Any number of cases have been 
seen that at their onset looked like influenza, but which afterwards 
proved to be typhoid fever; and who can wonder that the diagnosis is 
occasionally a halting one ? A large number of cases may each begin 
with headache, shivering, general aching, and a pulse but little above 
the natural rate. Sometimes, too, the spleen may be enlarged. How 
can the two diseases then be distinguished until some characteristic de- 
velopment occur ? Watson noticed the resemblance of the early stages 
of influenza to continued fever. Yet it is possible that a provisional 
diagnosis of influenza and a final one of typhoid fever was by no means 
always a mere mistake; and there are those who think that the occurrence 
of the one disease lays the patient open to an attack of the other. Such 
proclivities are well recognised between measles and pertussis; between 
scarlatina and diphtheria. It may be so here, although where mistake 
is so easy it might seem unnecessary to apply any such disputable 
hypothesis. There is, however, the more reason for thinking this to be 
possible, as there seems some small amount of evidence that influenza, or 
the conditions of our environment that favour its development, may also 
modify in various ways the natural course of other diseases. Some ex- 
amples of this tendency have already been alluded to. namely, the rapid 
development of pulmonary tuberculosis after influenza, the risk of pleurisy 
taking on a suppurative form, of an endocarditis assuming a malignant 
type, of a sore throat leading to an acute suppuration of the internal ear; 
and I cannot but think that typhoid fever has of late shown anomalous feat- 
ures that may possibly bear a similar interpretation. For example, a young 
man had been exposed to cold and wet during the prevalence of influenza, 
and had imperfectly guarded himself against such influences. He was 
seized with rigors and went to bed, and thenceforth his sole complaint - 
for he was quite clear in his mind - was that he was constantly drenched 
with perspiration. His temperature was 104°, his pulse only 90, his 
tongue moist and rather creamy, his bowels required some mild laxative. INFLUENZA 
699 
Clearly the disease, although undoubtedly typhoid fever, for he had pro- 
fuse intestinal haemorrhage about the twelfth day, from which he rapidly 
sank, was, in respect of the rigors and sweating, of an influenzal type. 
Of late there have been many such cases of typhoid fever associated with 
inordinate sweating. Another case that I have some knowledge of began 
with wild maniacal delirium, much more like influenza than typhoid; 
and other examples could be given where premonitory symptoms of 
influenza ushered in typhoid fever, and this would seem to be a new 
experience. That this is no more than a personal opinion I fully admit, 
but even the opinions of those who have lived through an epidemic of 
a disease that may not visit us again for many years are worth mention. 
They must be recorded now or not at all, and they may be useful in the 
future as suggestions for observation and inquiry. 
But difficulties of diagnosis arise in other directions. I well remember 
seeing a lady who was suffering severe and repeated rigors, which, to- 
gether with high fever, seemed ominously indicative of hepatic abscess, 
or some internal source of grave septicaemia. She had undergone, a few 
weeks before, some slight operation upon the uterus, but was supposed 
to have quite recovered, and, as it proved, had recovered. Had it not 
been for the late epidemic of influenza which has enlarged our breadth 
of view in the matter of rigors, the diagnosis would have been unhesi- 
tatingly of a very grave character. As it was it remained doubtful, and 
the doubt was solved by the patient convalescing without a drawback 
of any kind. 
One other point may be mentioned, namely, that influenza is often so 
indefinite in its features that the diagnosis can only be arrived at after 
the event, if then. And it is probable that this is of importance if any 
adequate notion of the impact of the disease upon the population is to be 
obtained. Here is an illustration of the sort of case that was constantly 
occurring. One member of a family had a sharp, febrile attack of quite 
indefinite nature. Within a few days another member had earache and 
double otitis; and then another had otitis, or a threatening of it, and 
mastoid pain, and this was followed by a troublesome orbital neuralgia. 
Taking the cases separately there is nothing to justify such a diagnosis, 
but putting them together, and bearing in mind the intimate relation that 
exists between influenza and inflammation of the internal ear, it is surely 
not improbable that the disorder in each case was influenza. To take 
another case: a man, apparently in perfect health, and having committed 
no indiscretion in diet that could by any means explain it, awakes in the 
middle of the night with indigestion and diarrhoea. The diarrhoea was a 
pure watery flux, was associated with slight pyrexia, lasted forty-eight 
hours, and left the man well but, for him, unusually limp and tired. There 
was no thought whatever of influenza. But, nevertheless, for weeks after- 
wards he was much troubled with an evening neuralgia of one side of the 
face; and not long afterwards, after a little excess of work and exposure 
that under ordinary circumstances would not have done any harm, he 
was seized again with a bad neuralgia, that woke him regularly for several 700 
SYSTEM OF MEDICINE 
nights out of his first sleep and compelled him to sit up for the rest of 
the night. There is surely some ground for suspicion that the initial 
attack of choleraic diarrhoea was of influenzal nature, and that the 
neuralgia afterwards was the sequela that made the diagnosis possible. 
Two other aspects remain to be considered, namely, prophylaxis and 
treatment, and these, though the most important of all, unhappily allow 
of a very brief statement. 
As regards prophylaxis, the obvious thing is to keep out of the way 
of contagion. Where strict isolation has been possible, as in certain 
institutions, the disease has seldom appeared; most risk of catching the 
disease is run in public buildings or ill-ventilated rooms of any sort, a 
railway carriage with closed windows not excepted. It also seems cer- 
tain that excesses in living of all kinds favoured the inroads of the 
disease, as also did exposure and fatigue. All observers have testified 
to the frequency of the disease and to its heavy mortality in the alcoholic 
particularly, and also in the overworked and harassed. 
A large section of the public, in addition to common sense hygiene 
of this sort, applied itself to various drugs and inhalations in the hope 
of warding off an attack. Quinine was in most frequent demand in- 
ternally, and eucalyptus as an inhalation; but it cannot be said that 
either quinine or salicin in the one way, or inhalation in the other, 
showed any positive success. 
We are as yet in ignorance how long the influenzal poison retains its 
vitality, but common prudence suggests that infected rooms and clothing 
should be well disinfected after they have been contaminated. 
Treatment. - There is no specific yet at hand for this disease. This 
is quite certain from the number of drugs that have been regarded as 
almost infallible by one observer and another. All are agreed, however, 
that mildness of attack and speedy recovery are best insured by taking 
at once to bed, and that it is the worst folly to struggle on with work 
and to attempt to fight the disease, - a plan that, although some came 
through successfully, was nevertheless the cause of the loss of many 
lives. 
To go to bed, to take plenty of light liquid nourishment and some 
liquor ammonite acetatis every few hours, was sufficient in most cases to 
induce a quick recovery. Other remedies largely in request were salicy- 
late of soda in ten grain doses every three or four hours, antipyrine, alone 
or combined with the former, phenacetin and quinine. Upon a review 
of the whole epidemic, there appears in these drugs nothing of a specific 
effect in cutting short the disease ; but in many cases, by their sudorific 
action and in the control that these drugs have over the temperature, 
they were productive of relief, and made for the return of health. For 
the rest it is necessary to combat symptoms as may seem best: the cough 
perhaps most readily with opium in some form; the aches and pains 
perhaps in a similar manner; and for the long-lasting after effects some 
of the many good nerve tonics, and the judicious use of alcohol, have 
been upon the whole the most successful. DIPHTHERIA 
701 
For most of the statements in the foregoing article I have appealed, 
in the first instance, to my own experience. But in the preparation 
of the article I have frequently referred to Dr. Theophilus Thomson's 
M/maZs of Influenza in Great Britain from 1510-1837; to the Report to 
the Privy Council on Influenza by Dr. Parsons; to the Further Report 
and Papers on Epidemic Influenza, 1889-92, by the same gentleman; 
to Dr. Klein's report in this latter volume ; to a Monograph on Influenza 
by Dr. Althaus; and to Dr. Creighton's recently published History of 
Epidemics in Britain. 
The literature of influenza scattered over the periodicals of the last 
few years is very voluminous; this also has been consulted as much 
as possible, but the task has been rendered incomparably lighter by 
such recent publications as those I have specially mentioned, containing 
as they practically do all the information that is to be obtained upon 
epidemic influenza. 
J. F. Goodhart. 
REFERENCES 
1. Althaus. On Influenza, p. 44. - 2. Brit. Med. Journ. 13th June 1871. -3. 
Bruce Low in Report to the Privy Council by Dr. Parsons, p. 61.-4. Lancet, 1893, 
vol. ii. p. 222, "The Nervous Sequelae of Influenza."-5. Creighton. History of 
Epidemics in Britain, vol. ii. p. 348.-6. Report on the Influenza Epidemic, 1889-90, p. 
14.-7. Further Report and Papers on Epidemic Influenza, 1889-92. -8. Guy's Hos- 
pital Gazette, 1894, p. 183.-9. Report to the Local Government Board on the Influenza 
Epidemic of 1889-90. -10. Annals of Influenza and Epidemic Catarrhal Fevers in 
Great Britain from 1510 to 1837. Sydenham Society, 1852. -11. Louis Ha yne. Practi- 
tioner, vol. liii. No. 4. 
J. F. G. 
DIPHTHERIA1 
Diphtheritis and Diphtheria are names which were invented by Bre- 
tonneau,2 in 1821, to denote a certain kind of specific inflammation 
{phlegmasie specifique'). In his endeavours to distinguish diphtheria from 
other diseases he was compelled to rely altogether upon observations made 
at the bedside and post-mortem table; nor has any other means of dis- 
crimination been possible until within the last few years. Yet the 
clinical definition has never been adequate to its intention, and, in 
respect of some cases of sore throat attended by the formation of false 
membranes, it has always been doubtful hitherto whether they are to be 
deemed diphtheritic or not. At one time it seemed probable that an 
1 The history of diphtheria being beyond the scope of this essay, the reader may be 
referred to the works (1, 2, 3) mentioned at the end of it. 
2 " Il me soit permis de designer cette phlegmasie par la denomination de DIPH- 
THERITE. derive de ai$©epa, pellis, exuvium, vestis coriacea" (4), p. 41. (putanplrri'; 
and 3i</>0epias have the same meaning: qui gestat pelliceam sen coriaceam tunicam.) 702 
SYSTEM OF MEDICINE 
adequate definition, based upon the essential cause of the disease (the 
very ens diphtheria}), could at length be propounded; that diphtheria 
might be taken to signify disease due to infection by the bacillus 
of Klebs.1 But now we are told that the bacillus of Klebs and Loftier 
is not found in some of the cases which we have been accustomed 
to call diphtheritic, and that certain micrococci have the power of 
setting up a pellicular inflammation. So, if we continue to use the 
word diphtheria in the sense of Bretonneau, we must distinguish several 
kinds of that disease (bacillary, micrococcal and so forth); or if we 
restrict the use of the word to those cases in which the bacillus is 
found, we must invent new words to signify the other forms of pellic- 
ular sore throat. It would probably be the better course not to diminish 
the extent of meaning of the word diphtheria, and still to use it as Bre- 
tonneau used it, but in a generic sense. However, the popular tendency 
seems to be strongly in the other direction, that is to say, to confine the 
name to those cases in which the bacillus is found. Moreover, causes 
seldom operate singly and simply; and even that diphtheria which is 
characterised by the presence of the aforesaid bacillus, is so complicated 
by the action or co-operation of other morbific microbes, that diphtheria 
is seldom or never due to a simple infection. Nor has skill in bacterio- 
logical research yet come to be a usual accomplishment of medical men; 
hence the uncertainty concerning the nature of some kinds of sore throat, 
which has always prevailed, is far from wholly dispelled. Indeed, for 
practising physicians, the main note of diphtheria is still found in the 
presence, not of special microbes and morbid poisons, but of false 
membranes upon certain mucous surfaces or upon abraded skin; it 
being well understood that false membranes are not quite peculiar 
to diphtheria, even when that word is used in its most extensive sense: 
the mucous surfaces referred to are those of the throat, nose, and 
windpipe - not to speak of surfaces seldom affected, such as those of 
the stomach, conjunctiva and vulva. Definitions of this kind, though 
rude and inadequate, serve useful purposes until wrought out into a full 
description of the disease. g g. 
Etiology and Prophylaxis. - There is much to justify Oertel's asser- 
tion that diphtheria is " one of the oldest epidemic diseases of the human 
race." A disease, in description like diphtheria, has prevailed from 
time to time in various parts of England. It occurred, mainly in a 
sporadic form, at intervals during the earlier half of the present century ; 
it assumed an epidemic form when the " Boulogne sore-throat " occurred 
on the French coast; and from 1855 onwards the disease has been more 
1 In a book called Scrutinium physico-medicum contagiosse luis quse dicitur Pestis, by 
Athanasius Kircher, published in 1659, will be found a remarkable exposition of the doctrine 
that contagious diseases are dependent upon living particles, contagia viva, semina animata. 
He frequently refers to male in canna (diphtheria) as a kind of pestilence. Pestilential 
" effluvium est animata foetura vermium. Sunt autem hi vermiculi pestis propagatores 
tam exigui, tam tenues et subtiles, ut omnem sensus captum eludant, nec non nisi exquisi- 
tissimo smicroscopio sub sensum cadant, atomos diceres." DIPHTHERIA 
703 
or less continuously present in this country. Until recent days available 
statistics of diphtheria in England and Wales have been limited to fatal 
attacks; and most of the data, especially the earlier ones, are more or less 
imperfect by reason of faulty diagnosis and faulty nomenclature. But, 
such as they are, they show that during the three decennial periods, 
1861-70, 1871-80, and 1881-90, the rates of mortality from diphtheria 
per million living were 187,121, and 163 respectively. The increase of 
the rate of mortality from diphtheria indicated in 1881-90 has been more 
than maintained. In the eighteen years 1871-88, the mean of the 
annual diphtheria death-rates per million living in England and Wales 
had been 137, the rate hardly ever exceeding 160; but for the five 
years 1889-93 the mean of the rates has been 216, the rates for 1892 
and 1893 being the highest ever recorded, namely, 222 and 318 re- 
spectively. Indeed, examination of the mortality returns shows that 
we are face to face with the fact that for a period of some twenty years 
there has been in England an increasing mortality from diphtheria, 
and that this increase has been specially marked during the more recent 
years of that period. To some extent this increase may be set down 
to improved diagnosis, and better methods for the certification of 
deaths; but no such explanation can account for an addition to the 
death-roll which, to use the description of the Registrar-General, must 
be regarded as "formidable." In studying the etiology of diphtheria 
account will be taken of this growing mortality from the disease; the 
more because there is ample evidence to show that diphtheria has not 
merely increased in fatality - whilst the total amount of sickness from 
that cause remains much as before - but that the increase in the number 
of diphtheria deaths has gone hand in hand with a wider diffusion of the 
disease throughout the country. 
It may be convenient at this stage definitely to formulate certain 
propositions respecting diphtheria which I consider to be demonstrated. 
It does not fall to me to give proof of their truth; but in that which 
follows they must be constantly borne in mind by any one seeking to 
apprehend the etiology of the disease. 
1. Diphtheria is a specific infectious disease, primarily and preferen- 
tially affecting mucous surfaces, notably the upper portion of the res- 
piratory and alimentary mucous tracts; also, but more rarely, affecting 
abraded surfaces of the skin. 
2. Diphtheria appears first as a local disease, the part attacked being 
the seat of an inflammatory process characterised by the formation of a 
false membranous deposit. The system as a whole is secondarily affected, 
the general disease being a sequence of the local one. 
3. Local diphtheria results from the reception at a particular point 
of the mucous membrane and the subsequent development there of a 
definite micro-organism - the Klebs-Loffler bacillus diphtheria. This 
micro-organism, which is vegetable rather than animal in its nature 
must therefore be regarded as the particulate and essential cause of the 
local disease. The general symptoms of diphtheria, on the other hand, SYSTEM OF MEDICINE 
704 
are largely due to absorption into the system of a chemical poison or 
toxin, a result of the life-processes of the bacillus. 
4. Diphtheria, or a disease ejusdem generis, is found in certain of 
the lower animals, and can be communicated to them from the human 
subject. 
Consideration of the factors which favour diphtheria will involve 
reference to much that is still obscure; but our present knowledge of 
the etiology of the disease may best be set out by considering the char- 
acter of the evidence on which certain conditions have been regarded as 
disposing to this disease. 
Topography, Soil, etc. - It has been shown by Dr. Longstaff that, 
during the twenty-six years 1855-80, the greatest incidence of death 
from disease registered as diphtheria in this country took place on our 
eastern coast, namely, in Lincolnshire, Norfolk, Sussex, and North Yorks; 
that next in order came East York, Extra-Metropolitan Kent, and Essex, 
counties which are also on our eastern coast, together with Wales and 
certain counties within or bordering upon the Midlands; whereas the 
smallest death-rates from disease thus registered were recorded in Lan- 
cashire, Devon, and Somerset on the one hand, and in inland counties 
such as Bucks, Herts, Northampton, Leicester, and Gloucester on the 
other. These data in themselves, apart from other considerations, 
afford no sufficient indication that one or other portion of England is 
especially liable to fatal diphtheria; but when they are considered in 
connection with conditions of soil, surface, aspect and rainfall, there is 
some ground for believing that areas which favour retention in the soil 
of wetness and of dead organic matter, and are exposed to the influence 
of cold wet winds, do tend to the fostering and fatality of diphtheria. 
But that there are other conditions of equal if not of greater importance 
is unquestionable; indeed, there are already indications that the locali- 
sation of the diphtheria mortality, which Dr. Longstaff referred to as 
holding good up to 1880, has, by reason of other and more potent 
influences, undergone modification since that date. 
Sea,son. - It is generally admitted that, although diphtheria is now 
never absent from this country, season exerts a marked influence on its 
behaviour. Taking this country as a whole, the death records over a 
series of years show that the second quarter of the year exhibits the 
smallest number of fatal attacks; that there is some increase in the third 
quarter; that a very substantial addition to the number of deaths takes 
place in the fourth quarter, when the rate of mortality is at its highest; 
and that during the first quarter of the year, which ranks second as 
regards amount of death, a diminution in mortality sets in. Thus, 
during the twenty-four years 1870-93, the average annual number of 
deaths registered as diphtheria in England and Wales was distributed 
as follows: 1st quarter 1000, 2nd quarter 819, 3rd quarter 847, 4th 
quarter 1192. But, judging from available material concerning attack, 
non-fatal and fatal, it would appear that the increase in the mortality at 
the beginning of the fourth quarter is due to increase of attacks in DIPHTHERIA 
September; and that a not inconsiderable amount of death registered 
in the first quarter of the year relates to attacks which date from 
the latter part of the preceding quarter. In short, an increase of 
diphtheria commonly begins about the second or third week in Sep- 
tember; the increase goes on augmenting through October and the 
greater part of November, and a decline in its amount usually sets in 
not later than mid-December. According to Mr. W. H. Power, October 
and November constitute "the well-known season of normal extra 
activity of diphtheria." There is a second tendency to exacerbation, on 
a much smaller scale, in the spring, commonly about the end of March 
or the beginning of April; after this the disease gradually falls to its 
minimum in June, July, or even in early August. 
Sex and Age. -There is some excess of diphtheria in the female sex, 
but it would appear to be largely due to the greater opportunities of infec- 
tion in girls and women than in the case of males. The excess in females 
commences at the age when little girls begin to tend the baby and 
younger children, whilst their brothers are occupied out of doors ; and 
it is maintained throughout that period of life when women and mothers 
are engaged in house duties and in caring for the sick. Amongst 
females also habits, such as that of kissing, prevail to an extent 
which may account for some excess of a disease that is often conveyed 
from mouth to mouth. At the extremes of life the rate of diphtheria 
death in females does not exceed that in males. 
The influence of age on diphtheria is very marked, whether 
death or attack be in question. By far the largest rate of mortality 
takes place during the first five years of life, and especially during 
the age-period 2 to 5 years; the period 5 to 10 years ranks next, 
and it is not till after the termination of the period 10 to 15 years 
that any substantial diminution sets in. In adult life and in old age the 
diphtheria death-rate is comparatively insignificant. With regard to the 
comparative immunity of infants under one year of age from death by 
diphtheria, it has been pointed out by Dr. D. A. Gress well, now chief 
health officer to the Victorian Government, that infants at times suffer 
from diphtheria deposits in the fauces without obvious inconvenience, and 
that this may be due to the rudimentary character of the tonsils at 
that age. Speaking generally, and including non-fatal with fatal attacks, 
it may be asserted there is a special incident of diphtheria on the age- 
period 3 to 12 years. Now it will be at once remembered that the age 
3 to 12 years is precisely that during which children are in attendance 
at the elementary schools. 
School Influence. - The influence of school attendance on the diffusion 
of diphtheria was noted almost as soon as skilled inquiry into the circum- 
stances of this disease was instituted. This was pointed out by Mr. W. H. 
Power in 1876, and in the following year I had an opportunity of study- 
ing the matter during a maintained prevalence of diphtheria at Cogges- 
hall in Essex. It was found practicable to divide the 928 children in 
the village into age-groups, and then to ascertain within each group the 
705 
VOL. I 
2 z SYSTEM OF MEDICINE 
706 
relative amount of diphtheria in those who attended school, and in those 
who did not. Under three years of age school attendance was not found 
to have materially influenced the number of attacks; but in the age- 
period 3 to 12 years the incidence of the disease was not far from 
50 per cent greater on school attendants than on others; and in the 
age-period 12 to 15 years the school attendants suffered nearly three 
times more than those who were not at school. The same result was 
noted by other observers; and, quite apart from age susceptibility, it 
soon became evident that, there were certain circumstances associated 
with school attendance which promoted diphtheria. Indeed, this is 
now so generally accepted that restrictions in school attendance often 
form one of the earliest, if not the chief of the measures adopted by 
local authorities to prevent the diffusion of the disease. But as 
the subject was more carefully studied, it became evident that the 
influence of school attendance was by no means the simple affair 
of personal infection under circumstances especially favourable to the 
transfer of infection from one child to another; and another stage was 
reached when Mr. W. H. Power investigated a maintained prevalence of 
diphtheria at Pirbright in Surrey. School attendances were recognised 
there as serving to diffuse the malady amongst a somewhat scattered 
population; indeed, in hitherto uninfected households, children between 
three and twelve years of age, who at a given period were attending 
school, became affected five or six times as numerously as children of the 
same age who at the same period were not attending school. Hence, it 
was deemed desirable to close the schools on several occasions. It was 
also seen that attacks of " sore throat," which did not present the typical 
signs of diphtheria, and seemed often but trivial in their character, 
served as links between the more marked outbreaks of the disease. 
Hence, besides resort to measures of disinfection at the school-house 
and in invaded houses, sustained medical effort was made to eliminate 
from the school, on the occasion of each of its reopenings, all cases of 
sore throat, however mild. Thus it came about that comparison was 
possible between nine alternating periods of school work and school clos- 
ure, - the intervals of closure lasting generally for some six weeks, and 
school operations not being recommenced until all signs of sore throat 
had disappeared amongst the scholars. "While the school remained 
open," writes Mr. Power, " in the early months of the year, the rate of 
attack in children aged from three to twelve, presumably susceptible of 
diphtheria, but not having the disease at home, was 16-6 per cent of those 
who were at school, and 3-8 per cent of those who were not. The next time 
the school was opened the respective rates were 4-8 and 0-0; the third 
time, 74 and 2-5; and on the November (the last) occasion, 4-1 and 0-0." 
The numbers on which the percentages are based were admittedly not 
large, but it is claimed for them that the indication which they furnish is 
too uniform to be mistaken. A newly-observed phase of school operations 
seemed here to have been at work; the bringing together of the school 
children operating again and again so as to give a serious specific quality DIPHTHERIA 
707 
to throat ailments which either appeared very trivial or were altogether 
unrecognised; and this with remarkable and even startling suddenness. 
Similar experiences were soon recorded by other observers; and definite 
" explosions " of diphtheria have been by no means uncommonly recorded 
in connection with school attendances. School influence has also operated 
in another way, and this especially at those seasons when diphtheria is 
least prone to show itself in recognisable form. At such seasons the 
unexpected occurrence of one or more severe attacks of the disease has 
led to the idea that the infection might possibly be lingering amongst 
the school children, and under such circumstances both other observers 
and I myself, as the result of personal examination of the throats of 
pupils and pupil teachers in elementary schools, have found an unex- 
pected and exceptional amount of throat sickness, the true nature of 
which has been revealed by the detection of cases of diphtheritic paraly- 
sis amongst some of those who admitted such antecedent throat or nasal 
symptoms as are common in mild attacks of diphtheria. 
Whilst dealing with this subject I would refer to a communication I 
addressed to the Epidemiological Society of London in April 1878, in 
which, from certain of my own investigations into outbreaks of diph- 
theria, 1 drew the conclusion that under certain circumstances the 
property of infectiveness appeared to be a matter of progressive devel- 
opment, and that throat illness which under one set of conditions might 
remain practically non-infective, might under others become specifically 
infective and, in their transmission, acquire characteristics not to be dis- 
tinguished from that which is clinically known as diphtheria. This view 
has since been accepted by a number of medical officers of health and 
other observers; but it has seemed insufficient to account for the explo- 
sive character of some of the outbreaks which have occurred in connec- 
tion with elementary schools. On this latter point I would venture to 
observe that a micro-organism possessing in small degree the property of 
infectiveness might, under one set of conditions of throat, season, and so 
forth, require repeated transferences and transplantations from throat to 
throat before any considerable modification of its morbific qualities was 
brought about; whereas under other conditions of " throat culture " the. 
stages in question might be reached at so rapid a rate as even to account 
for occurrences such as those met with at Pirbright. 
In a former work on the subject of diphtheria I have summarised 
the methods in which school influence appears to be operative for mis- 
chief much as follows: - 1st, It brings together those members of the 
community who are, by reason of age, most susceptible to diphtheria; 
2nd, The children thus brought together are placed, and remain for many 
hours of the day, in exceptionally close relation to each other; 3rd, The 
closer the aggregation and the greater the hindrance to free movement of 
air, the greater the risk; 4th, Faulty sanitary conditions of the school- 
house and its surroundings, and such other conditions as tend to a con- 
dition of general ill health, in so far as they induce sore throat, favour 
the reception of any imported diphtheria infection; 5th, There are 708 
SYSTEM OF MEDICINE 
ample grounds for believing that the aggregation of children in ele- 
mentary schools constitutes one of the conditions under which a form 
of disease of particular potency for spread and for death may be manufac- 
tured; 6th, The practices of kissing and of transferring sweetmeats from 
mouth to mouth - practices more common among girls than boys - the 
joint use of drinking cups and the like must assist in the diffusion of 
diphtheria amongst school-fellows. 
Amongst the more recent contributors to the etiology of diphtheria 
in connection with school influence is Mr. Shirley Murphy. He has 
pointed out (13) that in the metropolis there was during the ordinary 
late summer holiday period of 1893 a sudden drop in the number of 
notifications of diphtheria; and he adds "the whole of the holiday 
depression is due to diminished prevalence at the school-age period of 
life." Mr. Murphy does not regard statistics for so limited a period as 
conclusive; but he notes that, at least, they harmonise with other obser- 
vations, and indicate the need for further inquiry into the influence of 
elementary schools on the prevalence of epidemic disease. 
Direct Infection from Person to Person. - Incidentally this has been 
referred to more than once already. It is probably by far the most 
common cause of diphtheria, and as the fauces and respiratory tracts of 
the sick and healthy respectively are closely brought together, so is 
reception of the poison by this means the more likely to result. Young 
nurses who carry about in their arms little children suffering from 
diphtheria; relations and others who kiss persons suffering from diph- 
theria, whether in a recognised form or not, and children who during 
school attendances are packed closely together, and thus run risk of 
inhaling the throat or nasal emanations of school-mates having mild 
forms of diphtheria, - these are the sort of people who run most risk 
from diphtheria by direct infection. 
Fomites. -The infection of diphtheria has long been supposed to 
attach itself both to premises and to articles of bedding, clothing and the 
like; and there are indications to show that in so far as premises are 
concerned, the faculty of the diphtheria organism for retaining its vitality 
is distinctly enhanced by conditions leading to dampness - especially 
dampness of site. Growths of ordinary mould in premises may often 
indicate such dampness. In a number of instances the evidence of the 
communication of diphtheria by means of the bedding and clothing of the 
sick is such that no doubt can remain of the spread of the disease in this 
way. Again and again the distribution of such articles amongst relations 
and others has been followed by diphtheria amongst their recipients, 
and this under circumstances of time, and of previous immunity from 
any throat affection, that must remove all doubt as to the relation be- 
tween the two events. To name one instance only, I have known the 
despatch of a pillow from an infected house to another locality altogether 
free from any throat affections to be followed within a few days by the 
onset of fatal diphtheria amongst the members of the recipient family. 
Milk Diphtheria. - One of the most important discoveries of modern DIPHTHERIA 
709 
times in connection with the etiology of diphtheria is the relation of this 
disease to the consumption of milk; and it is not saying too much to assert 
that many occurrences of diphtheria which might otherwise have been 
set down to other or to altogether unknown causes, have received their 
explanation since the dissemination of diphtheria by the agency of milk 
was first demonstrated by Mr. W. H. Power in 1878 (14). Since that 
date many outbreaks have been traced with the greatest certainty to 
milk, - the disease not only-having followed the distribution of a certain 
milk-supply again and again, even when carried to widely different and 
distant localities, but having been limited at the onset of the outbreaks in 
those special localities exclusively to persons using the milk in question. 
In certain instances the infection of milk by means of the diphtheria 
contagium must be attributed to the exposure of milk to infection derived 
from antecedent diphtheria in the human subject. It is needless to dis- 
cuss at any length the means by which milk can thus become infected. 
Wherever the throat emanations go, and whether aerially or by means of 
material adherent to the hands and clothes of others, there will be risk 
of infection; hence milk may become specifically contaminated whenever 
the air of the sick chamber has access to it, or where persons in attend- 
ance on the sick take part in any dairy processes. In like manner milk 
may become infected with the diphtheria poison when persons who are 
engaged either in the dairy farm or the milk shop, or who are occupied 
in any way in the collection and distribution of milk, are themselves 
suffering from diphtheria in however mild a form. And it has been 
shown by Dr. Klein that milk, once inoculated with the diphtheria bacil- 
lus, serves as an excellent multiplying ground for the organism even at 
such ordinary temperatures as 18°-20° C. (64-4°-68° F.). 
But the more we learn of milk as a vehicle of diphtheria, the more 
probable does it become that the infection is much more frequently 
derived from the cow herself than from repeated specific contamination 
by the human subject. Thus it has happened that milk from a certain 
dairy, whatever the locality in which it has been distributed, has served 
to convey and to keep on conveying diphtheria to the retail customers; 
and this although all suspicion of antecedent diphtheria or " sore-throat " 
amongst the dairy hands could be eliminated with a degree of certainty 
leaving little or nothing to be desired. And this has happened when the 
milk, which was obviously conveying the infection, was derived from 
two different dairies situated at a distance from each other, and having 
little or nothing in common except the transference of cows from one 
to the other establishment. So strongly has the evidence in such cases 
pointed to the cow herself, that Mr. W. H. Power felt compelled to 
consider (as he wrote now some seventeen years ago) whether there might 
not have been " risk of specific fouling of milk by particular cows suf- 
fering from specific disease, whether recognised or not " (15). Later it 
became possible to trace the milk which conveyed diphtheria in very 
definite manner to certain cow-houses in which one or more cows - 
notably those which had recently calved - had suffered from an ail- 710 
SYSTEM OF MEDICINE 
ment which is certainly infective from one cow to another, and is asso- 
ciated with certain definite symptoms, including a rise of temperature 
and a form of eruption on the udder and teats which, when seen in its 
later stages, has hitherto been commonly regarded by cow-keepers as 
" chapped teats." This eruption usually begins in the form of vesicles, 
which rapidly pass into pustules and scabs, or crusted ulcers. At a next 
stage in the inquiry it was found that a similar disease could be pro- 
duced in the cow by inoculating the animal with sub-cultures of the 
diphtheria bacillus; and when this was done the material derived from 
the induced vesicles and pustules were in turn found to contain the 
same bacillus, which could be unmistakably demonstrated by cover-glass 
specimens and by culture. And, further, the milk of cows thus inocu- 
lated was found to contain the diphtheria bacillus in abundance. 
In a number of outbreaks of that which may now without question 
be called " milk diphtheria," it has been found that the different incidence 
of the disease on individuals has come to depend, among other things, on 
their opportunities for consuming the milk in question. Thus well-to- 
do persons, largely using raw milk in their families, have suffered out of 
all proportion to their poorer neighbours, who could only afford a small 
supply, to be used in their tea. And, further, it has been found that 
stored milk, in the form of cream and still more so of skim-milk, has been 
more potent for mischief than fresh milk - the storage of milk, as, for 
example, when set for cream, giving opportunity for the development 
and multiplication in it of the contained specific organisms. 
Diphtheria in the Lower Animals. - But the cow is not the only one 
of the lower animals which is capable of serving as a medium for the 
distribution of diphtheria, nor the only one to which the disease can be 
communicated from man. Different animals, including pigeons, turkeys, 
and cats, have been referred to in this connection; but, whether the mat- 
ter be studied from a bacteriological or etiological point of view, it will 
probably be admitted that the case of one animal only is altogether free 
from doubt in this connection, namely, that of the cat. There are a 
number of instances in which human diphtheria has followed on similar 
disease in cats; and, on the other hand, evidence has appeared that cats 
have contracted diphtheria from the human subject. Dr. Bruce Low, in 
reporting to the Local Government Board on an epidemic of diphtheria 
in Enfield, expresses the opinion that a disease resembling diphtheria 
which he met with in the cat was in all probability first contracted from 
human diphtheria, then communicated from cat to cat, and then trans- 
ferred again from the cat to the human subject. 
Writing in 1889, Dr. Klein (16) says "that cats are really subject to 
an infectious disease occurring in association with human diphtheria "; 
and, further, that "this disease casually occurring in the cat is very 
similar to the malady artificially producible in that animal by inoculating 
it with human diphtheria." We must, therefore, recognise the fact that 
diphtheria in the human subject may have its origin in disease of a like 
sort in at least one animal common in our households, namely, the cat. DIPHTHERIA 
711 
The Influence of Sanitary Circumstances. - Few questions relating to 
the etiology of diphtheria have led to more discussion than that which 
is concerned with determining the influence, if any, of faulty sanitary 
circumstances on the causation of this disease. The extremes of opin- 
ion are best illustrated by two classes of contentions. First, there are 
those who, having to deal with diphtheria, find that in the locality or 
house where it prevails there are certain more or less obvious faulty 
sanitary conditions; and these persons are content to regard the coinci- 
dence as cause and effect: secondly, there are those who, often meeting 
with diphtheria where there is no history of exposure to faulty sanitary 
conditions, have become convinced that the disease can in no way have 
relation to such conditions. The truth lies, I believe, somewhere between 
these two extremes. 
In considering this question it should be remembered, in the first 
place, that the quarter of a century beginning about the year 1870 has 
been a period in which unexampled progress has been made in England 
and Wales in improving the sanitary circumstances under which the 
people are living, whether of water-supply, sewerage and drainage, the 
disposal of refuse and excreta, or dwelling accommodation. It has also 
been a period in which the general mortality from all causes in this 
country has diminished from the mean annual rate, for the first five years 
of that period, of 22 per thousand living, to one of 19 for the latest five 
years of that period for which we have mortality returns; in which 
the corresponding rate from the seven principal zymotic diseases, 
including diphtheria, has fallen from 4-8 to 2-5; and in which the 
rate of mortality from enteric fever - a disease known to be intimately 
associated with bad sanitary circumstances affecting water-supply, sew- 
erage and drainage, and so forth - has fallen from 0-37 to 0-17 per 
thousand. But during this same period of sanitary progress, associated 
as it has been with a substantial diminution in the amount of death from 
the several causes specified, the corresponding death-rate from diphtheria 
in England and Wales has gone up from 0-12 to 0-19, an increase of 63 
per cent; and in London and the large cities the increase has been even 
greater-it has, indeed, more than trebled. From these facts it would at 
least appear that the removal of ordinary faulty sanitary circumstances 
has not only not been followed by diminution in diphtheria, but that 
precisely the reverse has taken place. In the second place, so far as I can 
learn, it has hitherto been found impossible by skilled observers - includ- 
ing the medical inspectors of the Local Government Board, many leading 
medical officers of health, and distinguished foreign epidemiologists, such 
as Professor Fodor - to identify the use of polluted water-supplies as a 
cause of diphtheria. In the third place, it is certain that in the vast 
majority of cases diphtheria is due either to infection from an antecedent 
case, whether in school or elsewhere, or to infection conveyed through 
milk; and that consequently the balance attributable to faulty sanitary 
circumstances cannot be a large one. The advocates, however, of general 
insanitary conditions as a cause of diphtheria lay special stress on the SYSTEM OF MEDICINE 
712 
influence of faulty sewers and drains, and of collections of offensive 
refuse, garbage, and the like; it is indeed to effluvia from such sources 
that they are disposed to attribute diphtheria. Their contention, there- 
fore, requires further examination. 
Diphtheria, as already stated, is due to the operations of a specific 
bacillus, but this organism has never to my knowledge been discovered 
in " sewer air." Indeed, such experiments as have been made in this 
direction have resulted in failure. Moreover, it is contended (17) that 
the micro-organisms found in sewer emanations are related rather to those 
commonly found in the outer air - being in the main moulds and micro- 
cocci - than to the micro-organisms found in the sewage. And further 
when, in such outbreaks of diphtheria as I have investigated, some obvious 
defect leading to pollution of respired air by sewer or drain emanations 
was regarded as the cause of the disease, I have in almost every instance 
found it not only impossible to eliminate other and better established 
sources of infection, but also that some alternative sources of infection 
were generally found to have had obvious causal relation to the disease. 
But after all has been said in this direction there remains a residuum 
of cases which cannot so easily be disposed of. These cases are, in my 
experience, usually limited to single attacks, to attacks in single house- 
holds, or on occasion to a small group of persons having opportunity of 
infection from the earlier cases. 
In dealing etiologically with such cases, it is impossible to ignore the 
fact that exposure to certain foul emanations is in certain persons often 
followed by sore throat; and it must be admitted that such sore throat, 
as also the common " household sore throat," have infective qualities, 
although as yet these affections have not been identified with any par- 
ticular organism. Some persons are extremely intolerant of these and 
other morbific conditions - such as damp, cold, etc. - and when exposed 
to them suffer from sore throat; and it is often among such persons that 
diphtheria may occur almost immediately after exposure to one or other 
of the emanations referred to. Now a sore throat, however induced, 
is peculiarly favourable to the reception and subsequent local multi- 
plication of the diphtheria organism. Children subject to chronic sore 
throats have often been found specially liable to contract diphtheria; 
and it is also matter of common observation, that convalescents from 
diseases, such as scarlet fever and measles - diseases in which the 
fauces may be denuded of their epithelial coating - are especially 
liable to contract diphtheria; whereas there is no corresponding liability 
on the part of diphtheria convalescents to contract scarlet fever or 
measles. In short, a morbid condition of the fauces affords a soil favour- 
able to the lodgment and maintenance of the diphtheria contagium - the 
process being one of " aerial-inoculation." Another explanation of the 
relation between exposure to foul emanations and an attack of diphtheria 
is, that where diphtheria has assumed an obscure and chronic form - 
the local manifestations being mainly nasal or exceptionally mild - 
exposure to drain emanations, to cold, and damp and like conditions, has DIPHTHERIA 
713 
almost certainly a tendency to induce and to accelerate the occurrence 
of those recrudescing attacks of diphtheria which are so fertile a source 
of the spread of the disease to healthy persons who associate with diph- 
theria convalescents. 
But these explanations do not cover a number of cases in which it 
is, at least, certain that diphtheria prevails concurrently with oppor- 
tunities for exposure to drain and other like emanations; and some 
observers, who do not assert that the diphtheria organism is itself con- 
veyed by means of sewer air, contend that there are circumstances under 
which sore throats, which in their early stages lack specific character- 
istics, do definitely acquire them at a later date. When I first suggested 
that the theory of the " progressive development of the property of in- 
fectiveness " was necessary to the explanation of many occurrences of 
diphtheria, I was inclined to assume that some substantial lapse of time 
was an essential element in the process. But some observers, including 
the late Dr. David Page, medical inspector to the Local Government 
Board, Dr. Posbroke, county health officer for Worcestershire, and Dr. 
Jacob, medical officer of health for Mid-Surrey, have recorded instances 
which seem to indicate that the process may begin and be completed 
during the stages of a single outbreak of very limited duration. Thus 
Dr. Jacob records "an outbreak of diphtheria which was preceded for a 
month by a series of ordinary sore throats," and " gradually worked up, 
so to speak, to the genuine characteristic form of the disease." How 
far the sore throats in question may, on the one hand, have been attacks 
of true but unrecognised diphtheria from the onset, or how far, on the 
other hand, such process of development as I have indicated may take 
place in a single individual, owing to the accelerating influence of foul 
emanations having special characteristics, I am unable to say; but I am 
bound to admit that, bacteriologically considered, we have as yet no 
proof that such development does occur. 
In brief I would observe: - First, that the only available vital 
statistics as to diphtheria do not support the contention that this disease 
and its increase in this country are related to faulty sanitary circum- 
stances ; second, that the operation of that which is included in the term 
" school influence " does account to a very important extent for the in- 
crease in question; third, that much diphtheria which in former times 
would undoubtedly have been assigned to faulty sanitary circumstances 
is now found to be communicated to man through the agency of milk ; 
fourth, that there are good reasons for believing that sore throats, which 
are induced by exposure to conditions such as drain emanations, render 
people especially susceptible to the influence of the diphtheria contagion; 
and, fifth, that amongst the residuum of attacks there remain a number 
in which there is, in appearance at least, a connection between exposure 
to foul emanations and diphtheria, and that some of these cases may 
possibly be instances in which a process of development, even in the 
same person, leads from a minor affection up to a major and definitely 
specific disease. 714 
SYSIEM OF MEDICINE 
No attempt can properly be made to divide the causes of diphtheria 
into definite groups. In one sense there is but one cause of diphtheria, 
namely, the operations of the bacillus diphtheriae, and the direct in- 
fluence of this organism has been indicated in each of the sets of circum- 
stances referred to. This is equally the case whether the organism be 
in a state of specific activity at the moment of its reception, or whether, 
as has been suggested, it be in a form requiring time and circumstance 
for development of its specific potency. The real difference between 
the several sets of conditions concerned in diphtheria is as follows: - 
Some involve conditions such as age, antecedent sore throat, dampness 
of soil, etc., which appear to favour the opportunities for mischief of 
any chance diphtheria bacilli which may be received on the fauces or 
other surface; the others, such as direct infection from an antecedent 
case, infected milk, etc., involve the reception of the infection in such 
form, quality, and quantity, as practically to ensure the production of 
diphtheria even where some of those conditions, regarded as favouring 
diphtheria, may be absent. Study of the operations of both sets of con- 
ditions will indicate the means of prevention. 
In the prophylaxis or prevention of diphtheria we have to consider 
both the general measures which may diminish the chance of contract- 
ing the disease, and also the more immediate and active steps which 
should be adopted to prevent its spread when the disease is actually 
prevalent. 
It is well to remember, and this especially as regards families who 
tend to suffer from "sore throat," that whilst the broad geological 
features of a district have not been observed to have any special in- 
fluence on the development and diffusion of diphtheria, yet residence in 
localities exposed to cold wet winds, and on sites characterised by con- 
stantly recurring dampness of soil and retention of organic debris and 
other refuse, is, if possible, to be avoided. It is a matter of almost equal 
importance to secure the influence of sunlight and movement of air 
about the residences of families and persons who are regarded as ex- 
ceptionally susceptible to diphtheria. These are points to be especially 
borne in mind in the case of old-fashioned and well-timbered country 
places. The adoption of general measures of sanitation, and especially 
the removal of those conditions of drainage, and disposal of refuse, 
which are believed to have some relation to the production of sore 
throat, should always be insisted on. 
Avoidance of infection through the agency of milk can only be 
ensured by habitual abstention from the use of any milk that has not 
been previously scalded or otherwise cooked. Fortunately we know 
that exposure of the diphtheria bacilli to a temperature of 60° C. 
(140° F.) for five minutes suffices to destroy their vitality. Recent 
scalding, therefore, gives ample protection against diphtheria through 
the agency of milk, and indirectly will tend to prevent infection 
from other contagia, such as those of scarlet fever, enteric fever, and 
tuberculosis. DIPHTHERIA 
Ailing domestic animals, notably cats, should be avoided. The evi- 
dence of the communication of diphtheria from the latter to man does 
not admit of doubt. 
Diphtheria being a highly infectious disease, easily communicated 
from person to person, and this at distances the limit of which cannot 
as yet be stated, the immediate isolation of the infected person should 
always be attempted. The most effectual form of isolation consists in 
the removal of the individual to an isolation hospital; but where this 
is not practicable the nearest available approach to isolation should be 
secured. Thus, the removal of a patient to the upper story of a house, 
when that story can be exclusively reserved for the patient and the 
necessary nurse and attendant, may suffice, provided strict precautions 
are taken to maintain the isolation. The apartment of the patient should 
be well ventilated; aerial communication between it and the remainder 
of the house may properly be hindered by the suspension, across the 
doorways of the infected apartments, of sheets which are kept con- 
stantly wet with some disinfecting fluid, the wetness of the sheet being 
an essential point to bear in mind; sputa should be destroyed by fire or 
by boiling; lint, rags, and the like, used in connection with discharges 
from the throat, nose, etc., should be burned in the apartment; all china, 
glass, spoons, and such articles used in connection with the patient's 
meals should be placed in boiling water before they are cleaned; and all 
communication with the remainder of the household should be avoided 
as far as possible. The need for stringency in these matters is often 
even greater during convalescence, for this is precisely the time when 
there is a tendency to relax them. Members of the family who are at 
the susceptible ages should, if practicable, be sent away from the house. 
On the termination of the illness all apartments and articles liable to 
retain infection should be dealt with (12) by such measures as lime- 
washing, stripping of paper, disinfection, etc. The question as to 
when freedom from infection in a convalescent may be regarded as 
complete, will be referred to in connection with the next measure. 
This measure has to do with the control of school attendances. 
Schools of all descriptions must always be looked upon as affording 
exceptional facilities for the diffusion of diphtheria. Hence, in boarding- 
schools, for example, all forms of sore throat should be dealt with as if 
infective; and if, after the effectual isolation of a few first cases, the 
disease still shows a tendency to spread, the school should be broken up 
at once, and measures of cleansing and disinfection resorted to. Early 
bacteriological examination of material scraped from the fauces or nos- 
trils will materially aid in a definite conclusion as to the need of such 
action; but even when bacteriological evidence is negative, the mere fact 
that " sore throat " is spreading should have great weight in forming a 
decision on measures of prevention. As regards the circumstances 
under which reassembly of scholars in boarding-schools may be allowed, 
useful information may be obtained from the publication of Codes of 
Rules by the Medical Officers of Schools Association (18). The advance 
715 716 
SYSTEM OF MEDICINE 
of bacteriological investigations is also certain to come to the aid of 
those who are concerned in arriving at a decision in this matter. In 
day schools, and notably in our elementary schools, early attacks of 
diphtheria have hitherto been apt to be overlooked; and it has not been 
until the attendance at schools began to diminish by reason of sickness 
that the matter received attention. This should not be wherever the 
operation of the Infectious Disease (Notification) Act is adopted. The 
existence of a case of diphtheria in a household should in itself be a 
reason why no member of that household should be allowed to attend 
school. If, notwithstanding the exclusion of children so circumstanced, 
cases of diphtheria continue to manifest themselves, and especially if 
first attacks in individual households are found to occur amongst chil- 
dren attending school, it may become necessary to close the schools for 
a time. The exclusion from school of scholars from infected houses or 
localities, or the actual closure of elementary schools, are matters in which 
sanitary authorities, acting under the advice of their health officers, are 
vested with considerable compulsory powers under the Education Code. 
It has already been shown that the reopening of schools after closure 
has often been the means of leading to a recrudescence of the disease, 
and to the development of a special potency in the infection. The 
recrudescences must now be regarded as mainly due to the fact that the 
bacillus diphtherise is retained about the fauces of convalescents for a 
much longer period than was formerly thought at all probable. Accord- 
ing to experiments made in the case of diphtheria convalescents, it has 
been found that the specific bacillus of the disease may exist in scrap- 
ings from the fauces in a state of vitality, as shown by cultivation, for 
several weeks at least after all disappearance of local indications of any 
throat affection. Bacteriological examination of such material in each 
individual case is necessary where the utmost procurable certainty is 
desired. Where such investigation is, for one or another reason, im- 
practicable, it may be stated that under no circumstances should a 
child be allowed to return to school from a household in which there 
has been diphtheria until at least two weeks have elapsed since the last 
indication of throat-mischief in any one of the family concerned. 
Whenever diphtheria or sore throat of an infective type are at all 
prevalent in schools or elsewhere, precautions should be taken to avoid 
the common use of drinking-cups and other like articles ; kissing among 
children should also be avoided. 
Whilst this article is passing through the press the question of the 
value of anti-toxins is under investigation and discussion. It is claimed 
that the serum of horses which have been inoculated with diphtheria 
organisms, or with the chemical products of those organisms, is able, 
when injected into the human subject, to confer on man an immunity 
against diphtheria infection. As yet the use of this diphtheria anti- 
toxin has been almost exclusively limited to the treatment of individual 
cases of the disease, a matter with which this article is not concerned. 
But Dr. Klein has made some preliminary experiments in this country DIPHTHERIA 
which go to show that guinea-pigs which have been rendered immune 
against diphtheria, by the injection of the prepared horse serum,- 
inoculations which would otherwise have been fatal to them, - succumb 
to fresh inoculations of the same diphtheria material after the lapse of a 
week or two. These experiments confirm very similar ones by Behring 
and Roux. It is not pretended that this is the limit of immunity that 
can be conferred on the guinea-pig, neither has it been practicable 
hitherto to determine definitely to what extent such immunity, if any, 
can be conferred on the human subject. Protective inoculations of 
ordinary doses of serum seem hitherto to be effective only for about 
three weeks. There appear to be grounds, however, for believing that, 
in so far as the guinea-pig is concerned, the use of larger doses of the 
serum would be followed by extension of the period of protection. 
But for the moment the indications suggest that any such immunity 
is likely to be evanescent, that such utility as it possesses may be limited 
to the protection of individuals who have just incurred, or must run 
risk, of exposure to the infection of diphtheria; and that prolongation 
of such risk may call for repetition of the injection of the material which 
confers such immunity. o m m 
J R. Thorne Thorne. 
717 
Bacteriology and Pathology of Diphtheria 
There are but few infective diseases the bacteriology of which has 
been so completely worked out as in the case of diphtheria. Although 
Klebs, in 1883, had described a special bacillus observed by him in diph- 
theritic membranes, Loftier was the first who succeeded not only in 
separating it by growth in artificial media, but also in producing in 
animals by means of inoculations distinct lesions, said by him to resem- 
ble diphtheria. After its discoverers, the bacillus is generally called the 
Klebs-Loffler bacillus. Lbfller's observations were soon confirmed by 
others, notably by Roux and Yersin in France, and Dr. Klein in Eng- 
land ; but the final proof of the specificity of the B. diphtheria we owe 
more especially to the researches of Dr. Sidney Martin. 
The Klebs-Loffler bacillus is found in every case of diphtheria; and 
from the results of investigations made, we may say, all over the world, 
we must refuse to call any lesion diphtheria, unless it is associated with 
that bacillus; conversely, any morbid process accompanied by this 
organism is diphtheria. Formerly, when physicians relied for their 
diagnosis merely on inspection of the affected parts, or on certain symp- 
toms and signs, cases were excluded because they did not conform to the 
accepted clinical " type "; and the absence of gangrene, necrosis, or mem- 
brane was almost sufficient for a denial of the existence of diphtheria. 
Bacteriology has taught us that we must alter our views, and include 
under diphtheria many cases which, according to the older conception, 
would not have been called diphtheria. At the present time we frequently 
hear that typical bacilli have been discovered in cases which clinically 718 
SYSTEM OF MEDICINE 
are not diphtheria: our clinical notions must then be amended and our 
position reconsidered. On the other hand, but a few years ago many 
forms of tonsillitis and laryngitis were diagnosed as diphtheria, which 
now by means of an adequate examination are readily excluded. We 
possess, then, in this organism of Klebs-Lbfiler, a certain test, with the 
help of which in competent hands it is easy to decide the true nature of 
a suspicious case; and the vexed discussion as to the identity or non- 
identity of croup and diphtheria ceases henceforth. In tubercle and in 
diphtheria the bacillus asserts itself with an authority which must put 
aside any preconceived notions. 
The Diphtheria Bacillus. - This organism is extremely polymorphic, 
and this character greatly facilitates diagnosis. Two varieties may be 
conveniently described, the long and the short variety - (a) Long forms: 
These are perhaps to the beginner the most characteristic forms. They 
are generally clubbed at one or other end, and are distinctly curved orf 
shaped, and frequently, when stained, they have a granular or segmented 
appearance, as they do not take up the dye uniformly. These clubbed 
forms are regarded by many as degeneration or involution forms; but we 
shall see that this idea is probably erroneous, since they are best marked 
in young growths. (&) Short forms: These occur, as a rule, as straight 
or slightly curved rods, not uniform in thickness, but generally slightly 
swollen at one end, or swollen in the middle with pointed ends. 
It is, however, not advisable to be too strict in this division of the 
bacilli into types according to their size because, although we may find 
growths in which all the bacilli are long and clubbed, or short and straight, 
yet they do frequently vary in size and shape in the same culture, and on 
transferring a long form from tube to tube it often changes in appearance 
from the long to the short form, and conversely. It has also been stated 
that cases presenting the long forms are more virulent than those pre- 
senting the short form. This, however, is misleading and erroneous. 
After an extensive examination, I can say confidently that it is futile to 
base a prognosis on the type of organism present. Some of the worst 
cases that I have seen were associated with the short variety exclusively, 
while many less serious cases exhibited long forms only. Again, I have 
found colonies of the long and the shore rorm side by side on the same 
agar-agar surface. 
In all cases the grouping of the diphtheria bacilli is characteristic. 
They never form chains or threads, but are generally arranged in irregu- 
lar clusters, which in structure have been aptly compared to the irregular 
Chinese characters which are built up of lines set unsymmetrically and 
at various angles. The bacilli possess no spores, and stain well with 
Gram's method ahd with ordinary aniline dyes. 
Artificial Cultivation. - The media best suited for artificial cultivation 
are serum or serum agar-agar, glycerine agar-agar, gelatine and broth, 
(a) On the surface of gelatine the growth appears slowly, and consists at 
first of a series of small isolated punctiform colonies, which gradually fuse, 
and form a thick, opaque, uneven white or yellowish streak which is char- DIPHTHERIA 
719 
acteristic and easily recognised by those familiar with the diphtheria 
bacillus. The middle of the streak is thick and prominent, while at the 
margins the growth is thinner and expands in an irregular, uneven out- 
line. (&) On the surface of agar-agar or serum the separate colonies when 
typical are round and whitish, with a thick, yellowish brown raised centre. 
Lateral expansion as a rule is slow, but varies greatly; and in some cases 
the growth is entirely made up of minute dotlike colonies, (c) Growth in 
alkaline broth is rapid, the liquid becoming turbid within twenty-four 
hours at the body temperature. The reaction of the culture medium at 
first becomes acid, but later it is once more alkaline. 
The bacilli thus artificially cultivated present the characters of 
type and grouping described above; they may appear either as long 
or short forms, clubbed, curved or straight. They do not move and 
they possess no flagella. It is in young cultures on serum or agar- 
agar especially that the peculiar clubbed and branched forms may be 
observed; so that we cannot regard these as degeneration forms, but 
with Dr. Klein may seek in them a clue to the ancestral history 
of the bacillus, inasmuch as they point to a mycelial origin. An 
attempt has been made to distinguish two types according to the size 
of the individual colonies on the surface of agar-agar; some diph- 
theria bacilli grow always in large colonies, and others grow always in 
small colonies. But this, again, is no distinctive character, since large 
colonies on subcultivation will frequently appear as small ones, and 
conversely; to a certain extent the smallness of the colonies seems to 
depend on the closeness and crowding together of the colonies. 
Bacteriological Diagnosis.-Having shortly described the most lead- 
ing characteristics of the Klebs-Loffler bacillus, it is well here to give as 
shortly a few directions as to the method to be pursued when a bacterio- 
logical examination has to be made for diagnostic purposes: - (a) If a 
piece of membrane is available, it should first be washed in several changes 
of sterile physiological salt solution; then a small piece is removed with 
a strong platinum loop, or the platinum needle is dug into the substance 
of the membrane. With the latter thus charged, a series of serum or 
serum agar-agar tubes are now streaked, three parallel streaks being 
made on each, passing from one tube to the other without recharging 
the needle, so that in the last tube the insemination is scantiest. The 
tubes are now incubated at 38-5° C. and examined next morning; 
suspicious colonies are selected, and traces thereof removed with 
the platinifm wire, and transferred to a drop of broth on a slide. The 
organisms may be examined stained or unstained; but it seems to me that 
in an unstained condition the bacilli are more easily, and certainly more 
speedily recognised. (&) If membrane be unobtainable, the platinum loop 
must be passed over or pushed into the affected part, if it be acces- 
sible, and with the charged wire tubes must be inoculated in the manner 
already described. This is easy enough when the fauces, nose, or conjunc- 
tiva are affected, but what is to be done in laryngeal diphtheria ? Ex- 
perience shows that in most of these cases the bacilli may be readily 720 
SYSTEM OF MEDICINE 
obtained from the pharyngeal or faucial - not tonsillar - secretions, and 
from these tubes should be prepared. 
For the purpose of diagnosis a medium must be chosen which, while 
specially favourable to the development of the Klebs-Loffler bacillus, has 
a retarding influence over the organisms generally associated with the lat- 
ter, such as streptococci, staphylococci, and the bacterium coli commune. 
From practical experience I should recommend an agar-agar prepared 
from ascitic, pleuritic, or hydrocele fluid containing 2 per cent of a 10 
per cent solution of caustic potash, with 5 per cent glycerine and 1 per 
cent grape sugar. It is more easily obtained and prepared than serum 
or serum agar-agar, since the above exudations are always within easy 
reach. The selective power of this medium towards the diphtheria 
bacillus is truly remarkable, and its inhibitory action over other organ- 
isms quite as striking. 
It must be remembered that membranes, produced by other bacteria 
besides the diphtheria bacilli, may appear in the throat, and that in 
many cases the clinical phenomena prove to be of but little assistance; a 
careful bacteriological examination is therefore required. In scarlatina 
especially membranous sore throat is common; it may be caused by 
pyogenetic cocci, especially streptococci, or it may be due to the Klebs- 
Loffler bacillus. Hench and Heubner on clinical grounds, and others 
guided by bacteriological investigations, state that the scarlatinal angina 
appearing concurrently with scarlet fever is not true diphtheria, while the 
membranous inflammation following some time after scarlet fever is true 
diphtheria. This statement, which is also supported by Dr. Klein, is only 
true in a general way, and must not be taken too literally; the rule is 
one to which there are numerous exceptions: nevertheless it is a useful 
rule, as it assists us materially in the early diagnosis of scarlet fever. 
Sore throats may appear in other infective fevers, and should always be 
subjected to a careful bacteriological examination ; for in several cases 
of typhoid fever and measles, for instance, diphtheria bacilli have been 
found, and it has been stated that the palsy which occasionally appears 
in or after enteric fever is actually due to diphtheria intoxication. 
As a rule, there is no difficulty for the experienced eye to recognise 
the diphtheria bacilli either on the surface of the nutrient medium as a 
colony or on the microscopic slide. Occasionally, however, there is some 
or even great hesitation before an opinion is hazarded. For bacilli do 
occur in healthy and non-diphtheritic sore throats which closely resem- 
ble the Klebs-Loffler organism, but yet are not entitled to* this name. 
These have been named " pseudo-diphtheria bacilli." The name pseudo- 
diphtheria bacillus apparently includes several varieties and species, and 
must be used with caution. At present there are at least two views and 
over half a dozen different descriptions of the alleged pseudo-diphtheria 
bacillus. Some observers give this name to organisms which bear a 
superficial resemblance to Lbffler's bacillus, but which any critical bacteri- 
ologist would not and could not confound with it; others use the term for 
organisms which morphologically cannot be distinguished from the typical DIPHTHERIA 
diphtheria bacillus, but which differ from it in so far as they fail to evince 
any pathogenetic properties when tested on guinea-pigs. This is not the 
place for the discussion of this question, but I think that we may fairly 
deny the claim of the former group to the title pseudo-diphtheria bacillus, 
just as we deny the claim of the bacillus coli communis to pose as a pseudo- 
typhoid bacillus. Whether, however, the virulence test is satisfactory 
and exclusive is a doubtful matter: on the face of it, it seems a weak reed 
to rest upon and, until stronger evidence is forthcoming, it is safer to 
regard with great suspicion any bacillus which not merely resembles the 
diphtheria bacillus, but agrees with it in every point except that of viru- 
lence ; and this the more since Eoux and Yersin have asserted that on one 
and the same agar-agar or serum surface we may find virulent and non- 
virulent forms side by side, and also since it is easy to deprive the true 
bacillus of its virulence. The French writers, in fact, consider that the 
so-called pseudo-diphtheria bacillus is a form of the true Klebs-Loffler 
bacillus, the virulence of which has become attenuated. 
Pathogenetic Properties.-We must now briefly consider the evidence on 
which the specific relation between diphtheritic processes and the Klebs- 
Loffler bacillus has been established. (1) If we except the cat, spontaneous 
diphtheria is not found in animals; the diphtheria-like lesions occurring 
in them are due to organisms other than the Klebs-Loffler bacillus. In 
the cat, however, a disease characterised by broncho-pneumonia, kidney 
disorder, and ophthalmia is described: in the consolidated areas of the 
lung Dr. Klein discovered the diphtheria bacillus in considerable num- 
bers ; and on artificial inoculation local diphtheritic changes were pro- 
duced. Hence Dr. Klein concludes that cats are susceptible to human 
diphtheria, and that in them a disease occurs, centred chiefly in the lungs, 
which is akin to the infection in man. Those who are acquainted with 
Klein's researches in this matter can hardly question the truth of his 
conclusions ; and since we are gradually recognising that the diphtheria 
bacillus is capable of producing non-membranous lesions, and that, when 
it finds access to the lungs, it may lead to pronounced broncho-pneumonia, 
they gain considerably in significance. However this may be, inocula- 
tion of the conjunctiva or of the buccal mucous membrane of the cat with 
diphtheritic material is followed by changes closely resembling human 
diphtheria. Loffler, Welch, and others succeeded in producing mem- 
branous inflammation in guinea-pigs by vigorously inoculating the vaginal 
mucosa; and in rabbits by treating the conjunctiva or tracheal mucous 
membrane in a similar manner. In some instances paralysis followed 
the inoculation. 
Subcutaneous injection of virulent diphtheria bacilli, whether of fresh 
broth cultures or of gelatine cultures suspended in broth, leads to death of 
the guinea-pigs in from eighteen to seventy-two hours. The first changes 
to be noticed are swelling at the seat of inoculation - due to round cell 
infiltration, oedema and exudation; also, as a rule, considerable local 
necrosis, and degenerative changes of the heart and the voluntary muscles. 
From the seat of inoculation diphtheria bacilli can easily be recovered, 
721 
VOL. I 
3 a SYSTEM OF MEDICINE 
722 
and occasionally also from the blood and from more distant organs, 
as for instance the lymphatic glands, spleen and liver. The guinea-pig, 
being highly susceptible, is the animal generally used for these experi- 
ments : if it be inoculated in a hind extremity with a small quantity of 
virulent material there appears first a distinct fibrinous exudation, sur- 
rounded by more or less extensive haemorrhagic oedema; the lymphatic 
glands in the neighbourhood soon swell; the exudation becomes more 
marked, necrotic changes take place, and the animal gradually wastes 
and dies, showing, besides the local lesions, haemorrhagic redness of the 
suprarenal capsules, pleural exudation, and degenerative changes in the 
muscles and nerves. Occasionally death is delayed even in these highly 
susceptible animals, and then paresis or even complete paralysis of the 
extremities shows itself, and the nerves show advanced degeneration. 
(2) The most striking morbid phenomenon in the course of human 
diphtheria is the loss of muscular power which accompanies or follows the 
acute disease. When it was shown that even these characteristic symp- 
toms could be reproduced in the animal by artificial infection, doubt as 
to the specific action of the Klebs-Loffler bacillus could scarcely persist 
any longer. Roux and Yersin demonstrated that the inoculation of the 
poisonous products precipitated from broth cultures is followed by pare- 
sis, a point which has received general confirmation. Dr. S. Martin has 
elaborated this question still further, and has demonstrated, so far as 
it is possible, the chemical and physiological identity between the toxins 
produced in artificial growths and the toxins produced in the human body. 
Their inoculation into the animal is followed by the same results; namely, 
by paresis, primary nerve degeneration, fatty degeneration of the cardiac 
and skeletal muscles, and respiratory disorder. The agreement in almost 
all points is so close that none but those who refuse to accept the con- 
clusions obtained through animal experiments will deny that in the 
Klebs-Loffler bacillus we have the specific cause of diphtheria. 
(3) The last vestige of doubt must be removed by the triumphant 
results of treatment with antitoxin. The serum of an animal protected 
against the diphtheria bacillus cures diphtheria in man. As this action 
is specific, it follows that the animal which gave the serum was protected 
against an infection equivalent to diphtheria; that is, that the Klebs- 
Loffler bacillus is the immediate cause of diphtheria. 
The Pathology of Diphtheritic Infection. - It may be said, with some 
degree of truth, that the diphtheria bacillus is found only in the affected 
area and its neighbourhood; so that the chief symptoms of the disease 
are due to intoxication by the poisons locally manufactured at the seat 
of infection. Until recently, and especially in this country, this was 
accepted almost as a law; recent researches, however, show that we must 
modify our views somewhat, for it has been demonstrated that after death 
the bacilli may be traced in certain viscera and organs not in direct 
communication with the diseased tissues. In the membranes, or at the 
primary seat of infection, they occur in largest numbers, and here the 
toxin is most copious; in distant parts the organisms, when present, DIPHTHERIA 
723 
are generally scanty and the poison more diluted. Hence, with due 
reservations, the original statement may be allowed to stand, and we 
may look to the seat of infection as the source of all the trouble. At the 
same time, however, we must keep in mind that the bacilli may escape, 
and do escape oftener than is generally imagined, into the blood or more 
distant organs; this is true especially of those cases which end fatally, 
and on them most of our pathological observations are based. This 
question, which here can only be considered in all brevity, has been 
more fully discussed by myself and Mr. J. W. W. Stephens at a recent 
meeting of the Pathological Society. The bacilli may escape from the 
seat of infection along various paths: (a) by transference of the con- 
tagium to other parts of the body, as, for instance, cutaneous infections 
during the course of diphtheria; (6) by direct extension of the diph- 
theritic process (with or without membranes) along the open passages 
in communication with the seat of infection, that is, for example, from 
the tonsils or larynx upwards to the nose, eyes, and ear, and downwards 
to the trachea, bronchi, bronchioles and lung alveoli, oesophagus, stomach 
and intestines ; (c) by extension along the lymphatic channels into the 
cervical, submaxillary, or bronchial glands; (d) through the circulation 
into the spleen, liver, kidney. Now it is evident that the first and second 
conditions cannot influence the generally-accepted notion of a local infec- 
tion, for in the one case we have an accidental additional lesion, and in 
the other merely an increased area of infection by continuity; but the 
other two conditions, if they occur frequently, would compel us to change 
our views. At present we do not possess sufficient information as to how 
often distant glands and distant organs contain diphtheria bacilli; but 
from the observations of others and ourselves it is certain that in the 
spleen, for instance, they may be found, at any rate in fatal cases, com- 
paratively often. Thus Frosch, Kolisko and Paltauf, Booker, Wright and 
Stokes, collectively discovered them there pretty often, and in twelve 
consecutive post-mortem examinations we obtained positive results in 
nine cases; hence it can no longer be doubted that an escape into the 
circulation does occur in lethal cases, and especially when a tracheotomy 
has been performed. Nevertheless for the present and in a general way 
we may regard diphtheria as primarily a local infection, the bacilli being 
found in enormous numbers at the seat of lesion, whence the deadly 
poison or poisons secreted or manufactured by them pass into the system. 
To the pathologist, then, the toxic substances are of the utmost im- 
portance, and to them we must now turn our attention. Roux and 
Yersin first demonstrated that by injection of the toxic products of the 
diphtheria bacilli into susceptible animals the nervous lesions so char- 
acteristic of the human disease may readily be induced in such animals. 
This observation was followed up and confirmed by Brieger and Frankel, 
and more especially by Sidney Martin in this country. Allusion has 
already been made to this inquiry in the general article on Infection. 
Youx and Yersin obtained the toxin by precipitation with alcohol and 
phosphate of lime, and therefore inclined to the belief that this substance SYSTEM OF MEDICINE 
724 
is a ferment, or, more correctly speaking, an enzyme; while Brieger and 
Frankel saw in it a toxalbumin, or rather a mixture of toxalbumins. Dr. 
Martin's view has already been explained, but may here be once more 
briefly repeated, since his experiments were more thorough than those 
of his predecessors. 
He separated from the blood, spleen and other viscera of children dead 
of diphtheria, albumoses (chiefly deutero-albumose) and an organic acid; 
the former being always present in far greater quantity than the acid. 
Subcutaneously injected into guinea-pigs, the albumoses produced local 
oedema and slight irregularity of the body temperature. When, however, 
they were intravenously injected into rabbits, the result was fever, or a 
lowering of the temperature, loss of coagulability of the blood, paralysis 
of the hind legs, coma and death. Oft-repeated intravenous injections 
of small doses were followed by fever (variable in degree), paresis (a 
constant effect), respiratory disturbances, loss of weight and diarrhoea. 
The fever may last a long time, the paresis may appear suddenly and 
rapidly, but its progress is slow, and the loss of weight is always tardy. 
The paresis is best seen in the extremities, but affects also the trunk 
muscles. There is no visible atrophy of the muscles and no loss of the 
knee-jerk. On examining the animals after death bacilli were not found, 
so that the lesions were due to the chemical substances; that is to say 
were truly intoxicative. The organic acid, like the albumoses, is a nerve 
poison, but not nearly so toxic. From diphtheritic membranes fibrin, 
hetero-albumose, traces of proto- and deutero-albumoses, and of organic 
acid were obtained; but the membrane extract consisted of proteid sub- 
stances with minute traces of albumoses, which extracts, when adminis- 
tered to rabbits, produced fever, paresis and death. It is thus seen that 
the membranes contain proteid substances which are not albumoses, but 
have, nevertheless, the same action; they are, however, far more viru- 
lent than the albumoses. From pure cultures of the Klebs-Loffler bacillus 
the same albumoses and organic acid were obtained, and these displayed 
the same physiological action as the tissue substances. Dr. Martin con- 
cludes that the bacillus diphtherias produces the same substances in the 
culture media as in the tissues, that these have the same action when 
injected into an animal body, and that undoubtedly the bacillus of the 
Klebs-Loffler is the immediate cause of diphtheria. Since the membrane 
extract contains no albumoses worth mentioning, and yet is extremely 
toxic, it is possible that in them a ferment-like substance is formed which, 
absorbed by the tissues, splits them up by virtue of its digestive action into 
toxic albumoses and an organic acid; and that the albumoses thus manu- 
factured will produce the characteristic lesions in the animal organism. 
This ferment-like body or enzyme corresponds to that obtained by 
Roux and Yersin, and is formed in and secreted by the bacilli themselves. 
Martin explains the pathological process in this manner. Since the 
infection is primarily a local one, the organism at the primary seat of 
lesion secretes a potent proteolytic enzyme which enters the tissues and 
blood, and wherever it comes in contact with them, digests them; the DIPHTHERIA 
725 
products of this digestion are toxic albumoses and the organic acid, 
substances which are diffusible and, on being absorbed, lead to the 
morbid changes and disturbances which belong to the diphtheritic infec- 
tion. We have already shortly criticised this view, and we found that, 
tempting though it may seem, it cannot be accepted in the form in 
which Martin offers it (see p. 524). Besides the reasons given there, 
Martin has not taken into consideration that in fatal cases of diphtheria 
the bacilli are frequently found in the lungs, spleen, and other organs; 
and therefore it seems far more probable that the toxin is secreted di- 
rectly by the bacilli than produced by intermediary fermentative proc- 
esses. The spleen contains toxins because they have been absorbed, 
and often for the further reason that bacilli have found their way there; 
and since the bacilli are vastly more numerous in the membrane than in 
the spleen, we find a poison of lesser virulence in the spleen. The albu- 
moses may be merely contaminations which happen to come down with 
the reagents which precipitate the true toxin; the latter is a direct cellu- 
lar product of the organisms - according to Gamaleia a nucleo-albumin 
- which is absorbed by the tissues, blood and lymph. There is no evi- 
dence that the process of intoxication is an indirect one, the bacterial 
cell forming an enzyme, the enzyme producing albumoses, and the latter 
inducing the intoxication; on the contrary we may assume that the bac- 
terial cell secretes its toxin, whatever its nature may be, and that the 
latter is absorbed as a direct tissue poison. 
Whatever view we take of the nature of the poison or of the process 
of intoxication, the laboratory has conclusively demonstrated that the 
Klebs-Lbftler bacillus is the cause - the specific cause of diphtheria: 
whether we inoculate the animal with the living germs or with the toxic 
products, all the characteristic symptoms and lesions of diphtheria can 
easily be reproduced by carefully thought out experiments. 
There is, however, another point to be considered briefly, namely, 
" mixed infection." But rarely on examining diphtheritic membranes do 
we find pure growths of Lbffler's bacillus; as a rule the latter is associated 
with various streptococci and staphylococci, many of which belong to the 
group of pyococci. Is their presence of significance? Foreign observers, 
especially Roux, Martin, and others, assert that such an association is 
most unfavourable, while Messrs. Washbourn, Goodall, and Card do not 
consider the association with streptococci on a single bacteriological 
examination as evidence of unfavourable import; in fact, they incline 
rather to the opposite conclusion. Personal observation made at St. Bar- 
tholomew's Hospital, where as a rule only serious cases are admitted, lead 
me to believe that the presence of streptococci in itself does not influence 
the prognosis; indeed that, as a matter of fact, they are rarely found 
absent, whether the cases be mild or serious, if a series of cultivations 
(two or three tubes) be made in every case. There can be no doubt, 
however, that secondary septic complications, such as suppurating 
glands, suppurative otitis media, septicaemia and pyaemia, may be pro- 
duced by these organisms. Most so-called septic and haemorrhagic forms SYSTEM OF MEDICINE 
726 
of diphtheria are caused by secondary pyococcal infection. It is, how- 
ever, a mistake to consider all swollen and inflamed glands, and all forms 
of lung affections such as broncho-pneumonia or otitis media, as being 
exclusively caused by these pyogenetic organisms. In the cervical and 
bronchial glands the Klebs-Lbffler bacillus is frequently found; so it is 
also in the lungs after death, and occasionally in the middle ear. Never- 
theless it is of the utmost importance to keep in mind the possibility of 
a secondary infection since, when we come to treatment, we cannot ex- 
pect a serum which specifically counteracts the diphtheritic process to 
be potent also against the pyococcal infections. For this reason the em- 
ployment of an antistreptococcal serum has been suggested, and in 
France this plan has already been adopted. Haemorrhagic diphtheria 
seems to be generally due to secondary infection, for in two or three 
cases examined personally, or in conjunction with Mr. J. W. W. Stephens, 
I found pyococci (pneumococci and streptococci) in the blood and organs; 
in a third case, however, the diphtheria bacillus existed in the spleen. 
The mortality of this kind of diphtheria is always high, in spite of the 
antitoxin now used; and we can readily explain the failure of the new 
remedy if it be a fact that most forms of haemorrhagic diphtheria are 
due to secondary infection or are true septicaemia. Broncho-pneumonia 
has also been generally attributed to streptococci; but my own observa- 
tions and those of Wright, Frosch, Stephens and others, tend to prove 
that in most cases we have a true diphtheritic infection in the lungs; and 
in almost all fatal cases, especially if the process were laryngeal, or if 
tracheotomy had been performed, the Klebs-Lbffler bacillus can be found 
in the lung. This point is worthy of the fullest consideration, since it 
shows the necessity of active and energetic antitoxin treatment in such 
cases; in these the area of toxin production must be enormous, and, as 
the lungs are extremely vascular, absorption thence must indeed be great. 
Although I feel tempted to say a few words on cutaneous and 
ophthalmic diphtheria, in order not to extend this article too much, I 
must now pass on to the morbid anatomy of diphtheritic processes. 
Morbid Anatomy of Diphtheria. - (a) Membrane: The presence of 
true or false membranes was formerly considered the characteristic of 
diphtheria, but, as we have already seen, it is by no means essential. If, 
for instance, we regard the process as it occurs in the tonsils and fauces, 
we may have extensive membranes, or small patches or mere powdery 
flakes; or again we may find an entire absence of membranous exudation. 
There may be mere redness or oedematous swelling, or there may be a 
gangrenous or necrotic lesion. Yet since the membrane must, for the 
present at least, remain an important clinical diagnostic factor, a few lines 
must be devoted to its description. These membranes consist mainly of 
fibrin, and are either coherent patches or small whitish flocculi; they 
maybe firmly or loosely adherent. In most cases the surface epithelium 
is shed in part before the deposition of fibrin begins; but membranes 
may also appear in, over and even under the intact epithelium. When 
fully formed they consist of filaments of fibrin, which form a network DIPHTHERIA 
enclosing within its meshes leucocytes, red corpuscles, and bacteria. 
The thickness and size of the fibrin filaments varies considerably and, 
if the membranes are firm, lamination is often seen. When detached 
they leave a reddened surface behind which, as for instance occasionally 
on the tonsils, may be in a state of ulceration; a second membrane may 
quickly develop on the denuded surface. Formerly distinctions were 
drawn between diphtheritic and croupous membranes - true and false 
membranes: there is, however, no reason why we should adhere to 
this more or less artificial division. Dr. Klein, in his report to the 
Local Government Board for 1891 and 1892, pp. 126, 127, summarises 
the more recent views tersely, and his words may be quoted with ad- 
vantage : - " True diphtheritic change of mucous membrane is regarded 
as involving exudation into the mucosa itself - a condition resulting, 
under engorgement and stasis in the vessels of the mucosa, in complete 
necrosis of that tissue. In this latter circumstance the mucosa becomes 
in effect diphtheritic membrane; its superficial part contains leucocytes, 
its middle or main part is a reticulated fibrinous necrosed tissue, while 
its deeper part, that in contact with the inflamed but still living portion 
of the mucous membrane, contains, like this latter, leucocytes. Most 
text-books now represent the above anatomical conditions as differentiat- 
ing croupous and diphtheritic change of mucous membrane." 
So far as diphtheria is concerned, we have first, when membranes 
appear, a superficial exudation into the epithelial surface, with fibrin for- 
mation and degeneration of the epithelium itself. Now the necrosed epi- 
thelium gradually disappears, in part or entirely; and the underlying 
connective tissue or tonsillar tissue becomes covered by a fibrinous layer 
containing dead epithelial cells, leucocytes, and the like, which gradually 
extends into the deeper strata of the mucous membrane or tonsil. Fresh 
layers of fibrin may be added until perhaps a thick membrane is formed. 
In the superficial layers,which generally are the oldest, cocci may be found; 
while in the deeper and younger layers we often find the diphtheria bacilli 
unmixed with other organisms. Often enough, however, the diphtheria 
bacilli are found in any part of the membrane. The tissue below the 
membrane is in a state of inflammation, showing collections of leucocytes, 
or fibrinous exudation and haemorrhages, and, according to my own obser- 
vations, may be invaded by the bacilli. Healing as a rule takes place with- 
out scarring, unless the tissue defect were so serious as to lead to destruc- 
tion of the mucosa. It is interesting to remark that the diphtheria bacilli, 
even in fatal cases, are frequently found in the leucocytes, which may be 
almost over-distended by the engulfed organisms. With the disappear- 
ance of the membrane the bacilli also generally disappear. In many cases, 
by means of careful test-tube experiments as the cases progress towards 
recovery, a steady diminution in the number of the specific organisms can 
be demonstrated. Exceptions to this rule, however, are numerous, for 
even after apparent recovery the bacilli may linger in the throat for 
weeks. In such cases they may be impaired in virulence, in others there 
is no attenuation. These observations show the necessity of examining 
727 728 
SYSTEM OF MEDICINE 
the throats of patients who have been treated in hospitals before dismiss- 
ing them; such patients must not be discharged until the bacilli have com- 
pletely disappeared, since.otherwise they may become sources of infection. 
Membranes may be seen in the mucous membrane of the soft palate 
and its pillars, the tonsil, fauces, and pharynx, and the larynx; and may 
extend also into, or appear primarily in the nose, conjunctiva, trachea, 
and bronchi: more rarely they extend into the oesophagus, or appear in 
the stomach and intestines. In cutaneous diphtheria membranes also 
generally cover the sores. When the process extends into the bronchi a 
diphtheritic broncho-pneumonia follows, as a rule; and we often observe, 
in the alveoli a fibrinous network enclosing the bacilli: as I have said 
there can be no doubt that diphtheritic broncho-pneumonia or capillary 
bronchitis is much commoner than is generally believed. A curious and 
important pathological condition is the so-called rhinitis fibrinosa, where 
we find membranous casts on the nasal mucosa. Clinically such cases are 
not diphtheria, but pathologically and bacteriologically they are so; in the 
cases personally examined I obtained, as others did, large numbers of vir- 
ulent diphtheria bacilli. These chronic fibrinous inflammations constitute 
what might be called "chronic diphtheria,"-not dangerous, perhaps, to 
the individual, but deserving the fullest attention as a source of infection. 
Besides the local changes in the parts mentioned, morbid appearances 
may be found, (a) in the lymphatic glands, (&) the spleen, (c) kidneys, 
(cZ) heart, and (e) in the nervous system. The glands, especially the 
cervical or bronchial according to tire seat of affection, are swollen, 
inflamed, or even in a suppurative condition. The spleen is frequently 
enlarged and injected or congested,though rarely soft; the kidneys are 
generally pale and cloudy, and microscopically they may show evidence 
of epithelial necrosis, fatty degeneration, or even of actual nephritis. 
The muscular tissue of the heart may be in a condition of fatty degen- 
eration, which varies to a greater or lesser degree, but is frequently 
absent. Of greatest interest are the nervous changes which have been 
more carefully studied by Dejerine, Gombault, Meyer, and Sidney Martin. 
The paralysis following diphtheria is due to a parenchymatous degen- 
eration in the peripheral nerves; so that the expression " peripheral 
neuritis " in this connection is unjustifiable. The white substance of 
the medullated fibres is broken up and attenuated, or may disappear 
altogether; the primitive sheath remains intact, and the axis cylinders 
are frequently ruptured. If this be the case, the nerve fibres below the 
rupture undergo the Wallerian degeneration, the white substance break- 
ing up along the whole course of the fibre, and the axis cylinder also 
degenerating. The different branches of the same nerve are affected to 
a varying degree, so that there are generally fibres intact which can 
still innervate the muscle if a motor nerve be affected. This explains 
why during life the paralysis is as a rule partial and not complete. 
The sensory and motor nerves may suffer alike, and so may also the 
sympathetic nerves; except that in the latter case we find changes only 
in the axis cylinders, there being no visible medulla. Some observers DIPHTHERIA 
729 
have described changes in the cells of the anterior cornu of the spinal 
cord, or have ascribed the nervous changes to a mild form of poliomyelitis. 
Martin, in the observation from which I have amply quoted, considers 
them all to be essentially peripheral, and has never detected lesions in 
the ganglia or central nervous system. This matter is still under 
discussion, and cannot be considered as finally settled. Meyer has 
described an increase of nuclei of the nerve fibres, and also nodular 
swellings of the nerves formed of cellular elements; but according to 
Martin these changes probably only indicate an attempt at repair of 
the nerve. 
The distribution of the nerve lesions will be considered in the clinical 
portion of this article, and I may conclude by mentioning that, necessarily, 
the muscle supplied by the diseased nerves are also degenerated to 
a degree proportional to the nerve lesion. The muscular fibres may 
present advanced fatty degeneration to such an extent that all fibres are 
affected; or fatty fibres may be mixed with normal ones, or parts of a 
fibre only may be fatty. It seems that the diphtheria poisons are special 
nerve poisons, for Martin has shown in man that even during the course 
of an acute attack which lasted only five days nerve degenerations may 
appear. 
The same observer further states that fatty degeneration of the 
cardiac muscle is observed chiefly in fatal cases of diphtheritic palsy or 
in cases which die in syncope; hence the signs of cardiac failure in 
diphtheria are due to a direct influence of the diphtheria toxins on the 
cardiac muscle: this is the more probable as the heart of the experi- 
mental animal is easily affected by these poisons. 
In discussing the pathology of diphtheria I cannot conclude 
without saying a few words on the hgemic changes, that is, on the 
increase or decrease of the number of leucocytes and on the possible 
import of these conditions. Most writers are agreed that diphtheria is 
accompanied by a marked leucocytosis which increases as the disease 
progresses, and again diminishes during convalescence, disappearing soon 
after the membrane. This leucocytosis is of the ordinary febrile type, 
affecting chiefly the " multinuclear, neutrophile " (finely granular oxy- 
phile) corpuscles. Gabritschewsky states that this increase in the num- 
ber of leucocytes is greatest in fatal cases, and believes that a progressive 
leucocytosis implies a bad prognosis. After antitoxin injections the 
leucocytosis steadily diminishes as it does in convalescence, and the 
hsemocytometer is therefore, according to him, a useful means of gauging 
the success of treatment. Dr. Ewing does not consider the high 
leucocytosis to be necessarily an unfavourable sign, for it may mean 
merely a pronounced reaction; but he agrees with others that in fatal cases 
there is leucocytosis till death; in mild cases the leucocytosis is but slight, 
and the leucocytosis steadily decreases in favourable cases. Dr. Morse, 
on the other hand, does not think that the examination of the blood is 
of value in prognosis, because, although fatal cases generally have a well- 
marked leucocytosis, it is not always present, and even in the mildest 730 
SYSTEM OF MEDICINE 
cases is often very pronounced. Judging from personal observations 
made at St. Bartholomew's Hospital in conjunction with Mr. E. L. Lloyd, 
I agree with this writer on the prognostic value of the leucocytosis in 
diphtheria. The daily counts made in a series of cases show that - 
(1) broadly speaking, a high leucocytosis signifies a good reaction, and 
was present in those which recovered; (2) a low leucocytosis at the 
height of the disease, before antitoxin has been injected, accompanies 
most, if not all the fatal cases; (3) the high leucocytosis of well reacting 
cases, after and during antitoxin treatment, steadily diminishes, the num- 
ber of cells decreasing by 50 per cent in three to four days. Dr. Wald- 
stein states that when during convalescence the leucocytosis declines, 
the number of 11 neutrophile " cells falls rapidly, while the uninuclear or 
lymphocytic elements increase; in the lymphocytosis he sees a prognos- 
tic sign of great value, so much so that he recommends subcutaneous 
injections of pilocarpin, in order to raise artificially the number and ratio 
of the lymphocytes. 
Artificial Immunity. - Guinea-pigs, which are highly susceptible ani- 
mals, can be protected against an infection with the Klebs-Lbffler bacillus 
in various ways: (1) by means of subcutaneous injections of broth cult- 
ures sterilised by heat or attenuated by adding trichloride of iodine; (2) 
by means of prophylactic injections of hydrogen peroxide ; (3) by a 
successful cure of an experimental infection; (4) by means of Behring's 
combined method, which consists in the administration first of attenuated 
cultures, followed by that of fully virulent ones or of strong toxin; (5) 
by means of feeding with diphtheria toxin. The serum of a highly 
protected animal, as mentioned elsewhere [see art. " Immunity when 
injected into a guinea-pig in a normal state, possesses the remarkable 
property of rendering it immune; and, when injected into one already 
suffering from the effects of a diphtheritic lesion, of curing it. This gives 
us the 6th method of artificial protection, namely, the injection of protec- 
tive serum or antitoxin, and on it is founded the serum treatment of 
diphtheria to be discussed presently: its principle has already been fully 
considered [see art. " Serum Therapeutics To obtain a good and active 
serum horses may be injected with toxins, gradually increasing in dose 
and virulence, or with the bacteria themselves, beginning with their dead 
bodies and gradually proceeding to large doses of living bacilli; or these 
two methods may be combined in order to obtain a serum which is both 
strongly antitoxic and highly protective. The immunity which this se- 
rum is capable of conferring on animals is of comparatively short duration 
(one to two weeks, and at most ten weeks) ; and when used on man is so 
slight as to be of little value for prophylactic purposes. Thus in a case 
under my own observation, a child acquired true diphtheria within two 
weeks after a copious administration of the antitoxin, which had been 
given for an angina erroneously diagnosed as diphtheria. Its curative 
value, however, as we shall see, cannot be questioned. 
A. A. Kanthack. DIPHTHERIA 
731 
Order of Development of Diphtheria 
The first result of diphtheritic infection is local. The infected part 
inflames, and it is in and upon the inflamed surface that the morbific 
microbes increase and multiply. Infection of the deeper tissues and of 
the whole body is chiefly due to absorption of soluble venom from the 
place where the growth of microbes is proceeding. Thus diphtheria 
may be compared with syphilis: the primary pellicular inflammation of 
the one and the primary sore of the other being strictly analogous; from 
the primary lesion the secondary infection of the whole body proceeds 
in both cases. This close analogy was discerned by Bretonneau (5), and 
the most recent and complete experiments upon the lower animals have 
confirmed the accuracy of his opinion. 
Omitting for the moment consideration of the nasal passages, the 
primary seat of infection is seldom any other than the fauces or the 
larynx. Hence two chief forms of diphtheria. The symptoms and 
whole appearance of the disease differ so much according to the part 
first affected, that many years elapsed before physicians universally 
accepted Bretonneau's doctrine of the essential identity of faucial diph- 
theria and membranous croup.1 The question cannot now be said to 
exist, bacteriological researches having finally decided it in favour of 
Bretonneau. 
Simple and Malignant Diphtheria. - From the time of Aretseus a dis- 
tinction has been made between mild (or simple) and pestilential (or 
malignant) diphtheria. Simple diphtheria is that which is characterised 
chiefly by the local affection; malignant is that in which the toxsemia 
predominates: the blood, and through it the whole body, is poisoned by 
venom prepared at the primary local lesion. 
A. Diphtheritic Sore Throat (Angina faucium) 
In the following pages diphtheria will be described analytically, 
symptom by symptom, yet not without reference to the association and 
succession of symptoms. A general description of the disease must 
always be more or less imaginary, and can never tally with actual 
experience and matter of fact - so many are the symptoms of diphtheria, 
and so infinitely varied is the manner in which they are associated.2 
1 " You have not forgotten the celebrated Concours, ordered by the Emperor (Napoleon 
I.) at the death of the young prince, his nephew, nor the division of the great prize between 
Jurine of Geneva and Albers of Bremen, authors of Memoirs, in which they both declare 
that angina maligna is a distinct and opposite disease from croup. No matter! " (4) p. 179. 
2 " Some such descriptions, when they have conveyed the truth with great force and 
faithfulness, have been regarded with the same sort of pleasure with which we look upon 
a well-drawn picture. But, after all, they are more pleasing than profitable. Perfection 
in this kind was reached ages ago, yet we go on describing what has been better described 
before, and are venturing with rash hands still to retouch the masterpieces of Aretseus." 
- P. M. Latham, Dis. of Heart, vol. i. p. 106. SYSTEM OF MEDICINE 
732 
I. Prodroma. - The first symptoms of disease relate either to the 
fauces or to infection of the blood; the diphtheria is manifested first in 
the throat or not. Symptoms which are due to infection of the blood, 
and precede the pellicular affection of the fauces, are called prodroma 
or premonitory symptoms. 
i. Fever, which is probably an early symptom in all cases, in some 
is the very earliest, preceding any signs of local disease. The onset is 
sometimes gradual and insidious, sometimes sudden and marked by chil- 
liness, not enough to cause shivering. The temperature seldom rises 
above 103°. Premonitory fever is of uncertain duration, seldom lasting 
more than a day or two. 
ii. Fever will be accompanied by its usual concomitants - drowsi- 
ness, giddiness, peevishness, aching and pains in the limbs and back; 
the frequency of the pulse will be increased, the digestion disordered. 
The digestive disorder, indicated by vomiting, disgust for food, head- 
ache, weariness and low spirits, will sometimes last fully four days be 
fore the sore throat begins, and may be (perhaps with reason) attributed 
to "biliousness." 
iii. Spontaneous lassitude is, in some patients, the most marked pre- 
monitory symptom - a great sense of weakness and weariness, lasting 
about four-and-twenty hours before the throat becomes sore. When the 
lassitude exists, as it may, nearly a week before the onset of sore throat, 
it lies open to question whether the lassitude is to be attributed to the 
diphtheria or to some other form of blood poisoning (such as bilious- 
ness) ; whether, in other words, the specific invasion (or prodromal) 
period of diphtheria can last so long. 
II. The Sore Throat.-In most cases the disease is first manifested 
in the throat or neighbouring parts, and by one or more of the following 
symptoms: - 
i. Soreness of the throat, especially felt on swallowing, and some- 
times causing cough. In young children the sore throat is indicated by 
disinclination to swallow. But the soreness is sometimes very slight, 
and may not be complained of even when examination shows that false 
membranes have already formed upon the fauces. 
ii. Noise in breathing, snoring, breathing with mouth open, change 
in quality of voice - all due to swelling of fauces. 
iii. Coryza, sneezing, nose-bleeding - due to simultaneous affection 
of nasal fossae. 
. iv. Swelling of neck on one side or on both; enlargement of lym- 
phatic glands at angles of lower jaw: pain felt in neck, especially on 
movement. 
v. Visible appearances in the throat; these demand much more 
close attention: they are of four kinds, appearance before occurrence of 
false membrane, false membrane, swelling, and muco-purulent secretion. 
1. Inflamed Throat before Formation of False Membrane. -When an 
opportunity is afforded for examining the fauces before the appearance of 
false membrane, they are seen to be swollen, sometimes pale and glisten- DIPHTHERIA 
733 
ing, or sometimes reddish. There are no signs by which the naked eye 
can distinguish diphtheritic inflammation (before the appearance of false 
membrane) from other kinds of inflammation. Upon this inflamed sur- 
face false membrane appears sooner or later. In some cases it is formed 
very rapidly, for however soon the throat be examined after the first 
signs of local disease false membrane is seen. On the other hand sev- 
eral days may elapse before the angina becomes pellicular. 
The diphtheritic affection of the throat does not always result in for- 
mation of false membrane, and this non-pellicular angina constitutes one 
form of latent diphtheria. 
2. False Membranes. - The first appearance of false membrane is 
as one or several small whitish specks or patches. Although there is no 
part of the throat where they may not first appear, they are especially 
apt to begin upon the tonsil or uvula. The margins of the mouth of 
the tonsillar crypts are often first affected, a point which will be alluded 
to hereafter with reference to the diagnosis of false membranes which 
are diphtheritic from those which are not. The diphtheritic membrane 
differs much in different cases in respect of - 
(a) Texture; being firm, tough, and coherent, or soft, loose, and 
friable. 
(&) Thickness; at first, being thin, the membrane is transparent, 
opaline, afterwards quite opaque. 
(c) Extent; by which the activity of the disease, so far as the throat 
alone is concerned, is to be judged of chiefly. But at first it cannot be 
said what the final extent of membrane may be; a very small pellicle 
may be the beginning of very extensive disease. Rapid extension is a 
sign of virulence: in forty-eight hours from the beginning of exudation 
the whole soft palate, uvula, tonsils and pharynx may be invaded, not 
to speak of the posterior nares, root of tongue, larynx, and even other 
parts, of less importance, to be named hereafter as occasional seats of 
diphtheritic disease. 
(cl) Adhesion to the tissues beneath, that is to say, to the mucosa; 
the membrane is sometimes very adherent, sometimes it can be removed 
by a soft brush with ease. The mucosa is left very slightly abraded 
and looking almost natural, or it is swollen, ragged, and bleeding. A 
new false membrane is formed upon the raw surface, and sometimes 
very rapidly, within two or three hours. 
(e) Rapid decomposition of the false membrane sometimes occurs, 
and indicates a bad form of disease. The whitish colour is lost and the 
membrane tends to become blackish; the smell of the breath is most 
offensive : putrid sore throat. 
These differences in the false membrane are believed to represent, 
to a great extent, differences in the relative abundance or activity 
of the several microbes growing in the exudation - whether specific 
bacilli, divers pyogenetic micrococci, or common putrefactive microbes. 
It is said that when the specific bacillus is the prevailing microbe the 
false membrane is tough, coherent, and not prone to decomposition; 734 
SYSTEM OF MEDICINE 
the puriform discharge from the affected part is scanty; when the false 
membrane is carefully removed, the mucosa beneath seems not to be 
much affected and does not bleed. When streptococci are found alone, 
or are largely mingled with the bacilli, the exudation is softer, more 
pulpy, more prone to decomposition and to be attended by an abundant 
puriform discharge; removal of the false membrane exposes a swollen, 
raw and bleeding mucosa. 
3. Swelling of parts beneath false membrane is usually proportionate to 
the activity of the local disease. Swelling of the fauces sometimes be- 
comes so great in two or three days that the uvula is pushed back and 
invisible, even the tonsils cannot be distinguished, and the isthmus fau- 
cium is reduced to a narrow vertical slit in the middle line. In conse- 
quence of this inflammatory swelling, the soft palate may be not less 
than three-quarters of an inch thick, firm and tough. 
4. Mucopurulent Secretion. - Abundant puriform discharge from the 
fauces occurs in severe cases so as to interfere greatly with examination. 
The secretion is sometimes offensive to smell. If a similar discharge 
(watery at first, afterwards more purulent) occur from the nostrils or 
ears, it may be assumed that the nasal fossae or tympana are invaded, 
and the disease so much the more serious, because more extensive. The 
discharge from the nostril is acrid, and excoriates the upper lip in a 
manner quite comparable to the effect of the vesicating virus of can- 
tharides, as Bretonneau pointed out. No doubt this diphtheritic fluid 
is also a powerful irritant to the mucous membranes with which it comes 
into contact, and thus prepares the way for the growth of false mem- 
brane. Cutaneous erysipelas sometimes starts from the point where 
these irritating discharges reach the surface of the body - a complica- 
tion especially apt to occur in diphtheritic otorrhcea. 
5. False Membrane cast off. - After the false membrane has ceased 
to grow it is soon cast off, either as coherent flakes and shreds, or soft 
pulpy material. The mucosa beneath is left at first somewhat reddened 
and perhaps swollen. Mere excessive redness soon passes away, swell- 
ing less quickly. 
Ulceration of the mucosa will follow but seldom upon the false mem- 
brane being thrown off. The ulcers may be deep, and on both sides of 
the throat, quite like the ulcers of scarlatina anginosa; the tonsil will 
sometimes be destroyed so as to leave a ragged cavity; the soft palate and 
uvula may be extensively ulcerated or sloughy; the mucous membrane 
about the epiglottis and ary-epiglottic folds may suffer in like manner. 
6. Relapse. - After the false membrane has been cast off, but before 
the patient has recovered from the whole disease, a renewed exudation 
upon the fauces may occur, and the relapse will aggravate the disease 
in all respects. Recurrence of diphtheria, after complete recovery from 
a former attack, is mentioned elsewhere. 
III. Affection of Lymphatic Structures in Neck. - Swelling of the 
lymphatic glands at the angle of the lower jaw is usually the first sign of 
poisonous infection spreading beyond the fauces. This is the case even if DIPHTHERIA 
735 
the glandular swelling precede the appearance of false membranes on the 
fauces, in which case the mucous membrane of the throat is infected by 
microbes, although they have not gone on to the formation of false mem- 
brane ; or, as sometimes happens, false membrane may have been formed 
in some situation where it is not visible; for example, on the back of the 
soft palate. But it is seldom that lymphadenitis precedes visible pellicles 
on the fauces. 
The degree of the glandular swelling is proportionate to the virulence 
of the angina faucium, but not always proportionate to the malignity of 
the disease; or, in other words, 'the most malignant form of diphtheria, 
which kills the patient by intense toxeemia, is not by any means always 
accompanied by much affection of the fauces or swelling of the neck. 
In bad cases swelling of the connective tissue around the glands occurs ; 
it may be to so great an extent as to deform the whole neck from ears 
to collar-bones, to render the enlarged glands hardly perceptible, and even 
to involve the cheeks and upper part of the chest. This external swell- 
ing is sometimes tender to touch, sometimes not; it does not pit upon 
pressure; the skin is either pale or reddened. Erysipelatous redness of 
the skin over the swelling will sometimes give rise to an appearance 
closely resembling that of an abscess. Great swelling of the neck is 
sometimes associated with very great swelling of the fauces; in this 
case the false membrane is often thin and delicate, the disease show- 
ing itself chiefly as swelling. Much coryza, with irritant discharge, is 
common. The malignant swelling occurs rapidly; it may be great on 
the third day of disease; and death, mainly from dysphagia and dysp- 
noea, may ensue on the fourth day. The dyspnoea is sometimes par- 
ticularly great, the frequency of respirations being nearly one hundred 
a minute; post-mortem the lungs are excessively inflated with air, and 
yet without any false membrane in the air-passages. 
The external swelling is useful as a prognostic sign; if the pellicular 
formation be not extensive, much affection of the glands and cellular 
membrane of the neck indicates a virulent form of disease. It is said 
that the virus of bacillus diphtherise does not cause more than a very 
moderate degree of lymphatic glandular swelling, and little or no infil- 
tration of the cellular tissue, and that the severer form of affection of 
the neck (cynanche cellularis) is due to the virus of micrococci. 
Suppuration of the lymphatic glands, or around them, is uncommon. 
The more virulent forms of the disease are fatal too soon for suppuration 
to occur. In cases which end in recovery, if there be any suppuration, 
it is slow and scanty. 
IV. Some rarer local lesions, that is of the mouth and salivary glands, 
attending diphtheritic angina faucium. 
(a) The parotid and submaxillary salivary glands sometimes suffer 
in diphtheria, probably in consequence of inflammation spreading from the 
mouth. The submaxillary glands especially may be felt to be distinctly 
enlarged, and the parotid swelling, in rare cases, is sufficient to resemble 
the swelling of mumps. 736 
SYSTEM OF MEDICINE 
(b) The mouth does not suffer severely; the tongue is furred more 
or less; the gums are somewhat swollen, and either pale or red, with a 
very thin film of fur upon them; sometimes they bleed a little, but 
nothing like the "scorbutic gangrene" described by Bretonneau is ever 
seen in England at the present day (4), (6). Small herpetic aphthae are 
sometimes present, and now and then a patch of false membrane upon 
the lip or cheek. 
The signs of diphtheria, which has spread from the throat to the nose 
or larynx, will be described under the heads of nasal diphtheria and 
diphtheritic croup. The laryngeal affection, when it supervenes upon 
disease beginning in the fauces, usually begins within three or four days 
from the onset of the angina faucium, and seldom after a week or eight 
days. Post-mortem, laryngeal false membranes are seldom found to be 
continuous with those in the pharynx. If the diphtheritic angina be of 
a malignant type the supervention of croup does not obviously change 
the aspect of the case; the patient dies just the same from debility and 
not from suffocation. 
V. Temperature of the Body. - Diphtheria, at its onset at least, is 
probably always a febrile disease. The fever follows no constant type 
or course ; as a sort of rough rule, it may be said that the fever of the 
onset falls on the second or third day, and that a moderate rise of tem- 
perature continues a few days longer. The temperature seldom rises 
above 103° or 104°, even at the beginning of the disease; when the sore 
throat is at its height, temperatures about 101° are more common. 
Diphtheria is not a very febrile disease, and the slighter forms are 
more febrile than the severer. Indeed, in bad cases the temperature 
is not only not raised, but is even depressed, temperatures between 97° 
and 98° being common; in the most malignant cases a temperature of 
96° in the rectum has been observed. 
The cause of such algidity is uncertain; it has been attributed to 
degenerative change in the muscular walls of the heart, but a more prob- 
able cause would seem to be the generation of a febrifuge poison; in- 
deed, the worst cases of diphtheria and of perforative peritonitis resemble 
each other much in this respect of algidity. 
VI. Albuminuria. - The urine, if it be often and carefully examined, 
will be found in very many cases to contain albumin. This albuminuria 
depends upon nephritis, which is in turn probably due to a soluble poison 
circulating in the blood. 
Albumin first appears in the urine at any period of the disease before 
the tenth day, seldom later. Albuminuria will sometimes come on co- 
piously, and for the first time, after the throat has seemed to have been 
free from disease for several days. If the patient survive albuminuria 
seldom lasts long, even if it have been great. In a few cases it may 
persist for some weeks after all other symptoms of disease have passed 
away. Now and then albumin seems likely to be permanently present 
in the urine, though whether the albuminuria is really permanent, or 
whether in such cases the patient's kidneys were certainly sound before DIPHTHERIA 
737 
the attack of diphtheria, speaking from my own experience, I cannot 
be sure. 
The amount of albumin affords no trustworthy prognostic sign. 
The urine may be highly albuminous one day, and two or three days 
afterwards contain the merest trace of albumin. Other things being 
equal, a case with albuminuria is more serious than a case without it; 
more patients die who have albuminuria than those who have it not, yet 
patients will die who have never had it, and patients will easily recover 
whose urine for a short time has been highly albuminous. 
If the nephritis be severe the urine is scanty and very albuminous; 
casts and corpuscles are found by the microscope: casts hyaline, granular, 
and corpuscular; corpuscles having the characters for the most part of 
leucocytes, but some probably being renal epithelium; a few red blood 
disks are seen. The urine is seldom or never smoky or bloody. Com- 
plete suppression of urine is observed at the end of life in cases which 
prove fatal by vomiting and heart failure. 
Dropsy occurs very seldom, if ever. Symptoms which can without 
doubt be attributed to uraemia are not met with. 
VII. Haemorrhages and Changes in the Blood.-In some cases of 
malignant diphtheria the affection of the blood is so profound that during 
life the lips and even the whole surface of the body are of a slaty gray 
colour, quite apart from any dyspnoea or mere respiratory lividity. The 
blood itself is of a dirty brown colour, which has been compared to prune 
juice or Spanish liquorice; but microscopical examination detects nothing 
amiss. Spectroscopic examinations have not been made, and the nature 
of the very obvious change which the blood undergoes is but ill under- 
stood. 
Haemorrhagic tendency shows itself now and then; whether dependent 
upon changes in the blood or blood-vessels, or both, remains unknown. 
Small specks or larger blotches of extravasated blood appear in the skin, 
mucous membranes, serous membranes and retinae. Free bleeding from 
the mucous membranes occurs, especially from the nose, but also from 
the throat, stomach, and bowels; the bleeding may prove fatal, either 
very speedily or more slowly. Haematuria is a very uncommon event 
even in haemorrhagic diphtheria. The spleen is sometimes enlarged as 
in purpura, and sometimes not. Haemorrhage, even when too scanty 
to be the cause of death, will do much towards increasing the weakness 
of the patient; such cases are always to be deemed serious. 
The haemorrhagic tendency bears no proportion to the affection of the 
throat; indeed, the latter may be so slight that the diphtheritic character 
of the disease shall be wholly overlooked, and the death of the patient 
be certified as due to purpura haemorrhagica. 
Cerebral haemorrhage of the same nature is a cause, but a very un- 
common cause of hemiplegia. 
VIII. Failure of Heart. - In diphtheria the function of the heart is 
more apt to fail than in any other virulent disease which we meet with 
in our country. This primary debility of the heart (vital debility, 
VOL. T 
3 B SYSTEM OF MEDICINE 
738 
lipothymia), not due to exhaustion of the powers of the whole body, but 
to a peculiar operation of morbid poison upon the heart itself, which is 
selected as it were for this effect, constitutes the primary or protopathic 
malignity of the older writers (Stoll, for example)-the word malignity 
being used in a much more restricted sense than that referred to on page 
731. The cause of the heart failure is degeneration of its muscular 
walls (myocarditis); when degeneration is not found after death (if this 
ever be the case) the heart failure must be attributed to paralysis of the 
cardiac branches of the par vagum. 
A sign of this affection of the heart is found in the pulse, which be- 
comes small and weak; it is often irregular also, in some cases it is very 
frequent, in others very infrequent. The temperature of the body falls 
even as low as 95-5° in the rectum; the skin and limbs are cold. The 
first sound of the heart is weak or quite inaudible, sometimes a systolic 
murmur at apex or base springs up. Unpleasant fluttering or palpitation 
of the heart may be complained of, and the weakened pulmonary circula- 
tion may be indicated by shortness of breath. The face becomes remark- 
ably pale. The patient is sensible of great muscular weakness, is very 
sluggish, dislikes to be moved, and even takes food unwillingly. 
These symptoms often come on gradually, the patient's heart steadily 
becoming weaker and weaker; patients of this kind may lie a week or 
ten days in a state of prostration. But the symptoms sometimes set in 
suddenly, all at once faintness (lipothymia, collapse) occurs, attended by 
a marked change (which cannot be described) in the look of the patient's 
face, and by the aforesaid signs of heart failure. The patient may 
die suddenly and unexpectedly, but usually he lingers for some hours 
in a state of extreme prostration, consciousness is retained to the end, 
and the power of the voluntary movements is in remarkable contrast 
with the weakness of the heart muscle. 
Failure of the heart is usually met with during the height of the 
diphtheritic disease, say at any time between the fourth and fourteenth 
day. A slight affection of the throat may be followed by serious disorder 
of the heart. When the heart fails later it is especially associated with 
paralytic symptoms.1 
Signs of dilatation of the heart and a systolic murmur sometimes 
occur during convalescence, and may be expected to disappear when the 
health of the patient is fully restored. If endocarditis and pericarditis 
ever occur as a result of diphtheria they are probably dependent upon 
micrococci. 
IX. Vomiting. - Another serious symptom, and one often associated 
with cardiac failure, is a tendency to vomit. The cause of it is not 
always the same. But whatever it be, repeated vomiting is a dangerous 
1 Rabot and Philippe (7) describe an interstitial myocarditis which occurs during con- 
valescence from diphtheria, when the patient has been allowed to get up, and thinks him- 
self to be well. This form of disease must be uncommon. [I remember such a case in 
the private practice of the late Dr. Fuller. The patient, a young man, convalescent at 
the seaside, rose quickly from a sofa and fell back dead. The autopsy revealed " degen- 
erated heart." - Ed.] DIPHTHERIA 
symptom; most of such patients die in a state of heart failure and 
algidity within a few hours or a few days. 
In very rare cases vomiting is a sign of diphtheria of the stomach. 
In most cases vomiting is associated with affection of the kidneys. 
Sometimes the urine is highly albuminous and scanty, or even completely 
suppressed; the diminished secretion is probably in greater part de- 
pendent upon the vomiting. Sometimes the quantity of albumin in 
the urine is small; sometimes the renal affection is manifested more by 
corpuscles and casts in the urine than by much albumin. The patient 
retains consciousness. Convulsions in rare cases precede death. 
Now and then vomiting occurs late in the disease, in the course of 
paralysis, four or live weeks from the onset of the diphtheria. 
X. Paralysis. - The period at which paralysis occurs in the course 
of diphtheria is uncertain, and very variable. Palsy sometimes sets in 
while the primary disease (the formation of false membrane) is progress- 
ing, say as early as the fourth day. On the other hand, as much time 
as ten weeks may intervene between the onset of the diphtheria and of 
the palsy. The mean interval, computed from many cases, is three or 
four weeks. More often than not paralysis may be called a sequel 
of diphtheria; that is to say, a period of convalescence intervenes be- 
tween the primary disease and the paralysis. 
Palsy may be consequent upon any form of diphtheria, yet diphtheria 
which is mainly or altogether laryngeal is seldom followed by palsy; 
indeed, few patients survive the primitive disease. The patellar tendon 
reflex is lost in some cases of diphtheritic croup, and this symptom may 
be regarded as akin to palsy. Some of the cases in which the tube 
cannot be removed after tracheotomy are probably of the nature of 
laryngeal palsy. Anything like extensive paralysis after diphtheritic 
croup must be most uncommon. 
Diphtheria of the fauces is by far the commonest primitive lesion, 
indeed, there is seldom any other. About one-tenth of all cases of 
diphtheritic sore throat are attended by paralysis sooner or later. It 
mostly begins after the second week of the angina; it may occur much 
sooner, as mentioned above; seldom later than the seventh week. 
(Paralysis after nasal diphtheria is referred to further on.) 
The usual course of the palsy is this, that it gradually increases 
until the patient dies, or until the disease begins to decline as gradually 
as it arose. In the latter case recovery is complete. 
There is no proportion between the severity of the primary disease 
and of the palsy ; or at least paralysis often ensues when the primitive 
diphtheria has been very slight. Indeed, in some cases the sore throat 
altogether escapes observation, the paralysis being the first evidence of 
diphtheria. 
The fauces, and especially the soft palate, usually suffer first. The 
signs of palsy of the soft palate are two: the voice becomes nasal, and 
drinks are apt to return through the nose; moreover, the patient can 
hardly blow out a candle, inflate the cheeks, suck or gargle. The palate 
739 SYSTEM OF MEDICINE 
740 
will be seen to have lost its arching, and to hang straighter than natural 
on both sides. The sensibility of the mucous membrane and the reflex 
movements are more or less diminished. These signs are sometimes 
more marked on the one side of the palate than on the other; or they may 
even be present on one side alone. Palsy, insensibility and abolished 
reflex by no means always concur: one or more of these symptoms may 
be absent; for instance, the reflex may be lost though sensibility is re- 
tained. Paralysis of the lowest constrictor of the pharynx is indicated 
by entry of food into the glottis, causing choking and cough. 
Paralysis is often confined to the fauces and spreads no farther; 
in this case it will last ten days or a fortnight and then begin gradually 
to disappear. The fauces sometimes escape even though the limbs and 
trunk are severely affected. Sometimes paralysis diminishes in the 
fauces as it increases in the limbs. 
Paralysis of the rima glottidis is indicated by weakened voice and 
inefficient cough, both dependent upon imperfect closure of the glottis. 
Together with the paralysis go insensibility and deficient reflex of the 
epiglottis and interior of the larynx. Hence great danger of pneumo- 
nia from entry of food into the windpipe; great danger of suffocating 
bronchitis also, from deficient expectoration. Recovery from laryngeal 
palsy is possible. 
Paralysis of the limbs affects the legs before the arms; indeed the 
arms often escape. When the patient is able to walk at all the gait is 
staggering: at last he becomes unable to stand, or even to move the 
legs in bed. Palsy of the limbs usually takes about seven weeks to 
reach its height. The muscles tend to waste, and sometimes waste 
greatly; partly in consequence of the nerve disease, but partly in some 
cases from insufficient feeding. The electrical reactions of the nerve- 
trunks are normal. The excitability of the muscles to faradisation is 
diminished or even wholly lost; voluntary power is sometimes much les- 
sened while faradic excitability remains normal; in some instances faradic 
excitability will go on diminishing, while voluntary power is increasing. 
The degree of galvanic excitability of the muscles is uncertain; it is 
often diminished or slow, may possibly be increased for a time, and 
sometimes, not always, there are qualitative polar changes. Abnormal 
electrical reactions can sometimes be discovered long after voluntary 
power over the muscles has been completely restored. Sensibility is 
mostly retained; when lost it is seldom lost higher up than the knees. 
Patellar reflex is abolished as a rule, but is sometimes retained even when 
the palsy is great. On the other hand, patellar reflex is sometimes lost 
for a considerable time during or after diphtheria, although the legs 
never show any weakness. When the reflex returns it has been noted, 
in a few rare cases, to be excessive for a time, and to be associated with 
ankle clonus. The palsied limbs are sometimes painful. Recovery of 
the proper use of the limbs, and of normal electrical reactions, will 
certainly occur, and is only a matter of time. But the time necessary 
is often considerable, and may amount to six or eight months or more. DIPHTHERIA 
741 
The hemiplegia which occurs now and then in the course of diph- 
theria is a different form of disease, being due either to cerebral haemor- 
rhage or to embolism of the cerebral arteries; in the latter case the 
source of the embolus is not always discovered. [Vide section on 
Cerebral Disease.] 
The muscles of the trunk sometimes suffer in the ordinary form of 
diphtheritic paralysis, but the case is not rendered more serious thereby 
unless tiie diaphragm and intercostals be paralysed. A cause of death 
is paralysis of the respiratory muscles. The sphincters are very seldom 
affected. 
The eyes sometimes suffer. The commonest affection is dimness of 
sight, due either to asthenopia consequent upon paralysis of the ciliary 
muscle (cycloplegia), or to amblyopia consequent upon retinal insensibil- 
ity and contraction of the field of vision; in the latter case glasses are 
useless. Any form of ophthalmoplegia externa, indicated by diplopia or 
squint, is less common. Incomplete blepharoptosis has been observed. 
The pupil is unaffected, or at most but somewhat dilated and sluggish. 
Palsy of the oesophagus, tongue, lips, cheeks, are possible but very 
improbable occurrences. The failure of the heart is in some cases per- 
haps of a neuro-paralytic nature. 
In children and in some epidemics death is not seldom the end of 
diphtheritic palsy. When death does not ensue complete recovery is 
certain sooner or later. The duration of paralysis in cases of recovery 
depends much upon the extent of the affection. When confined to the soft 
palate recovery may be expected in two or three weeks; when the limbs 
are affected the duration will probably be three or four months. A 
duration of eight months, or even more, has been noticed in rare cases. 
Excluding cases of heart failure death is due either to laryngeal or re- 
spiratory palsy. Laryngeal palsy causes death through inability to cough 
and to expectorate properly, the result being accumulation of mucus in 
the lungs. Death is seldom due to impaction of a morsel of food in the 
larynx. Pneumonia from the entry of smaller particles of food into 
the windpipe is a much more common event, especially in cases of 
tracheotomy, or of anaesthesia of the glottis. 
When paralysis follows nasal diphtheria, the fauces may be unaffected 
while the limbs suffer severely. 
Although good observers have found changes in the medulla oblon- 
gata and spinalis in cases of diphtheritic palsy, yet the prevailing opinion 
is that the chief and often the only cause of the paralysis is multiple 
neuritis. The cause of the neuritis is supposed to be a specific soluble 
poison; the palatal palsy which follows palatal diphtheria looks like a 
purely local effect of the poison. 
XI. Eruptions. - Besides the purpura and erysipelas which have 
been already referred to, erythema and urticaria of no constant or 
peculiar characters have been observed. Suffusion of the skin, almost 
scarlatiniform, is common. 
XII. Arthritis. - Rheumatoid affection of the joints has been 
observed in rare cases and in some epidemics. SYSTEM OF MEDICINE 
742 
Diagnosis of Diphtheritic Sore Throat. - Diphtheritic sore throat 
is not in all cases attended by the formation of false membrane, and 
is therefore sometimes indistinguishable by the naked eye from simple 
or catarrhal sore throat. The proof of this assertion is afforded by two 
facts: First, that the bacillus has been found to exist upon the mucous 
membrane of throats which were, to the naked eye, simply slightly 
reddened and swollen. Next, observations made in epidemics of diph- 
theria have rendered it certain that the disease is sometimes transmitted 
by cases which have the characters of simple catarrhal or inflamed sore 
throat. (See Latent Diphtheria.) 
But the diagnosis of diphtheritic sore throat relates mainly to the 
false membrane. Inasmuch as not all sore throats accompanied by false 
membranes are diphtheritic, we endeavour to distinguish the different 
kinds of pellicular angina faucium. Even if it were admitted that the 
bacillus is the absolutely peculiar and necessary note of diphtheria, yet 
it is clear that for the immediate needs of practice a mere inspection of 
the throat must be relied upon, and it is in this spirit that the following 
remarks upon diagnosis are written: - 
1. Many vesicants and escharotics, when applied to the fauces, pro- 
duce appearances which closely resemble diphtheria. Cantharides, lunar 
caustic, nitric acid, liq. ammoniae, carbolic acid, white precipitate, hot 
chestnuts or potatoes, boiling water and steam, may be mentioned as 
instances of such irritants. The diagnosis in many cases cannot be 
made from the look of the throat alone. The conditions which led to 
the pellicular inflammation must be known. 
2. The disease (or rather the diseases), which in England is most 
commonly called follicular tonsillitis, demands very careful considera- 
tion in regard to its relation with diphtheria. Many cases of this follic- 
ular tonsillitis are diphtheria in an early stage, the appearance of 
ulceration round the mouths of the tonsillar crypts being due to false 
membrane, which often is first formed in that situation. The membrane 
may spread afterwards so as to cover the greater part of the fauces in 
two or three days. In other cases the membrane does not spread upon 
the fauces, but laryngeal diphtheria is associated with the tonsillar affec- 
tion ; in others again the membrane does not spread in any direction, 
and the true nature of the disease becomes apparent only when the pa- 
tient infects another person with manifest diphtheria: or the reverse 
may be the case, that the disease conveyed from a person suffering from 
manifest diphtheria will take on the form of follicular tonsillitis in the 
infected patient. But although in all these cases there can be no doubt 
concerning the diphtheritic nature of the follicular tonsillitis, yet it 
seems to be equally certain that in other cases the disease is not diph- 
theritic, those, namely, which show no contagious tendency. But ad- 
mitting this distinction, it can seldom be drawn in a given patient, and 
therefore in practice it is wise to consider the disease to be in all cases 
probably, or at least possibly, diphtheritic. 
3. Herpes, of the same nature as herpes labialis, may affect the palate DIPHTHERIA 
743 
so as to produce the appearance of one or more small false membranes 
which show no tendency to spread after they have once been formed. 
The diagnosis (not always certain) is much helped by the concurrence 
of herpes on the tongue, cheeks, or lips. 
4. A fungus (oidium albicans ?) sometimes affects the fauces, and 
causes them to be covered by a growth which looks like a false mem- 
brane, and which may be so extensive as to cover the soft palate and 
tonsils. Compared with the false membrane of diphtheria, the growth 
of oidium is of a purer and more opaque white colour, it is much softer 
also, and when once it has been removed by detergents it seldom re- 
appears. Microscopic examination is easy and decisive. 
5. A fungous growth (leptothrix buccalis ?) sometimes occurs within 
the crypts of the tonsils, and, coming to the surface, simulates follicular 
tonsillitis. Or the growth may spread over the tonsil so as to form a 
white patch. The chief distinction from oidium and pellicular diseases is 
to be found in the fact that the leptothrix affection is essentially chronic. 
6. At any time during the first week of scarlet fever false mem- 
brane may appear upon the fauces. This membrane is said to be due 
to nicrococci, and not to afford the Klebs bacillus. Yet by the unaided 
eye the exudation, which is sometimes abundant, is not to be distin- 
guished from that of diphtheria. The diagnosis depends mainly upon the 
eruption. The scarlatinal false membrane is very much more prone to 
be followed by ulceration than is the diphtheritic, and the lymphatic 
glands are much more likely to suppurate. It is quite true that scarlet 
fever does not often affect the larynx, yet in rare cases of that disease 
false membrane may be found even there. Subsequent paralysis does 
not occur. True diphtheria may complicate scarlet fever during the 
second or third week, and may occur in scarlatinal nephritis at any stage. 
7. The mucous tubercles of syphilis, when they involve the fauces 
and before ulceration sets in, may resemble diphtheria closely. 
8. In rare cases of typhoid fever and early in the disease, false 
membrane forms upon the fauces; it does not last for more than a few 
days, but it cannot be distinguished from diphtheria until the course of 
the disease is manifest. 
It seems unnecessary to do more than refer to the faucial affections of 
small-pox, chicken-pox, and pemphix. The ulceration of tubercular an- 
gina faucium is sometimes at first mistaken for diphtheria. And the same 
is true of that very uncommon disease, primary gangrene of the fauces. 
Recurrent Pellicular Angina. - Some forms of pellicular angina are 
very prone to recur, and the recurrences may be frequent, for example, 
once every two or three months for a year or two, or even as many as 
four attacks in twelve weeks. The appearance of the throat is that of 
slight diphtheria (or follicular tonsillitis) ; but the precise nature of the 
disease is doubtful, and it is equally doubtful whether that nature be the 
same in all cases. This recurrent pellicular angina is often a very febrile 
disorder, is not attended by albuminuria, nor followed by paralysis. It 
can seldom be traced to insanitary conditions; and when it recurs fre- 744 
SYSTEM OF MEDICINE 
quently it seems to be probable that the contagium vivum lurks about 
the throat in an inactive state. In many cases the disease is but 
slightly if at all contagious. 
An attack of true diphtheritic sore throat does not protect against 
recurrence of the disease. Yet as a rule (which, however, does not always 
hold good) recurrent diphtheria is not so severe and dangerous as the 
first attack. 
Prognosis. - The prognostics which may be derived from individual 
symptoms will be found scattered through the preceding pages and 
need not be repeated here. 
The cause of death differs in different cases, (i.) Suffocation by 
extension of disease to the larynx is common, (ii.) Poisoning of the 
blood (malignant diphtheria) is a less common cause of death. This 
malignity is indicated by nasal discharge, glandular swelling, erysipela- 
tous redness of the skin over the swelling, tendency to haemorrhage, 
failure of the circulation (as shown by a bad pulse, pallor, and coldness 
of the surface), and delirium. Death is often sudden, (iii.) Heart 
failure, (iv.) Palsy of respiratory muscles. 
Recovery of the former state of health is sometimes a very slow 
proceeding, even excepting the cases of paralysis. 
Treatment.1-From the remotest ages of medicine it has always 
been assumed that the foremost indication for the treatment of 
diphtheria consists in disinfection of the primary disease, which is 
usually that of the throat. Both laboratory experiments and clinical 
experience point to carbolic acid as the germicide which most of all 
combines efficacy and safety. It may be used in a solution as strong as 
twenty per cent in the case of children, and thirty per cent in the case 
of adults. Glycerine, castor oil, and rectified spirit have been much 
employed as solvents for the acid; sulphoricinic acid has of late been 
recommended as the vehicle (8), under the belief that it affords the least 
painful application; I have used this sulphoricinic phenol and believe 
it to be efficient for the purpose. Remove as much of the false 
membrane as possible by means of some close soft material (" molleton" 
is suitable) (9) tied on the end of a probe or an osier twig, or held 
by forceps, and afterwards apply the carbolic solution freely to the 
denuded surface. Should the false membrane continue to form and 
to show signs of spreading, the treatment may be repeated once or 
oftener, according to the discretion of the physician. These applica- 
tions to the throat tend to exhaust the strength of the patient, and the 
doctrine of local disinfection may be carried out in practice to a danger- 
ous length. The frequent use (for two or three minutes every hour) of a 
spray of a saturated solution of boric acid is always serviceable, whether 
the throat be also swabbed with carbolic acid or not. If deglutition 
be painful it is well for the patient to benumb his fauces by means 
of ice before attempting to swallow. 
The most important part of general treatment consists in feeding the 
1 For the serum treatment refer to the last chapter. DIPHTHERIA 
745 
patient, and milk is the most suitable article of food. It should be given 
every two hours by day, and every three hours by night. Brandy is 
useful and even necessary in many cases, especially if an insufficient 
quantity of milk be taken, or if the patient be exhausted, or if the heart 
show signs of failing. Should the patient refuse to take the necessary 
quantity of food he must be fed by means of a soft catheter passed 
through the nostril into the oesophagus. 
It is not possible to lay down any universal rule concerning the 
employment of drugs. None are specific, and the indications for their 
use must be left to the judgment of the practitioner who is directing the 
treatment of a case. Chlorate of potash is cleansing to the mouth, but 
to give the salt in large doses is useless or even dangerous. The old- 
fashioned chlorine mixture1 is the best way of giving the chlorate. 
Signs of heart failure should be carefully watched for. If they 
appear the patient must be kept as still as possible in the recumbent 
position, and he must not be allowed to sit up, still less to get out of bed, 
for any purpose. Alcohol and strychnia are the best medicines. 
If there be any signs of laryngeal paralysis the patient must be fed 
by means of a tube through the nose, and by nutritious enemata. The 
use of the tube is favoured in most cases by insensibility of the fauces 
and pharynx. If vomiting follow the first use of the tube the practice 
should not therefore be given up, for the vomiting is seldom repeated. 
The patient must be watched, and if he vomit he must be turned over on 
his side, with his head low, so that the vomit may not enter the larynx. 
Treatment of palsy of the limbs is guided by the knowledge that, if 
the breathing muscles escape and the heart do not fail, the patient will 
recover. The chief means of promoting recovery consist in rest and in 
maintaining or improving the nutrition of the whole body. Massage and 
electricity may be used, but must be used gently. In respiratory palsy 
faradisation of the phrenic nerve has been known to do good. 
For the vomiting and the purpuric state no treatment avails; the 
nephritis must be managed upon general principles. 
B. Diphtheritic Croup (Laryngitis) 
That is to say, diphtheria which causes predominant laryngeal symp- 
toms, is discovered by means of the laryngoscope, or of the expectora- 
tion, or of certain indirect signs of the disease. 
I. Laryngoscope. - The use of the laryngoscope, which is not always 
easy even in the case of adults, is difficult or quite impossible in the case 
1 Put ten grains of powdered chlorate of potash into a pint bottle, and add half a drachm 
of strong hydrochloric acid. Keep the bottle corked until the effervescence has ceased; 
then add an ounce of cold water and shake the bottle well, not allowing the gas to escape; 
then add another ounce of water, and again agitate well, and so on until the bottle is full. 
The resulting solution does not taste nearly so badly as it smells; a little sugar may be 
added. A tablespoonful or two, according to the age of the patient, may be given fre- 
quently. An adult may take the whole pint in the day. Chlorine vapour was recom- 
mended by J. Johnstone as early as 1779. 746 
SYSTEM OF MEDICINE 
of children, especially young children. Hence it seldom avails much in 
the diagnosis of croup;1 however, in a case of doubtful nature it is always 
well to try what the laryngoscope can show. A small, warmed mirror 
can be passed back into the fauces without any attempt to depress the 
tongue or to draw it out of the mouth, and in this way the epiglottis, at 
least, can be seen, if there be not much gurgling of frothy mucus in the 
throat. Should false membrane appear this is enough, but it need not 
be said that the nonappearance of membrane proves nothing. 
II. Expectoration.-Children seldom expectorate false membrane 
before tracheotomy has been performed; ejection of false membrane 
through the tracheotomy wound is a very common event. Yet even 
after tracheotomy for diphtheritic croup it may happen that no false 
membrane will at any time be seen. Adults, on the other hand, suffer- 
ing from diphtheria strictly confined to the windpipe, will sometimes 
expectorate false membrane in large quantities, and this even when the 
dyspnoea is slight and the chief laryngeal symptom is dysphonia. 
III. Signs of Laryngeal Disease.-In most cases the diagnosis depends 
upon certain signs which indicate derangement of the laryngeal func- 
tions. These functions are two - vocal and respiratory: vocal, that is 
the proper and peculiar function of the larynx, the larynx being the organ 
of voice ; respiratory, that is transmission of the breath, the larynx being 
part of the windpipe. The signs of disease correspond with these 
functions. Disorder of the vocal function is indicated by dysphonia; 
disorder of the respiratory function, by laryngeal dyspnoea and laryngeal 
stridor. To these must be added a third sign, wholly adventitious, 
allied to voice on the one hand and to breathing on the other, namely, 
a peculiar stridulous or laryngeal cough. 
1. Dysphonia. - As the voice is the peculiar function of the larynx, 
so dysphonia is the pathognomonic sign of laryngeal disease. Dysphonia 
relates to the quality or to the loudness of voice, (a) When the quality 
of the voice is changed it is called paraphonia, of which hoarseness is 
the commonest form, being a lesion of the simple glottic sound and not 
of the articulated voice. (&) When 'the loudness of the voice is dimin- 
ished it is called aphonia, a term which implies not only absolute priva- 
tion of voice, but also any degree in diminution thereof. When aphonia 
is complete the patient can speak only in a whisper - whispering being 
articulation pure and simple without any glottic sound. 
2. There is nothing pathognomonic about the disordered respiratory 
functions met with in laryngeal disease. Laryngeal stridor and dyspnoea 
have to be distinguished from other forms of stridor and dyspnoea; and 
this can be done by determining the presence or absence of certain by- 
symptoms (signa assidentia). (a) By stridor is meant a sound which is 
produced in the windpipe (larynx, trachea, bronchi) by breathing, and 
which can be heard without auscultation. Stertor, on the other hand, is 
a sound which breathing produces in the parts above the windpipe. 
xFor exact definition of the word Croup, see Medico-Chir. Trans, for 1879, vol. Ixxii. 
p. 27. DIPHTHERIA 
747 
Narrowing of the windpipe is the cause of stridor, and its loudness 
depends upon the swiftness of the air-currents; hence when the narrow- 
ing of the air passages becomes great, and the air currents become 
correspondingly weak, stridor diminishes or even disappears. The 
peculiar quality of stridulous breathing is a fact which must be taught 
by experience, and which cannot be described by words. (6) The char- 
acters and associated symptoms of laryngeal dyspnoea are these: - (a) 
The dyspnoea is chiefly inspiratory or expiratory; usually the inspiratory 
movement is much prolonged, but it may happen that the expiration will 
be at least twice as long as inspiration. (/?) The dyspnoea affects the 
movements of both sides of the chest, inspiratory dyspnoea being marked 
by powerful contraction of all the inspiratory muscles, and by recession 
of the yielding parts of the chest, expiratory dyspnoea being marked 
by powerful and prolonged contraction of all the expiratory muscles, 
(y) The breath-sounds heard by auscultation are weakened. (8) The 
nostrils dilate during inspiration or expiration, or are permanently 
dilated, (e) The up and down movements of the larynx (depressed 
during inspiration) which attend respiration are much increased in 
laryngeal dyspnoea; similar movements of the lower jaw are some- 
times to be seen. (£) The radial pulse is withdrawn from the finger 
during inspiration in severe laryngeal dyspnoea. 
3. The stridulous cough (or croupy cough), a most important sign of 
laryngeal disease, does not admit of being described in words. 
IV. Course of Disease. - In a case of diphtheritic croup dysphonia 
and stridor mostly precede dyspnoea, inasmuch as dyspnoea requires a 
greater amount of disease than suffices for the production of dysphonia 
and stridor. The voice is more or less weakened (aphonia) and husky 
(paraphonia), yet in strict truthfulness it must be said that sometimes the 
voice is very little affected, or even not at all. The breathing, instead of 
being silent, becomes dry and husky, characters more marked in inspira- 
tion than in expiration. The cough is usually dry and husky; sometimes 
it is loose; and sometimes there is a loud barking cough (tussis ferina); 
the noisier the cough the less the obstruction. 
Dyspnoea follows, often the day afterwards; but, as a rule, it does not 
attain a high degree for another day, or even for two or more days after 
its onset. There are no remissions, worthy so to be called, in the 
dyspnoea; when once it sets in it abides, except that it sometimes abates 
shortly before death. Moderate dyspnoea may at any time become 
suddenly very great so as to demand instant tracheotomy.1 In adults 
the dyspnoea comes on later, progresses less rapidly, and is less severe 
than is the case with children - the reason of the difference being 
due chiefly to the relatively small size of the glottis in children, but 
partly to the more powerful inspiration of the adult, and to his smaller 
liability to collapse of lung. 
1 Should the reader require a picturesque description (in the style of Aretseus) of the 
dyspnoea of croup, he may refer to Trousseau, who has performed this work once for all 
(Trousseau, Clin. Med., New Sydenham Soc. vol. ii. p. 477). 748 
SYSTEM OF MEDICINE 
V. Comitant Symptoms. - 1. The lividity of the patient is not 
exactly proportionate to the dyspnoea. Sometimes there is but little 
lividity, or even none at all, though the dyspnoea be permanent and at 
intervals great. Lividity is often due in part to associated pulmonary 
disease, bronchitis (catarrhal or diphtheritic), congestion of lungs, or 
collapse. 
2. The fever is not high. Indeed, the temperature is often normal, 
or even subnormal, especially when the lividity is great. When the 
lividity is not great the temperature may rise to 102°, or if the fauces 
be affected, even higher. Scarcely need it be said that tracheotomy 
interferes with the course of temperature. 
3. The fauces often look healthy, but even upon apparently healthy 
fauces specific bacilli may breed. In some cases small or extensive 
false membranes will be seen. 
4. Puffiness on one or both sides of the neck may exist, or even an 
enlarged gland or two, the fauces being natural. 
5. Albuminuria is common, yet sometimes there is none even in 
fatal cases. There is often an excess of flocculent deposit containing 
leucocytes. 
6. Symptoms of the virulent kind, due to poisoning of the blood, do 
not occur. Paralysis (except, perhaps, glottic paralysis) does not follow 
diphtheritic laryngitis, yet the patellar tendon reflex will sometimes be 
lost for a long time after an attack of membranous croup in persons 
who were known to have such a reflex before they suffered from diph- 
theria. 
Prognosis.-1. Recovery occurs in a very small proportion of the 
cases of laryngitis which have been proved to be diphtheritic by the ex- 
pectoration of false membrane, or by the comitant affection of the 
fauces.1 Tracheotomy saves a few lives, but recovery may occur with- 
out tracheotomy. The younger the patient the smaller the chances of 
life, for reasons which have been already referred to when speaking of 
dyspnoea; but even children of less than a year old may escape with life, 
after having expectorated false membrane. 
The feeble and husky voice and croupy cough will remain for a week 
or more after the dyspnoea has ceased, both in cases which have under- 
gone tracheotomy and those which have not. The laryngoscope, when it 
can be used, does not always afford an explanation of these symptoms. 
Recovery after tracheotomy is sometimes imperfect, that is to say, 
the tube cannot be removed; the reasons of this will be given hereafter. 
Relapse occurs in rare cases; the patient has survived the worst 
period of the disease, and seems to be convalescent, although not quite 
well, when the diphtheria breaks out again in full vigour, and will proba- 
bly kill the weakened patient. 
Diphtheritic croup very seldom recurs after an interval of perfect 
health. But it is a disease which does not often give the patient a 
1 The serum treatment enables us to give a very much more favourable prognosis in 
cases of laryngeal diphtheria: see the last chapter. DIPHTHERIA 
chance of undergoing it a second time. The croup which recurs is of 
the catarrhal and spasmodic kind. 
2. Death is due to one of two causes, either to laryngeal or to pul- 
monary dyspnoea. 
(a) Laryngeal dyspnoea is a cause of death which is now usually pre- 
vented by tracheotomy. The duration of cases which are fatal without 
tracheotomy is two, three, or four days from the onset of the croupy 
symptoms. Unfavourable conditions which aggravate the fatal tendency 
of croup are infancy and rickets, for reasons which are sufficiently 
obvious. 
(/?) Pulmonary dyspnoea is due to many causes: - (i.) Extension of 
the inflammation downwards into the lungs, the smaller air-tubes becom- 
ing choked by false membrane, or more commonly by creamy muco-pus; 
upon this condition lobular pneumonia (catarrhal or broncho-pneumonia) 
is very apt to supervene, (ii.) Congestion of the lungs, which occurs 
when the lungs cannot inspire more than from one-fourth to one-half of 
their normal supply of air. (iii.) Collapse of lungs more or less extensive, 
(iv.) Acute emphysema (or insufflation) of the front part of the lungs 
beneath the sternum and the neighbouring cartilages, (v.) Inability to 
cough and consequent retention of secretions, (vi.) Pneumothorax, 
which is not uncommon in fatal cases which have undergone tracheotomy. 
Pulmonary dyspnoea mostly sets in from four to seven days from the 
onset of the croup. Hence it is especially seen in cases of tracheotomy, 
because other cases of laryngeal diphtheria by the end of the first week 
are either dead or recovering. The dyspnoea sometimes becomes very 
great all at once. 
The signs of pulmonary affection are these: - (i.) Increase of fever, 
especially in bronchitis and pneumonia, (ii.) Physical signs of bron- 
chitis, extensive collapse, insufflation of lungs, or pneumothorax, (iii.) 
Expectoration from canula becomes more or less abundant or sticky, or 
even purulent if the patient live long enough, (iv.) The dyspnoea 
follows one of two courses: (a) Either it recurs, and becomes as great 
as before, so that nothing whatever is gained by having substituted, by 
means of tracheotomy, pulmonary for laryngeal dyspnoea. Conscious- 
ness being retained, the patient suffers as much distress after the trache- 
otomy as he suffered before it. (/S') Or vital debility prevails, there 
being no great dyspnoea, but the respiration becoming very frequent, 
and the pulse very small and weak. Lividity steadily increases. The 
animal constitution soon suffers; drowsiness ensues, the patient being 
almost continually asleep unless disturbed by cough; sleepiness passes 
into coma and death, which is easy and without dyspnoea. 
Tracheal Diphtheria. - Now and then a case will be met with in which 
the disease is almost limited to the trachea. 
The tracheitis is not primary, but is preceded by a diphtheritic 
affection of the fauces or larynx, which may have been slight or severe, 
(i.) The primary sore throat may be attended by the least possible ex- 
udation, and the laryngitis be indicated by nothing more than a little 
749 750 
OF MEDICINE 
hoarseness, and perhaps a few shreds of false membrane seen by the 
laryngoscope. In about seven days from the first signs of illness the 
patient begins to expectorate casts from the trachea, (ii.) Or, after a 
severe and regular attack of diphtheritic angina and croup (which will 
in some cases have rendered tracheotomy necessary), the patient seems 
to be fairly convalescent, when the disease relapses in the tracheal form, 
expectoration of false membrane occurs, but no recurrence of angina 
faucium or of laryngitis. 
This tracheal diphtheria often deserves the name of chronic, the 
patient expectorating casts of the trachea from time to time for two 
months or even longer from the beginning of the disease. Albuminuria, 
amblyopia, and paralytic symptoms may occur. The prognosis is 
doubtful; some patients die in one way or another, and some survive. 
Diagnosis. - 1. Catarrhal laryngitis (catarrhal croup) and diphtheritic 
laryngitis cannot be distinguished during life unless false membrane 
be coughed up, or be seen upon the larynx or fauces. Catarrhal croup 
is never fatal, however severe the dyspnoea be for a time, unless the 
inflammation spread to the bronchi so that the patient really dies from 
suffocating bronchitis. A case of croup which becomes steadily worse 
is probably diphtheritic. But, on the other hand, what seems to be 
catarrhal croup may be diphtheria in its slightest form. 
2. The respiratory stridor in some cases of catarrhal croup is exces- 
sive, and reaches a height of noisiness which is uncommon in diphtheritic 
croup. This stridulous laryngitis is especially apt to occur in measles 
just before the rash comes out; the dyspnoea and distress of the patient 
are great; the rash appears, and the croupy symptoms speedily subside. 
The croup which occurs in measles from four to fourteen days after the 
appearance of the rash is a more serious disease; it often renders 
tracheotomy necessary, and is usually laryngeal diphtheria. 
3. Spasmodic croup (spasmodic laryngitis, Millar's acute asthma for 
the most part) is distinguished from other kinds of croup on account of 
a peculiarity in the course of the dyspnoea. The onset (as in all sorts 
of croup) is marked by dysphonia and stridor. Dyspnoea soon follows 
and attains a high degree, especially in the middle of the night. After 
urgent dyspnoea has lasted from half an hour to two hours it begins to 
abate, and soon becomes slight, the dysphonia and stridor continuing. 
Such attacks of dyspnoea are prone to recur for two or three nights in 
succession, each fit being less severe than the foregoing. Now and then 
(but very seldom) diphtheritic croup will take on the spasmodic form, 
wherefore it is prudent not to be too confident in pronouncing at first 
upon the benignant nature of spasmodic croup. Laryngismus stridulus 
cannot possibly be mistaken for diphtheritic croup. 
4. When a child has inhaled a foreign body which sticks in the 
larynx, and when the history of the occurrence of the accident is wanting 
or untrustworthy, it is easy to mistake such a case for croup. It will 
hardly be possible to gain any help from the laryngoscope. At the in- 
stant of the foreign body entering the glottis urgent dyspnoea occurs, so DIPHTHERIA 
751 
that an attack of laryngismus is simulated, and the patient may die on 
the spot. But if he survive the dyspnoea abates, and then the case sim- 
ulates croup. The diagnosis sometimes cannot be made until after tra- 
cheotomy by exploring the larynx by means of a probe passed upwards 
through the wound. 
5. Exacerbations of dyspnoea occurring in children suffering from 
pectoral diseases, such as hydrothorax and acute pulmonary consumption, 
sometimes strongly simulate croup; and the more so when the dyspnoea 
is attended by a husky cough. / 
6. In the case of adults the diseases most likely to simulate laryn- 
geal diphtheria are sundry forms of laryngitis, oedema glottidis, laryn- 
geal paralysis coming on suddenly, and hysterical laryngismus. But in 
adults the laryngoscope is available. 
Treatment. - Inasmuch as we cannot apply germicides to the air- 
passages, and as we possess no antidote to diphtheritic poison in the 
blood, it follows that for us no direct specific treatment of laryngeal 
diphtheria is possible? Moreover, very little, short of tracheotomy, can 
be done to mitigate the most distressing symptom. To surround the 
patient with pure, warm, and somewhat moist air would seem to be indi- 
cated by common sense. The only local application which can be recom- 
mended is that of ice or of ice-cold water to the front of the neck. 
Emetics are best avoided; they empty the stomach of food, and any good 
they may do to the dyspnoea is very temporary; usually they do no 
good at all. 
When the dyspnoea becomes considerable the remedy of tracheotomy 
must not be deferred too long. It removes the laryngeal dyspnoea, but 
lividity often persists, and pulmonary dyspnoea often supervenes and kills 
the patient, as has been already described. Tracheotomy is sometimes 
followed by evils of its own, for example (i.) Emphysema of the medi- 
astinum, due, according to Dr. Champneys, to the fascia being stripped off 
from the trachea in the operation, (ii.) Pneumothorax and Mediastinal 
Suppuration are apt to follow emphysema of the mediastinum, (iii.) 
Thrombosis, starting from veins injured during the operation, and pos- 
sibly extending so far as the right auricle, (iv.) Embolism of a large 
branch of the pulmonary artery, possibly followed by gangrene of the 
corresponding portion of lung, (v.) Ulceration of the trachea, due 
to irritation set up by the end of the canula. (vi.) Sloughing of phage- 
daenic ulceration due to septic infection of the wound. 
Tracheotomy, although it usually raises the temperature of the body, 
does not always do so. It is a bad sign when the nostrils act strongly, 
or when the breathing through the canula becomes sawing or hissing. 
Young children after tracheotomy should be fed by means of an india- 
rubber catheter passed through a nostril into the oesophagus, and the 
same method should be employed in all cases which show any tendency 
for the drink swallowed to pass into the larynx. 
The tube should be removed as soon as possible, nor is it too early to 
1 Refer to the last chapter upon the Serum Treatment. SYSTEM OF MEDICINE 
752 
make the attempt within twenty-four hours after the operation. But 
sometimes the tube cannot be removed for a long time after, or, indeed, 
cannot be removed at all. The cause of the difficulty is not always the 
same. An abundant growth of granulations sometimes obstructs the 
windpipe about the wound; this is said to be especially the case when 
the cricoid cartilage has been divided. Cicatricial contraction of the 
windpipe above or below the wound is another possible cause of obstruc- 
tion. The trachea is sometimes dislocated backwards, so that the chan- 
nel of the windpipe below the wound is not continuous with that above. 
But in many cases it is hard to say what the cause of the difficulty is, 
and little or no help can be gained from the use of the laryngoscope. 
Paralysis of the glottic dilators is an explanation possible in some 
patients; in some the emotion of fear seems to play a large part in 
aggravating any distress which follows removal of the tube. In many of 
these doubtful cases time alone will suffice to cure. 
The use of tubage or intubation of the glottis is a topic which hardly 
needs to be discussed with reference to diphtheritic laryngitis. In this 
disease tubage is not a reasonable method of treatment unless, in a given 
case, we know that the exudation is confined to the larynx and will not 
spread beyond it.1 But these are certainties to which we cannot attain, 
and in practice we have nothing more to guide us than probabilities 
which may be high or which may be low. If we can believe that the 
croup is not membranous, or that, if membranous, the disease does not 
extend below the larynx, we may be disposed to try intubation, but 
always with the prospect of having to perform tracheotomy afterwards. 
My own opinion is that tracheotomy should be preferred in all cases. 
Difficulties and dangers attend tracheotomy, and tubage is not free 
from them. What are called statistics are of little value in determining 
the relative merit of the two operations, and are of no value at all, if 
among successful intubations are to be reckoned cases in which the tube 
passed out per anum. 
C. Nasal Diphtheria 
Diphtheritic membranes in the nose are often associated with diph- 
theria of the fauces, a combination which usually indicates a severe form 
of the disease, but not always. Very slight pellicular sore throat, so 
slight that its diphtheritic nature is doubtful, may be attended and fol- 
lowed by puriform discharge from the nose, the patient in all other 
respects seeming to be in good health; and yet this discharge will be 
capable of conveying diphtheria to other people. Still the rule is, as 
aforesaid, that diphtheria affecting both throat and nose is malignant 
or pestilent diphtheria. 
Diphtheria sometimes affects the nose alone, so far as can be made 
out. The sign of this form, as of all forms, of nasal diphtheria is stuffing 
1 See the last chapter on the Serum Treatment. DIPHTHERIA 
753 
of the nose and a puriform discharge, sometimes offensive, sometimes 
bloody, and often very irritant to the nostrils and upper lip. The 
haemorrhage is sometimes sufficient to weaken the patient, or even to be 
the cause of death. The redness and swelling may spread from the 
nostrils so as to affect the whole nose and the eyelids. The swelling is 
sometimes attended by erysipelatous redness of the skin. Yet it may 
happen that there shall be no discharge, and stuffiness be the only sign 
of nasal disease. Very seldom do membranes come away so as to be 
discovered in the discharge; they can sometimes be seen by inspection 
of the nasal fossae, more commonly they are limited to the hinder parts 
of those cavities. 
The glands at the angle of the jaw tend to be swollen, tender, and 
painful. Should one nostril alone be affected the glands will be enlarged 
upon the same side. 
The general symptoms of diphtheria confined to the nose are usually 
marked enough, but they are often supposed to be due to a common 
cold in the head, and are not much attended to. Albuminuria is usually 
present during the time of the nasal discharge, and even for some time 
afterwards. Paralysis will follow in some cases, and may present this 
peculiarity, that the fauces are not affected even although the limbs 
suffer severely 
Nasal diphtheria is to be treated upon the same principles as faucial 
diphtheria. 
D. Other Local Forms of Diphtheria 
Otitis media is sometimes diphtheritic, and false membranes are 
found in the tympanum after death. The amount of associated faucial 
disease may be considerable or may be slight, even so slight that its 
nature is doubtful. The signs of otitis are the same as those of other 
forms of the disease. The diagnosis depends upon the discovery of 
diphtheria elsewhere. Erysipelas of the ear and neighbouring parts 
sometimes follows upon rupture of the tympanic membrane. Chronic 
otorrhoea may ensue. 
A portion of the skin which is excoriated or blistered is prone to be 
attacked by diphtheria in a patient already suffering from that disease; 
the membrane, if thick, looks very much like a layer of lard. The skin 
around is often erysipelatous. 
A granulating wound is very seldom attacked, the wound of tracheot- 
omy often becomes foul and phagedeenic, but anything like false mem- 
brane is rarely or never seen. 
Conjunctival diphtheria (which is said to be sometimes due to the 
disease spreading up the lachrymal passages), and diphtheria of the 
vulva, vagina, anus, or prepuce, are diseases very uncommon in England. 
The oesophagus is seldom affected. This form of disease affords no 
characteristic symptoms, and is usually not suspected during life unless 
a membranous cast be rejected. 
VOL. I 
3 C 754 
SYSTEM OF MEDICINE 
Diphtheria of the stomach has been referred to in the chapter on 
vomiting. 
E. Latent Diphtheria 
The diphtheritic poison may affect the throat without being revealed 
by the formation of false membrane. In this case the mucous membrane 
is either red, swollen, tender and painful, or it looks quite natural. 
The former condition cannot be distinguished from simple inflamed or 
catarrhal sore throat, unless there be good reason for believing that the 
patient has been exposed to the operation of the diphtheritic poison, 
unless the specific bacillus be found in the secretions, unless the 
patient convey diphtheria to some neighbour, or unless the peculiar 
paralytic symptoms follow what seemed to be a common sore throat. 
After a manifest attack of diphtheritic angina faucium the throat may 
seem to have returned to its normal condition, and yet the microscope 
may discover the specific bacillus in the secretions, even after a con- 
siderable time (seven months it is said) has elapsed since the cessation 
of the disease. 
Diphtheria of the larynx is often latent; that is to say, a patient has 
croup, and from first to last it is impossible to say whether the disease 
be diphtheritic or not. 
Latent nasal diphtheria is either primary or secondary: (i.) A patient 
has a discharge from one or both nostrils, which is deemed at first to be 
a simple coryza, and which, if the disease last several weeks, is supposed 
to be due to syphilis, disease of the turbinate bones, or of the maxillary 
antrum; and surgical proceedings may be recommended. But the debility 
of the patient is noted to be greater than the local disease can account 
for, or the urine is found to be albuminous, or paralytic symptoms occur, 
and thus the true nature of the disease becomes apparent, (ii.) The 
latent nasal diphtheria which is secondary to a manifest attack of the 
disease has been already described. 
S. Gee. 
Serum Treatment 
As explained elsewhere [see art. on " Serum Therapeutics in certain 
diseases the blood serum of artificially protected animals, if injected into 
others still susceptible, has a protective power; and Behring conceived 
the idea that a similar treatment might be adopted in diphtheria (1). 
He found that it could be used not only as a protecting agent, but also 
as a cure (2), and after many trials he succeeded in producing a serum 
strong enough to be of use for man. From that time to this modifica- 
tions have continually been introduced by Behring himself and by 
others, which have enabled us to produce stronger and stronger prepara- 
tions of the serum: to describe these in detail is beyond the scope of 
the present article. To Aronson we owe the employment of horses, 
from which animals the serum now in use is obtained. 
The new remedy was first employed, and the first accounts of its DIPHTHERIA 
755 
effects were published by Berlin physicians (3, 4). Their results were 
confirmed in Paris by Roux, and by other physicians in Germany. 
Since then it has been used all over the world. 
It is unnecessary now, and will probably be still less needful when 
these words are published, to quote at length the great number of clinical 
and statistical papers on which our judgment has been formed. They 
have been collected and excellently analyzed up to July 1895 by Welch. 
No one man has published finer work upon the subject than Baginsky, 
whose book, besides resting on a larger number of cases than has fallen 
to the lot of any other physician, contains the most cogent proof of the 
value of the serum ever yet brought forward. Between 15th March 
1894 and 15th March 1895 he treated by the antitoxin 525 children 
up to fourteen years of age, of whom 83, or 15'6 per cent, died. The 
supply of serum failed about August and September, and during that 
time 126 children were treated without the antitoxin, of whom 61, or 
48-4 per cent, died. When the serum was resumed the mortality at 
once fell again. The higher rate is about the level of previous years. 
At the Eastern Hospital in London (8), from 1st January 1893 to 
22nd October 1894, 797 patients under fifteen years of age were treated 
by the old methods, of whom 310, or 38-8 per cent, died. From 23rd 
October to 27th November 1894, 72 such patients were treated by the 
antitoxin, of whom only 14, or 19'4 per cent, died. 
At St. Bartholomew's Hospital (9) we treated, during 1893 and the 
first part of 1894, 95 cases under ten years of age with 50 deaths, a rate 
of 52-7 per cent. Between 1st July 1894 and 8th July 1895, 50 cases 
of the same age were treated with the antitoxin, of whom only 8 died, 
a rate of 16 per cent. This fall in the death-rate must be a little dis- 
counted ; first, because proportionately more patients were admitted in 
the first three days after symptoms were noticed; and, secondly, because 
proportionately fewer patients were admitted under two years of age 
during the second period than during the first. But the difference thus 
made is, when calculated, slight, and if by grouping like cases with like 
the numbers are more closely compared, the value of the serum is more 
clearly shown. Thus, of cases in which the diphtheria affected together 
with other parts the nose - 
During the first period 28 died out of 39 
" second " 3 " " 12 
Of cases in which both fauces and larynx, but not the nose, were 
affected - 
During the first period 16 died out of 39 
" second " 4 " " 20 
Of tracheotomy cases - 
During the first period 39 died out of 67 
" second " 6 " " 32 
Most physicians agree that under this treatment the local symptoms 
clear up with much greater rapidity than of old. That the disease is 756 
SYSTEM OF MEDICINE 
also robbed of its power on the constitution is proved partly by the great 
fall in the death-rate and partly by clinical observation. It does not, 
however, appear to influence the temperature (9), and whether paralysis 
occurs less often now is still doubtful. Hayward (9) found that of the 
above 50 cases only 2 showed any trace of paralysis; however, the num- 
ber is but small, and, moreover, the average rate of incidence is an 
unknown quantity. No hospitals retain their patients long enough to 
settle the question, and I have had many out-patients suffering with 
these symptoms who had been discharged from hospitals as cured. 
Albuminuria is certainly not more - in our case it was rather less - 
frequent under this treatment, and the same is true of nephritis. 
Dr. Gee thinks it probable that intubation will now be of more use 
than hitherto. The great objection to intubation has been that it affords 
no egress for the membranes continuously formed in the trachea. If 
by serum we can stop the formation of membrane the objection ceases 
to be valid. 
In some cases the injection of the serum is followed by a rash, 
erythematous or urticarious, upon the skin [see also art. on " Serum 
Therapeutics"]. In a few cases there is itching, but it has no other 
ill effect, and it passes off sometimes within a few hours, sometimes 
within a few days. Less often - we have never seen it - there is pain 
and swelling in some of the joints, which is also transient. Both these 
effects are due rather to the serum than to the antitoxin - whatever 
that may be-which it contains; and the smaller the dose of serum 
the less likely are these symptoms to occur. 
The injections are best made deeply into the buttock. The syringe 
must be such that it can be perfectly sterilised by boiling, and should 
hold at least 10 c.c. It is best to connect it with the needle by an india- 
rubber tube. The whole should be boiled before each injection, and the 
skin washed first with soap and water, and then with a solution of 
carbolic acid. The puncture should afterwards be covered with a small 
piece of isinglass plaster, or similar protective [see art. on " Serum Thera- 
peutics The dose varies with the different preparations of serum. 
Of Klein's serum, which we are now using at St. Bartholomew's Hospital, 
we give 5-8 c.c. once or twice daily for several days, or even oftener, 
according to the severity of the case. In serious cases the treatment 
must be pushed to get the full effect immediately, or as quickly as pos- 
sible. Especially where there is broncho-pneumonia the injections should 
be practised energetically; for Dr. Kanthack and Mr. J. W. W. Stephens 
have shown that in such cases the lungs generally, if not always, contain 
the diphtheria bacilli in enormous numbers; in other words, the amount 
of poison to be rendered harmless is very considerable (yide supra). The 
strongest serum is the best. yy p. Herringham. 
REFERENCES 
1. Longstaff, G. B„ M.A. Oxon. Studies in Statistics. London, Edward Stan- 
ford, 1891. - 2. Thorne Thorne, R., M.B., &c. "On the Origin of Infection," Trans- DIPHTHERIA 
757 
actions of the Epidemiological Society of London, vol. iv., Sessions 1875-80. - 3. Thorne 
Thorne, R., C.B., M.B., F.R.S. - Diphtheria: its Natural History and Prevention, 
being the Milroy Lectures delivered before the Royal College of Physicians of London, 
1891. Macmillan and Co. - 4. "Presidential Address to the Epidemiological Society," 
Session 1894-95. See Transactions of the Society. - 5. Power, Mr.W. H. Report to the 
Local Government Board on an Epidemic of Diphtheria in North London, December 
1878.-6. Diphtheria: its Natural History and Prevention. Milroy Lectures, 1891. 
Macmillan and Co. - 7. Report of the Medical Officer of the Local Government Board 
forWSQ. - 8. Reports on Sewer Air Investigations. By J. Parry Laws, F.I.C. Presented 
to the London County Council, 1893. Steel and Jones, 4 Spring Gardens, S.W. - 9. These 
publications are issued by Messrs. J. and A. Churchill, New Burlington Street, London. 
R. T. T. 
10. Hirsch, August. Handbook of Geographical and Historical Pathology. Trans- 
lated by Charles Creighton. New Syd. Soc. 1886, vol. iii. chap. 5. -11. Haeser, Hein- 
rich. Lehrbuch der Geschichte der Medicin: dritte Aufl. Jena, 1882, vol. iii. pp. 428 
et passim. -12. Index Catalogue of the Library of the Surgeon-General's Office, United 
States Army, vol. iii. Washington, 1882. And its continuation, the Index Medicus.- 
13. Bretonneau, Pierre. - Des inflammations Speciales du tissu muqueux, et en par- 
ticulier de la Diphtherite, ou Inflammation Pelliculaire, connue sous le nom de croup, 
d'angine maligne, d'angine gangreneuse, etc. Paris, 1826. -14. Bretonneau, Pierre. 
Memoirs on Diphtheria, translated by Dr. Semple for the New Sydenham Society, 1859, 
p. 177. -15. Trousseau. Clin. Med. (edit. 1865), i. 380. -16. Rabot and Philippe. 
" De la myocardite diphteritique aigue," Arch, de med. exp er. vol. iii. p. 647. -17. Jour- 
nal de med. et de chir. pratiques, vol. Ixii. p. 724. Paris, 1891. -18. Traite de med. par 
Charcot et autres, vol. iii. p. 221. Paris, 1892. 
S. G. 
Bacteriology of Diphtheria: - 1. Papers by Dr. E. Klein and Dr. Sidney Martin 
in Annual Reports of the Local Gov. Board 1891-92 and 1892-93. - 2. Dr. Klein's article 
in A Treatise of Hygiene, by Stevenson and Murphy. - 3. Th. Escherich. Diphtheria, 
Croup, Serumtherapie. - 4. Numerous papers by Roux, generally in conjunction with 
others, in Pasteur's Annates.- 5. Loffler. Mittheilungen a. d. kaiserl. Gesundheit- 
samte, ii. p. 439. Babes (in Wiener klin. Wochenschr. 1889, No. 14; and Tangl, Cen- 
tralb.f. Bakt. und Parasit. vol. x. No. 1). - 6. Councilman, W. T. American Journ. 
of the Med. Sc. 1893, vol. cvi. No. 5. Williams, F. ibidem. - 7. A very good summary 
on the Pseudo-diphtheria bacillus, with full literary references, will be found in the 
" Report on Bacteriological Investigations and Diagnosis of Diphtheria," Scientific 
Bulletin, No. 1, Health Department, City of New York, 1895, pp. - 8. For refer- 
ences respecting the escape of the diphtheria bacillus into the blood and tissues, see 
J. H. Wright. Boston Med. and Surg. Journ. 1894. - 9. Brieger and Frankel. 
Berlin klin. Wochenschr. 1890. Frankel, ibidem, 1893. -10. Sidney Martin. Rep. 
of the Local Government Board, 1891-1892, Supplement, 1892-1893, Supplement. - 
11. Washbourn, Goodall, and Card. Clinical Society, 14th Dec. 1894. -12. Gabrit- 
schewsky. Ann. de I'Inst. Pasteur, 1894. Ewing. New York Med. Journ. 10th and 
17th Aug. 1895. Waldstein, Berl. klin. Wochenschr. 1895, No. 17. Goldscheider 
and Jacob, Zeitschr. f. klin. Med. 1894, xxv. p. 273. Morse, Boston City Hosp. Med. 
and Surg. Reports 1895. -13. Behring. Die Geschichte der Diphtheric. Leipzig, 1893. 
Further references will be found under " Immunity " and " Serum Therapeutics." 
A. A. K. 
Serum Treatment: - !. Behring. Deutsche med. Wochenschr. 1890, p. 1113.- 
2. Behring and Wernicke. Zeitschr. f. Hygiene, 1892, xii. p. 11.-3. Heubner. 
Internat. Med. Congress. Rome, 1894.-4. Ehrlich, Kossel, and Wassermann. 
Deutsche med. Wochenschr. April 1894. - 5. Roux. Internat. Congress of Hygiene. 
Buda-Pesth, 1894. - 6. Welch. Trans, of Assoc, of American Phys. 1895, vol. x.- 
7. Baginsky. Die Serum Therapie der Diphtheria. Berlin, 1895. - 8. Washbourn, 
Goodall, and Card. Clin. Trans. 1895, xxviii. p. 61. - 9. St. Barth. Hosp. Rep. 1895, 
vol. xxxi. 
W. P. H. 758 
SYSTEM OF MEDICINE 
TETANUS 
Syn. - Greek, reravos (a straining, from t^vm) ; Latin, Rigor Nervorum 
(Celsus); Germ., Starrkrampf 
Tetanus may occur in any person of either sex, at any age; it may 
ensue from any wound at any part of the body, and in any condition 
of the wound; or without any apparent wound. It less often follows 
wounds of the trunk than of the extremities, and wounds of the lower 
extremities give rise to it more frequently than those of other parts; but 
it does not appear that wounds of the feet or hands are more liable to 
cause it than those of other parts of the limbs. On the whole, however, 
it occurs more frequently in parts exposed to contact with earth and dirt. 
How the popular but mistaken idea arose that it has any especial rela- 
tion to injuries in the region between the thumb and the forefinger is not 
easy to tell. It is most likely to occur in cases of severe or lacerated 
wounds, or when some foreign body is lodged in a simple incised wound, 
or in compound fractures or burns. It may ensue upon a mere scratch; 
the slightest wounds, such as those caused by subcutaneous injections; 
dilation of the neck of the uterus by a sponge-tent; after confinements 
(the post-parturient cases are said to be especially fatal); after cupping; 
the insertion of a seton; the extraction of a tooth; the injection of a 
hydrocele;1 or the plugging of a nostril for epistaxis. In a woman in 
Addenbrooke's Hospital the only discoverable local lesion was a chronic 
ulcer of the leg. It has also been known to take place after complete 
cicatrisation of the wound (4). In horses it is said to be caused by 
wounds in the gums from eating straw; and cases supposed to be idio- 
pathic may have originated in this way. It is liable to follow exposure 
to cold and a damp, chilly atmosphere, as in the cases of wounded sol- 
diers lying upon the field of battle. In an early case of ovariotomy in 
the country, long before the days of antiseptic surgery, all had gone on 
well, the wound had nearly healed, and I had taken my leave of the 
patient, when tetanus supervened and proved fatal. I witnessed another 
fatal case after ovariotomy, with antiseptic precautions, performed by 
the late Dr. Meadows. I judge that the disease has been less frequent 
since the introduction of the antiseptic method in the treatment of 
wounds; and we may hope that this immunity will be still more observ- 
able as the new methods are more generally and completely carried out, 
and a more thorough cleansing and quicker healing of wounds effected. 
For obvious reasons the disease is more frequent in men than in 
women, and it is said to be less fatal in women. I have seen three cases 
in women, and it proved fatal in all. One female infant, whose case is 
subsequently mentioned, recovered. It is most frequent between the 
1 Gross relates that in a lad who had a bruised chin with a small ulcer on the tongue 
probably caused at the same time, and who died of tetanus, a large hydatid was found in 
the liver. TETANUS 
759 
ages of ten and twenty, and is rare after sixty (20). It is much more 
common in warm countries than in temperate regions, which is somewhat 
remarkable, seeing that its occurrence in the latter is often attributable 
to exposure to cold and damp. It sometimes occurs as an epidemic. Gross 
says (I do not know upon what authority) that in 1858 it appeared in 
rapid succession in several of the London hospitals. Macnamara (5) 
states that in Bengal tetanus has been observed to occur especially after 
changes of temperature, and that it is rarely absent from the hospitals 
of Calcutta. He adds that within a period of five years 83 cases were 
treated in the surgical wards of the Mayo Hospital; of these 44 were 
traumatic, and 24 (a small proportion) died: of the remaining 39 idio- 
pathic cases 10 died (3, 21). It is more frequent and more fatal in 
military than in civil practice. The records, however, of the "Great 
Rebellion" (see appendix) are more favourable than those usually 
given of the results in civil practice. 
G. M. H. 
Pathology. - Although it is only within recent years that any proof 
of the bacterial origin of tetanus has been forthcoming, this disease has 
for some time been classified by surgeons amongst the specific infective 
fevers of septic origin. • Perhaps one of the most remarkable foreshadow- 
ings of the exact nature of tetanus is given by Sir James Simpson who, 
writing in 1854, says: " Tetanus is known to follow wounds very various 
in their degree of severity. . . . The disease, when developed, essentially 
consists of an exalted or superexcited state of the reflex spinal system, 
or of some segment or portion of that system." He then goes on to say, 
"We have in obstetric pathology evidence almost amounting to certainty 
that the analogous superexcitable state of the cerebro-spinal system of 
nerves which gives rise to eclampsia or puerperal convulsions is gener- 
ally produced by the existence of a morbid poison in the blood. And 
it seems not impossible that the generation of a special blood poison, at 
the site of the wound or elsewhere, may sometimes in the same way 
give rise to obstetrical and surgical tetanus." He further pointed out 
that the symptoms of this disease are comparable to those produced by 
strychnine and brucine. It was, however, found impossible by clinical 
observation to determine the nature of this poison, and it was not until 
several years after the publication of Koch's experiments on septicaemia 
that this poison was proved to be the result of the activity of a micro- 
organism which had found a nidus in injured tissues. 
Most of the earlier experiments were directed to the discovery of 
micro-organisms in the blood, in the lymphatics around a wound, or along 
the course of the peripheral and central nerves. Simpson says that 
attempts had been made even before his time to reproduce the disease 
experimentally by injections of the blood of patients who had succumbed 
to tetanus.' But all such attempts were fruitless, and the matter was 
eventually settled by a very different line of experiment. 
Carle and Rattone, in 1884, discovered a virus in tetanus that could 760 
SYSTEM OF MEDICINE 
be inoculated from man to animals (of twelve rabbits inoculated, all 
except one were attacked); they regarded this virus as a contagium 
vivum, probably a bacterium. In the following year Nicolaier published 
his dissertation, in which he recorded his success in obtaining from pus 
a virus which he was able to propagate outside the living organism; 
he also found that certain animals, such as rabbits, guinea-pigs and mice, 
when inoculated with particles of soil obtained either from the streets or 
from cultivated land, became affected by symptoms which he described as 
tetanic in character and as identical with those observed in man. This 
soil, introduced into a little pocket under the skin, was almost invariably 
followed by an abscess. The pus in this abscess was found to contain 
several species of micro-organisms, one of which (although he carried on 
cultivations for seven generations he could never obtain absolutely pure) 
he identified as being specially active in setting up tetanic convulsions. 
He described this organism as a small, slender bacillus, somewhat longer 
but thinner than Koch's bacillus of mouse septicaemia, but he gave no fur- 
ther specific features of identification. In 1886 Bosenbach corroborated 
and established Nicolaier's observations, by inoculating two guinea-pigs 
with pus from a tetanic patient, which produced tetanic muscular con- 
traction like that invariably produced by the inoculation of Nicolaier's 
earth. Bosenbach also produced evidence that one of two bacilli was 
probably the cause of the tetanic condition: (a) a rapidly-growing, thick 
bacillus, which developed large spores, and had the power of peptonising 
serum; (6) a slender bacillus, which first appeared in the liquefied serum, 
and then formed spores. He agreed with Nicolaier that the tetanus 
bacillus was probably the small and slender organism. 
It was not till 1889 that the tetanus bacillus was obtained in pure 
cultures by Kitasato, and also by Tizzoni and Cattani, who were able to 
separate the specific tetanus organism, as at present recognised, from the 
pus of the abscesses occurring in cases of tetanus, and from the tissues 
immediately surrounding these abscesses. Knud Faber, in investiga- 
tions carried on about the same time as those of Kitasato, although not 
successful in obtaining a pure culture of the tetanus bacillus, states that 
his experiments support Kitasato's view that the organism is an obligate 
anaerobe. He was the first to obtain by filtration of very virulent tetanus 
cultures a perfectly germ-free filtrate which, when inoculated into animals, 
reproduced the whole of the disease phenomena of experimental tetanus. 
The organism described by these authors, and now recognized as the 
specific cause of tetanus, usually occurs as delicate threads, and it 
varies in length from 4 p. to 5 /z long, to but slender threads; these 
are slightly thicker than the bacillus of mouse septicaemia (one of 
the smallest organisms known), and the ends are somewhat rounded. 
In the shorter rods, which are non-motile during this stage, spores 
usually make their appearance at blood temperature in about thirty 
hours after multiplication has commenced; but at the temperature 
of the room they are not observed until about a week has elapsed 
from the commencement of the growth, although the organism con- TETANUS 
761 
tinues to grow readily enough at this temperature. Until the spores 
begin to form the threads are usually motile, and the segmentation 
into short rods may be incomplete; but as soon as sporulation com- 
mences the segments become more perfectly marked out, they become 
motionless, and a clear point is observed at one end of the rod; this 
becomes larger and larger until it causes marked distension of the end 
of the bacillus in which it is developed, and thus is formed what is 
known as the "pin-head" or "drum-stick" bacillus. This organism 
grows best at a temperature of from 36° C. to that of the blood. Below 
14° C. it becomes inactive: at 42° C. to 43° C. it also becomes less active, 
and undergoes what are looked upon as degenerative changes, involu- 
tion forms being pretty constantly developed; and exposure to a tem- 
perature of from 60° C. to 65° C. rapidly kills off the bacillus, but does 
not destroy any spores that may have been formed. These spores are 
exceedingly resistant, even to moist heat, as they can withstand the 
action of water at a temperature of 80° C. even for an hour; whilst 
steam at a temperature of 100° C. does not appear to be fatal to them in 
a less time than five minutes. It is also stated that it requires fifteen 
hours of treatment with a 1 in 20 watery solution of carbolic acid, or 
three hours with a 1 per 1000 corrosive sublimate solution, to kill them. 
Protected from air and light the spore may retain its vitality for as long 
a period as twelve months, at the end of which time it still appears to be 
capable, under certain conditions, of developing into the vegetative form. 
The tetanus bacillus is anaerobic, and grows best in an atmosphere of 
hydrogen; it appears, however, to be almost as inactive in the presence 
of carbonic acid gas as in the presence of more than traces of oxygen. 
This bacillus is stained by Gram's method. The spores are best 
stained by leaving them for some time in a 10 per cent alcoholic solution 
of basic fuchsin, 10 parts, added to 100 parts of a 5 per cent watery 
solution of carbolic acid. The specimen may be left in this stain for 
about twelve hours ; or the same result may be obtained in two or three 
minutes if the solution be heated until steam rises from it. The bacilli 
give up the stain in 25 per cent solutions of mineral acids, but the 
spores retain it firmly. A contrast stain is obtained by placing the 
specimen for a couple of minutes in a watery solution of methylene blue. 
The tetanus bacillus has been found in garden earth, in dust from the 
streets, between the boards of the floors of rooms, and in the pus from 
certain suppurating wounds. It has also been met with in the excrement 
of animals, especially of the horse. Marches! found that samples of soil 
freshly gathered often give rise to mixed infections in which tetanus 
poison may not appear to play a part; but if to the same soils he added 
a 5 per cent solution of carbolic acid (which appears to kill most other 
organisms), he could usually demonstrate their tetanising power; other 
infections seldom or never occurring. By using this method he has 
been able to produce tetanus symptoms, not always at the first attempt 
but often on the second; and he points out that the absence of an infec- 
tion after the first inoculation does not necessarily show that a soil 762 
SYSTEM OF MEDICINE 
contains no tetanising organisms. He has found tetanus bacilli to a 
depth of two metres; but, below that, soils examined by him had not 
the power of inducing tetanus when inoculated subcutaneously. 
It always occurs, then, in these positions along with other organisms, 
and, from the fact that it grows anaerobically, it had, as we have seen, 
been known to exist for five years before any one succeeded in obtaining 
it in pure culture. Kitasato, however, at last overcame the difficulty 
by taking advantage of the fact that the spores of this organism are 
specially resistant to the influence of heat. Taking as his seed material 
some of the pus from the wound of a patient suffering from tetanus, he 
made cultures on the surface of agar-agar. At the end of a couple of 
days he found a number of organisms developed on the nutrient medium 
kept at the temperature of the body; and amongst these were charac- 
teristic tetanus bacilli. He then exposed some of the mixture for one 
hour to a temperature of 80° C.; from the material so treated he made 
fresh anaerobic cultures, and in a certain proportion of these he was 
able to obtain pure groups of the tetanus bacillus. It should be pointed 
out, however, that certain anaerobic bacilli, which may even be mistaken 
for the tetanus bacillus, except that they do not give rise to a similar 
poison, may form spores which are equally resistant to the action of 
heat. This admixture most frequently accompanies the tetanus organ- 
ism when it occurs in soil; but, as a rule, we are not met by the same 
difficulty when the cultures are made directly from purulent material 
derived from tetanus cases. 
The bacillus, as we have seen, grows best at the temperature of the 
body, and anaerobically. It certainly retains its virulence only so long 
as the free access of oxygen is interfered with; but it is stated that 
constant cultivation in an atmosphere of pure hydrogen also, to a certain 
extent, interferes with its virulence. 
It grows readily on any of the ordinary media to which an addition 
of 2 to 3 per cent of grape sugar is made, even when oxygen is present 
at the surface of the mass. In gelatine plates at the temperature of the 
room there are seen at the end of about four days small, slowly growing 
colonies with delicate marginal processes. Under the microscope each 
colony appears to have a dense centre whilst the margin is clearer, and 
radiating from the main mass are numerous exceedingly fine threads. 
In stab-cultures in gelatine, kept at a temperature of 21° or 22° C., a 
growth makes its appearance in the deeper part of the gelatine in the 
form of a fir-tree, situated some little distance from the upper surface 
of the medium, the gray, delicate, fluffy-looking branches getting longer 
and longer as the surface is left. At the end of the second week 
the gelatine begins to liquefy, and this liquefaction continues until the 
whole becomes a cloudy, sticky fluid. After a time the growth sinks to 
the bottom, leaving the upper part of the gelatine comparatively clear. 
There is a similar growth in grape sugar agar; but as this medium can 
be kept at the temperature of the body, the growth goes on much more 
rapidly, and is of course not accompanied by liquefaction. It is a dis- TETANUS 
763 
puted point whether gas bubbles are formed under these conditions or 
not. This appears to be entirely a question of the rate of formation of 
gas; if it is formed more rapidly than it can be diffused through the 
agar - as in the case of very energetic growth - bubbles may be seen; 
but this, in my experience, is comparatively rare, and the presence of 
gas bubbles affords strong evidence of the impurity of the culture. In 
grape sugar peptone bouillon the organisms grow luxuriantly, especially 
at the temperature of the body, and the fluid rapidly becomes cloudy; 
but after a lapse of six or seven days the upper layers of the fluid 
become clear, and a grayish white mass falls to the bottom of the tube. 
All these cultures have a peculiarly disagreeable aromatic odour. 
The Tetanus Bacillus is a Facultative Parasite.-It grows outside 
the body, and is especially associated with the stable and with manured 
fields. Sheep and cattle are often affected. The disease is most com- 
mon amongst agricultural labourers, gardeners, soldiers on campaign, in 
those who go about with bare feet, or who, like young children, are 
liable to get their knees or hands accidentally wounded by contact with 
the ground. It is somewhat important to remember these facts, as it 
has been found that the tetanus organism only retains its virulence 
under cultivation so long as it is grown under anaerobic conditions; 
especially is this the case where there has been no time for spores to 
develop themselves. Even the pus from wounds of a patient suffering 
from tetanus may no longer be capable of setting up tetanus infection, 
as the bacilli are often there placed under conditions unfavourable to 
the retention of their specific virulence. 
Inoculation. - This infective process maybe set up in the smaller 
animals by the insertion under the skin of minute particles of almost 
any cultivated garden earth ; by inoculation of pure anaerobic cultures 
of the tetanus bacillus; by the inoculation of a pure culture plus the 
tetanus poison, or plus lactic acid or bacillus prodigiosus; or by inocula- 
tion into a bruised wound. It is worthy of note, however, that the older 
the culture and the more poison there is present, the greater the cer- 
tainty that the disease will follow inoculation. It should be remembered 
that the tetanus bacillus forms its poison exceedingly slowly, and that 
the organisms themselves, if unaccompanied by any material which will, 
as it were, draw off the attention or paralyse the activity of the tissue 
cells, are rapidly destroyed by these cells - so rapidly, indeed, that they 
have no time to form sufficient poison to set up the nerve changes asso- 
ciated with the disease. Slowly as the poison is formed, however, it is 
tremendously active, as will readily be supposed when I say that the 
five-millionth part of a cubic centimetre of a filtered two to four weeks 
old slightly alkaline broth culture of the tetanus bacillus - that is, of a 
solution of the poison formed by these organisms - is sufficient when 
inoculated subcutaneously into a mouse to kill that animal in twenty- 
four hours. The Idthal dose for a rabbit is about a thousand times this 
quantity; for dogs five to ten thousand times; and for fowls and 
pigeons ten to twenty-five thousand times of an even stronger fluid. 764 
SYSTEM OF MEDICINE 
Tetanus may be produced in frogs, but only, it appears, when their tem- 
perature is maintained at a higher point than normal: the period of 
incubation usually extends over a period of two or three weeks. Un- 
like the poison produced by many other organisms, that of the tetanus 
bacillus seems to produce much the same results whether it be injected 
subcutaneously into the thorax or abdomen, or into the veins. This 
bacillus appears never to attack an animal from the alimentary canal. 
In experimentally produced tetanus the spasms are first observed in 
the muscles near the site of inoculation; but ultimately the process may 
become general. After intra-peritoneal and after intra-venous injection, 
however, there is usually a general infection from the commencement. 
In many cases the changes at the seat of inoculation may be so slight as 
to be overlooked unless carefully searched for. This point is of special 
importance as many cases of tetanus are said to be idiopathic; in these, 
however, it is probable that the initial local damage has escaped obser- 
vation. Even in experimental tetanus there is as a rule only slight 
infiltration at the seat of inoculation. This absence of local manifesta- 
tion significantly indicates also that the tissues at this point are incapa- 
ble of reacting, and that the poison has been rapidly absorbed from the 
point of introduction. It is only when mixed cultures are injected, or 
cultures mixed with other foreign bodies, such as pus, pieces of tissue 
from a wound, soil, etc., that a local suppuration takes place. 
The tetanus bacillus, or its spores, when introduced alone does not set 
up suppuration. Vaillard points out in connection with this class of case, 
that in one of his animal experiments, in which he had introduced spores 
under the skin, the wound healed immediately. For some time no 
symptoms of tetanus arose; but when later the wounded limb was irri- 
tated the spores became active and an attack of tetanus was the result. 
In those cases where tetanus is propagated in wounds treated antisepti- 
cally, it must be assumed that spores which have not been killed by the 
antiseptic agents have remained latent in the healing tissues for some 
time. Later they have developed into bacilli, have commenced the 
manufacture of their toxins, and so have induced an attack of tetanus. 
Vaillard and Rouget, along w'ith Vincent, state that spores of the 
tetanus bacillus from which all traces of poison have been removed by 
careful washing, when inoculated alone into an animal, are incapable of 
setting up tetanus. Klipstein, on the other hand, maintains that this 
washing of the spores injures them so seriously that they certainly lose 
a great part of their infective property, but that this infective power is 
never entirely lost. Vaillard and Rouget, however, are satisfied that 
their own observations are correct. It is certainly a fact that in many 
cases pure cultures of tetanus bacillus fail to set up a tetanic infection; 
but this may be due to the activity of the tissues, as equally well- 
marked failures may be observed in the infective agents of other 
diseases. 
Speaking generally, tetanus follows so distinctive and regular a 
course that it may be divided into three stages (Knud Faber) - (a) the TETANUS 
765 
incubation period, (b) the stage in which local spasms are developed, and 
(c) the stage in which ice have general tetanic convulsions. In certain of 
the smaller and very susceptible animals the incubation period extends 
over a comparatively short time, especially in the case of the experi- 
mentally produced disease. For instance, in mice inoculated with pure 
fluid cultures of the tetanus bacillus, the incubation period may be as 
short as five or six hours, though it may be as long as from twenty-four 
to forty-eight hours. When earth is used the incubation period is some- 
what longer, and is usually put down at from two to three days. In the 
guinea-pig the incubation period is slightly longer, being usually from 
one to two days. There is some difference of opinion as to the period 
of incubation in the rabbit. Knud Faber describes the incubation period 
in this animal as being from twenty-four to forty-eight hours; other 
observers place it at from eight to fourteen days. There can be no doubt 
that the period of incubation varies considerably in rabbits according to 
the dose administered and the size and age of the animal experimented 
upon. Trismus, which is a marked feature in the rabbit when the incu- 
bation period is short, is seldom observed in the mouse and the guinea- 
pig. After injection of very virulent cultures the general tetanic 
convulsions, as seen in the mouse, are never observed in the rabbit. 
A most important point observed by Knud Faber is that there is not 
a gradual transition from the local spasm into the general tetanic con- 
vulsions, but a sharp line of demarcation between the two; the general 
muscular spasm beginning as an entirely new phenomenon perfectly 
distinct from the local symptoms. The disease in the rabbit is spe- 
cially interesting, because in it the disease manifests itself much as it 
does in the human subject, both as regards the non-fatal form of the 
disease, in which merely local spasms are developed, and the malignant 
type, which begins with local spasms, and passes on to trismus and 
stiffening of the neck; when an intra-venous injection of the virus is 
made a general tetanic condition may be produced corresponding in 
almost every detail with that seen in the human subject. In the human 
subject the period of incubation is of course somewhat longer, from one 
to twenty-two days; in the frog, as we have seen, this period of incuba- 
tion is from one to two weeks. 
On examination it is found that the tetanus bacillus is localised 
entirely in the region of the seat of inoculation: it is never found in 
the blood or fluids of viscera, or in distant tissues; and no changes are 
demonstrable in the various organs. Hence the failure of earlier experi- 
menters to produce the disease by the injection of blood from tetanic 
patients. Tetanus, then, is essentially a toxic infective process, the 
poison being absorbed from the seat of inoculation, where it may have 
been originally introduced in sufficiently large quantities to bring about 
the characteristic tetanic symptoms in a very short time; or the tetanus 
organisms may there be so favourably situated that they can develop a 
sufficient quantity of their products to set up toxic symptoms : the bacilli 
are distinctly localised, but the poison may be widely diffused. Kitasato 766 
SYSTEM OF MEDICINE 
and Knud Faber, working independently, pointed out that the whole of 
the phenomena of a fatal attack of tetanus could be induced by the injec- 
tion of the poison quite apart from the bacilli by which it was formed. 
Kitasato inoculated mice at the root of the tail with cultures of the 
bacillus; and after a half, one, and one and a half hours respectively, 
he cut freely around the inoculation wound and carefully cauterised it, 
thus removing all the bacilli that he had introduced. He found, how- 
ever, that only the animals in which the parts were removed at the first 
of these intervals escaped an attack of tetanus; from which he argued 
that the poison formed by the bacilli is the essential factor of the disease 
in experimental tetanus, and not the bacilli themselves. Vaillard and 
Vincent, who repeated these experiments, obtained much the same results. 
Most cases of accidental traumatic tetanus differ materially from 
cases experimentally produced, in that other organisms and foreign 
bodies are frequently introduced with the specific bacillus ; suppuration 
is set up, and under these conditions this bacillus appears to have pecul- 
iar powers of developing its poison. It is sometimes held that the tetano- 
toxin is produced for a time only, and that the development of the 
bacillus is soon arrested, even in cases that ultimately succumb to the 
disease; but Boux and Vaillard maintain that this is not the case, and 
that before a case of tetanus can be treated with any degree of success 
the infective focus must be freely removed so that the supply of toxin 
may be cut short. So long as bacilli continue to multiply in the wound 
they are probably producing poison ; and therefore every attempt should 
be made to cut short their increase. The point of entrance of tetanus 
virus is usually a wound which may be at the outer surface; say, of the 
uterus shortly after childbirth, or in the severed cord of new-born chil- 
dren. Patients, as we have seen, are usually affected when working 
amongst horses, or when wounded while following agricultural pursuits. 
It is maintained, indeed, that the horse is the natural host of the tetanus 
bacillus, which is found in and spread with the dung of this animal. 
The tetanus poison resembles the enzymes in many respects; it is 
destroyed at a temperature of 65° C. in about five minutes: if kept 
at the temperature of the body for any length of time it gradually 
becomes weakened. When kept on ice, and protected from the action 
of light, it retains its poisonous properties, unchanged, for months. By 
the addition of 0-5 per cent carbolic acid, or of an equal volume of glyce- 
rine, it may likewise be preserved for some time. It is not affected by 
drying at ordinary temperatures ; but owing to its great instability in the 
presence of most of the ordinary chemical reagents, it is an exceedingly 
difficult matter to obtain this poison as a pure substance. Brieger first 
isolated three substances-tetanin, tetano-toxin, and spasmo-toxin - by 
means of which tetanic symptoms, and in some instances death, could be 
induced in animals; but these substances had to be given in doses of such 
enormous volume that it is evident that none of them can be the essential 
poison of tetanus which acts in the extremely minute doses described on 
p. 763. Kitasato and Weyl obtained two ptomaines, one very slightly TETANUS 
767 
toxic, which they named chlorhydrate of tetanin, the other a tetano- 
toxin compound which produced paralytic symptoms. Brieger and 
Frankel then described a proteid poison which they obtained from cultures 
of the tetanus bacillus, and named tox-albumin; they obtained it by 
saturating with alcohol the fluid in which the organism had grown, 
whereupon a precipitate having an extremely powerful action is thrown 
down. It was maintained, however, that this albuminous precipitate 
simply serves as a kind of network in which the essential toxic substance 
is entangled; and Knud Faber, Tizzoni and Cattani, and Vaillard and 
Vincent, affirmed that this poison is probably of the nature of a diastase. 
Brieger and Kitasato and Weyl then succeeded in obtaining an extremely 
virulent poison which does not give the reaction for albumins. It con- 
sists of yellow, transparent flakes readily soluble in water; it is not 
destroyed by drying, nor in the dried state by absolute alcohol, chloroform, 
or anhydrous ether; it is very readily decomposed by acids or alkalies, 
by sulphuretted hydrogen, and by high temperature: in these features 
it resembles tetanus poison in its original solution. Its toxic power is 
represented as being 500 times as great as that of atropin; and 120 to 
400 times as great as that of strychnine. Although so much knowledge 
of the physiological action of this substance has been obtained, very little 
light has been thrown on its chemical composition. Brieger and Cohn 
maintain that since tetanus bacilli have the power of producing the 
poison in non-albuminous media the poison must be looked upon as prob- 
ably non-proteid. It must be remembered in this connection, however, 
that the protoplasm of many bacteria has the power of building up pro- 
teid substances out of non-proteid foods. The virulence of the poison 
and the nature of its action upon animals both indicate that it belongs to 
the enzymes or diastases. 
Tetanus in man is accompanied by the same series of processes that 
have been induced in animals in experimental tetanus. As we have 
already seen, it occurs sometimes in patients suffering from suppurating 
wounds, such suppuration being the result of a mixed infection. In man 
as in animals it is found that the bacilli never pass from the immediate 
neighbourhood of the seat of the original lesion which, then, must be 
looked upon as merely the local manufactory of the poison. The toxic 
products of the tetanus bacillus can, however, be demonstrated in the blood 
of the general circulation; and in certain comparatively recent experi- 
ments tetanic symptoms have been induced in mice by injecting the serum 
of the blood from a tetanic patient: again toxic products have been 
obtained from the liver, spleen and spinal cord of patients who had 
succumbed to tetanus. These toxic products, obtained by throwing 
down an alcoholic precipitate and dissolving it in water, when injected 
into small animals have set up all the symptoms of tetanus. The 
tetanic poison appears to be excreted in the urine and also in the milk. 
Bacteriological Diagnosis. - A drop of the pus or other suspected 
material is inoculated into a subcutaneous pocket just above the root of 
the tail of a mouse; if the material contain tetanus bacilli the animal 768 
SYSTEM OF MEDICINE 
usually succumbs in the course of a few days. Or a small amount of pus 
taken from the seat of inoculation may be used for inoculating nutrient 
media to be treated by Kitasato's method. Or again the suspected 
material may be inoculated into bouillon which is incubated in an atmos- 
phere of hydrogen for three to live days; this broth, with the organisms 
growing in it, is then placed in a water bath kept at a temperature of 
80° C.: here it is left for one hour, after which a fresh anaerobic bouillon 
culture is made, and this process is repeated until pure cultures of the 
tetanus bacillus are obtained. 
Effect of Tetanic Poison on the Nervous System.-From the fact that 
muscular spasms are such a constant and striking feature in poisoning 
due to the action of the tetanus bacillus, and from the fact, too, that the 
dosage of the poison can be pretty accurately measured, and the living 
bacilli eliminated from the equation, much experimental work has been 
done on the etiology and pathology of tetanus; though many points 
still remain to be cleared up. As regards the pathogenesis of the disease, 
the earlier researches of Pasteur on rabies led those who were engaged 
on the investigations to suppose that tetanus is due to the presence 
and action of some virus which they assumed to be formed in the 
nervous system, especially in the spinal cord; and that the violent ner- 
vous symptoms were induced by the action of this virus. Knud Faber 
made a number of experiments on inoculation of the nervous centres 
with the tetanus virus: but, like the experiments of those whose work 
in this direction had preceded his own, they entirely failed; as did also 
his attempts to obtain any bacilli from the tissues of the central nervous 
system even in marked cases of tetanus. On this account he concluded 
that the virus could not be formed in the central nervous system, as it 
was evident that the poison could not be formed without the inter- 
vention of the tetanus bacilli. Following up Brieger's intoxication 
theory, Knud Faber was able to show that a pure culture of the 
tetanus bacillus produces during its growth a poison or group of 
poisons which, when separated entirely from the bacilli, is capable 
of setting up characteristic tetanic symptoms. This fact was not 
entirely new, but it is to Knud Faber that we owe the first observa- 
tion that the poison only acts after a certain period of incubation, 
this period depending upon the amount of the poison introduced. He 
also pointed out that it has many of the characteristics of the diastase or 
enzyme group, and that we should argue from this period of incubation 
that it must have time to set up certain fermentive or diastatic changes 
in the fluids or tissues of the body. He also showed that five minutes 
heating at a temperature of 65° C. is sufficient to destroy the activity of 
this poisonous substance; and, moreover, as was afterwards pointed out 
by Vaillard and Vincent, that the poison can be separated from a filtered 
fluid by the method used for separating diastase, that is, along with a 
precipitate from a solution of calcium hydrate by weak phosphoric acid. 
This is a very important matter in connection with the production of 
the toxin of tetanus. TETANUS 
769 
An important fact to be borne in mind is that when this poison is 
introduced into the subcutaneous tissues it sets up local spasmodic con- 
tractions; when injected intravenously general contractions occur at the 
very outset after the incubation period; the incubation period is, however, 
well marked in both cases. Now come the observations of Tizzoni and 
Vaillard, who cut through the nerves of a limb before inoculating the ani- 
mal with tetanus virus. This limb remained flaccid when all the rest of 
the muscles had been thrown into a state of spasm. Buschke, adopting a 
different method, curarised a tetanised frog, and found that tetanus was 
immediately cut short. It may, therefore, be concluded that the poison 
does not act directly either on the muscles themselves or on the peripheral 
nerves. He also found that the tetanic state still remains even after 
removal of the brain of the frog. Then again tetanus is not set up on 
the direct application of tetanus virus to the cortex of the cerebrum. On 
the other hand, progressive destruction of the spinal cord caused the 
tetanic symptoms to disappear from the part corresponding to the region 
of the spinal cord removed from the tetanised animal. Consequently the 
action of the poison seems to be localised in the spinal cord just as in 
the cases of strychnine and brucin poisoning pointed out by Simpson. 
Gumprecht, from a series of experiments on frogs - in one series of 
which he used strychnine, and in another filtered bouillon cultures of teta- 
nus bacilli - came to the conclusion that the general spasms produced by 
both substances must be referred to a toxic affection of the central nervous 
system causing increased reflex excitability of the spinal cord. The local 
tetanic spasms, although more difficult to explain, he considers also to be 
due to excitation of the nerve centres, this excitation taking place at a very 
early period after the introduction of a large dose of the poison, which, 
as pointed out by Behring and Vaillard and Vincent, may travel in an 
almost incredibly short space of time from the seat of inoculation through- 
out the body. Gumprecht maintains, too, that the local spasms around 
the point of inoculation do not arise reflexly by irritation of the peripheral 
ends of the sensory nerves; for when the whole of the sensory nerve roots 
of a limb were cut, and the limb completely anaesthetised, tetanic spasms 
still made their appearance. He also found that the motor terminal plates 
and the muscle itself were unaltered by the tetanus poison; as muscles 
tetanised for a long period still gave perfectly normal contraction curves, 
and there was complete absence of the reaction of degeneration from such 
muscles. Gumprecht considers that the local symptoms are most readily 
explained on the assumption that the poison travels along the nerves, 
and thus enters the spinal cord at certain definite points, corresponding, 
of course, to the point of inoculation, where it is more or less localised 
for some time after its arrival at the cord. In this way he explains the 
extension of the tetanic symptoms to those muscles which have their nerve- 
centres in the immediate neighbourhood of those of the nerves which pass 
from the site of inoculation; it is found also, and probably for the same 
reason, that the inoculated half of the body of the experimented animal 
is usually affected earlier and more profoundly than the opposite side. 
VOL. I 
3 D 770 
SYSTEM OF MEDICINE 
Goldscheider agrees with Gumprecht that after the subcutaneous 
injection of the tetanus bacillus, or tetanus poison, the outbreak of gen- 
eral tetanus is preceded by the contraction of those muscles which lie 
next to the region of inoculation; and he believes that this is due to the 
action of the tetanus poison on the central nerve cells, in consequence 
of which they assume an increased and ever increasing excitability, the 
change taking place gradually, but going on continuously so long as there 
is an absorption of the poison from the wound. He maintains, too, that 
the poison is conveyed to the nerve centres by the nerve trunks, and 
that it there acts on the ganglion cells, increasing their excitability and 
gradually covering a larger and larger area; but he believes that in addi- 
tion there is diffusion of the poison by means of the blood and lymph, to 
which the general spasms are to be attributed. An exceedingly inter- 
esting point is noted in connection with the resistance of fowls to the 
action of strychnine in which irritability of the central nervous system 
is such a marked feature; for it is found that the fowl has also a similar 
resistance to the action of the tetanus poison, large doses of which may 
be introduced subcutaneously with very slight effect indeed. A some- 
what similar explanation may be obtained from Brunner's observation, 
that spasms in the facial muscles are set up both by subcutaneous inocula- 
tion in the face, and by subdural inoculation in the opposite half of the 
brain. Kubler in a note on this observation points out that tetanus in man 
does not follow the course above described. In man local symptoms in 
the vicinity of the site of infection are seldom manifested; trismus is as a 
rule the first sign, the pharyngeal muscles are then affected, and gradually 
in turn the muscles of the trunk and the lower limbs. This criticism, 
however, does not appear to be very forcible. In cases of tetanus in the 
human being, except in those which run their course with exceeding 
rapidity, the formation and diffusion of the poisonous products of the teta- 
nus bacillus go on much more slowly than in animals under experiment; 
and it appears quite probable that, as diffusion takes place so slowly, a cer- 
tain time is required for the poison to accumulate to a degree sufficient 
to give rise to manifest symptoms of nervous irritation. If this be so, 
those muscles which are least under control, and which under emotion 
are most readily stimulated, would be first attacked, and this appears to 
be the order in which they are attacked in tetanus - those muscles, that 
is, are first attacked which are least under control of the will, and in 
which the inhibitory mechanism is least strongly developed. 
Following up Pasteur's and Salmon and Smith's experiments on the 
production of immunity, and on the antitoxic power of the serum of immu- 
nised animals in the treatment of a particular specific septicaemia, certain 
experiments were made on the establishment of immunity from tetanus. 
For a long time these experiments bore little fruit. At length Behring 
and Kitasato succeeded in producing a transient immunity in rabbits by 
inoculating them with the filtrate from a culture of the tetanus bacillus, 
and then injecting at the same point a small quantity-3 c.c. of a 1 per 
cent solution - of terchloride of iodine for five days at intervals of twenty- TETANUS 
771 
four hours. On injecting 0-2 c.c. of the blood of a rabbit so immunised 
into a mouse (an animal in which they had previously failed to obtain 
any immunity), the animal was found to have become protected to a 
certain extent against the disease when the virus was inoculated sub- 
cutaneously. This same treatment also proved efficacious when carried 
out after mice had already been infected with the tetanus bacillus, and 
even after symptoms had appeared after such infection. It was found, 
moreover, that as much as three hundred times the lethal dose of a 
virulent culture, if first mixed with a certain quantity of serum from 
an immunised animal, might be injected without producing any morbid 
symptoms. The following year Tizzoni and Cattani confirmed Behring 
and Kitasato's observations on the specific antitoxic power of blood 
serum taken from immunised animals. Roux and Vaillard obtained 
similar results by taking four to five weeks old bouillon cultures of the 
tetanus bacillus, passing them through a Chamberland filter to keep 
back the bodies of the bacilli, and then injecting them, mixed with 
weak iodine solution, using less and less iodine at each successive 
injection until, as the animals became more and more poison proof, 
considerable quantities of the unmixed fluids could be tolerated. Once 
attained, they found that this immunity may be easily kept up by 
fortnightly injections; but that if the animal be left untreated for a 
fortnight or three weeks the antitoxic power of the serum begins to 
diminish, though it may not be entirely lost for a very long time - 
say a couple of years. When tetanus poison is injected it is absorbed 
rapidly, and antitoxic substance almost as rapidly makes its appearance 
in the blood; Roux points out that thirty-five minutes after the injec- 
tion of toxin into the abdominal cavity of a rabbit antitoxin may be 
found in the blood drawn from the lateral vein of the ear. 
Tetanus was really the first disease of this class in which careful 
investigation led to results which, though comparatively unimportant in 
themselves, paved the way for the more important serum treatment of 
diphtheria. In tetanus there was a certainty of obtaining definite 
symptoms in animals in which the experimental infection succeeded; 
here also the toxic products of the bacillus could be readily separated, 
and the dose required to produce certain symptoms accurately deter- 
mined. Ehrlich, and Tizzoni and Cattani again, experimenting with the 
rat and rabbit and treating them with the blood serum of animals 
which had been rendered refractory to tetanus, maintained that they 
were always able to obtain a cure if the injections were commenced as 
soon as the slightest symptoms manifested themselves. When the local 
symptoms were established, or beginning to disappear, the results 
obtained by the serum treatment in their hands were slower and less 
certain; while in those cases in which tetanus was already becoming 
generalised success never followed this treatment. In the light of the 
somewhat unsuccessful use of antitoxic serum in tetanus in the human 
subject, it is interesting to find that the quantity of serum required for 
a successful result after local symptoms have commenced is at least one SYSTEM OF MEDICINE 
772 
or two thousand times greater than that required to confer an antece- 
dent immunity. This remarkable fact should be borne in mind in 
determining the efficacy of the antitoxic serum method of treatment. 
Further, it is calculated that a dose of serum at least 150 times as great 
as the above must be employed if any success is to be obtained when 
the local symptoms have reached their height. 
The curative action of the serum is said to depend entirely on 
the proportion of antitoxin which it contains, so that given the pro- 
portion of antitoxin in the serum the dose can be accurately calculated. 
Antitoxin is said by Roux and Vaillard to be an enzyme, which it 
resembles in many respects, but it differs in its comparative stability; it 
will stand even a temperature of 70° C. without undergoing any 
appreciable alteration. Tetanus antitoxin may be kept indefinitely by 
evaporating blood serum at low temperature in vacuo. At the moment 
of using it is dissolved in six times its weight of sterilised distilled water. 
Tizzoni and Cattani found that the antitoxic substance, when pre- 
cipitated from the serum by alcohol, does not lose its strength; they 
urge, therefore, that the alcoholic precipitate, which is non-dialysable, 
may be substituted for the serum itself. Assuming that the experiments 
made on the rabbit can be applied to man, they calculate that it would be 
necessary to give 0-7 c.c. of the serum, or 0-06 gramme of its alcoholic 
precipitate, at the outbreak of the first symptoms of tetanus; whilst at a 
more advanced period it might be necessary to inject 210 c.c. of serum, 
or 12 grammes of its precipitate. This is an exceedingly large quantity 
to inject subcutaneously, yet in medical practice even this quantity has 
failed to give satisfactory results. In fact, these observers were unable to 
obtain a much greater percentage of recoveries by this method than had 
previously been obtained in cases treated without serum. They were 
the first to differ from Behring who maintained that the antitoxin, or 
the antitoxic serum, directly destroys or antagonises the toxin formed 
by the tetanus bacillus ; they rather ascribe to it a power of enabling the 
tissue cells to continue their work in the presence of larger doses of 
poison. Roux and Vaillard also maintain that Behring's theory is un- 
tenable, namely, that each injection of toxin diminishes the immunising 
power of serum; and that, if too large or too frequent doses be injected, 
the antitoxic property of the blood may disappear for a space and the 
blood actually become toxic. Were the antitoxic serum merely a 
neutraliser of the toxin, the horse under these conditions should mani- 
fest the symptoms of tetanus. This, however, is not the case, and since 
the antitoxin has disappeared, the immunity of the animal must depend 
upon something else, a something which appears to be the habituation 
of the tissue cells to the presence of the toxin; the cells can go on 
doing their work under the gradually acquired new conditions, and no 
tetanus is set up. This result is best obtained by the injection (into a 
horse) of 200 or 300 c.c. of the toxin, after which dose the animal 
is ready to supply a sufficiently potent serum. 
Antitoxic serum confers an immunity which is perfect for a time, but TETANUS 
is more transient than the immunity brought about by the injection of 
toxins or of the specific organism (when it may last for as long a period 
as a couple of years). In most cases it is lost at the end of six or eight 
weeks. Immunity certainly continues as long as any antitoxin remains 
in the blood. As would be expected, therefore, the antitoxic property of 
blood disappears long before the immunity of the animal from the dis- 
ease is lost. This immunity can only be obtained with the toxins -when 
they are injected repeatedly and in large quantities. It must be remem- 
bered in this connection that the antitoxic substance is constantly being 
excreted by the kidneys, by the mammary, and probably by other glands; 
but a certain quantity undoubtedly remains for some time after the in- 
jections have been discontinued. Ehrlich believes that the hereditary 
transmission of immunity is due to the large quantities of antitoxin ex- 
creted in the milk: if this opinion be true the stability of the antitoxic 
substance is much greater than has generally been supposed. The prac- 
tical importance of this assertion should not escape observation. 
Although the antitoxin is so rapidly excreted by the glands, it has 
been observetl that repeated blood lettings, if they be carried on during 
a short period, do not seem to lower the antitoxic power of the serum. 
In man, as in animals, it is found that the shorter the incubation 
period - that is, the period intervening between the infection and the 
outbreak of the disease - the more severe the disease and the worse the 
prognosis. It is stated that of those cases where the incubation period 
is under ten days, not more than 3 to 4-5 per cent recover; when the 
incubation period is from eleven to fifteen days, 25 per cent recover; 
in those cases in which the incubation period is still longer, about half 
the patients attacked throw off the disease. Different authors give 
somewhat different statistics, but these are the general results. 
Dr. Kanthack, in a series of tables of the cases that have been 
treated with antitoxin serum, gives the duration of the incubation 
period, date of the disease when treatment was begun, quantity of serum 
injected, the result and the duration of the illness. It is gathered from 
these tables that the cases of cure all belong to the chronic or benign (?) 
form of tetanus; whilst those cases that ended fatally were invariably 
developed in less than fourteen days; in the majority of cases the dura- 
tion of the disease did not exceed four or five days. In these cases, too, 
the period of incubation was comparatively brief. These tables have 
been brought well up to date, and bring out the fact that, so far, the 
success obtained by the antitoxic serum treatment of tetanus is compara- 
tively slight, except in exceedingly chronic cases, where it appears to 
have been attended with a little more success than has been attained 
by the ordinary methods. 
Ehrlich's theory of immunity is based upon the fact that in an animal 
immune from a specific infective or toxic disease the tissues are poison 
proof; that is, the poison (the tetanus poison, in this instance) can no 
longer exercise upon the immune animal or its tissues any deleterious 
effects. As is well known, some animals are less susceptible to the 
773 774 
SYSTEM OF MEDICINE 
action of certain specific infective diseases than are others; and in the 
case of tetanus it has been found that comparatively insusceptible ani- 
mals- such as the dog and the fowl - may be rendered less and less 
susceptible, by the injection of gradually increasing doses of the specific 
poison. It is then found that their serum (although previously it had 
no antitoxic action when injected into another animal), and in cattle 
the milk, and in the fowl the yolk of the egg, have, as the result of this 
treatment, acquired considerable immunising power; and this serum 
(or these other substances) on being artificially introduced by injection 
into susceptible animals acts so rapidly upon their tissues that they in 
turn are rendered comparatively insusceptible. This power, as we have 
already seen, is extremely well marked if the serum be introduced at 
the same time or shortly after the tetanus poison; but its power of 
doing good diminishes more and more rapidly as the tetanus poison 
obtains a longer start. 
Susceptible animals, such as the mouse, rabbit, horse and sheep, may 
also be immunised; but in their case the process requires to be much 
more carefully carried on, and is necessarily much more tedious and pro- 
longed. Behring after long-continued experiment found that he was 
able to obtain the necessary immunity by injecting bouillon cultures of 
the tetanus bacillus, to which had been added a solution of iodine tri- 
chloride, first in the proportion of 0-25 per cent, then of 0-2 per cent, 
then of 0'15 per cent, until, finally, unaltered culture was used, first in 
small doses at intervals of three to five days, then in constantly increas- 
ing doses at intervals of eight days. In place of this method Vaillard 
has produced a similar immunity by injecting for a few days a filtrate 
previously heated to 60° C., then a series heated to 55° C., and finally to 
50° C. Gram's solution and lactic acid have both been also used for the 
purpose of attenuating the strength of the tetanus poison and the activ- 
ity of the bacilli. 
Behring has shown that mice which had been poisoned with fatal 
doses could be cured even after the appearance of the first tetanus 
symptoms, in some cases five hours after. The animals survived, but 
only after a prolonged illness; and if he allowed a period of twelve 
hours to intervene between the first appearance of the tetanus symptoms 
and the commencement of treatment, the cases almost invariably had 
a fatal termination. He worked this out so accurately that he found if 
the animal were treated before inoculation with the tetanus bacillus it 
required for its protection only one-hundredth part of the dose that 
was necessary if the treatment was not commenced until a quarter of 
an hour after infection. 
The immunising serum appears to have a special action on the same 
tissues as those attacked by the poison - probably on the ganglion cells 
of the central nervous system; and the substance first in the field, be it 
toxin or antitoxin, appears to work at a very great advantage over that 
subsequently introduced. It should be pointed out that even in those 
cases in which, through the use of large doses of antitoxic serum, the TETANUS 
775 
action of the toxin is brought to a standstill, these cells may, before the 
treatment commenced, have suffered very considerably; if so the recovery 
must necessarily be slow: in other cases the damage to the tissues may 
be so far advanced that recovery is impossible; for it must be borne in 
mind that the antitoxin can play no part in regenerating structures 
already destroyed or impaired. Its power appears to be, if used suffi- 
ciently early, to fortify the cells against the action of the poison, allowing 
them to carry on their work unchanged in the presence of what, under ordi- 
nary conditions, would lead to their complete disorganisation. It should 
be noted in this connection, too, that the symptoms of spasm and irrita- 
bility, for some short time after the exhibition of the dose of serum, are 
considerably increased; as though a contest for the mastery were actually 
taking place in the central nerve-cells. The more marked this feature 
the more prolonged is the process of recovery. It indicates, apparently, 
considerable disorganisation of the cells before the antitoxic serum has 
had time to act. German observers agree with Tizzoni and Cattani that, 
up to the present, no case treated by the antitoxic serum method has 
recovered which might not have recovered under ordinary treatment; 
none of them were so acute as to indicate a fatal prognosis. On the other 
hand this method does not give rise to any unfavourable conditions, so 
that in cases in which dirty wounds might contain the factors of tetanus, 
prophylactic doses of the tetanus antitoxin might be injected. 
While on this point, it may be well to indicate the difference between 
the results obtained by the antitoxic serum treatment in tetanus, and 
by the similar method of treatment in diphtheria. In both cases there 
is a manufactory of the poison on or near the surface of the body. 
In both cases there is an absorption of this poison into the body, and 
in both cases the nervous and muscular systems are specially attacked 
by the poison. But in the case of diphtheria our attention is called 
to the manufactory of the poison at a very early stage of the disease; 
for it usually occurs in some part of the throat, where it gives rise to 
considerable discomfort: moreover, from the nature of the tissues in 
this region a false membrane is usually formed at a very early stage of 
the disease. Attention is therefore drawn to the local poison manu- 
factory almost as soon as it begins to discharge its poisons into the 
system, and the serum may be utilised to antagonise the poison before 
it has had time to injure the nerves and muscles. It is interesting to 
note, tod, that in a large number of cases of diphtheria paralysis, the 
diphtheria has been said to be slight; that is, the local manifestations 
of the disease have not attracted attention, and the process has been 
allowed to go on so long that the poison, though perhaps small in 
amount, has been allowed to act for a considerable length of time, and 
thus to bring about paralysis. In tetanus, on the other hand, the local 
wound by which the poison is absorbed is for a long time looked upon 
merely as a wound, a suppurating one perhaps, but not a manufactory of 
the tetanus poison; consequently nothing is known of the tetanus until 
the poison has had time to exert its evil influence on the nervous system: 776 
SYSTEM OF MEDICINE 
now by the time we find out that the patient is suffering from tetanus 
this disease is so far advanced that any chance of treating it successfully 
by means of antitoxic serum is reduced to a minimum. 
German Sims Woodhead. 
Symptoms. - The chief symptom and feature of tetanus is the occur- 
rence, and recurrence at varying intervals, of spasms of greater or less 
severity in the voluntary muscles. These spasms are superadded to a 
state of persistent tension of the muscles which, however, like the 
spasms, is commonly relaxed during sleep. They sometimes commence 
in the neighbourhood of the wound and spread to other parts of the 
body. It was so in a case of gunshot wound of the thigh, in a case of 
wound in the perineum by a pitchfork, and in the case of a wound in the 
face by the lash of a whip, all of which I saw. In another case the spasms 
in the injured part (the thigh) continued after those in the rest of the body 
had ceased under the influence of chloroform. In all these the affection 
was severe, and proved fatal. In inoculated animals the earliest tetanic 
symptoms commence in the muscles adjacent to the wound, and, later, 
become general (6). But more commonly in man the tension and spasms 
are first observed in the neck, giving the sensation of ordinary stiff neck 
from cold. This is quickly followed by tension and spasms of the muscles 
of the jaw, causing more or less inability to open the mouth or protrude 
the tongue, the tip of which is pressed between the teeth in the attempt 
to show it; and the tongue is often wounded by the sudden closure and 
snapping together of the teeth. The effort to put out the tongue causes 
spasm of the facial muscles, giving that peculiar strained expression or 
grin designated the risus sardonicus. Often on asking a patient to show 
the tongue have I been startled by the unexpected manifestation of this 
fatal omen in cases of wounds which otherwise seemed to be doing 
well. Coincident with these early symptoms, or soon after, the front of 
the abdomen is felt to be firm or hard from contraction of the abdominal 
muscles. There may also be a sense of oppression or pain about the 
precordia, penetrating to the spine, which is attributed to tension of 
the diaphragm; though, it may be observed, the tension and spasm 
of the muscles in this stage are not commonly attended with pain. Soon 
the spasms extend to the other muscles of the trunk and to the muscles 
of the limbs, and, in some instances, are so severe as to cause rupture of 
their fibres; this event has occurred in the rectus abdominis and psoas 
magnus. Indeed, a case is quoted by Curling from Desportes in which 
both thigh-bones were broken by the force of the contracting muscles, 
and another in which the second cervical vertebra was dislocated. The 
spasms usually affect the voluntary muscles in all parts about equally, 
those of the fingers, however, least; and the pain attendant on them varies. 
I do not think the pain is generally so severe as commonly stated, and it 
rarely equals that attendant on common " cramp." In some cases it is 
sufficient to cause the patient to cry out, but often even boys do not 
give this or any indication of great suffering; the condition is rather TETANUS 
777 
that of forced and distressful straining, which is often very exhausting. 
When the spasm ceases the patient is worn out, subsides into quietude, 
and perhaps into sleep. The pain is chiefly felt along the back; and the 
dominating power, with perhaps more excited contraction, of the dorsal 
and lumbar muscles, as compared with the muscles in front of the body, 
causes some arching of the trunk backwards, to which the term of opistho- 
tonos has been given. I have not seen this condition in the marked form 
occasionally described, nor have I seen the bending in the opposite di- 
rection called emprosthotonos, nor that to one side called pleurosthotonos. 
The spasms arise spontaneously, sometimes waking the patient from 
sleep. They may be excited by any slight cause which disturbs the 
patient, and are often induced by the effort to swallow the viscid saliva 
which accumulates in the mouth, is pressed out between the lips and is a 
source of much distress. The muscles of the glottis are not uncommonly 
affected, causing noisy, difficult inspiration, or stopping of the breathing; 
and death may thus result. Not unfrequently, when the sufferer has 
become worn out, a severe spasm, compressing the thorax, suspending 
respiration, and embarrassing the heart's action, squeezes life out, as it 
were, and leaves no power to recover it. In acute cases death usually 
occurs about the third day. In less severe cases life may be prolonged for 
a fortnight or three weeks, or even more. These prolonged cases afford the 
best prospect of recovery. On the whole, the disease is most severe and 
most quickly fatal when it commences soon after the injury, and when 
the injury is most severe. The brain commonly shows no sign of being 
affected, the intellect remaining clear to the last, though delirium has 
ensued in a few cases. The pulse is quickened during the seizures, but 
in the intervals between them the pulse and the respiration may be 
natural in rate. The iris commonly responds to light, and variations 
which have been observed in the pupil - contraction or dilatation - were 
probably due to the drugs administered. The temperature varies, and 
commonly rises during the paroxysms. In a case, lately in Addenbrooke's, 
in which tetanus followed a wound in the perineum by a pitchfork, the 
temperature was 99-5° on the third day of the attack (the day of admis- 
sion), on the fourth day it was 100°, and on the fifth day, during a 
severe and prolonged spasm which terminated the case, it rose to 106-4°. 
In a lad, who recovered, the temperature was on several occasions 
104°-105o, and at these times the spasms were severe and frequent, and 
the breathing hurried. A similar remarkable or even greater rise of the 
thermometer (up to 110°) has been observed in other cases, and the 
high temperature probably contributed to bring life to an end. The 
thermometer has also been observed to rise after death. In some in- 
stances, however, where death has been preceded by a longer period of 
exhaustion, a fall of temperature has preceded the fatal event.1 In the 
1 The rise of temperature may be due to the increased muscular metabolism caused by 
the continuous and the spasmodic contractions, or to an excitation of the nerve heat- 
centres. This question is much discussed, and many examples given by Rose, " Ueber 
Starrkrampf," in the Handbuch der Chirurgie, von Pitha und Billroth, 1 Band, 11 Abtheil. 778 
SYSTEM OF MEDICINE 
case from a perineal wound just mentioned the catheter was required 
on the third day, though only seven ounces of urine were withdrawn. 
Subsequently the urine was passed voluntarily, though with pain. The 
amount of urine varies, in some cases it is more, in some less than nor- 
mal. It has been found to contain the tetanus toxin in considerable 
quantity, and injection of the urine into animals has induced fatal tetanus. 
This passage of toxin with the urine has given rise to the idea that an 
increase of diuresis might assist in the elimination of the poisonous 
material from the system; I am not aware, however, that the idea has 
been carried into practice. The presence of the toxin does not cause 
any increase in the quantity of urine secreted. The amount of toxin in 
the urine has been observed to diminish after the injection of antitoxin. 
As tetanus is not usually attended with fever, so the blood drawn 
does not present inflammatory characters. The appetite and digestion are 
good. The tongue is usually whitish and the perspiration excessive. In 
most instances there is marked and rapid wasting of the system and 
diminution of strength. This wasting and exhaustion, indeed-this rapid 
wearing out of the bodily powers - constitutes an important and grave 
feature in the malady, and one which directly or indirectly leads to the 
fatal result. It is proportionate to the acuteness of the attack, and seems 
to depend upon some deleterious influence of the toxic agent acting im- 
mediately upon the system. I say this because, though much increased 
by the recurring spasms, it goes on manifestly when these are mitigated 
or suspended. The spasms, in truth, are but a peripheral symptom of 
the disease, though they exert a depressing and exhausting influence 
upon the body. 
The involuntary muscles do not appear to participate with those of 
the voluntary system in the disturbances caused by tetanus. The bowels 
are commonly inactive, the muscles of the alimentary canal give no 
indication of spasms, and purgatives act as usual. The bladder and 
heart are in like manner free. Some observers, as Dr. Parry, attach 
much importance to the state of the heart, and think it to be the organ 
which first loses vital power; there seems no sufficient reason for this 
view. The pulse does but vary with the state of the patient, rising 
during the paroxysms, falling again when they subside, and becoming 
weaker as the general strength fails; death ensues from general failure 
of strength or violent general spasm rather than from any special failure 
or spasm of the heart. 
In a young man, a horse-dealer who lived on the other side of Ely, 
and was confined to his bed by a rather severe grazed wound of the leg, 
the first indication of tetanus was a shudder, or general spasm, caused 
by the removal of an adherent dressing. The affection thus ushered in 
ran on quickly to a fatal termination. 
Many cases of so-called spontaneous and idiopathic tetanus have been 
recorded in which no wound or other local lesion could be discovered. 
I remember such a one in a young man in St. Bartholomew's Hospital 
under Sir Wm. Lawrence. Aperients were given, and he recovered. TETANUS 
779 
The attack has in many instances been attributed to cold or damp. 
A healthy-looking man, aet. 54, was admitted into Addenbrooke's 
Hospital, 11th May 1856, with the usual symptoms of tetanus well 
marked. They had commenced four days previously, with stiffness 
in the neck and jaws, after exposure to steam and cold winds in his 
occupation of boiling bones. There was no apparent local lesion. The 
spasms were severe and general, and attended with difficulty of breathing, 
attributed in part to the firm closure of the lips. Still he was able to 
swallow in the intervals, though with some difficulty. Quinine, beef tea, 
and wine were given in considerable quantities and frequently. Though 
thinner and weaker he held on without change for a week. After this 
he grew worse. He could not sleep, yet morphia seemed to do him 
harm, causing increase of spasm. Chloral did better and gave some 
repose. On the 26th he began evidently to improve, and he finally 
recovered, though it was long before he was free from the stiffness in 
the back, neck, and jaws. 
The affection is said also to have occurred in cases of contusion, and 
in simple fractures and dislocations. The following case, of which Mr. 
Charles Lucas, of Burwell, has kindly sent me the particulars, appears to 
belong to this class. A stalwart man, set. 30, received a kick from a 
horse in the left thigh on 9th March 1883. On the 13th, when first seen 
by Mr. Lucas, there was a hard, brawny swelling, very tender and pain- 
ful, in the middle of the outer side of the thigh. No scratch or trace of 
wound was discoverable there or elsewhere. Fomentations and poultices 
were applied. In the night of the 24th his back and jaw became stiff, he 
was unable to open his mouth, and swallowing was difficult. Next day 
these symptoms had increased, and there were violent, painful spasms, 
with rigidity of the muscles of the face, neck, back, and abdomen; also 
pain about the region of the stomach, firm clenching of the jaws and com- 
plete inability to swallow, the attempt to do so bringing on severe spasms. 
A free incision into the swelling of the thigh gave vent to a large quantity 
of foetid greenish fluid, which was followed by almost immediate relief 
to the symptoms. On the following day, 26th, and on the 27th he could 
swallow gruel, and the stiffness and spasms had nearly subsided. On the 
28th there was a complete recurrence of all the tetanic trouble, and a 
cessation of the discharge from the wound. The symptoms again ceased 
when the wound was freely reopened, and did not recur. The man 
completely recovered, though the convalescence was slow. 
In this and similar cases it is possible that the tetanic symptoms 
may be due to reflex irritation of motor centres in the spinal cord by 
the local disturbance, rather than to any intermediate influence of 
bacilli or toxins acting through the blood. 
It is important to remark, with reference to the possibility of the 
occurrence of idiopathic tetanus, that the reported cases of this nature 
have in most instances been milder, and have more frequently recovered 
than the traumatic cases. Still, if the now prevailing view be correct 
that the disease is due to the introduction into the wound of certain 780 
SYSTEM OF MEDICINE 
special bacteria, there must be some lesion to admit of their entrance. 
This may be an ulcer in the mouth, the pharynx, the alimentary canal 
(8), or in some other undetected part. Possibly the proportion of re- 
coveries in the supposed idiopathic cases is attributable to the fact that 
the undetected local lesion is small in them, and the amount or virulence 
of the infection less. 
Diagnosis.-Tetanus may be distinguished from hydrophobia by 
the persistence of the muscular contraction in the intervals between 
the spasms, evinced by the closure of the jaws, by the hardness of the 
abdomen, also by the cause of the wound. In hydrophobia there is 
commonly more wildness of expression, more movement, more jerking of 
the limbs, greater apprehension of taking any fluid. Even the mere ap- 
proach of a drinking cup may throw the sufferer into violent spasms. 
There is a variety of tetanus, a sort of modification of trismus, described 
by German writers as kopftetanus, or head-tetanus, the special features of 
which are that it is caused by some injury to the face, and is attended 
with paralysis of the side of the face injured. I have seen the following 
examples of it: - (I.) A man, set. 35, in the Norwich Hospital in 1837, 
with a wound in the forehead caused by a fall from a cart, lacerating 
the occipito-frontalis but not exposing the bone. The symptoms began 
a week afterwards with stiffness of the neck and jaws, and paralysis of 
the right side of the face, the mouth being drawn to the left. These 
were followed by frequent severe spasms of the jaw and body muscles, 
more especially of the fore part of the body, the man bending forwards 
and clasping his knees with his hands, this being attended with much 
suffering and difficulty of breathing. There was no loss of consciousness. 
He died the day after his admission. The brain presented no morbid 
appearance. The spinal marrow and the lining membrane of the larynx 
were rather vascular. (II.) A man, set. 34, was kicked and wounded 
about the head and face, 19th December 1858. On the morning of the 
27th he could not open his mouth wide. On the following night he was 
troubled and kept awake by sudden closure of the jaws biting his tongue. 
This occurred each night and was a source of much pain. On the 4th 
of January he came into Addenbrooke's Hospital. There was a festering 
wound on the bridge of the nose and scars on the forehead; also imper- 
fect power of movement of both sides of the face, especially of the right 
side amounting to facial paralysis ; inability to open the mouth and pro- 
trude the tongue; tension of abdominal muscles; voice indistinct; when he 
tried to speak he put his finger into his mouth to prevent the lips, which 
were drawn to the left, being pressed between the teeth on the right side; 
difficulty in swallowing, partly owing to the difficulty in deglutition and 
partly to the fluid being returned between the lips. The introduction of 
a tube into the pharynx caused severe general spasm; enemata of beef- 
tea and port wine were therefore given twice daily. The choking and 
throat spasms caused by accumulation of phlegm in the fauces were much 
relieved by smoking tobacco. He gradually recovered, and the facial 
paralysis nearly or quite ceased. (HI.) A man, set. 42, was admitted into TETANUS 
781 
Addenbrooke's 21st March 1891, with a wound under the left eye by a 
kick from a horse. There was paralysis of that side of the face, with 
clenching of the jaws, abdominal tension, and laryngeal spasms. These 
last were so severe and almost asphyxiating during the night that tra- 
cheotomy was performed, with great relief. On the 23d he became quiet, 
but for some days coughing and choking was caused by milk and other 
fluids passing into the trachea and bronchi, and escaping through the 
wound in the throat. This gradually ceased and he got well. During 
the spasms which occurred under chloroform, and subsequently through 
the night, the back and limbs, as well as the right side of the face, 
were affected. (IV.) A strong, healthy man, get. 28, on 4th February 
1895, fell on to a heap of dirt, and cut the cheek just below the left eye- 
lid. The wound was cleaned, dressed, and united by sutures at the 
hospital. On the 6th it was again dressed and was doing fairly well. 
On the 10th he felt a little stiffness of the jaws. On the 11th the wound 
was again dressed, but the stiffness of the face did not attract much 
attention. On the 12th this symptom had increased. On the 13th he 
was admitted into the hospital. Milk was given, but he became less 
and less able to swallow it. On the morning of the 16th, when I first 
saw him, the affection had increased considerably. He was unable to 
open the mouth or protrude the tongue. The attempt to do so caused 
severe spasms of the face, neck, and back, inducing a certain amount of 
opisthotonos, also decided spasm of the front of the neck with blueness 
of the face. There was no hardness of the abdomen and no spasm of the 
limbs. Decided paralysis of the left side of the face, the mouth was 
drawn to the right, the eyelids could not be closed, and the left pupil 
was dilated. He had been able to swallow very little during the night. 
The case was evidently urgent. Antitoxin was telegraphed for; but 
before it arrived or other measures were taken he had a severe spasm, 
during which he became blue and died evidently from laryngeal stop- 
page of the breath. On post-mortem examination on the 18th no trace 
of disease was discovered. 
It will be observed that in all these cases, in addition to the wound 
of the face with paralysis, clenching of the jaws, and tension of the 
abdominal muscles, there was spasm or paralysis of the glottis which 
constituted the most urgent symptom. This was fatal in No. IV., prol>- 
ably also in No. I., and required tracheotomy in No. III.; in No. II. the 
pipe of tobacco seemed to give relief. The paralysis of the glottis permit- 
ting fluids to pass from the mouth into the respiratory passages was a very 
troublesome feature in No. III.; and in No. IV. the pupil was dilated. 
In I., II., and III. the muscular affection did not extend beyond the ab- 
domen, where it caused firmness of the abdominal wall; but in No. IV. 
the back muscles were affected, and the abdomen was soft. Tn all the 
limbs were free. The facial paralysis is difficult to explain. It has 
been attributed to swelling or some inflammatory or other influence 
radiating from the wound and involving the facial nerve, to inflamma- 
tion of the nerve in its course through the temporal bone or on the cranial 782 
SYSTEM OF MEDICINE 
side of that bone, but no satisfactory conclusion has been arrived at. In 
No. IV. the paralysis extended to the iris. There was no loss of con- 
sciousness or of sensation in the parts affected in any of the cases. 
Rose, in the article before mentioned, gives two similar cases, in one 
of them the affection extended to the limbs and the patient died ; in the 
other recovery took place. In the early part of last year a case of kopf- 
tetanus was related by Caretti. There was a lacerated, contused wound 
of the forehead, paralysis of the face on both sides, and trismus. The 
arrest of the malady was attributed to the use of antitoxin. Another 
case in which the cure was also attributed to antitoxin is there quoted. 
[See also 22.] 
The spasms of strychnia poisoning somewhat resemble those of 
tetanus; but they are more sudden and more rapid in sequence, affect- 
ing the whole frame, including the digits. The muscular relaxation in 
the intervals of the spasms is more complete. The affection is more 
quickly fatal, or on the other hand subsides; a speedy termination 
which contrasts with the somewhat slower course of tetanus, especially 
of those cases of tetanus in which there is no discoverable external 
lesion. Strychnia may be found in the urine. 
Tetany, so-called from its simulating tetanus, is a spasmodic affection 
resulting from an irritated condition of the nervous centres, either origi- 
nating there, or transmitted from some disorder of other parts, such as 
the stomach or bowels, the uterus, the urinary or genital organs. It 
appears to be less common in this country than in other regions. The 
spasms progress less steadily and recur less regularly than those of 
tetanus, and they are attended with less wear of the system. Often 
they are localised, and not unfrequently they are confined to the hands 
and feet; this is particularly the case in children, in whom the malady, 
often associated with rickets, easily yields to treatment, or subsides 
spontaneously. In some instances the spasms are more general, more 
severe, or more frequent, and they may lead even to a fatal termination. 
This has occurred in several cases after complete removal of the thyroid 
gland, and under these circumstances the diagnosis from tetanus might 
be difficult. One cause of tetany, at any rate, appears to be a deficiency 
in the secretion of the thyroid gland; and cases of its cure, either after 
removal of the gland or otherwise, by administration of the thyroid 
extract, were published last year by Dr. Byrom Bramwell (23). If this 
sequence be verified thyroid extract would serve as a ready means of 
diagnosis. Sudden and fatal attacks of tetany sometimes occur in cases 
of dilatation of the stomach. 
The following case, which I saw in consultation with Dr. Buckenham 
and Dr. Lawrence Humphry, the latter of whom has kindly given me 
the notes, may be regarded as an example of the severe form of tetany. 
A pale, thin, apxious looking lad, set. 13, sitting on a sofa with the 
head bent on to the chest, and rigidly fixed in that position; knees 
firmly extended, and rectus abdominis contracted, mapped into squares, 
and bending the body forward; upper limbs stiff, but not so fixed TETANUS 
783 
as the lower; muscles of back rigid, and sterno-mastoid and trapezius 
especially so; muscles of face not rigid; he could open his mouth and 
put out his tongue, which was much scarred; tenderness over fourth and 
fifth cervical vertebrae, which were rendered prominent by the bending 
of the neck; temperature 100°, pulse 90. Slight spasms during the day 
were easily brought on by movement, swallowing, or any irritation. At 
night these were severe, causing him to bite his tongue and cry out, and 
his respiration was then difficult; no loss of consciousness during the 
spasms, or at other times, and no fits. The affection began three weeks 
previously without apparent cause, with spasms of the jaw causing him 
to bite his tongue. The spasms extended and increased in severity. 
They continued in spite of various treatment, and he died in a month 
(seven weeks from the commencement of the attack) of exhaustion. 
A post-mortem examination could not be obtained. It was stated that 
he had a similar attack, not so severe, three years before, and recovered. 
Among the many features which hysteria and hystero-epilepsy occasion- 
ally assume are spasmodic or convulsive seizures; these may present some 
resemblance to tetanus, but can scarcely be mistaken for it. The sex, 
appearance, general character of the patient's constitution, and the char- 
acter of the seizures, are commonly sufficient to indicate the nature of the 
malady. The writhing, the distortion of features, the laughing or crying, 
the hallucinations, the more or less complete ansesthesia or paralysis of 
parts of the body, the affections of consciousness, most of which are due 
to influences acting on the cerebral hemispheres, are very unlike the 
manifestations of spinal excitement which we witness in tetanus. 
Treatment. - With regard to the treatment of tetanus it is necessary 
to bear in mind, firstly, that, like most other diseases caused by toxic 
agencies in the blood, it runs a definite course, having, as it were, a 
certain life-history - a period of incubation which varies from a few 
hours to several weeks, a period of increase, and a period of decline. 
These may not be defined or regular as to their time of occurrence or 
duration, but they clearly exist; and the severity and impression of the 
attack upon the system may be taken as proportionate to the amount 
and virulence of the admitted poison as compared with the resisting 
powers of the individual. Secondly, as already mentioned, the symptoms 
of tetanus are usually seen first in the muscles of the neck, jaws, and 
face. This early condition has been called trismus; and if the affec- 
tion go no further the patient commonly recovers. Thirdly, we have 
hitherto, that is to say till recently, known of no antidote or agency 
whereby the poison could be neutralised or its influence upon the sys- 
tem mitigated. Fourthly, our means of modifying the poison being very 
small, the contest lies between the strength of the attacking poison and 
the resisting strength of the tissues; and the treatment resolves itself 
mainly into the adoption of measures which may increase the latter 
and enable the patient to hold on till the malady runs its course and 
terminates by resolution. The alleviation of particular symptoms, such 
as the spasms, may do something to alleviate the distress, but little 784 
SYSTEM OF MEDICINE 
to modify the progress of the malady; and the drugs employed for the 
purpose have often done, on the whole, more harm than good. The only 
hopeful means of treatment has hitherto consisted in the endeavour to 
maintain the strength by the administration of nutriment - this being 
especially indicated by the wasting and exhausting influence which, as 
already mentioned, forms so prominent a feature of the disease. Un- 
fortunately, in most of the severe cases this cannot be efficiently carried 
out owing to the difficulty of swallowing; and the difficulty of giving 
enemata is often such that they cannot be continued, though in some 
cases they are well borne and should then be persevered with. When 
food cannot be swallowed recovery rarely takes place, and nothing can 
be relied on even to postpone the fatal event. A great variety of drugs, 
chiefly of the sedative kind, have been tried; some have been thought, 
in particular cases, to have done good, but no decidedly good results have 
been obtained. Even the relief from distress which may be produced 
by them does not seem in the severe cases to influence the progress 
of the malady materially, and the mild cases in which they have seemed 
beneficial would probably have recovered without them. Electricity, 
antipyrin, and cold baths have been used, as well as injections of car- 
bolic acid, phenol, and corrosive sublimate; but the cases in which benefit 
is reported have been of the mild type. In short, whenever the patient 
can be induced to swallow, the administration of nutriment should be 
regarded as the sheet anchor, and no medicinal treatment should be 
allowed to interfere with it. Unhappily, even in these milder cases 
it will often fail, but, saving the antitoxin method, we have no hopeful 
resource. The worst case in which I ever saw recovery was that of an 
infant from whom I had removed a large adipose or fibro-adipose tumour 
situated in the back of the neck. The spasms were frequent and so se- 
vere that, on several occasions, we thought the child was dead. She con- 
tinued, however, in the intervals to swallow milk. I did not allow any 
medicine to be given, but relied exclusively upon the milk. Gradually 
the spasms became weaker and less frequent, the malady ran its course, 
and the child recovered. I once went several miles to see a case of 
tetanus in a man, employed in the stables of a horsedealer, who had been 
accidentally shot in the back of the thigh by his master. I directed the 
administration of port wine, beef-tea, and eggs, as much as he could take, 
and prohibited all medicine. It was rather a severe case, but the man 
got well. I have had other cases treated in the same manner and with 
the like result. All, be it remarked, were able to swallow, though some 
with difficulty, and were therefore of the milder type. It is surprising 
how much nourishment can be taken and well borne in these cases, which 
indicates that there is no failure in the digestive and assimilative powers. 
In the earlier years of my practice I tried a variety of drugs very 
perseveringly, but without any appreciably good effect. In some in- 
stances I thought they had done harm • and I came to the conclusion, 
after many struggles with the disease, that I could not boast of any 
success even in prolonging life by these means. Most if not all of TETANUS 
785 
these drugs-such as morphia, aconite, Indian hemp, chloroform, chloral 
- were given with the view of lessening the spasms which, after all, as 
I have just said, are but a symptom of the disease; and I found, in 
some instances, that when the spasms had been delayed they recurred 
after the interval with the greater severity. In one case, where the 
wound was in the thigh, I kept the patient continuously under the influ- 
ence of chloroform for several hours. Then a violent spasm occurred 
and was fatal. In another case, that of a young gentleman who had 
received the charge of a gun in the buttock, and in whom the spasms 
were frequent and severe, at the request of himself and his friends, whom 
I warned that it would do no good, I kept up the influence of chloroform; 
and though the spasms were in great measure controlled by it, I thought 
that it rather shortened life. In yet another case a severe and nearly 
fatal spasm was induced by the administration of chloroform before 
amputation of the damaged leg. After the operation and the chloroform 
there was a temporary cessation of spasm, but the disease ran a fatal 
course. I may observe that the effect of chloroform varied much in 
different cases : in some, as in the case just mentioned, its administra- 
tion caused violent spasms; in others these did not occur. In some its 
administration was followed by a period of quietude and relief from all 
distress; in others the spasms seemed to be rather aggravated, and the 
patient was weaker, as though the chloroform left him more susceptible 
and less able to bear the attacks. I had some hope from tobacco given 
in the form of an enema; but it had to be used with much caution on 
account of its great depressing effect, and after several trials I was not 
convinced that it afforded any sufficient compensating advantage. One 
man smoked incessantly and got well, but it was not a severe case; in 
others the smoking did no good. Nicotine also proved of no avail. In 
so far as these sedatives have any initial action of stimulation of the 
ganglionic and other nerves they may indeed do harm. Chloral gives 
some relief and sleep, and perhaps enables the patient to swallow. In 
the case of the chronic ulcer of the leg I have mentioned - a woman 
set. 50 - the dyspnoea from closure of the glottis during the spasms was 
so urgent that I performed tracheotomy. It relieved that symptom, 
and the spasms, for a time, were less severe; but she became weaker, 
and died on the twenty-second day from the commencement of the 
attack. Opium and Indian hemp in large doses did no real good ; and 
the same, on the whole, has been the experience of others. The extract 
of Indian hemp, in one case that I saw, was found after death to have 
accumulated into a dangerous mass in the stomach, where it had not 
been digested or absorbed. I came, therefore, long ago, to the conclusion 
that the administration of nutriment was the only hopeful treatment; 
that where this could be done nothing should be allowed to interfere 
with it, and that where it could not be done it mattered little what 
measures were adopted, the result being almost invariably fatal. It 
need scarcely be added that the patient should be kept quiet and pro- 
tected from cold, and from all draughts and other external irritants. 
VOL. I 
O E 786 
SYSTEM OF MEDICINE 
The wound should be cleansed from all foreign substances, and 
freely soaked with antiseptic solutions. Removal of the limb by 
amputation, also division or stretching of the nerves connected with 
the wounded part, have been resorted to, but rarely with good result. 
The poison has already entered the system, and is working its evil way 
there; and as in the case of hydrophobia, and of primary syphilitic 
sores when the glands are affected, the further progress of the malady 
does not appear to be much influenced by the removal of the primary 
source of infection. Where a good result has followed, the same would 
probably have ensued had there been no surgical interference. Thus, 
in a lad set. 13, admitted into Addenbrooke's a fortnight after a contused 
wound of the fourth and fifth fingers, the fourth finger, which was in a 
foul state, was amputated under chloroform, a bad spasm occurring 
when he was being anaesthetised. The spasms were not very severe, 
the temperature never rose above 100°, and he took nourishment. 
Chloral hydrate and bromide of potassium were given; the spasms 
diminished in frequency and severity till April 16th, when the last 
occurred, and he got quite well. Gross (i. 633) relates that in a case 
of tetanus he dissected out from the face of a girl a tender cicatrix 
which had followed a lesion from a splinter of wood a month before 
the occurrence of tetanic symptoms; no further paroxysms occurred. 
On the other hand I have seen amputation of the leg in four cases in 
which tetanus ensued upon injuries to the foot, but without good effect 
in any. A more favourable view of the operation seems to be afforded 
by the Surgical History of the War of the Rebellion in America (vide 
Appendix), where it is stated that'the operation was resorted to in 
twenty-nine cases after incipient tetanic symptoms, with favourable re- 
sults in ten. It is not stated whether in these cases the disease was 
acute or chronic, though it would appear to have been acute in four out 
of the seven cases related. The observation that the bacillus germinates 
chiefly in the deeper parts of the wound, and disseminates itself in the 
surrounding tissues, renders free excision or amputation necessary if 
any local measure of this sort is attempted; and of no less importance 
for the prevention of tetanus is the free cleansing of the wound with 
antiseptic solutions in all cases if, as appears to be the fact, the bacilli 
have their seat and residence in and near the wound, where they gen- 
erate the toxin which enters the blood, and if their development and 
increase are favoured by the presence of pus. 
If by extraction of one or more teeth, or by the nostril, no way can 
be made for the passage of a tube, the operation of gastrostomy has been 
rendered comparatively so safe and simple by the modern appliances of 
surgery, that it might be resorted to in some of those cases of medium 
severity in which swallowing is difficult or cannot be accomplished. 
The requisite steps should be taken to open the stomach at once and 
introduce a tube through which nourishment may be passed with a free 
hand. I am not aware that this proceeding has been tried or even 
suggested; but I think it deserves consideration, and it might prove an TETANUS 
787 
assistant to the treatment with antitoxin by maintaining the strength 
during the days in which that remedy is being employed. 
For a new hope is dawning with regard to the treatment of this and 
of other affections, dependent like it upon a toxic infection of the blood; 
a hope based upon a method which is really antidotal, and consists in the 
introduction into the system of a material engendered by the poison or 
toxin, and called antitoxin. Should this hope be realised in the future 
application of the method, one which concerns not tetanus only but 
other kindred diseases also, we shall be able to boast of the most impor- 
tant discovery ever made in therapeutics, one of the most important 
ever made in medicine-perhaps the greatest and most beneficent medi- 
cal discovery of our generation. In what manner the antitoxin is pro- 
duced, whether by the toxin stimulating the cells or other tissues of the 
body to its formation, or by any change, such as an increased oxygena- 
tion, which the toxin itself undergoes, or from the disintegrating bodies 
of exhausted or dead bacteria, or by what other process, is not clearly 
known. It seems to act, like the toxin, as a ferment. Thus we have 
in the blood, at the same time, the two ferments - the poison and its 
antidote, the toxin and the antitoxin - the one leading to the production 
of the other; and also, somewhere within the surface, the bacteria which 
are the source of one or the other, of the poison and its antidote, or of 
both. In the case of diphtheria this therapeutic method is so far gradu- 
ally gaining ground. In tetanus it has not been tried in a sufficient 
number of severe cases to enable us even to come to a provisional 
conclusion; and some at least of the milder cases might have recovered 
equally well without it. The general opinion, however, seems to be 
that in many of the cases in which it has been tried it has so far 
afforded relief as to justify the hope that further experience will show, 
at any rate, that it has more potency in resisting and overcoming the 
malady than any other agent which has yet been tried (9). We read 
that in several cases of the milder kind where it has been tried the 
spasms have been mitigated, and the amount of toxin in the urine has 
been reduced; there seems to be no record of any acute case in which the 
antitoxin treatment was even of temporary benefit. It has been noted 
also that the symptoms have returned during the temporary suspension 
of the injections, to be mitigated again on their resumption. We read, 
too, that a large proportion of the recorded cases in which it has been 
used have recovered, though, as I have already said, these were chiefly 
of the milder type (10); it does not seem to have been productive of 
ill effects in any of the cases. In most cases the relief afforded by 
the antitoxin injections, if any, was soon manifested. In some there 
was a longer interval, the symptoms continuing unabated or even in- 
creasing at first, though they ultimately yielded to the influence. In two 
cases of li kopftetanus " referred to above the good results were attrib- 
uted to the use of antitoxin. These and other variations in the effects 
of the agent may not improbably have depended on variations in its 
strength and quality or on the method of its preparation. Respecting SYSTEM OF MEDICINE 
788 
all this there is much to be learned, and we must look for practical 
information concerning the antitoxin treatment of tetanus, in the main, 
to those countries in which the disease is more frequent than happily it 
is in our temperate regions. In our own country the cases are compara- 
tively few and sporadic, and they occur without any warning; there is 
nothing in the nature of the local lesion to give intimation of the prob- 
ability of so serious a complication. Hence the practitioner is probably 
not at once prepared with the means of giving trial to the antitoxin 
treatment. Happily the remedy is becoming less expensive and more 
easily procurable 'in an emergency. It may now be obtained from 
Messrs. Allen and Hanbury, in Plough Court, E.C., at a moderate cost, 
though as many as thirty injections or more may be required in the 
treatment of a single case. It must be used early; the cases, therefore, 
in which it can be tried with good hope of success are few, and some time 
must elapse before we can form a true estimate of its value. We should, 
at any rate, whether we resort to the new remedy or not, persist in the 
plan of treatment which I have indicated, and maintain the strength of 
the patient till the storm is overpast, in the hope that the vessel may be 
enabled to weather its blasts. 
When the disease subsides the spasms become less severe and less 
frequent, the face more natural, and the periods of sleep longer and less 
disturbed. For a considerable time after all spasms have subsided a 
sense of stiffness, as if from cold or rheumatism, is experienced in various 
parts; it is longest felt in the neck, back, and loins, and is liable to be 
increased by exposure to damp or cold, or by fatigue. It is in some 
cases felt about the jaws for months. Much care in diet and in the 
avoidance of cold should be enjoined, for instances have occurred in 
which the disease has returned after many days somewhat in the man- 
ner of relapsing fever. 
Morbid Anatomy. - The examination post-mortem in cases of tetanus 
has commonly revealed to the naked eye no trace of disease in any part 
of the body. Naturally, attention has been directed chiefly to the 
nervous system; but here, for the most part, whether in the brain, 
spinal cord, meninges, or nerves, nothing abnormal has been discovered. 
In a few cases, it is true, congestion has been observed in the spinal cord, 
or in its membranes, or in both, more particularly about the regions con- 
nected with the nerves of the injured part. This congestion has, in some 
instances, been attended with changes or degenerated conditions in the 
gray matter of the cord, and some swelling. Thus an instance is related 
by Dr. Dickinson (11), in which there was, in addition to the congestion 
of the dura mater and the pia mater, swelling of the cervical and lumbar 
portions of the cord caused by transparent exudation into the substance 
of the cord with consequent lesion of the substance. Lockhart Clarke 
and Clifford Allbutt also found swelling and areas of disintegration of the 
gray matter of the cord with exudation of finely granular matter and 
debris of blood and vessels. The nerves in the neighbourhood of the 
wound have also been found inflamed. These occasional appearances TETANUS 
789 
confirm the view, which on other grounds can scarcely be doubted, that 
the tetanus poison vents itself in an especial manner upon the spinal 
cord, causing functional disturbance; though it is usually attended 
with little or no gross structural lesion. This absence of actual nerve 
lesion formed an argument (12) against the supposition that the real, 
at any rate the primary seat of the disease was in the nervous system 
itself, and prepared us for or suggested the view, since confirmed by the 
bacteriological investigations, that blood-poisoning by noxious material 
introduced into the system must be the essential cause of the malady. 
The rigor mortis is said to persist long (13). As already stated, cer- 
tain muscles have been found ruptured, and even bones broken, by the 
force of the spasmodic contraction of the muscles. 
Infantile Tetanus (Tetanus neonatorum) 
Is commonly, and probably with reason, attributed to some infection 
taking place at the umbilicus. I have only seen one case: the child 
was stiff all over, persistently so, as far as I could judge, and did not 
live long. Escherich (14) has tried the antitoxin treatment in four of 
these cases, of which one recovered. In case 1 the doses administered 
were too small in quantity; in case 4 the disease was exceptionally 
severe, so that a good result could not be expected; in case 3 the injec- 
tions had to be discontinued in consequence of the onset of septic pneu- 
monia. Inoculation of mice from two of the cases (1 and 4) with a bit 
of tissue taken from near the umbilicus caused typical tetanus; but in 
the other cases the inoculation was without result. The disease is said 
to be common in some regions, especially in India, where antitoxin has 
been tried, at least in one case, but with no good result (15). 
APPENDIX 
History of War of Rebellion. - The fullest statistical record hitherto pub- 
lished is to be found in that marvellous compilation and evidence of American 
work, the Medical and Surgical History of the War of the Rebellion,Vimd surgical 
vol. p. 818. Of 246,712 injuries by weapons of war 505 (0-20) per cent, or a 
little over 2 in 1000, were followed by tetanus, which is regarded as not a large 
proportion. The seat of the injury and the result are tabulated as follows : - 
Seat of Injury. 
Total Cases. 
Recoveries. 
Deaths. 
Ratio of 
Mortality. 
Head, face, neck .... 
21 
1 
20 
95-2 
Trunk 
55 
5 
50 
90-9 
Upper extremity .... 
137 
18 
119 
86-8 
Lower extremity .... 
292 
30 
252 
89-7 
Aggregate 
505 
54 
451 
89-3 
" The belief that wounds of the foot and hand are particularly liable to 
cause tetanus is not confirmed by the cases recorded during the war." The 790 
SYSTEM OF MEDICINE 
rarity of tetanic complication of chest-wounds is noted; and in all but one of 
the 17 of these there were injuries to scapula, shoulder, or arm. 
In 131 instances tetanus followed closely upon operations in the extremities, 
namely, in 116 cases after amputations, and in 15 after excision. 
The recoveries were chiefly in the slighter or more chronic cases; and the 
later the occurrence of the disease after the injury the greater the chance of 
life. 
In 6 cases the disease occurred within twenty-four hours after the injury. 
Few on the second, third, and fourth days. From the fifth day the number 
rapidly increased until the eighth, when it diminished till the fourteenth day; 
after which it " appeared irregularly " - in one not till seven months after the 
injury. 
In 203, one more than one-half, the duration of the disease did not exceed 
three days; of these only two recovered. The longest duration of the fatal 
cases was twenty-seven days. 
In several instances the removal of the missiles or foreign bodies, or pieces 
of bone, seemed to have quieted the threatening symptoms. 
Amputation was resorted to in 29 instances after incipient tetanic symptoms; 
10 of the cases resulted favourably. This is very strong evidence in favour of 
the proceeding; but it is not stated whether the disease was acute or chronic. 
In 4 of the seven cases related it would appear to have been acute. Relief was 
afforded by the chloroform and continued after the operation. No anatomical 
lesions of the medulla oblongata cerebellum or spinal cord were found in the 
cases that were examined post-mortem. 
George Murray Humphry. 
REFERENCES 
1. Dr. Nicaise in International Enclyopsedia of Surgery, in. 607. - 2. Gross. Sys- 
tem of Surgery, i. 629. - 3. Le Gros Clark. Diagnosis of Visceral Lesions, p. 176.- 
4. British Medical Journal, Oct. 21, 1892, Epitome, No. 352.-5. Quain's Dictionary 
of Medicine, 1894, ii. 104.-6. Ibid. p. 99.-7. Dr. Parry. Cases of Tetanus and 
Hydrophobia. - 8. Brit. Med. Journal, March 5, 1892; Epitome, No. 199.-9. Ibid. 
Sept. 15, 1894. -10. Dr. John Marriott of Northampton. Brit. Med. Journal, June 
19, 1895. -11. Medico-Chirurg. Trans, vol. xli.-12. Bowlby in St. Bartholomew's 
Hospital Reports, xix. -13. Curling, p. 77. -14. Escherich. Brit. Med. Journal, 
Sept. 23, 1893; Epitome, No. 253. -15. Ibid. Jan. 19, 1895. -16. Lockhart Clarke. 
Medico-Chirurg. Trans. 1865. -17. Clifford Allbutt. Path. Trans. 1871.- 
18. Leyden. Virch. Arch. 1863. -19. Coats. Medico-Chirurg. Trans. 1878. - 20. 
Poland and Hulke. Holmes' System of Surgery, 1882. -21. Rose. Pitha u. Billroth 
Handbuch der Chirurgie, §63.-22. Caretti. Brit. Med. Journal, Epitome, March 
16, 1895.-23. Bramwell. Brit. Med. Journal, June 22, 1895. - 24. Trevelyan. 
Brit. Med. Journal, Feb. 8, 1896. 
G. M. H. 
1. Behring. Das Tetanusheilserum, Leipzig, 1892; see also his Infection und 
Disinfection, 1894; and Berlin, klin. Wochenschr. No. 4, 1893.-2. Behring and 
Kitasato. Deutsch, med. Wochenschr. No. 49, Dec. 1890.-3. Brieger and Cohn. 
Cf. Centralbl. f. Bakteriologie u. Parasitenkunde, Bd. xiv. 1893, p. 711, and Bd. xv. 
1894, p. 442.-4. Brunner. Deutsch, med. Wochenschr. No. 5, 1894. First paper pub- 
lished in 1892. - 5. Buschke and Oergel. Deutsch, med. Wochenschr. 16th Feb. 1893. 
Nachtrag von Dr. Buschke.-6. Carle and Rattone. Giornale della R. Academia di 
Medicina di Torino, vol. xlvii. March 1884.-7. Goldscheider. Zeitschrift f. klin. 
Med. Bd. xxvi. 1894. - 8. Gumprecht. Deutsch, med. Wochenschr. No. 26, 1894.-9. 
Kanthack. The Medical Chronicle, May 1895. -10. Kitasato. Zeitschrift f. Hygiene, 
Bd. vi. Nov. 1889; also Congress of Hygiene, London, 1892; and Zeitschrift f. Hygiene, DISEASE. 
Enteric Fever 
with 3 re/a pses. 
Notes oF Case. 
, Jane 8~ 
damej 
dye - 17 
Diet 
Case Book Nf 
Reported bylFf Johnson 
Med. Chronicle 
(VolX/V. p.t02). 
O O 
Indicates dates on which 
rose spots ware noticed. 
Date of admission 
Oct. 26. 1830 
desalt -Recovery. 
Dreschfe/d's Enteric Fever, System of Medicine, Va/E To face p. Z9i ENTERIC FEVER 
791 
Aug. 1892. -11. Kitasato and Weyl. Zeitschrift f. Hygiene, Bd. viii. 1890, p. 41.- 
12. Klipstein. Hygien. Rundschau, Jan. 1893. -13. Knud Faber. Om Tetanus som 
Infektionssygdom. Dissert. Copenhagen, 1890. Also " Die Pathogenese des Tetanus," 
Berliner kiln. Wochenschr. 1890, No. 31. -14. Kubler. Centralbl. f. Bakt. u. Parasi- 
tenkunde, Bd. xvi. 1894, p. 838. -15. Marchesi. Annali dell' 1st. d'igiene Sperim. 
d. R. Univ, di Roma, vol. ii. fase. i. 1892, pp. 47-61.-16. Nicolaier. Beitrage 
zur ^Etiologie des Wundstarrkrampfes. Dissert. Gottingen, 1885.-17. Bosenbach. 
Langenbeck's Archiv, xxxiv. 1886. -18. Roux and Vaillard. Annales de I'Institut 
Pasteur, No. 2, Feb. 1893. -19. Simpson. Edinburgh Monthly Journal of Medical 
Science, Feb. 1854, p. 97. - 20. Tizzoni and Cattanl La Riforma Medica; and 
Centralbl. f. Bakteriologie u. Parasitenk. from 1890 onwards; also Deutsch, med. 
Wochenschr. No. 6, 1894; and Berliner klin. Wochenschr. Nos. 49-52, Dec. 1893, 
and Nos. 3 and 32, 1894. - 21. Vaillard and Rouget. Annales de I'Institut Pas- 
teur, t. vi. 1892, t. vii. 1893, p. 755. - 22. Vaillard and Vincent. Annales de I'Institut 
Pasteur, t. v. 1892. - 23. Worthington, G. V. Digest of Sixty-eight Cases of Tetanus. 
Thesis for M.B. degree. Camb. 1895. 
G. S. W. 
ENTERIC FEVER 
Synonyms. - Gastric Fever, Typhoid Fever, Pythogenic Fever; Fr. 
Dothten enterite, Figure typhoide; Germ. Abdominaltyphus, Nervenfiebre. 
Definition. - An acute infectious fever, due to a specific micro-organ- 
ism, occurring endemically, sometimes epidemically; clinically charac- 
terised in ordinary cases by a gradual onset, followed by a period of 
continuous fever with diarrhoea, an enlarged spleen, tympanites, and a 
roseolar rash, usually lasting three weeks; anatomically characterised 
by more or less extensive ulcerations affecting the Peyer's patches in the 
ileum, with swelling of the mesenteric glands and enlargement of the 
spleen. 
History. -Enteric fever appears to have been known to the ancient 
writers (for example, Hippocrates and Galen); but it was not until the 
beginning of this century that it was distinguished from other acute 
febrile affections, especially from typhus. 
In Germany Von Hildsbrandt (1810) clearly distinguished these 
two affections; in France Bretonneau (1818) proposed the name of 
dothienenterite, to denote the specific nature of its intestinal lesion; 
whilst in England, after some older writers, the observations of Perry 
(1836), Barlow (1840), Stewart (1840), and especially the classical pa- 
pers published by Sir Wm. Jenner (1849-53), led to the final distinc- 
tion between the two diseases, which ever since has been universally 
recognised. Enteric fever having then been recognised as a specific 
fever, its etiology was made the subject of further investigation. Its 
infectious nature, and its propagation by the faecal discharges of the 
patient, led many physicians, headed by Budd, to look upon it as due 
to one specific agent, and to deny its origin de novo. 
The advances made in sanitary science, the establishment of special 
sanitary medical officers, and the interest with which all matters relating 
to public health were considered by corporate bodies, a movement in 
which England took a prominent part, led on to investigations into the SYSTEM OF MEDICINE 
792 
cause or causes of enteric fever; and though the agent was not discov- 
ered, yet the source of the propagation and dissemination of outbreaks 
were carefully studied, and many of them were traced to contaminated 
water or milk and to " sewer gas." This led to the improvements in 
drainage and water-supply of many English towns, with the result of a 
marked diminution in the prevalence of enteric fever, and of an almost 
total extinction of typhus (see Table I., Appendix). With the develop- 
ment of bacteriology the history of typhoid fever entered upon a 
new stage. 
Murchison, whose classical writings on the continued fevers of 
England still maintain a prominent place in the literature of enteric 
fever, believed in the origin of enteric fever from decomposing organic 
material, and also in its spontaneous origin. The observations of Stich 
and later of Panum, which showed that the ingestion of putrid material 
may produce, amongst other symptoms, fever, diarrhoea, and intestinal 
lesions, not only supported this opinion, but gave rise to that of the 
autogenetic origin of enteric fever, namely, that the disease may be 
generated in the system from decomposition of faeces in the intestinal 
canal without any infection from outside. 
Eberth (1880) discovered a peculiar bacillus in the organs of persons 
who had died of enteric fever, and subsequent investigations not only con- 
firmed this observer, but placed the pathogenetic nature of this organism, 
and with it the etiology of enteric fever, on a firm basis; thus the pytho- 
genetic theory of Murchison and the autogenetic theory of other observers 
became untenable. The discovery, however, of another micro-organism 
- the bacterium coli commune - which occurs in the normal human 
body, and apparently elsewhere also, which is seen in increased numbers 
in persons affected with enteric fever, and in many of its characters and 
properties resembles the bacillus of typhoid fever, has led authors to 
review the older theories: some, like Roux and Rodet, believe that the 
bacterium coli commune may be converted, under suitable circumstances, 
into the typhoid bacillus; others, like Peter (68), hold that in typhoid 
fever we have simply an intoxication of the human body by the retention 
of substances elaborated by it. The majority of pathologists and clini- 
cians, however, firmly believe in the specific nature of enteric fever, as 
thus only is its infectious nature explained - though, on the other hand, 
the mode and source of infection in many cases are difficult to prove. 
In sketching the history of enteric fever the progress in the treat- 
ment of the disease must not be forgotten. Whilst depletion and 
starvation were for a long time the guiding principles in the treatment 
of fever, the liberal use of stimulants was advocated chiefly by English 
physicians (Alison, Graves, Todd, and Stokes); but in the course of time 
their administration was again restricted, and used only on definite in- 
dications. The antipyretic treatment by the cold bath, however, first 
recommended by Currie (1787) and resuscitated by Brandt (1861), is 
said to have diminished considerably the mortality from enteric fever, 
and is now widely adopted. The various antipyretic drugs and their ENTERIC FEVER 
application in febrile diseases have scarcely displaced the cold water 
treatment. With the discovery of the typhoid bacillus new methods of 
treatment have been tried: the antiseptic treatment proposed by Bou- 
chard (though antiseptic drugs had been given long before in enteric 
fever), and subsequently adopted in various forms by many English and 
continental observers; and more recently a quasi-specitic treatment, con- 
sistingin the subcutaneous injection of sterilised cultures of typhoid bacilli 
have been tried, but the latter method is yet in the experimental stage. 
Geographical Distribution. - Enteric fever prevails all over the globe. 
It is endemic in Great Britain, but is less common in Scotland than in 
England or Ireland; its frequency in the British Islands has, however, 
considerably diminished during the last ten to fifteen years, owing to 
better sanitary arrangements. It is met with throughout the whole of 
Europe; it is widely distributed throughout the whole of the United 
States and Canada; it is met with in India, Africa (Egypt, Tunis), and 
in Central and South America. 
Etiology. - The specific cause of enteric fever is the bacillus of typhoid, 
or Eberth's bacillus. This organism was first described by Eberth (22), who 
found it in sections of the mesenteric glands and of the spleen of persons 
who had died of enteric fever. Koch about the same time gave photographs 
of the same organisms present in the tissues, and Coats of Glasgow also 
described and figured them. Gaffky prepared pure cultivations of the 
bacillus, and described some of its chief morphological properties. Since 
then numerous observations have been made on the morphology, life 
history, distinctive characters, and pathogenetic nature of this organism; 
the more important of these features will be described in the following 
account, in the working out of which I have been greatly assisted by 
Mr. James Richmond, who for many months has studied the bacteriology 
of enteric fever in the pathological laboratory of the Owens College, and 
has tested the statements of other observers by his own investigations. 
Character and Biology of the Typhoid Bacillus. - The appearance of 
the bacillus may be studied from sections, from juices and scrapings of 
the organs, and from pure cultures. 
The typhoid bacillus may be seen in sections prepared in the usual 
way, stained for twenty-four hours in Loeffler's alkaline methylene blue 
solution, or in Ziehl's carbolic fuchsin, and washed subsequently in water 
so as to wash the dye, if possible, from all that appears in the sections 
except from the bacteria and the tissue nuclei; they are then dehydrated 
in aniline oil: if now washed in alcohol, or treated by Gram's method, the 
colour is removed from the bacteria, but if the section be placed for ten 
minutes in a one-fifth per cent solution of mercury dichloride, and then 
stained by Gram's method, the bacilli take the stain deeply [Woodhead]. 
In preparations made from the juices of the organs or from cultures on 
cover-glasses, watery solutions of any of the aniline dyes, especially 
fuchsin or Ziehl's carbolic fuchsin, may be used as stains; in the latter 
case a much shorter action of the stain is necessary. The cover-glass is 
rinsed in water, dried, and mounted in xylol balsam. Washing with 
793 794 
SYSTEM OF MEDICINE 
alcohol or the use of Gram's method removes the stain entirely. They 
often stain at the ends, leaving, with the watery dyes, a bright unstained 
portion in the centre. 
The typhoid bacillus is a short, thickish bacillus - 2-3 p. long, and 
0-7-0'9 p. in breadth - having rounded ends; cultivations outside the 
body often grow in threads composed of bacilli strung end to end; 
in sections the bacilli are single. In drop cultivations they have very 
lively motions of progression; the longer threads have a slower sinuous 
motion. When stained by Loeffler's method (60), or one of its modifica- 
tions, they are seen to be provided with a number of (8-12) fine wavy 
flagella having a length twice that of the bacillus. These are inserted 
at the sides as well as into the ends of the bacillus. 
The bacillus grows in the ordinary nutritive media. Its growth 
is favoured by the presence of oxygen and a temperature of 25°-35°, 
although growth can go on in the absence of oxygen (Liborius and 
Roux) and at lower temperatures. 
In plate cultures, on nutrient gelatine, the youngest colonies seen 
under a low power are round or oval, and of a yellowish colour and 
sharp outline. The older, deeper colonies are darker, with regular 
borders and fine irregular linear markings. The superficial colonies 
grow quickly into an expansion, which may attain to a diameter of 
3-4 mm., having a notched border, a grayish white colour, and a fur- 
rowed and wrinkled iridescent surface. The gelatine is not liquefied. 
Gelatine stab cultures show the same appearance of the superficial 
and deep growths. 
On agar there is a superficial white growth. 
On solidified blood serum a white superficial growth occurs, without 
liquefaction of the serum. 
On ordinary potato the growth is scarcely to be distinguished in forty- 
eight hours, only a moist appearance being noticeable. The area of 
inoculation when touched with the platinum needle has a feeling of 
greater resistance than the uninoculated part, and typhoid bacilli are 
found in the part which offers this resistance to the needle. 
On alkalised potato older cultures have a dirty yellow appearance, and 
cultures of typhoid recently isolated from fgeces give a thicker, more 
pulpy growth. The other characters are given in tabular form below. 
The bright unstained parts, once supposed to be spores, are known 
now to be due to retraction of the protoplasm to the poles of the cells 
where it takes on the stain. This retraction is a sign of degeneration, due 
to unsuitability of the medium, either from exhaustion of the nutriment, 
or from an unsuitable reaction (acidity). So far from these forms being 
spores they are on the contrary more easily killed by heat, drying, and 
bactericidal substances than bacilli which stain uniformly. 
Vitality of Typhoid Bacilli-Influence of Temperature.-The bacilli are 
killed when exposed to temperatures of 60° C. for twenty minutes (Pfuhl), 
but in this respect the various cultures show a somewhat different be- 
haviour; low temperatures do not readily destroy the vitality of the ENTERIC FEVER 
795 
bacillus, and several observers (Chantemesse, Widal, Janowsky, Prudden) 
have seen cultures of bacilli in beef-tea live for weeks, although re- 
peatedly exposed to a freezing temperature. 
By cultivation it has been found that in sterilised stools and in stools 
which have stood for some time the bacilli may remain alive for months; 
in fresh typhoid stools and in normal stools they die much sooner. In 
threads soaked in cultures they remained alive one year; on potato 
cultures two years; in sterilised garden soil twenty-one days; on 
sterilised linen sixty to seventy days; in street sweepings thirty days. 
When dried in various ways by more or less active agents their duration 
of life was from one to sixty-four days; free access of air shortens the 
duration. Hydrochloric acid of the strength in which it occurs in the 
normal gastric juice does not destroy their vitality till it has been in 
contact with the cultures for several hours. 
Action of Antiseptics. - Seitz found that quinine, chlorate of potash, 
salicylic acid, and calomel destroyed the life of the typhoid bacilli. Dr. 
A. C. Latham experimented with calomel, chalk and mercury, ft naphthol 
and bismuth, and found that all, except bismuth, killed the typhoid 
bacillus. 
Carbolic acid (2-3 per cent solution), and corrosive sublimate (1 in 
5000) also quickly destroy the typhoid bacilli. From a prophylactic 
point of view the observations of Liborius, confirmed by Richard and 
Chantemesse, are important. According to the latter observers 4 parts 
of slaked lime (milk of lime) in a 1000 of water destroys the bacilli in 
typhoid stools in less than half an hour; the same result could not be 
obtained with chloride of lime (1 to 1000) or corrosive sublimate (1 in 
50,000). 
In the sunlight they are killed more rapidly. Cultures in a 
dish exposed to sunlight were killed in one to seven days ; in sterilised 
water exposed to sunlight they were killed in an hour. It has been 
shown that this action is due principally to the chemical rays: all the 
rays have this bactericidal action, but the rays having the smaller wave 
lengths have the greater effect. In sterilised distilled water few have 
been found alive in twenty days after their immersion. 
In sterilised river water they disappear in forty-three to eighty-one 
days. In ordinary well water or river water they rapidly diminish in 
numbers, whilst the water bacteria at first increase and then diminish. 
Few typhoid bacilli were seen in one case on the thirtieth day; in another 
none were seen on the fourteenth day. In some cases it was found that 
whilst living typhoid bacilli had disappeared from the liquid they were 
still to be found in the sediment at the bottom of the vessel. In distilled 
sterilised water the bacilli show signs of degenerative changes, the proto- 
plasm gradually losing susceptibility to stains, and the organism becom- 
ing thicker and plumper, more oval in shape (Curt Braem.). They 
have been found alive after 196 days. The typhoid bacilli can also 
grow in milk, and live on various food stuffs, as in butter, where they 
have been found alive a week after the date of inoculation. 796 
SYSTEM OF MEDICINE 
Poison. - In old peptone cultures Brieger by his method found that 
a poison is present which produces in guinea-pigs quickening of the 
respirations and increased glandular secretions ; the limbs are weakened 
and the animal lies down, the pupils become dilated, the respiration 
becomes feebler, diarrhoea comes on, and death occurs in twenty-four 
hours from the beginning. The poison causing these symptoms is a 
diamine, having a provisional formula C7H17NO2. It is not always 
found in the cultivation of the typhoid bacillus. To compare with this 
Luff isolated from the urine of typhoid patients a ptomaine, the reac- 
tions of which are given in a tabular form alongside those of the 
ptomaine isolated from the cultures of the bacilli (9a). 
Ptomaine from Typhoid Urine (Luff) (61). Ptomaine from Cultures, on Meat Peptone, of 
Solutions gave 
With phospho-molybdic 
acid 
Phospho-tungstic acid 
Iodine solution 
Tannic acid solution 
Chloride of gold 
Picric acid 
Chloride of gold and 
picric acid 
Platinum chloride 
A white precipitate 
Nil 
Brown precipitate 
Yellowish brown precipi- 
tate 
Dense yellow precipitate 
Dense yellow precipitate 
Nil 
A white precipitate 
Nil 
Deep brown precipitate 
Deep yellow precipitate 
Gold salt soluble 
Not stated (in the refer- 
ence) 
Yellow precipitate 
From the liver, kidneys, and spleen of a fatal case of typhoid Brieger 
and Wassermann (96) obtained a glycerine extract which, after filtration 
through a Berkfeld's filter, gave a precipitate with alcohol. This, being 
further purified by reprecipitation and dried, yielded a grayish white 
powder soluble in water, giving a yellow solution which frothed on 
being shaken up and presented the chemical reaction of albumin. One 
decigramme of this powder, dissolved in 1 c.c. of water, when injected 
into the peritoneal cavity of a guinea-pig, caused paralysis of the hind 
limbs, feebleness, lowered temperature, and death. On examination the 
animal was found to be emaciated, the liver fatty, and the peritoneum 
reddened, its cavity containing a little fluid. The same results were 
produced by the injection of 5 c.c. of the blood serum obtained after 
death from a fatal case of typhoid. 
Diagnosis of Typhoid Bacillus from Bacterium Goli Commune. -In 1885 
Escherich pointed out that in the normal stools of infants at the breast, a 
straight bacillus, of length varying from 1 p. to 5 p. and of a breadth of 
0-3-0-4 p. was constantly found. The bacilli stained well with ordinary 
dyes, but not with Gram's method. In peptone sugar culture the bacilli 
were easily obtained, and fermentation took place. These bacilli when 
grown on gelatine do not liquify it. The deep colonies on plates have 
the appearance of very small yellow granular discs; the superficial ENTERIC FEVER 
colonies form whitish lateral expansions of a uniformly granular aspect, 
sometimes iridescent; the outline is sometimes circular, but generally 
irregularly notched and wrinkled. 
In drop cultivations the bacilli have a slight motility. On potato 
they form a juicy layer varying in colour from a greenish yellow to a 
maize-yellow. Milk is coagulated by these bacilli. Cultures of them 
are pathogenetic in guinea-pigs and rabbits; when injected into the 
jugular vein they produce diarrhoea, lowering of the temperature, and 
death in three days. On post-mortem examination the small intestine 
is in its upper part hyperaemic; the caecum normal. The contents of 
the small intestine consist of a serous alkaline fluid, and the mucous 
membrane of the injected part is hyperaemic, soft and swollen; the 
Peyer's patches are swollen as in typhoid fever. 
This bacillus being constantly found in the stools of persons in health 
was termed the bacterium coli commune. On account of its great 
similarity in size, shape, mode of staining, and growth on gelatine, to 
the bacillus described by Eberth (typhoid bacillus), other differential 
tests were sought for than those given by Escherich as distinctive of 
his bacillus (46). 
797 
Typhoid Bacillus (Eberth, Gaffky). 
1. Size, length 2-3 n, breadth O'T-O'S 
(Gaffky). 
2. Has active movements. 
3. Has 10-12 flagella (Nicolle and Morax), 
18-24 (Remy and Sugg). 
4. Produces no indol in peptone water 
inoculated with it when kept at 35° 
for forty-eight hours. 
(To 10 c.c. of the culture 1 c.c. of a 0-02 
per cent solution of potassium 
nitrite is added, and one or two 
drops of pure sulphuric acid; in 
the presence of indol, a violet-pink 
colour is produced (Kitasato)). 
5. Causes no formation of gas in media 
containing sugar, for example, 2 per 
cent sugar bouillon, 2 per cent sugar 
agar, etc. (Smith). 
6. No evolution of gas in gelatine " shake 
cultures" (Klein). 
Bacterium coli commune (Escherich). 
1. Size, 1-5 m length, 0'3-0'4 m breadth. 
2. Movements more sluggish. 
3. Has 8-10 flagella more fragile than 
those of typhoid (Nicolle and Mo rax). 
1-3 (Luksch). 4-6 (Remy and Sugg). 
Note to 3. - Some of my specimens of 
bacteria coli commune have six fla- 
gella, most have only two or three. 
They appear to be very easily broken 
off. The bacilli adhere very tena- 
ciously together in agar cultures. 
In drop cultivations a better result 
is obtained, but even then the num- 
ber of flagella varies much more 
than in the specimen of typhoid. 
The bacillus was from a diarrhoeal 
stool. The diagnosis by flagella may 
be made from my specimen. -J. R. 
4. Indol produced in forty-eight hours at 
37° in peptone water. 
5. Causes abundant evolution of gas in 
media containing sugar. 
6. Bubbles surrounding the colonies in 
gelatine " shake cultures." 798 
SYSTEM OF MEDICINE 
7. Does not curdle sterilised milk (Chan- 
temesse and Vidal). 
8. In cultivations in neutral whey an 
acidity equal to 2-3 per cent in 
volume of Ath normal sodium hy- 
drate solution is produced (Pet- 
ruschky). , 
9. Growth typical on potato acidified 
with 0 3-1 per cent solution of tar- 
taric acid or monosodium phosphate 
(Ferrati). 
10. Grows more slowly on gelatine. 
11. Does not split up amygdaline in bouil- 
lon (Pere). 
12. In fresh bouillon an acid reaction re- 
mains for some days (Pere). 
13. Does not grow in bouillon containing 
ToWh part of formalin (by volume) 
(Schild). 
14. The surface of gelatine upon which 
typhoid bacilli have already grown 
no longer grows them when again 
inoculated (Wurtz). 
7. Curdles sterilised milk. 
8. In similar cultivations an acidity 
equal to 7-8 per cent of alkali is 
produced. 
9. Growth on potato thus acidified - a 
thick yellow layer (Ferrati). 
10. Grows more quickly on gelatine. 
11. In bouillon cultures amygdaline is 
split up into glucose and hydrocy- 
anic acid (Pere). 
12. In fresh bouillon the reaction, at first 
acid, becomes alkaline in five days 
(Pere). 
13. Grows in bouillon containing ^th 
part (by volume) of formalin (Schild). 
14. Will grow on a stratum of gelatine on 
which typhoid bacilli have previously 
grown (Wurtz). 
Klein says the colonies of typhoid bacilli are iridescent, those of 
bacillus coli communis are not, and that the latter bacillus is much 
smaller than the former. 
For practical purposes the distinction of the two bacilli must be 
made by means of the tests 4, 5, 6, 7, 9, and 13. By these tests we can 
ensure the similarity of the conditions of growth; and, if a micro- 
organism similar to that of Eberth in its morphology and gelatine plate 
cultures gives also these reactions of Eberth's bacillus, it is extremely 
probable that the bacillus in question is identical with that of Eberth.1 
Examination of Stools. - Three volumes of the stool are mixed with 
one volume of 1 per cent solution of phenol in order to provide a mixture 
1 Since the above paragraph went to press a method has recently been published by 
Elsner (Zeitsch.f. Hygiene und Infections Kr. vol. xxi. 1895), which appears to fulfil the 
long-felt want of easily isolating the bacillus of enteric fever and to distinguish it from the 
bacterium coli. As the cultivating medium acid potato gelatine is used, after Holz (Zeitsch. 
f. Bacteriologie, vol. xiii.), to which 1 per cent of iodide of potassium is added. On this 
medium very few microbes grow; among them are both the bacillus of enteric fever and 
the bacterium coli; they grow, however, in so different a manner, that in the course of 
forty-eight hours the two can be readily distinguished. The colonies of Eberth's bacillus 
appear as small shining masses like drops of water; those of bacterium coli appear as 
coarsely granular, brown coloured collections of larger size. When the colonies are very 
closely set it may happen that the colonies of bact. coli, being checked in their growth, 
resemble those of the Eberth's bacillus, but if so, further plate cultivation will show the 
difference at once. In fifteen out of seventeen cases of enteric fever the bacillus was easily 
isolated from the faeces in the various stages of the disease. The importance of this method 
for clinical purposes, as it enables an observer, without being an expert bacteriologist, to 
isolate the bacillus of enteric fever from the faeces within forty-eight hours after inoculation, 
is shown by the observations of Lazarus (Berliner klinische WocAenscA.1895,December 9th) 
and Brieger (Deiitsche med. Wochensch. 1895, December 12th). The latter found numerous 
bacilli in the dejections of patients suffering from enteric fever at a time when the symptoms 
were still very obscure. During convalescence the bacilli rapidly diminished; in two cases 
they persisted after the fever had disappeared, and both cases were followed by a relapse. ENTERIC FEVER 
containing a quarter per cent of phenol. This is left for three hours at 
a temperature of 21° C. Plate cultivations are now made in Petri's 
dishes (four plates of various dilutions) from this mixture, using a 
moderately large amount of the sample for the first inoculation. The 
gelatine used should contain 0-25 per cent of phenol. 
The plates when set are kept for forty-eight hours in an incubator 
at 22°. At least ten of the colonies, which present a superficial irregu- 
larly bordered expansion somewhat like a fig-leaf, are chosen; and each 
is inoculated into a tube containing 2 per cent of sugar as a stab culture 
(or made into shake cultures with gelatine); the former are kept at 
37° C. for twenty-four hours, and no bubbles should be produced if 
typhoid bacilli are present; the latter are kept at 21° C. for two or more 
days. The growth of the typhoid bacillus takes place along the track as 
well as on the surface. If the growth takes place only superficially, or 
is very slow, or if bubbles are produced, the typhoid bacillus is excluded. 
The tubes which may contain the typhoid bacilli are next inoculated 
(ct) in peptone solution (2 per cent peptone, 0-5 per cent sodium chloride), 
kept at 37° C. for forty-eight hours. To each is then added twenty drops 
of 0-02 per cent solution of potassium nitrite, and one or two drops of 
pure sulphuric acid when no violet-pink colour should be produced. (5) 
In sterilised fresh milk; this should not be coagulated after some days' 
stay in a temperature of 35°. (c) On a half of a potato, the other half 
of which is inoculated with an authentic typhoid bacillus. These should 
show no difference after incubation. By using this method Mr. Rich- 
mond did not succeed in finding typhoid bacilli in the stools of convales- 
cence from typhoid fever in seven cases at periods of 5, 7, 8,10, 15, 16, 
23, 24, and 30 days after a normal temperature had been reached. In 
the course of the investigation it was noticed that some apparently 
typical colonies produced gas formation in saccharine media, others did 
not; of those which produced no gas some gave the indol reaction, but 
three did not. These three coagulated milk so that the typhoid bacillus 
was excluded. Thus either organisms must have been present in the 
stools very like Eberth's bacillus in all their reactions except that of 
coagidation of milk, or Eberth's bacillus may under certain circum- 
stances acquire the property of coagulating milk, a property possessed in- 
deed by some of the recent cholera vibrios, but not possessed by the young- 
cultivations of the older specimens and some of the recent specimens. 
Phenol kills those organisms which, by producing liquefaction of the 
gelatine, would interfere with the plate cultures, but does not hinder 
the growth of typhoid and some other bacteria. 
The results of the examination of stools based upon the diagnosis of 
the typhoid bacillus before the introduction of the indol and fermenta- 
tion tests are, therefore, not so valuable as those made afterwards. 
Pathogenetic Nature of the Bacilli. - The typhoid bacilli fulfil the 
necessary conditions as the veritable cause of enteric fever, namely - 
they are found in living organisms, and in the organs of persons who 
have died of enteric fever, and in no other disease ; they can be cultivated 
799 800 
SYSTEM t>F MEDICINE 
outside the body; when inoculated into animals, lesions like those of 
typhoid fever are produced, and they are found in the organs of the 
animal so inoculated. 
It now remains to give briefly the results of observations on these 
points. 
1. Typhoid Bacilli in the Living Patients. 
In the stool of the patient they are constantly found (Strpolansky and 
Stroganoff). Wratch found them in 90 out of 96 cases examined. It 
must be noted, however, that they are rarely found before the 9th day 
of the disease (Karlinski), they may disappear from the stools before 
the end of the fever and, according to the observation of Mr. J. Rich- 
mond (see above), they quickly disappear after convalescence has set in. 
Strpolansky and Stroganoff have in two cases observed them in the stool 
nine days and fifteen days after the temperature had become normal. 
In the blood, taken from the finger tip or from a vein by inserting 
the nozzle of a small syringe, bacilli have very rarely been found, and 
cultivations have either given negative results, or have shown the pres- 
ence of streptococci or staphylococci, indicating a mixed infection. In 
the blood taken from the roseolar eruption some observers (Neuhans in 9 
out of 15 cases, Roux, Meisels) have found bacilli like those of Eberth. 
The blood from the spleen, drawn off by means of a small syringe, 
has often given positive results (Meisels found them from the 9th to 
the 18th day of fever, Buschelt in 8 out of 15 cases; in 2 of theso 
streptococci also were present). 
In the foetus, after abortion or premature labour in typhoid patients, 
the bacillus has repeatedly been found. They were present in various 
organs of the foetus (Neuhans, Hildebrandt, and Ernst). 
In the urine Eberth's bacillus has been found by Leitz in 2 cases out 
of 7 examined. Newman found them in some cases on the 10th, 16th, 
and 21st day of convalescence; they were present in 8 cases out of 48 
cases examined. Bouchard found them in 21 out of 65 cases; the urine 
in these cases contained albumin, which on precipitation settled at the 
bottom of the test-tube (retractile albuminuria); 9 out of these 21 cases 
were fatal, and the bacilli were found in the kidney. As early as the 
3rd day of fever they were found in the urine by Karlinski. 
In the sputum of typhoid patients suffering from pneumonia they 
may occur (Chantemesse). 
Lastly, in the sequelae of typhoid. There are already a great many 
cases recorded where the pus of abscesses, chiefly in connection with 
periosteum or bone, which appeared long after the patient had recovered 
from the fever, contained living typhoid bacilli. In Sultan's case (86) 
they were cultivated from the pus of an abscess opened six years after 
recovery from typhoid, and in a case recorded by Buschke (11) twenty- 
seven years had elapsed. In many of the cases recorded other micro- 
organisms, chiefly streptococci and staphylococci, were found in addition 
to the typhoid bacilli. 
2. Typhoid Bacilli in the Organs after Death. - They have been con- ENTERIC FEVER 
801 
stantly found in the Peyer's patches, mesenteric glands, spleen and liver; 
occasionally in the myocardium (Chantemesse), kidney and meninges, 
and very often in areas concerned in the various complications of 
typhoid fever: instances will be given under Symptomatology. 
3. Inoculation on Animals. - As animals do not suffer from enteric 
fever (there is some doubt whether the well-known outbreak of enteric 
fever at Kloten in Switzerland was really due to meat derived from a 
calf suffering from enteric fever), it is not easy to produce a disease in 
its symptoms like enteric fever in animals by inoculation, as was found 
by Murchison and others who fed animals with matter containing 
dejections from typhoid fever. Now, however, we have abundant evi- 
dence that under certain conditions a disease not unlike enteric fever, 
with lesions resembling those seen in it and presenting typhoid bacilli 
in the various organs, can. be produced by inoculating animals with 
pure cultures of typhoid bacilli. Positive results were first obtained by 
E. Frankel and Simmonds by intra-peritoneal injections in mice, guinea- 
pigs and rabbits; and they found consequently enlargement of spleen, 
hypertrophy of mesenteric glands and of Peyer's patches, and typhoid 
bacilli in the spleen. Sirotinin and Beumer and Peiper, on repeating 
the experiments, came to the conclusion that the animals died, not from 
an infection, but from an intoxication by the soluble product of the 
bacillus, and that no growth or multiplication of the typhoid bacilli 
had taken place. Numerous experimenters (A. Frankel, Fodor, Leitz, 
Chantemesse and Vidal, Sanarelli, Cygnoeus, Gilbert and Girode) have, 
however, since confirmed the observations of Frankel and Simmonds. 
The experimental methods were varied, some (A. Frankel) injected the 
bacilli directly into the stomach or duodenum after laparotomy, as done 
by Koch in cholera inoculations; others (Chantemesse and Vidal) used 
small doses of very virulent cultures, or diminished the resistance of 
the animal by injecting at the same time into the peritoneal cavity ster- 
ilised cultures of other micro-organisms - streptococci (Chantemesse), 
bact. coli commune (Sanarelli); but all obtained positive results: the 
bacilli were found in the various organs, and even in the foetus after an 
abortion, thus showing conclusively that an infection, and not an 
intoxication only must have taken place. 
Cygnoeus used a virulent culture which he injected into animals in 
various ways - intra-venous, intra-peritoneal - and into the duodenum 
or ileum after laparotomies; he also introduced the culture by the 
mouth and by inhalation. Many of the inoculated animals (mice, rab- 
bits, dogs) died, and at the post-mortem the spleen and mesenteric 
glands were found swollen, and the Peyer's patches reddened. Bacilli 
were found in the spleen, the liver, the intestines, the kidney, and the 
medulla of bone. Positive results were also obtained with some of the 
mice which had inhaled cultures of bacilli. 
The results of the experiments where other micro-organisms were 
introduced in order to weaken the resisting power of the organism re- 
ceive a further confirmation by recent observations of Alessi, who found 
3 F 
VOL. I 802 
SYSTEM OF MEDICINE 
that guinea-pigs made to breathe the effluvia from cesspools were killed 
by feeble cultures of typhoid bacilli which had no action upon animals 
of the same size kept under more favourable conditions. 
Relation between B. Coli Com. and Typhoid Infection. - Pisenti and 
Biancho-Mariotti found - 1. On simultaneously injecting into animals 
cultures of typhoid bacillus and B. coli com. (which latter had been 
proved to be inactive), that B. coli com. increased in virulence, so as to 
act like very virulent B. typh. on animals. 
2. That if sown in gelatine mixed up with filtered cultures of B. 
typh., B. coli also gains in virulence, which is due to typho-toxin acting 
on the B. coli. 
3. That healthy intestinal epithelium hinders infection from the 
intestine; but that if Peyer's patches undergo changes this defence is 
in abeyance. Filtrates from typhoid cultures exert an influence on 
Peyer's patches, as proved by experiments (nature not stated), so that 
in typhoid fever the toxin in the blood alters the Peyer's patches, and 
thus B. coli are permitted to get into the body and add to the virulence 
of the typhoid infection. 
4. That the virulence of B. coli is increased by simultaneous injec- 
tions of streptococci pyo. aur. (explaining Vincent's observation that 
typhoid is more severe when streptococci are present in the blood). 
5. That with very virulent cultivations of B. coli they could get 
similar results (such as thermometric curves, for instance) to those 
obtained by very virulent B. typhoides, and could immunise animals 
against B. typhoides; at the same time they guard against any expres- 
sion of opinion as to the identity of the two. 
Ways of Infection. - Having shown that the typhoid bacillus is the 
immediate cause of enteric fever, we may now consider by what chan- 
nels it may be conveyed. The general conclusions as to the etiology of 
enteric fever arrived at by many years of experience and observation 
before the discovery of the typhoid bacillus were - that it occurs in 
sporadic cases or in epidemics; that the poison is contained in the 
alvine discharges of the typhoid patients, contact with which may com- 
municate the disease to a healthy person; that an outbreak of enteric 
fever implies poisoning of air, soil, drinking water, milk, or other 
ingesta with the fever poison. In some cases the source of the poison 
cannot be traced, hence, as I have already said in the short historical 
sketch at the outset of this article, many have believed that typhoid 
fever may arise spontaneously. 
In some instances it is no doubt very difficult, often even impossible, 
to trace the origin of a case of enteric fever, or to explain the source 
of an outbreak of the disease; but considering the long vitality of the 
typhoid bacillus under certain conditions, its probably wide distribu- 
tion, its rapid multiplication, the great dilution to which it may be sub- 
jected without losing its potency - as shown in some epidemics, where 
the source of infection was undoubtedly proved, as in the outbreak at 
Lauseji (12) - and the influence which the presence of other micro- ENTERIC FEVER 
803 
organisms and imparities of the air have either in favouring its develop- 
ment, or in diminishing the power of resistance of the individual, we can 
quite understand that it may often be difficult to trace the source of 
infection. Is there not the same difficulty in other infectious diseases, 
such as small-pox or scarlet fever; yet no one believes in the spontaneous 
origin of these affections ? 
The typhoid bacillus is contained in the dejections of the typhoid 
fever patient, and "typhoid fever " is chiefly propagated by these. 
It is stated by most observers that fresh typhoid stools are not 
infectious (Murchison, Caley), and that they only become so after one or 
more days. If this be so, it could be explained readily by the observa- 
tions of Hiippe, who found that the typhoid bacilli in recent stools being 
anaerobic when leaving the body, were more influenced by external 
agents than bacilli found in stools that have stood for some time and 
have thus become aerobic (41). 
We have seen that the bacilli are occasionally contained in the sputum 
and in the urine; these secretions, therefore, cannot be neglected as 
sources of infection, and should be thoroughly destroyed. 
The paths of conveyance are - 
1. Direct contact with particles of dried faeces contained in the 
clothes of the patient, bed linen, etc.; many instances have been recorded 
where washerwomen, nurses, and others have been infected in this way. 
It is also quite possible that insects, such as flies, may carry infectious 
particles from typhoid patients to fruit and vegetables. This mode 
of infection may explain the occurrence of some sporadic cases. We 
know that the bacillus grows well on many vegetables besides potatoes 
and other articles of food (39); and on the other hand, experimental obser- 
vations by Hoffman and others have shown that both cholera bacilli and 
tubercle bacilli may be conveyed by flies; Burgess has recently given 
further proof how easily micro-organisms may be conveyed by flies. 
With other articles of food taken raw - such as milk, oysters, watercress 
- which are now known to be a source of infection, contamination is due 
to the water. Infection by oysters has been recently observed in London 
and elsewhere (10), and cases like those observed by Sir Wm. Broadbent 
seem to prove that oysters not infrequently act as carriers of the poison. 
2. Water into which the excretions find their way. This may be 
drinking water, or water used for rinsing milk-cans, etc., which may thus 
give rise to epidemics, when the disease is propagated by milk; or, as in 
one or two outbreaks recently recorded, by ice cream: vegetables, again, 
may be washed in contaminated water; or oysters may contain it (see 
above). 
3. Air. This is now known to be a very rare mode of infection. It 
is, however, not impossible that dried bacilli may be suspended in the air. 
Tryde and Salomonson found typhoid bacilli on the floor of a barrack 
where enteric fever was prevalent. (It is doubtful, however, whether 
these were proved to be typhoid bacilli.) Lassurie (54) passed a pulver- 
ising spray of water over a quantity of dried typhoid bacilli, and found 804 
SYSTEM OF MEDICINE 
that the particles of spray carried the bacilli some distance. The part 
played by sewer air will be alluded to later. 
4. Food from animals affected with the fever. Several such epi- 
demics have been recorded, whether actually enteric fever or not. In 
the one at Kloten the affected person not only partook of the meat 
(supposed to have been derived from a calf suffering from typhoid), but 
also partook of wine and other drinks. It is very probable that the 
beverages consumed contained the active agent, the action of which 
would be assisted by the putrid condition of the veal. Enteric fever, 
moreover, has not been recognised in animals. 
It would be beyond the scope of this article to go fully into the 
various outbreaks of enteric fever and their respective sources, which 
subject is fully treated in works on hygiene and in larger treatises on 
enteric fever, as in one just published (9c). 
The facts ascertained with regard to the outbreaks of typhoid fever 
are, briefly, that in very few cases is there any evidence of direct con- 
tagion from the sick to the healthy; in a considerable number of cases, 
especially of isolated cases, no direct or indirect contagion can be proved; 
in a large number of cases, especially in large epidemics, the disease 
arises among persons who drink unfiltered and unboiled water or milk 
contaminated with typhoid stools. 
Enteric fever due to milk contamination is chiefly confined to houses 
served by a particular dairy; the attacks are simultaneous, and confined 
at first to those members of the family who had partaken largely of 
unboiled milk, especially the younger. As a rule the cases have not a 
high mortality. In many of them it has been proved that enteric fever 
existed at the farms from which the milk was derived; that the water- 
supply of the farms was infected with the stools, and that the milk 
cans were washed with the infected water. As fresh warm milk is a 
favourable medium for the growth of the typhoid bacillus, a small 
amount of infected material would contaminate a large amount of milk. 
In epidemics from the use of contaminated water, the cases arise to 
a much greater extent among those who use the suspected water than 
among those who have another water-supply (6), the percentage of at- 
tacks not being very high; or severe outbreaks arise in connection with 
the consumption of water from a particular well contaminated with 
typhoid stools, as in Budd's Cowbridge case, where of 140 persons who 
possibly might have drunk of water from a well polluted with typhoid 
stools forty or fifty had typhoid fever - some after a very short period 
of incubation. In the Tees valley outbreak a large body of water was 
contaminated: in the former one a small body was more intensely in- 
fected, and a very large percentage of consumers were attacked. In these 
cases bacteriological examination of the water may be carried out in the 
way recommended for the examination of stools; or the first step by which 
the liquefying organisms are got rid of may be attained by Parietti's 
method. In this method three, six, and nine drops of a solution of 5 
per cent phenol and 4 per cent of hydrogen chloride in distilled water are ENTERIC FEVER 
805 
added to tubes, each of which contains 10 c.c. of neutral bouillon. These 
are capped and kept at 37° in the incubator for twenty-four hours. The 
tubes which have become turbid are now excluded. To each clear tube 
are then added one to ten drops of the suspected water, according to the 
amount of impurity. The tubes are capped, shaken, and incubated for 
twenty-four hours. Plate cultures are now made from the turbid tubes. 
Other methods have also been formulated and described in bacterio- 
logical text-books: when the infecting material is largely diluted, or 
the examination is made some time after the fouling has occurred, the 
typhoid bacillus may not be detected, and bacterium coli only found. 
In these cases a much larger quantity of water must be examined; this 
can be effected by passing a large quantity of the water through a ster- 
ilised Chamberland's porcelain tube contained in a sterilised stoppered 
vessel, as suggested by Professor Delepine; the scum collected on the 
outside of the tube is afterwards to be examined bacteriologically. 
Typhoid bacilli have often been found in water which has been con- 
sumed by persons who have suffered from enteric fever: in some of 
these cases the water has been derived from wells into which cesspools 
containing such stools have drained; in others the water .of rivers or 
brooks has been contaminated by sewage, by drainage from fields manured 
by privy refuse, or by drainage from laundries where clothes soiled by 
typhoid stools have been washed. In conducting bacteriological exami- 
nation of water, it must be borne in mind that a number of bacilli may 
occur in water, which closely resemble the typhoid bacillus both in 
appearance, in the character of the colonies, and even in some of the 
reactions; so that it becomes necessary to use every one of the differ- 
ential tests given above: indeed in the present state of our knowledge, 
even if the organism do present the various test reactions we can then 
only say that it is like the typhoid bacillus. For further references on 
the subject we refer to Lustig's treatise (63). In many of the cases in 
which enteric fever has been associated with the use of a particular water- 
supply, some of the persons exposed to the infection have escaped; in 
other cases persons living in particular districts have scarcely suffered, 
whilst in other districts having the same water-supply the fever has 
been very prevalent. Thus there is a local immunity as well as an 
individual immunity. Chantemesse points out that the 20th arrondisse- 
ment had in the ten weeks beginning with the 20th February 1894 a 
mortality from enteric fever of 0-5 per 10,000; whilst in the 17th, 18th, 
and 19th arrondissements, inhabited by the same classes of people, and 
where the same water was drunk, the mortality was 0'88 per 10,000. 
The same arrondissement for the last thirty years has had a lower mortal- 
ity from enteric than the mean mortality of the other arrondissements of 
Paris (50). The Tourelles barracks did not present a single case. The 
water-supply, examined on the 6th April, yielded bacilli coli commune - 
probably, but perhaps not necessarily, due to fsecal contamination-but 
no typhoid bacilli. The 20th arrondissement has a less crowded popula- 
tion and more open spaces than the others, except in Belleville which, 806 
SYSTEM OF MEDICINE 
though thickly populated, is situated on a well-ventilated and elevated 
site. On this subject Mr. Hart's articles on Water-borne Typhoid in the 
British Medical Journal for 1895 may be consulted. 
Fodor found that the mortality from typhoid fever in Buda-Pesth 
was greater in those houses which were supplied by well water than in 
those supplied by pipe water (filtered); and greater in those houses 
where the ground water was more impure, and where the ground was 
more polluted with organic matter which did not present evidence of 
active oxidation. 
In Dublin, which has a pure water-supply, but where the soil is satu- 
rated with the filth from privies and ashpits formerly in use, those living 
on clay suffered much less from enteric fever than those living on the 
porous gravel; and Sir C. Cameron believes this difference to be due to 
emanations from the filthy soil. At Stockport the grouping of cases of 
enteric was noticed in three particular areas, the three highest points 
in the town at which the sewers were ventilated. This association has 
been noted elsewhere. In many cases insanitary conditions allowing 
sewer gas to pass into houses are found where this fever occurs. In- 
stances might be infinitely multiplied. Thus impurity of the soil and 
the breathing of sewer air are often found in connection with enteric 
fever, but there is no exact evidence that these act otherwise than as 
accessory agents. There is no evidence that sewer air contains typhoid 
bacilli; it is found that in well-ventilated, well-constructed sewers the 
air contains fewer bacteria than the outside air; but where the sewage 
is stagnant it is possible that gas abundantly produced by the formation 
and the bursting of bubbles may disseminate solid particles in the air, 
and some of these may be wafted up into those houses where the soil- 
pipes act as sewer ventilators, or into the air about the ventilating grids. 
In some of these ways it is possible to explain the origin of cases which 
appear obscure without invoking the action of any miasma, except as an 
adjuvant cause as in Alessi's experiments. 
This brings us to the consideration of remoter causes which favour 
the occurrence of the disease. Of these may be mentioned - 
1. Age. - Enteric fever occurs much more frequently amongst the 
young, and adult persons under 35. It is not uncommon in children, 
but very rare in infants. This will be evident from some of the tables 
which accompany this article. 
2. Sex. - The male sex appears, from the number of cases admitted 
into hospitals, somewhat more disposed to the disease than females. 
Thus there were admitted into Metropolitan Asylum Board's Hospitals 
in the years 1871-1892, 3293 males and 3030 females between the ages 
of 10 and 35 years. But probably more males are admitted into hospi- 
tal than females, so that the liability to enteric fever may be the same 
in the two sexes. 
3. Season. - Though enteric fever occurs at all seasons, it is much 
more prevalent in autumn and beginning of winter, especially after a dry 
and hot summer. In London the maximum mortality is in November; ENTERIC FEVER 
807 
in England the maximum prevalent in October. This seasonal prev- 
alence must be due to some meteorological influence; but the favouring 
conditions of temperature, atmospheric pressure, and rainfall are not 
definitely known. 
Pettenkofer and Buhl pointed out that in Munich the maximum 
prevalence of enteric coincided with the lowest recession of the ground 
water from the surface of the soil, and was especially marked when the 
ground water was previously high. These are just the circumstances 
favourable for the pollution of wells by filthy soil, as Buchanan has 
pointed out. Fodor showed that at Buda-Pesth the maximum of the 
prevalence of the fever coincided with the maximum height of the ground 
water, that is with the highest level of the Danube. The same observation 
was made by Thorne Thorne in an outbreak of the disease in Jerling,Essex. 
In many places Pettenkofer's observations have been confirmed, in 
many they have not; moreover, as Fliigge (27) points out, the number 
of cases in the quarter of the year in which the ground water is at the 
lowest level, compared with the average number of cases in the other 
quarters, shows only a difference amounting to 10-20 per cent of the 
total number of cases (17 per cent in Berlin); so that the sinking of the 
ground water only increases the number of cases by a small fraction of 
the whole, the rest occurring during the rising and the high level of the 
ground water. 
English observations have led to the conclusion that a permanent low 
level of the ground water (at depth of 15-20 feet) is the best for health. 
4. Defective drainage and sewerage, accumulation of filth, over- 
crowding and disregard of ventilation, in fact, all shortcomings in sani- 
tation of the individual and of the community are most important agents 
in favouring the power of the typhoid bacillus, and in lessening the 
resistance of the individual. The improved sanitary condition of most 
of the English towns as regards water-supply, sewerage, open air spaces, 
etc., is the chief cause of the diminished mortality. This diminution 
amounted to 45-4 per cent in twenty-one out of twenty-four English 
towns; in three towns where the typhoid mortality was increased, the 
sewerage arrangements were manifestly faulty. (See accompanying table 
giving the annual mortality from typhus and typhoid per million persons 
living, in England, Table I., Appendix.) 
5. Other less potent causes are peculiarities of constitution (see under 
Prognosis), and recent residence in an infected district. Occupation and 
station of life have no influence. 
Immunity. - We will confine ourselves entirely to a few facts, in 
relation to this subject, the general consideration of which is dealt with 
elsewhere. 
Some persons show a natural immunity from enteric fever; acquired 
immunity is a well-established fact in this as in some other infectious 
fevers. Of over 2000 cases of enteric fever which came under obser- 
vation at the Hamburg General Hospital, only fourteen persons were 
affected twice, and only one person three times by enteric fever. Of the 808 
SYSTEM OF MEDICINE 
experimental investigations we may briefly allude to the observations of 
Widal and Chantemesse, Brieger, Kitasato, Wassermann, and Stern. 
In the course of these investigations it was found that when cultures 
of typhoid bacilli which were virulent, or which had been sterilised by 
heat, were used to infect animals, and the animals survived the action of 
the virus, that these animals were more or less immune to the action of a 
stronger virus. By regulated doses of the weakened virus injected sub- 
cutaneously (or in some cases into the veins) guinea-pigs were rendered 
immune from the action of a stronger virus. The blood serum of these 
guinea-pigs was then found to confer immunity upon other animals when 
used in the same way, and to retard the disease in animals already 
affected. According to R. Pfeiffer, if the serum of a highly immunised 
guinea-pig be injected with a small dose of typhoid bacilli into the 
peritoneal cavity of a normal guinea-pig, and drops of the peritoneal 
exudation then removed for examination, the bacilli are seen rapidly to 
undergo degenerative changes, and finally to disappear. Other bacteria 
when subjected to the same process remain unaffected. Hence this 
" specific immunising power " of the serum in question may be used as a 
diagnostic test for the typhoid bacilli (68a). Dunbar confirms Pfeiffer's 
results (21&). It is obvious, however, that if moderate doses of the 
bacilli to be tested will not grow in the peritoneal sac of a normal 
guinea-pig the reaction will not be available. The blood serum of men 
who have enteric fever, and of some who have not had it, has the same 
property (Stern). The serum of protected guinea-pigs injected sub- 
cutaneously in the enteric fever patients gave no important results 
(Chantemesse). 
Frankel and Simmond's observations with sterilised cultures of 
typhoid bacilli will be referred to under Treatment. 
Portals of Entrance into the Human Body of the Typhoid Bacilli. - 
The digestive tract forms the principal channel along which the 
typhoid bacilli find their way into the body. This is evident from the 
well-established fact that from the post-mortem appearance most out- 
breaks can be traced to contaminated water or milk. Chantemesse 
quotes a case of Klebs, where a man died on the second day of the dis- 
ease, and in the mucous, submucous, and muscular coat of the intestines 
masses of typhoid bacilli were found. From what has been stated before, 
it is evident that typhoid bacilli may find their way into the air, and 
may thus enter by the respiratory tract. Yet it is quite possible that 
they may be arrested in the pharynx, and thence find their way into the 
digestive tract. Wyssokowitch was not able to find typhoid bacilli in 
animals which had inhaled dried culture of typhoid bacilli, or in which 
he had injected typhoid bacilli into the trachea. The occurrence of pneu- 
monia at the very onset of entric fever, and the presence of typhoid 
bacilli in the lungs in these cases, make it not improbable that occasion- 
ally, though no doubt very rarely, the bacilli may enter the system 
through the respiratory tract. 
Recently Anderson described two cases of enteric where the fever ENTERIC FEVER 
809 
was contracted in the hospital, and where there was presumptive evi- 
dence that the infection was conveyed by an enema syringe; the en- 
trance in this case would be per rectum. 
Symptomatology. - The symptoms of enteric fever vary considerably 
in individual cases both as regards character and intensity; this is due 
partly to the intensity and localisation of the poison, and partly to a 
mixed infection by septic organisms. It will be well to describe at first 
an ordinary case, then to give an analysis of the symptoms and of the 
complications, and the sequelae. In each case of enteric fever we may 
take certain periods to represent the several stages of the affection. 
The following stages are recognised by most clinicians: incubation, 
onset or invasion; the fever period itself, which is divided into the 
first, second, and third week of the fever - or, according to Murchison, 
into the stage of glandular enlargements extending to the 12th or 14th 
day, the stage of ulceration or sloughing of the intestinal glands extend- 
ing to the end of third week - lysis, or gradual diminution of the fever, 
and convalescence. 
The incubation period varies considerably; it seems in most cases to 
be about fourteen days; in some cases, however, it has been ascertained 
to be as short as four or five days, or even shorter; in others it may 
extend over three or four weeks. During the period the patient may 
either experience no symptoms whatever, or, as is most commonly the 
case, towards the end of this period, he may complain of headache, loss 
of appetite, sleeplessness, and a sense of fatigue ; this stage may gradu- 
ally pass into the next stage. 
The Onset. - In many ordinary cases the onset is insidious. The 
patient complains of pain in the limbs, of excessive fatigue, of cold and 
chilly sensations, of headache often very severe, of loss of appetite, and 
of sleeplessness : epistaxis is a very common symptom, and generally 
occurs about the second or third day of the disease. These symptoms 
become more severe, the patient has to take to his bed, and from this day 
we generally reckon the duration of the fever. In many cases, however, 
as shown by the changes after death, the beginning of the morbid process 
must be dated from the very first symptom. The tongue becomes furred, 
and is at first moist; there is a steady rise of temperature, the evening 
temperature being generally one and a half degree (F.) higher than the 
morning temperature, so that about the fourth day the temperature 
reaches 103° F. or 104° F.; the pulse rises to 90 or 100, rarely higher 
except in very severe cases, or in very young or debilitated subjects, is 
dicrotic and indicative of low blood pressure; there is increased thirst; 
the abdomen is slightly distended and tender on pressure; diarrhoea 
may as yet be absent, and there may be constipation, or there-may be two 
or three fluid stools from the first. Beyond the headache, which persists 
for a few days, and sleeplessness, there are as yet no other symptoms; 
the skin is dry, but there are paroxysms of profuse perspiration. The 
spleen is as yet but little enlarged, and there are as yet no roseolar spots, 
though when perspiration is profuse sudamina are noticed; the urine has 810 
SYSTEM OF MEDICINE 
febrile characters and. as yet does not show the diazo reaction. This stage 
lasts about seven days, and constitutes the first week of enteric fever. 
During the second week more characteristic symptoms appear. The 
fever remains high and steady, the morning remissions being less; the 
pulse is quicker; the skin remains moist; the tongue becomes dry and 
brown, and the lips likewise; the roseolar rash appears, between the 
seventh and twelfth day, in the form of isolated, circular, rose coloured 
spots, slightly elevated, and about the size of lentils, from two to four 
millimetres in diameter, disappearing on pressure, and reappearing with 
the removal of the pressure; they appear chiefly on the abdomen and 
back, occasionally on the arms and thighs; they may be very few in 
number, dr at times very numerous, and they appear in successive fresh 
crops, while the old ones gradually fade: the appearance of the spots 
continues up to the end of the second week, and often to the middle or 
end of the third week, or even during convalescence. In some cases a 
minute vesicle may be seen at the apex of the roseolar spot. During 
this stage the abdomen becomes more distended, gurgling in the right 
iliac fossa is noticed, and the abdomen may be painful on pressure. The 
diarrhoea is now more profuse, and the motions have the characteristic 
pale yellow (" pea-soup ") colour, and, especially in children, are highly 
offensive. The spleen is now considerably enlarged, is often to be felt 
below the costal margin, and is occasionally painful on pressure. The res- 
piration is quickened, but not as quick as in pneumonia; still there may 
be some bronchial affection with mucous expectoration. The temperature 
during the first few days of the second week continues high, with marked 
evening exacerbations. About the middle of the second week, in moder- 
ately severe cases, the morning temperature is lower than it was before; 
in others the morning remission is but slight, and the fever has a less 
remittent character; in very mild cases the fever may disappear about 
the end of the second week. The urine is scanty, high coloured, and of 
high specific gravity; occasionally it contains albumin, and in most cases 
gives the " diazo reaction." The headache usually disappears during 
the second week if not before; there is often marked and increasing 
deafness. The patient in the second week, except in very slight cases, 
assumes a somewhat characteristic appearance. He is dull, apathetic, 
and has a heavy look; the face is pale, the cheeks occasionally flush, the 
pupils dilate, and the lips are dry. In severer cases there is delirium, 
especially at night, and in still more severe cases other nervous symptoms 
(constant delirium, somnolence, subsultus tendinum) may supervene, and 
death may take place during the second week. Haemorrhage from the 
bowel occasionally occurs towards the end of the second week. 
During the third week, in mild cases, the symptoms gradually subside. 
In moderately severe cases most symptoms remain the same as during 
the second week; but the temperature shows marked morning remissions, 
and the fever gradually declines, and may show for a few days an inter- 
mittent fever type, - the morning temperature being normal, the evening 
temperature still reaching 100° F. or 101° F.; in more severe cases the ENTERIC FEVER 
811 
temperature may remain high and even increase, the pulse becomes 
smaller and quicker, the tongue quite dry and brown and often fissured, 
the lips covered with sordes, the diarrhoea persistent, and the perspira- 
tion profuse: the delirium is now constant, and often of a low, mutter- 
ing, or sometimes of a violent maniacal character; the loss of flesh 
becomes particularly apparent during this week, and bed-sores may 
appear if the nursing be inefficient. Haemorrhage from and perforation 
of the intestines are apt to occur during the week. Pulmonary compli- 
cations and failure of the heart's action are to be feared, and would show 
themselves by quick and small pulse, cyanosis of the face, clammy per- 
spiration, and the like; other unfavourable symptoms relating to the 
nervous system may also occur towards the end of the third week, such 
as retention of urine, or involuntary discharge of urine and faeces. 
With the fourth week convalescence commences in ordinary cases, in 
very severe cases later. The evening temperature now falls gradually 
to the normal, or nearly so; save a few exceptions (Fagge, Morris), there 
is no crisis, but a gradual defervescence; the alvine evacuations become 
formed, the pulse improves, and the tongue begins to clean, while the 
appetite returns and becomes almost ravenous; the pulse becomes slower 
and firmer; there is often polyuria, the urine having a low specific grav- 
ity ; the nervous symptoms quickly disappear; the sleep becomes more' 
natural, and though the patient feels excessively weak, often complains 
of vertigo and palpitation, and is pale and anaemic, the strength gradu- 
ally returns and is maintained; unless the convalescence be interrupted 
by relapses, or some of the sequelae to be mentioned below ensue. In 
very severe cases the fourth week often brings not only no relief, but 
even an aggravation of the symptoms of the third : the pulse may reach 
140 or more, the respirations become laboured, the face is dusky and cov- 
ered by clammy perspiration, urine and faeces pass involuntarily, and 
coma gradually sets in, soon followed by death: some few patients, how- 
ever, in spite of the severity of the symptoms, take a favourable turn, 
and eventually recover. Convalescence begins in the majority of cases 
with the fourth week: in not a few cases, however, the fever does not 
subside till the end of the fourth week; whilst in some protracted cases 
it may continue during the fifth or even the sixth week. 
The above is a brief description of the symptoms in ordinary cases 
of enteric fever. Certain variations both in the onset and course of the 
disease are, however, sometimes noticed. 
As regards the onset, it is well to know that occasionally this may 
be sudden, in one of the following ways - (a) Symptoms resembling an 
ordinary febrile cold: repeated shivers, with headache and rise of tem- 
perature ; but a single rigor, so characteristic of pneumonia, is very rarely 
seen in enteric fever. (&) Symptoms resembling acute gastritis: such as 
frequent vomiting, which may persist for a few days, and be soon fol- 
lowed by diarrhoea; the gradual increase of the temperature, which on 
the fourth day may reach 103° or more, assists us in diagnosing such a 
case from gastro-intestinal catarrh, (c) In other cases the patient at 812 
SYSTEM OF MEDICINE 
first complains of sore throat, and the tonsils may be so swollen as to 
interfere with breathing and swallowing; the accompanying headache, 
epistaxis and pyrexia here assist us to make an early diagnosis, (d) The 
first symptoms may be those of pneumonia, and only after some days the 
typhoid symptoms (diarrhoea, enlargement of spleen, roseola) present 
themselves. These cases are known as pneumo-typhoid, and, as in 
some of them the typhoid bacillus has been found in the pneumonic 
lung, we have probably here to do, in some cases at least, with enteric 
fever in which the typhoid bacillus established itself first in the lungs; 
in other cases we probably have to do with two coincident affections - 
pneumonia and enteric fever (Chantemesse). (e) The fever may set in 
with severe headache and vomiting, soon followed by delirium, retrac- 
tion of the head, and photophobia, - indeed with all the symptoms of 
meningitis; and it is only after five to six days that the true nature of 
the case reveals itself: this onset is not rare in children. (/) Symp- 
toms of acute nephritis (nephro-typhoid) (see below). 0) In very 
rare cases laryngeal symptoms (laryngo-typhoid). 
During the stage of glandular enlargement the temperature may not 
show the characteristic curve; it may be normal, or but little above 
normal, throughout the whole course (apyrexial type), or slightly febrile 
(in mild cases), or it may show great variations; again diarrhoea may 
be absent throughout the whole course, or there may even be obstinate 
constipation. Grave nervous symptoms may persist throughout the 
whole period, as in the form of constant delirium or drowsiness; the 
presence of the other symptoms characteristic of the disease helps us 
in the recognition of these aberrancies. As the symptoms vary consider- 
ably in some cases, I will now give a brief analysis of the symptoms 
relating to the various organs. 
Temperature in Typhoid. - For the majority of cases the observations 
of Wunderlich on the temperature curve in enteric fever still hold good. 
With the onset the temperature rises gradually during the first four days, 
an evening exacerbation of about 1-5° to 2° F., being followed by a remis- 
sion next morning of about 1° F., so that there is a gradual mean rise 
with a daily zig-zag, the summit of which reaches about 103-5° to 104°, 
on the fourth day. This is followed by the fastigium, lasting for about 
seven days, during which time the temperature is more uniform and of 
continuous type, the morning temperature being 102° to 103°, evening 
temperature 103° to 104° F. In many cases there is on the seventh 
day a distinct but only temporary fall of a few degrees. From this 
point to the end the temperature varies with the severity of the case 
(excluding such accidents as haemorrhage); in ordinary moderately 
severe cases the temperature, after the eleventh or twelfth day, has for 
three to four days a remittent character, the morning temperature now 
falling, and more rapidly than the evening temperature; during the 
remaining days (from about the sixteenth to the twenty-first) it assumes 
an intermittent character, the morning temperature being about normal, 
the evening temperature reaching 101-5° to 101°, and coming somewhat ENTERIC FEVER 
813 
rapidly down to the normal on the twenty-first day : in mild cases the 
temperature may fall more rapidly at the end of the second week, and 
may reach the normal soon after; in severe cases the morning tem- 
perature remains high after the second week, between 103° and 104°, 
and the evening temperature reaches 105°; or we have irregular tempera- 
tures for several days after the twelfth day (the " amphibolic stage " of 
Wunderlich, the " stage of changing fortunes " of Murchison). Defer- 
vescence thus takes place more or less gradually; but sometimes the fever 
may terminate by sudden crisis on or before the end of the third week. 
For the majority of cases, then, Wunderlich's observations on the tempera- 
ture hold good, and from a diagnostic point of view it is well to remember 
his general rule: - Any fever which on the second day reaches to 104° 
F. is not enteric fever, nor is it enteric if the fever does not approach 
104° F. on the evening of the fourth day; on the other hand, enteric fever 
may be diagnosed, if in a middle-aged person suffering from an acute 
febrile attack the evening temperature on the fifth day, or within the 
first week, is between 103° and 105°, and alternates with morning 
temperatures, which are 1-4° to 1-7° lower, unless some other disorder 
can be discovered to explain the height of the fever. It is well to state 
that by morning temperature we mean the temperature about 9 a.m., 
by evening temperature that about 6 p.m. If the temperature be 
taken every two hours greater differences are sometimes noticed during 
the twenty-four hours. 
There are, however, many variations of the temperature curve. 
Thus, sometimes, especially if pneumonia intervene, or even in simple 
cases there may be a very high temperature on the second day; again, we 
occasionally meet with hyperpyrexia, which may reach 109°, and even 110°. 
Such temperatures generally occur during the third week, and are quickly 
fatal; but temperatures between 105° F. and 106° F. may be met with 
even towards the end of the second week in cases which recover, espe- 
cially in young subjects. Again the temperature may undergo sudden 
alterations from incidents which arise during the fever; thus an attack 
of pneumonia, occurring, as it often does, towards the end of the fever, 
causes a sudden rise of temperature; various septic affections, which 
so often complicate enteric fever, considerably disturb the fever curve;1 
haemorrhage from the ulcers causes a sudden fall of the temperature; 
perforation of the bowel often has a similar effect; and even nervous 
symptoms, or failure of the heart, may be ushered in by a fall. Again 
1 It is stated by many observers that in persons who have had malaria the temperature 
in typhoid shows a distinctly intermittent type, accompanied by rigors and sweating, and 
the typho-malarial fever of the tropics has been looked upon by some as enteric fever. 
Osler and others have described cases where malarial fever came on during an attack of 
typhoid without the temperature becoming intermittent; and other observers (Purjez, 
Weil) (96) describe a true intermittent temperature in enteric fever without any malaria, 
which may persist throughout the whole course. (Vide art. " Fevers in India.") 
In a few cases oscillation between high and very low temperatures has been recorded; 
thus in a child suffering from enteric fever the temperature fell from 104° F. to 91° F., and 
then gradually rose to normal. With the rapid fall of temperature signs of pneumonia 
appeared (71a). 814 
SYSTEM OF MEDICINE 
the fever, instead of terminating at the end of the third or fourth week, 
may run on for weeks, protracted by a variety of causes, such as continued 
ulcerations, septic complications, etc. 
Some cases of enteric fever may run their whole course without any 
rise of temperature, or with a temperature but slightly above normal, or 
even with a subnormal temperature. Such cases have been described by 
Gerhardt (34, 97) and myself (21). Even epidemics of such cases have 
been described (30). In two of the cases observed by me, not only were all 
the prominent symptoms of enteric fever present, with the exception of 
pyrexia, but there was also a distinct relapse, lasting in one case exactly 
three weeks, during which there was marked haemorrhage from the 
intestines. The prognosis of these cases, in spite of their apyrexial 
nature, is as grave as that of ordinary enteric fever; one of my patients 
died from perforation, and the two cases described by Wendland termi- 
nated fatally. 
Post-Typhoid Pyrexia. - Apart from the cases which are mentioned 
above, in which the temperature, on account of some complication or 
continued ulcerations, does not come to the normal for many weeks, we 
may note a rise of temperature lasting a short time; this occasionally 
happens during convalescence, and is sometimes referred to errors in diet, 
or too nitrogenous a diet, or to constipation (in one case the temperature 
ran to 105° after having been normal for three days, and quickly sub- 
sided again after an enema). Slight elevations of temperature during 
convalescence are often noticed in very anaemic persons or in those of 
highly nervous temperament (Osler). 
From these post-typhoid temperatures must be distinguished the 
fever of the relapse, which will be described hereafter. 
Symptoms on the Surface of the Body. - The roseolar eruption has 
already been described. It is present in about 77 per cent of the cases; 
it is more often wanting in children, but may be even copious in them. 
Of other eruptions which are met with we have to notice: - 
(a) Maculae caeruleae, taches bleuatres, peliomata, blue tinted spots 
of indefinite size, situated chiefly over the abdomen ; these appear to be 
caused by the irritation of pediculi, and occur in other febrile affections. 
(&) Petechiae or Purpura Spots. - In rare cases the typical typhoid 
rash may be accompanied by petechiae; at other times, in badly nourished 
and debilitated persons, or when septic complications occur, petechiae 
may appear at the height of the disease. 
(c) Miliaria and sudamina are not unfrequently met with; they 
appear sometimes early, but generally in the second and third week of 
the disease; they are very numerous, and principally situated on the 
front and back of the chest and on the abdomen; the sudamina are small 
vesicles, filled with clear fluid, and are not likely to be mistaken for any 
other affection. This eruption, of course, occurs in many other diseases. 
(d) Erythema. - A rash of vivid red colour, not unlike the scarlet 
fever rash, sometimes appears during the first week, chiefly on the 
chest and abdomen. I have twice noticed a similar rash occurring ENTERIC FEVER 
815 
during the third week, and chiefly affecting the arms. This rash may 
in some cases be due to the administration of drugs - quinine, salicylate 
of sodium, antipyrin, etc. It has been observed, however, quite inde- 
pendently of such drugs (65, 100), and is probably of septic origin. 
(e) Morbilliform rash, resembling measles (58, 66), in larger or 
smaller patches, with a dark haemorrhagic centre and a lighter coloured 
periphery, affects the neck and trunk, spreads rapidly, but does not 
extend to the mucous membrane, and appears not materially to affect 
the course of the fever. Neumann found the streptococcus pyogenes 
on the arms of a patient during the existence of this rash. 
(/) Urticaria is occasionally observed, but is probably in most cases 
a drug eruption. 
0) Herpes, so common in pneumonia, is very rare in enteric fever; 
it has been observed sometimes, however, during the first week. In 
two cases in which I noticed it the enteric fever was complicated by 
pneumonia. 
(It) Desquamation in fine branny scales is often observed towards 
the end of the fever or during convalescence. 
(Edema of the skin is noticed sometimes towards the end of the 
febrile period (from thrombosis of a vein), or during convalescence 
(from anaemia and nephritis). 
Erysipelas. - This is occasionally noticed as a complication. I have 
seen it twice in children; it occurred when the fever symptoms were 
subsiding. It commenced in the usual way - the face, forehead, and 
ears being chiefly affected, and it ran a favourable course. Silvestrini 
(81), in a case of erysipelas complicating enteric fever, found the 
typhoid bacillus in the erysipelatous eruption. 
Bed-Sores. - The marked improvement which has taken place in the 
nursing and management of fever patients has almost abolished bed- 
sores ; yet in a few very protracted cases in very debilitated persons, 
whatever the precautionary measures, they may perhaps be unavoidable; 
and several factors, besides mechanical pressure - such as the condition 
of the blood, and trophic changes due to central nervous causes - help 
in their production. They are noticed over the sacrum, or over the 
trochanters, knees, elbows, ankles, shoulder, head, etc. At first the 
skin reddens, then small superficial erosions or fissures appear, and 
these deepen, giving rise to gangrenous patches, which may slough off, 
leaving the subjacent parts bare; occasionally the destruction of tissue 
extends, and may be accompanied by suppuration and the appearance 
of septic symptoms. We may thus have extensive destruction of bone, 
which, when it affects the sacrum, may lead to septic meningitis, or 
when the bed-sore is situated over a joint may lead to opening of the 
joint cavity, and further changes. 
During convalescence one notices occasionally loss of hair, which, 
however, in most cases grows again. As in other fevers and severe 
diseases, a transverse ridge of the nails, from interference with nutrition, 
is noticed after recovery from enteric fever. There is an opaque white 816 
SYSTEM OF MEDICINE 
line, followed usually at some little distance by a depression; starting 
close to the bed of the nail, gradually with the growth of the nail it 
advances forward till eventually it disappears; in older people, how- 
ever, it may remain visible for a long time. 
The circulatory system presents important symptoms, especially from 
a prognostic point of view. As in other febrile infectious diseases, the 
continued high temperature, the toxic products of the micro-organism, 
and the presence of the typhoid bacilli in the myocardium (Chante- 
messe), and especially also secondary infection, exert a deleterious 
effect on the heart muscle, and are often the cause of death in typhoid; 
the blood itself presents important changes which differ somewhat from 
those seen in other acute febrile affections, and lead to further disturb- 
ances, especially noticed in the post-febrile period. 
Pulse. - During the first week, and during the whole period of the 
fever in cases which are likely to end in recovery, the pulse, except in 
children, ranges from 86 to 100 in men, and from 100 to 120 in women; 
it is distinctly and markedly dicrotic, indicating a paresis of the arterial 
muscular coat and low blood pressure. The force of the pulse varies, 
of course, with the age and strength of the individual and the condition 
of the heart; according to Potain, the blood pressure in the arteries is 
always diminished, see on this subject also Moser (65a). During the 
second and third week the pulse generally becomes a little quicker and 
less dicrotic, and during convalescence may be very slow. A small and 
quick pulse is of bad omen; Liebermeister found that when the pulse 
reached 140 pulsations per minute death occurred in 50 per cent, and 
when over 140 the mortality was 80 per cent. Equally unfavourable is 
the prognosis when the pulse becomes irregular and intermittent, even 
if not very frequent; such a pulse is often followed by pulmonary or 
cerebral thrombosis, with sudden death at a later period, and it indicates 
myocarditic changes. In some cases of enteric fever a slow pulse (50- 
40) has been noticed throughout the disease, which returned to its 
normal frequency during convalescence (Murchison). There is no defi- 
nite relation between the temperature and the pulse, though often with 
rise of temperature the pulse also increases. The physical examination 
of the heart in ordinary uncomplicated cases reveals nothing abnormal; 
in severe cases the first sound may be very feeble or quite inaudible, as 
pointed out by Stokes; or the first and second sound become very simi- 
lar in timbre and duration; sometimes a systolic murmur is heard at 
the apex or over the area of the pulmonary artery. With these signs 
dilatation of the heart, cyanosis, and venous pulsation may be noted. 
French observers have described a cardiac form of enteric fever. These 
cases are characterised from the first by quick, small, and irregular 
pulse, a low temperature, pallor of the face and extremities, and retro- 
sternal pain. The prognosis of these cases is always very grave, and 
death often occurs from collapse or syncope. 
As further complications, especially during the last stage of and 
during convalescence from enteric, blocking of arteries and of veins ENTERIC FEVER 
817 
occurs, the latter being much more common. The affection of the arte- 
ries has been described by Landouzy and Siredey as an arteritis, of 
which they distinguish a parietal and an obliterating form. This affec- 
tion, if it occur, is almost always met with during convalescence; it 
affects the large trunks, and is ushered in by fever and by pain over the 
affected artery, which can be felt as a cord-like mass; the pulse in the 
vessels below the obstruction is very much diminished, oedema appears 
in the peripheral part of the affected limb, and in some cases dry gan- 
grene follows: the surface temperature of the affected part is most usu- 
ally diminished. In a case reported by Sydney Phillips (69), in which 
blocking of the left common femoral artery took place, the surface 
temperature of the affected limb showed an increase of 5° E. 
Thrombosis of veins is of much more frequent occurrence. It affects 
most commonly the left femoral vein, but may affect other veins, as of 
the upper extremity; it is ushered in by slight rise of temperature, 
severe local pain, often lasting several days, and marked swelling of 
the limb; occasionally several attacks of thrombosis may occur during 
convalescence. In one case under my own observation each attack was 
preceded by a rigor, very high temperature, very quick pulse, and pro- 
fuse sweating. In the clot obstructing the vein micro-organisms have 
been found (Vaquez). The thrombosis may extend into other veins; it 
may lead to pyaemic symptoms, and sometimes it causes sudden death 
from pulmonary embolism. If by the thrombosis of the vein the adja- 
cent artery be much compressed, or if clotting in the artery be associated 
with it, gangrene of the distal part of the limb ensues. 
Infarcts of the spleen, kidney, and lungs are sometimes seen post- 
mortem. Unless these infarcts are very extensive, they cannot often 
be diagnosed during life. 
The blood in enteric fever shows some marked changes. For the 
literature on this subject I must refer to the paper by W. S. Thayer in 
the Hospital Reports of the Harvard University, vol. iv. No. 21, p. 83. 
The older writers state that the clot obtained by blood letting in this 
fever shows, by an absence of the buffy coat, that the fibrin is diminished. 
The histological examination of the blood has not always given uniform 
results, but the majority of observers are agreed upon the following 
broad facts:-the number of red blood corpuscles, normal at first, falls 
gradually during the fever, but not to a very large extent; with the 
cessation of the fever the number falls still lower, and may fall to a very 
low degree (post-typhoid anaemia). The red blood corpuscles may 
undergo temporary changes in number during the fever; thus profuse 
diarrhoea may cause a temporary increase, haemorrhage a decrease. The 
amount of haemoglobin falls and rises with the number of the red blood 
cells. The leucocytes are stated by most recent observers to be not only 
not increased, but rather diminished in enteric fever-a marked difference 
between enteric fever and inflammatory affections and other infectious 
fevers. Some observers, however, have noticed a slight increase at the 
beginning of the attack. With convalescence the number gradually 
VOL. 1 
3 G 818 
SYSTEM OF MEDICINE 
returns to the normal. In post-typhoid anaemia certain changes in the 
relative proportion of the various forms of leucocytes have been noted 
by Thayer, namely, a great increase of the large mononuclear leucocytes, 
and a diminution of the multinuclear neutrophiles. Eichhorst found in 
one case large granular cells containing several red blood corpuscles. 
The specific gravity of the blood taken after the method of Schmelz 
shows considerable diversity. The glycogen of the blood has been found 
increased. Typhoid bacilli have repeatedly been found in blood drawn 
from the spleen by a syringe, but very rarely in blood drawn from the 
finger or a superficial vein, or from the roseolar eruption. Streptococci 
and staphylococci have been found in the blood in mixed infection [see 
" Mixed Infection," p. 832]. 
Respiratory System.-Epistaxis as an early symptom has already 
been mentioned. In severe cases of the so-called "haemorrhagic 
typhoid" profuse epistaxis, haemorrhages from the stomach, kidneys, 
and other organs, and cutaneous and subcutaneous haemorrhages, have 
been observed at a late stage of the fever. 
Laryngeal Affections.-The larynx is not unfrequently found affected 
in enteric fever. About the proportion of cases affected authors vary 
considerably. In many cases there are no subjective symptoms, and 
laryngoscopic examination only can reveal the nature and extent of the 
affection; in others the symptoms are dryness and tickling of the throat, 
hoarseness, cough; while some affections, like oedema and perichondritis, 
may give rise to alarming and sometimes quickly fatal symptoms. The 
various affections are - 
1. Catarrhal Affection. - This, according to Landgraf, Lewin, and 
others, is a simple hypersemia of the mucous membrane. 
2. Ulcerations, which, according to some observers, are due to the 
typhoid bacillus, and may thus be looked upon as a typical form of 
typhoid, " laryngo-typhoid." These ulcerations are situated in the 
parts of the larynx provided with adenoid tissue, namely, the base of 
the epiglottis, the posterior wall of the larynx, especially the inner sur- 
face of the arytenoid cartilages, and the false vocal cords. These ulcers 
may be simple erosions and heal readily, or they may become necrotic 
and leave sharply-defined defects, or they may lead to extensive peri- 
chondritis and exfoliation of the cartilages. As yet typhoid bacilli have 
not been found in these ulcers, and some therefore look upon them as 
allied to the next class, namely, 
3. Ulcerations due to an epithelial necrosis, and caused by strepto- 
cocci and staphylococci (Eppinger, Landgraf). They appear at first 
in the form of yellowish spots, which break up into smaller masses. 
These masses slough and become detached, leaving more or less deep 
ulcers, which may lead to further changes. 
4. True Diphtheritic Affection. - This is extremely rare, and but few 
undoubted cases (35) are recorded. In one case the diphtheritic mem- 
branes extended to the bronchi, and the soft palate was also affected. 
5. Perichondritis with exfoliation of the cartilages, which may lead ENTERIC EE VER 
819 
to marked, narrowing of the larynx, or in rare cases to subcutaneous 
emphysema of the neck, must be looked upon in nearly all cases as 
secondary to the ulceration. It is chiefly noticed during convalescence; 
it may lead to suppuration and extensive destruction, and to alarming 
symptoms of suffocation. In several cases small portions of cartilage 
have been coughed up, and recovery has taken place; in many trache- 
otomy is necessary, though this is not unfrequently followed by fatal 
results (62). Some authors (Dietrich, Richie) have looked upon the 
laryngeal ulcers in enteric fever as allied in their origin and nature to 
bed-sores, and due partly to pressure and partly to disturbance in the 
circulation and innervation of the parts: they have accordingly pro- 
posed for these ulcers the name of " decubitus ulcers." 
Lastly, we have to notice paralysis of the vocal cords, which has 
occasionally been observed during convalescence, or some time after. In 
some cases it has been found due to pressure on the recurrent laryngeal 
nerve, either by enlarged glands or thickened pleura (Schrbtter); in 
others it is probably the result of changes in the muscles or nerves due 
to the toxic effect of the poison. Thus in one case paralysis of the 
vocal cord was noticed with multiple peripheral neuritis. 
For a more detailed account of the laryngeal affections see (52, 28). 
Bronchitis is very often noticed in enteric fever, especially in the 
older subjects. It may occasionally become very severe, and extend to 
the smallest bronchi. 
Broncho-pneumonia occurs chiefly in the disseminated form, and may 
lead to small foci of suppuration. 
Hypostatic congestion occurs frequently in enteric fever owing to 
the enforced and prolonged recumbent posture of the patient; it may 
lead to hypostatic pneumonia or collapse. 
Croupous or Lobar Pneumonia. - It has now been clearly demon- 
strated that in most cases the pneumococcus of Frankel is the cause of 
pneumonia in typhoid. In others (septic pneumonia) a streptococcus 
has been found. Some few cases are, however, recorded where the 
typhoid bacillus has been detected in the inflamed lung, and such cases 
must be regarded as a specific localisation of the disease (pneumo- 
typhoid) (70a). Clinically considered, it must be noted that in some 
cases pneumonia occurs at the outset of the disease, and masks the enteric 
symptoms for some days, till in the second week, on the subsidence of the 
pneumonic symptoms, but slight abatement of the fever follows, and the 
enteric symptoms become more pronounced; in others, and this is more 
frequent, pneumonia sets in at the end of the second or third week of 
the fever. The usual symptoms - such as rigor, pain, and rusty sputum 
- are often absent, and the affection is often to be recognised only by 
increased frequency of breathing, by rise of temperature, and by the 
physical signs; in some few cases, however, acute pleuritic pain and rusty 
sputum may be noticed. Of the combination of septic pneumonia and 
enteric fever I have lately seen a case in which the pneumonia was of 
the creeping kind, attacking first the base and then the apex on each 820 
SYSTEM OF MEDICINE 
side; the sputum contained masses of streptococci but no pneumococci. 
During the influenza epidemic the combination of influenza pneumonia 
with enteric fever was occasionally noticed (93). The association of 
pneumonia with true enteric fever must be distinguished from the 
" typhoid pneumonia," in which diarrhoea and all the symptoms known 
as the "typhoid" state occur - namely, great prostration, low muttering 
delirium, etc. In many cases the diagnosis cannot be made until the 
disease has lasted some days by the marked enlargement of the spleen, 
the appearance of roseolar spots, the persistence of the fever and the 
occurrence of intestinal haemorrhage. 
Pleurisy and empyema have occasionally been noticed during the 
course of enteric. Milder attacks of pleurisy, in which spontaneous 
absorption of exudation takes place, are not uncommon. Extensive 
exudations occur much less frequently, and are to be considered as the 
result of a mixed infection, due to streptococci or pneumococci. The 
typhoid bacillus has been found in a very few cases only (Weintrand, 
Belfanti). 
Tuberculosis of the lung has occasionally been observed during con- 
valescence or some time after; probably the disease in these cases was 
already present in the patient before he caught typhoid. Acute tuber- 
culosis following enteric fever has been noted especially in some of the 
epidemics of enteric in soldiers during war (38). 
The Mouth. - The state of the tongue, as already indicated in the 
general description, varies with the severity of the disease and the stage 
of the disease. At the onset it is covered with a white fur, which 
gradually thickens, but is still moist; and in milder cases this condition 
may not alter throughout the whole of the course: in the ordinary cases 
after the first week the tongue becomes dry, and is covered by a brown 
fur; later the dryness still further increases, and the centre of the 
tongue is covered by a deep brown, almost black, dry fur, which may 
form crusts and leave fissures. The gums and lips become likewise 
covered by brown, dry masses of sordes. With the beginning of con- 
valescence the tongue becomes moist again and quickly cleans. The 
secretion of saliva is in most cases very much diminished, as indeed is 
the case in most fevers. 
Parotitis is occasionally observed during the later course or as a 
sequela; it gives rise to more or less extensive swelling, and is usually 
unilateral; the exudation may gradually become absorbed, or suppura- 
tion may ensue, which not unfrequently leads to other septic symptoms 
and death. It is more frequently noticed in some epidemics than in 
others, and is either due to an extension of the inflammation from 
Steno's duct or to a metastatic inflammation. Murchison recorded six 
cases of which five terminated fatally; Osler noticed some cases which, 
however, all terminated favourably. 
Cancrum oris occurs chiefly in children, and appears to be much less 
frequent now than formerly. It is observed during the latter stage of en- 
teric, and its commencement, as it begins without pain as a small necrotic ENTERIC FEVER 
821 
patch on the mucous surface of the cheek, is not likely to be noticed. 
The necrotic patch extends in depth, and soon a hard, brawny, shining, 
indurated patch, at first pale and gradually deepening in colour, appears 
on the outside of the cheek; the patch softens, a deep slough forms, and 
on separation a hole may form through which the gums and teeth can be 
seen; at the same time the process extends on the mucous surface, causing 
extensive ulcerations of the gums, and even of the tongue. The gangrene 
may now spread farther, affecting the greater part of the cheek, the jaw 
may be laid bare, the teeth become loosened and fall out, and necrosis 
of the alveoli follow. There is marked salivation, and the breath is 
very foetid. In spite of the extensive spreading of the necrosis there 
is rarely any haemorrhage, and there is no pain throughout the whole 
course of the disease. In most cases the patient dies from septic pneu- 
monia or other septic complication. Recovery is very rare, and in this 
event a marked disfiguration of the face remains. The affection is of 
the nature of gangrene, and is not due to typhoid bacilli; long threads 
of small bacilli have been found in the spreading edge by Lingard. 
Pharynx. - Catarrhal affection of the pharynx is often observed, 
and during the latter stage of severe cases there is occasionally a thick 
deposit on the fauces, which can be detached, and is found to consist 
of debris, particles of food, masses of epithelial cells, leucocytes, and 
numerous micro-organisms. In some cases a deposit roughly resembling 
a diphtheritic membrane is seen; this owes its origin probably to 
streptococci and staphylococci, which are found in large numbers 
together with necrotic tissue and fibrin. This is usually a complication 
of very severe and fatal cases. 
A peculiar ulceration has been described by several French and 
German observers (Bouveret, Devignac, Duguet, Wagner, Cahn) (9), 
and is looked upon as specific of enteric fever. It has been named 
pharyngo-typhoid. The ulcers are superficial, circumscribed, cleanly 
cut, and occur principally on the soft palate, close to the hard palate. 
From the observations of Renon it appears, however, that they are not 
due to typhoid bacilli, but to streptococci and staphylococci. 
Gastro-Intestinal Symptoms. - Nausea and vomiting, as already 
noticed, may be present at the onset and continue for some days. In 
most cases these symptoms disappear after the first week, so that the 
patient, as a rule, has no difficulty in taking large quantities of milk; 
the secretion of gastric juice is very much diminished, and free hydro- 
chloric acid, as in most febrile affections, is absent. In cases where 
severe nephritis is noticed during the course of the fever, persistent 
vomiting, probably uraemic, has been noted. Epigastric pain and 
vomiting, due to inflammatory changes and ulceration of the stomach, 
have also been recorded (A. Chauffaro). 
Diarrhoea is one of the characteristic symptoms of enteric fever. It 
may be present from the first, and persist throughout the whole course, 
continuing sometimes even when the temperature has reached the 
normal. In other cases there is constipation at first, and diarrhoea 822 
SYSTEM OF MEDICINE 
begins about the end of first week; in others diarrhoea may be absent 
throughout, and even obstinate constipation may exist. Profuse diarrhoea 
is noticed principally in severe cases, but there is no relation between 
the diarrhoea and the ulceration of the intestines, and even in constipated 
patients extensive ulcerations have been found. The number of stools, 
usually four to ten in twenty-four hours, varies considerably; sometimes, 
however, the stools occur even more frequently. With each evacuation 
a fairly large quantity is discharged. The stool is thin at first, but of 
ordinary brown colour; soon it becomes yellowish, of the colour and 
consistency of pea-soup: it is often uniform, but in children, and some- 
times in adults when very large quantities of milk are taken, it contains 
curds. With the approach of convalescence I have frequently noticed 
the colour of the stool to become greenish and less uniform, showing 
small solid particles. The stool, especially in children, has a very foul 
smell. On standing, a clear upper stratum separates, which is very rich 
in albumin. Microscopically examined the stool, besides the partly 
digested particles of food, contains a large quantity of triple phosphates, 
desquamated epithelial cells, embryonic cells, blood corpuscles, necrotic 
tissue elements, and granular detritus. Numerous micro-organisms are 
found, micrococci and larger and smaller bacilli. The typhoid bacillus 
has not been found in the alvine discharges before the ninth day; its 
detection, especially its distinction from the bacterium coli which occurs 
constantly in the faeces, both in health and in disease, has already been 
described; and it has been seen that at present no clinical diagnosis can 
be based upon it. Careful examination of the stool on the third week 
often reveals the presence of small shreds, probably sloughs from Peyer's 
patches. There is usually no pain either before or after the discharge. 
Haemorrhage from the bowels in any marked quantity occurs in from 
3 to 7 per cent of the cases (Murchison, Liebermeister). It is much 
rarer in children. In some cases it may occur at the end of the first 
week, and is then probably due to intense congestion; most commonly 
it occurs after the second week ; it may occur only once, and is then 
not a very unfavourable symptom, or repeatedly, and there may be eight 
to ten, and even more discharges in twenty-four hours, consisting of 
almost pure liquid blood. In two very severe cases (husband and wife) 
the haemorrhage was so profuse that pressure on the abdomen, or any 
movement on the part of the patient, was followed by a discharge of 
blood, but both patients recovered. In less severe cases the stool is 
black and tarry. Slight haemorrhage does not give rise to any subjective 
symptoms. Profuse haemorrhage is indicated by a sensation of faintness, 
rapid fall of temperature (from 2° to 5° F.), pallor of the face, smallness 
and rapidity of the pulse, and extreme prostration. According to 
Ztilzer, whose statement is confirmed by Moore, profuse haemorrhage, 
by filling several coils of intestines, may give rise to a dull percussion 
note where previously the note was tympanitic. Such abundant haemor- 
rhage during the later stage of typhoid is due either to erosion of the 
vessels on the separation of a slough, or to an increased diapedesis from ENTERIC FEVER 
823 
the small arteries, whose walls are degenerated (72). As to the prog- 
nostic importance of the hsemorrhage authors differ somewhat. Graves, 
Trousseau, and Griesinger are of opinion that the occurrence of haemor- 
rhage is not an unfavourable symptom. This is probably correct when 
haemorrhage occurs only once and early, as by the haemorrhage some of 
the toxic material accumulating in the blood may be got rid of. Profuse 
haemorrhage, on the other hand, occurring at a later period, must always 
be looked upon as a very serious event, and the mortality, from syncope 
chiefly, is very high (30 to 40 per cent). 
In haemorrhage typhoid, with petechial eruption, and abundant epis- 
taxis, intestinal haemorrhage is a prominent symptom, and may occur 
earlier in the disease. 
Tympanites is almost a constant symptom in enteric fever, and when 
excessive is of grave omen. It may favour perforation, or by displace- 
ment of the diaphragm upwards cause cardiac disturbances. Of gur- 
gling and pain on pressure we have already spoken. Abdominal tender- 
ness is sometimes observed for the first week or later; it is sometimes 
diffuse, at other times limited to the region of the umbilicus, or the 
right iliac region. Persistent and localised pain is probably due to 
slight peritonitis. 
Perforation of an intestinal ulcer is one of the most terrible of acci- 
dents. It seems to occur in about 2-5 to 3 per cent, and was noticed 
114 times in 2000 fatal cases (42). It is rarer in children, and occurs 
more frequently in men than in women. It may occur any time after 
the second week, and it has been observed after all fever symptoms 
have subsided. Osler observed one case as early as the eighth day. 
In Hoelscher's table, of the 114 fatal cases, no case is recorded in the 
first two weeks of the fever. As accessory causes, indigestible food, 
excessive tympanites, obstinate vomiting, movements on the part of the 
patient, and the presence of intestinal worms, are cited; but occasion- 
ally perforation may occur without any such aids. It may occur in mild 
cases, and I have noticed it in apyrexial typhoid. The perforation, 
setting in suddenly, quickly gives rise to the symptoms of perforative 
peritonitis: severe pain, at first situated over the right iliac fossa (or 
referred pain over the left iliac region), soon becomes general. The 
pain may be persistent, or more like colic; in some few cases it has 
been entirely absent. Vomiting usually occurs early; the patient shows 
symptoms of collapse; the features become pale and pinched, the pulse 
small and threadlike, the abdomen more distended, and the liver dulness 
can no longer be made out on percussion (Wagner, Flint). In some 
cases the abdomen, instead of being distended, may be retracted, with 
marked rigidity of the walls (Wagner). The breathing becomes thoracic, 
and the temperature suddenly falls, though it may afterwards rise again 
considerably. There is often suppression of urine. Soon the prostra- 
tion becomes extreme, the voice husky, cold clammy perspiration covers 
the face and body, and the patient gradually sinks, the sensorium often 
remaining clear to the end. In some cases death may occur at a later 824 
SYSTEM OF MEDICINE 
period from subacute peritonitis. Thus a patient was admitted into the 
Manchester Infirmary with symptoms of intestinal obstruction which 
had lasted for some days; the patient died soon after admission. At 
the autopsy typical typhoid ulcers were found, one of which was perfo- 
rated, and faecal extravasation had taken place. There was extensive 
peritonitis and a small quantity of faecal matter lay free in the abdo- 
men. Recovery does occasionally, but very rarely, occur. If the per- 
foration be a tiny one the symptoms may not be very characteristic: the 
pulse, however, will rise over 120, and the temperature may fall. The 
area of liver dulness may also be diminished, and the respiration be 
thoracic. There may be a disposition to vomit, and a little increasing 
pain. Yet even in such a case laparotomy can scarcely be advisable, as 
the enfeebled heart, extensive intestinal ulceration, and febrile prostra- 
tion, prevent much hope of success. 
Perforative peritonitis, apart from the perforation of an ulcer, may 
occur from ulceration of the gall-bladder, rupture of a suppurating mes- 
enteric gland or of abscess of spleen, rupture of spleen, etc. 
The occurrence of peritonitis without perforation may occur from 
extension of the inflammation to the serous coat of the intestine. It is 
then generally circumscribed, and tends to form adhesions. Occasion- 
ally it may give rise to a local suppuration. 
Complications relating to the Liver and Biliary Apparatus. - Recent 
experimental investigations have shown that in microbic diseases the 
liver plays an important part, the vessels with their endothelial lining, 
and probably also the liver cells, being actively concerned; but these 
changes do not give rise to symptoms which can be clinically recognised, 
and the changes which we notice are due not so much to the typhoid 
bacillus, as to a mixed or secondary infection, and to complications. 
Jaundice is very rare in the enteric fever of our climate. It has been 
noticed late in the disease, or even during convalescence, and is most 
commonly due to catarrhal secretions blocking up the bile duct. In other 
cases the jaundice is due to micro-organisms which have been found in 
the biliary passages, such as the bacterium coli commune, streptococcus 
pyogenes, etc., which give rise to inflammation of the biliary ducts (cho- 
langitis) with or without formation of abscesses. Such cases usually run 
a fatal course, with symptoms of pyaemia. The gall-bladder from a 
similar cause may be the seat of suppuration, and may even be ruptured. 
Some observers draw attention to the formation of gall-stones after 
recovery from enteric fever, and Dufourt collected nineteen cases where 
gall-stone colic occurred thereafter. Chantemesse gives a case where 
a woman eight months after enteric began to suffer from hepatic colic, 
jaundice, and fever. The gall-bladder, removed by operation during life, 
showed the presence of biliary catarrh and living typhoid bacilli. I 
may here draw attention to the not unfrequent coexistence of gall-stone 
and ulcerative endocarditis [see article on " Ulcerative Endocarditis 
Spleen. - The enlargement of the spleen is a constant symptom in 
enteric fever, and its gradual increase can often be demonstrated during ENTERIC EE VER 
825 
the course of the disease. During the second week, especially in chil- 
dren, the edge of the spleen can often be readily felt, particularly on 
deep inspiration. The enlargement continues to the end of the third 
week, when it gradually subsides. The spleen is found increased in its 
various dimensions, and the enlargement can be readily made out by 
percussion. When there is great distension of the abdomen, or when 
the stomach or colon are inflated and displaced, the splenic enlargement 
cannot easily be made out; in other cases the area of splenic dulness, 
though not enlarged, is increased in intensity. Palpation of the spleen 
is occasionally painful. Abscesses and rupture of the spleen have been 
occasionally noticed; they are, however, extremely rare, and more of 
pathological than clinical interest. 
Genito- Urinary System. - The urine in enteric fever presents the 
ordinary character of febrine urine. It is decreased in quantity, high- 
coloured, very acid, and of high specific gravity. Uric acid, kreatinin, 
and ammonia are increased; urea is usually increased, though sometimes 
it is diminished during the first few days. Chloride of sodium1 and 
phosphoric acid (Zuelzer) are found diminished - the potash salts and 
relative sulphuric acid (Zuelzer) increased. Of abnormal constituents, 
albumin is found in 70-80 per cent of the more severe cases. Of the 
various forms of albumin serumalbumin is constantly found, and with 
serumalbumin globulin often, hemi-albuminose or prepeptone occasion- 
ally. In several cases the urine has given the reactions of hemi-albu- 
minose for one or two days, which was then replaced by serumalbumin. 
The urine may contain blood when haemorrhagic nephritis complicates 
enteric fever, and in petechial typhoid. In some severe cases haemoglo- 
binuria has been observed. Mucus occurs when cystitis is present. In 
some cases acetone and aceto-acetic acid are found in the urine without 
the presence of sugar. Microscopic examination may reveal the presence 
of various forms of casts, as will be presently pointed out. In very severe 
cases of enteric fever leucin and tyrosin have been found in the urine. 
Ehrlich'1 s Diazo Reaction. - Ehrlich described this test in 1882, and 
since then a large number of observations have appeared on the subject 
(40). The peculiar reaction is probably due to the presence of some 
nitrogenous products in the urine. To carry out the test we use two 
solutions: No. 1, a saturated solution of sulphanilic acid in dilute hydro- 
chloric acid (1 in 20); No. 2, a solution of sodium nitrite in water (i per 
cent solution). The urine to be tested is put into a test-tube, and a 
quantity of the solutions 1 and 2 equal to that of the urine is added 
(about 40 c.c. of the sulphanilic acid and 1 c.c. of sodium nitrite solu- 
tion), the mixture is well shaken, and then some drops of liquor am- 
monise are allowed to slip down the side of the tube. At the junction of 
the two a deep brownish red ring appears; if again shaken the whole 
1 Terray (88) compared the quantity of sodium chloride in the food with that voided 
by the urine and the faeces in four cases of enteric fever, and found the chloride diminish 
during the whole fever period, and also for some days after the fever had disappeared. 
The diminution, according to Leyden, is due to the retention of water in the system 
during the fever. 826 
SYSTEM OF MEDICINE 
fluid mass appears red, and if the diazo reaction be present the foam 
appears also rose tinted. This test has undoubtedly some diagnostic 
value (87). It is certainly present in a very large majority of cases of 
enteric fever both in adults and in children, and even in the apyrexial 
type; according to Taylor, it does not often appear before the end of the 
first week (Hewetson noticed it in 77 per cent of his cases in the first 
week), and it often disappears during the third and fourth week. The 
reaction, however, is also seen in other febrile affections (typhus, measles, 
scarlet fever, pneumonia, acute tuberculosis), and in some apyrexial dis- 
eases (chronic hepatitis, carcinoma, leukaemia, etc.), and its diagnostic 
value is thereby somewhat lessened. 
Albumin in the urine is an important symptom; it is not always due 
to the same cause, and from analogy with other infectious diseases, and 
from a consideration of the pathological changes in the kidney found 
after death, we may distinguish the following forms of albuminuria: - 
1. Febrile Albuminuria. -- The albuminuria is here due to the 
pyrexia,1 though the retention of toxic products in the blood cannot be 
overlooked as a probable cause. Clinically this albuminuria is charac- 
terised by the small amount of albumin in the urine without blood, and 
often without casts; if casts be present they are hyaline and few in 
number. This albuminuria may be noted early, sometimes even in the 
first week. It occurs in children as well as in adults; it is sometimes 
absent for a day or two, and it disappears with convalescence. It does 
not give rise to very serious symptoms, and is not followed by any per- 
manent damage of the kidney. 
2. Albuminuria due to Acute Bright's Disease (Haemorrhagic Neph- 
ritis, Nephro-typhoid). - The albumin is here often abundant; the urine 
contains also blood, and granular, fatty, and blood casts are seen. Vari- 
ous micro-organisms, amongst them the typhoid bacilli, have been found 
occasionally in the urine during life, or in the kidneys after death in this 
affection. This complication, if stress be laid on the free admixture of 
blood, is of rare occurrence - the presence of large quantities of albumin 
and casts without any blood, or with but a small quantity of blood, is of 
more frequent occurrence (Osler and Mason's figures give about 10 per 
cent of the observed cases of enteric fever). This complication is usually 
observed in the second week, but sometimes (Gubler, Robin) it may be 
an early symptom. It may last for several days, and end in recovery; 
or uraemic symptoms, low delirium and convulsions may set in. When 
this complication occurs early with pain in the back and the passage of 
urine containing much blood, and is followed by uraemic symptoms, 
the primary disease is difficult to recognise. The affection is most 
likely due to the action of bacterial products on the kidney, products 
which either circulate in the blood or pass to the kidney from another 
1 As it has been demonstrated by means of Roy's oakometer that with an increase of 
the body temperature the kidneys decrease in size considerably, the diminished quantity 
of urine passed and the presence of albumin in the urine are readily explained (64); again 
experimental investigations have shown that albumin may appear in the urine of animals 
exposed to high temperatures. ENTERIC FEVER 
827 
part of the urinary tract (67) : thus it is allied to the nephritis seen in 
other infectious fevers, and scarcely deserves the designation of nephro- 
typhoid. 
3. As septic infection is a common complication of enteric fever, we 
notice sometimes an acute suppurative nephritis, an earlier stage of 
what is probably Wagner's lymphatic nephritis. This gives rise to no 
diagnostic symptoms, except perhaps the presence of multinuclear leuco- 
cytes in the urine not due to any other complication in the urinary 
tracts, such as cystitis. 
4. During convalescence albuminuria may be observed with other 
symptoms of nephritis, and be followed by oedema. It is allied to the 
post-febrile nephritis seen in other infectious fevers (Osler). 
Of other complications we may notice: - 
Pyelitis, cystitis, when there has been retention of urine, haemorrhage 
from the bladder, urethritis. 
Orchitis, followed by epididymitis, occurs during convalescence. The 
patient becomes again feverish, the testicle is very painful and swells 
rapidly. Resolution sets in quickly, or suppuration ensues. 
Ovaritis and salpingitis have also been occasionally noticed. Changes 
in the menstrual period occur sometimes during convalescence. 
■ Symptoms relating to the Nervous System. - The nervous system is 
often profoundly implicated in enteric fever throughout the fever period 
and even after; so much so that in Germany the popular designation of 
typhoid is nervous fever (Nervenfieber). The nervous symptoms vary 
considerably in individual cases. 
At the onset, and sometimes even during the incubation period, 
headache and insomnia are the principal features; these usually sub- 
side after the first week. In milder cases there may be no other 
symptoms within the nervous sphere; in the more severe cases there 
are symptoms of irritation, and in the most severe cases of paralysis of 
the higher centres. Some of these have already been alluded to in the 
general description of the disease. 
Delirium is common in the ordinary, and especially in the severer 
cases. In the milder cases it may only occur at night, when the patient 
awakes from a slight slumber; in the more severe cases it is persistent, 
but varies in its manifestations. We have the quiet delirium, when 
the patient is easily roused, answers questions fairly rationally, but soon 
lapses into delirium again: violent delirium, when the patient gets very 
excited, talks or sings, or may even become violent; this may lead gradu- 
ally to acute maniacal delirium, which sometimes occurs in paroxysms, 
during which the patient must be carefully watched, as he may attempt 
to escape or do himself some bodily injury. It must be remembered 
that even without showing marked signs of delirium patients in enteric 
fever may manifest suicidal tendencies. Low muttering delirium is 
seen in the more severe cases: the patient is restless, mutters con- 
stantly, and trembles and twitches; equally serious is the delirium in 
which the patient is quiet, lies with his eyes open, but is quite uncon- SYSTEM OF MEDICINE 
828 
scions. The more severe forms often lead to coma. In tipplers the 
delirium often takes the form of delirium tremens - the patient con- 
verses with imaginary people, fancies himself at his usual avocations, 
gives orders, or serves customers, etc. 
In some cases, especially in women, the delirium has more the char- 
acter of lipemania; the patient imagines himself the subject of some 
persecution, he refuses to speak, keeps himself wrapped up in his 
blankets, appears terrified when any one approaches him, and is often 
absorbed in one fixed idea (4). The fixed idea from which the fever 
patient suffers sometimes persists for a while during convalescence. 
In one case a patient fancied he had received a commission in Her 
Majesty's service, and after he recovered from the fever he searched 
over all the newspapers to see if he had not been gazetted. 
In most cases the delirium occurs during or after the second week, 
but occasionally it is an early symptom, and when preceded by head- 
ache, and accompanied, as it sometimes is, by retraction of the head and 
neck, convulsions, taches cerebrates, etc., - and these occur more par- 
ticularly in children, - the diagnosis from meningitis is often difficult; 
in some cases, indeed, the post-mortem examination has shown the 
existence of meningitis besides the lesions of enteric fever. The men- 
ingitis may be the result of a mixed infection; the typhoid bacillus, 
however, has been found in the meningeal exudation (Ferult). 
Convulsions are noticed sometimes in children, both at the onset 
and during the course of the disease; in adults they occur sometimes 
in the meningeal form, or from uraemia in the so-called nephro-typhoid; 
or they may precede death when myocarditis complicates enteric fever. 
Severe nervous symptoms are seen, especially in those patients who 
have a marked neurotic disposition, either acquired or inherited; though 
the toxic effects of the fever poison cannot be excluded. 
The deep reflexes (knee-jerks) have been found increased, but this, 
from numerous observations I have made, is not invariably the case. I 
have found the knee-jerks absent in a few cases, though there were no 
indications of peripheral neuritis; in this latter case the knee-jerks are 
absent. 
The muscles often show increased irritability, and when marked ema- 
ciation is present they exhibit idiopathic contractions on being tapped. 
Muscular tremors affecting the limbs (the upper extremity more than the 
lower extremity), the tongue, and sometimes the muscles of the face, often 
accompany other severe nervous symptoms; and subsultus tendinum in 
enteric as well as in other affections is a grave though not a fatal omen. 
Retraction of the head and rigidity of the muscles of the neck, back, 
or extremities, may occur in severe cases, and, if associated with coma- 
tose symptoms, may suggest epidemic cerebro-spinal meningitis. 
There is scarcely any other febrile affection, except perhaps epidemic 
influenza, which is followed by so many nervous sequelae as enteric fever. 
Some of these are observed during the decline of the fever and during 
convalescence, others occur some time after. Of these we may mention - ENTERIC FEVER 
829 
Mental Diseases. - Loss of memory and feebleness of intelligence, 
leading to dementia, melancholia, monomania, and other forms of in- 
sanity, may appear. Some of these symptoms, probably due to malnu- 
trition, are of short duration; others, probably due to the toxic effect 
on the nerve elements, are of longer duration; in some cases recovery 
takes place after many months, whilst others remain incurable. 
Aphasia has often been observed in children, and is generally a tem- 
porary affection. 
Neurasthenia in its various forms may supervene - cerebro-spinal, 
spinal, sympathetic, and visceral. Under the name of " typhoid spine," 
cases of spinal neurasthenia, characterised by severe pain in the back 
and sometimes in the legs, have been described (67). 
Local pain, allied to local neurasthenia (topalgia of Blocqui), is occa- 
sionally noticed. The affection described as tender toes (acroparesthe- 
sia of Schulze), that is, an excessive tenderness on the slightest pressure 
of the toes, sole of the foot, and sometimes dorsal surface of the foot, 
also belong to this group; the opposite of this, more or less persistent 
anaesthesia of a circumscribed area, not due to peripheral neuritis, is 
occasionally seen. Local vaso-motor neurosis, consisting of redness 
with slight swelling of parts of the extremities, has been described. 
Hysterical manifestations during convalescence are not frequent, yet 
are occasionally seen both in men and women. 
Hemiplegia, due to haemorrhage, thrombosis, or merely temporary 
and due to anaemia or spasm of the arteries, is very rare in enteric. 
Disseminated sclerosis is found more often after enteric fever than 
after any other infectious disease. 
Acute disseminated myelitis is mentioned by Leyden and others as 
following enteric fever (21). 
Poliomyelitis. -Paralysis of one limb or portion of a limb, followed 
by atrophy, with partial recovery, has occasionally been noticed. Some 
of these cases are more likely to be forms of 'peripheral neuritis (80) ; 
some are due to an acute inflammation of the anterior cornua, as proved 
by the post-mortem examination (80). 
A peculiar complication occurring in enteric fever has been described 
by Eisenlohr (24). In three cases he observed symptoms of bulbar 
paralysis, affecting the lips and tongue, interfering with articulation, 
and accompanied by weakness in the muscles of the trunk. One of the 
three cases ended fatally, and numerous typhoid bacilli were found in 
the brain, medulla, cord, and chiasma of optic nerves. 
Peripheral Neuritis. - Occasionally extensive multiple neuritis, 
affecting both upper and lower extremities, with sensory disturbances 
and atrophy, is seen. One such case I saw in a young girl (75a), and 
the other in a child three years old, in whom contraction of both hands 
and feet set in after the paralysis had been established, but it yielded 
completely to treatment. More often the peripheral neuritis is located 
in a plexus of nerves, or in the root or trunk of one nerve only. The 
affection usually sets in with excessive pain, followed by numbness and 830 
SYSTEM OF MEDICINE 
paresis, going on sometimes to complete paralysis of the muscles supplied 
by the affected nerve or nerves, and often followed by marked atrophy. 
I have seen one case in which the root (both sensory and motor) of the 
fifth was evidently affected; partial recovery took place. Prof. Osler 
has recently published some careful observations on such cases (67a). 
Paralysis of cranial nerves is very rare in enteric fever. Occasion- 
ally paralysis of one or other of the ocular muscles has been noticed. 
Of the special sense organs hearing is commonly affected in enteric 
fever. In many cases the deafness is due to otitis media, which in the 
course of time may be followed by the well-known cerebral complica- 
tions - meningitis, thrombosis of cerebral sinus, abscess of the brain. 
Sometimes the deafness is due to an affection of the auditory nerve, and 
is more permanent. 
Optic neuritis is a rare complication. I have seen one case in which 
amblyopia and colour blindness occurred in one eye after the fever, and 
the optic disk was blurred; this probably was a case of retrobulbar 
neuritis. Ulceration of the cornea and suppuration of the orbit have 
been described (Panas). 
Bone and Joint Affections. - It has been pointed out by Chantemesse, 
that in inoculation experiments the typhoid bacillus can be traced to the 
medulla of bone, and it is therefore not astonishing to find that affections 
of the bones are no uncommon sequelae of enteric fever. The most com- 
mon event is the formation of an abscess periosteal or myelogenic. The 
tibia and femur are the usual seats of these abscesses, though they may 
occur in other bones, such as the sternum, ribs, etc. In the pus of them 
streptococci or staphylococci have been found; in some, however, only 
the typhoid bacillus. These abscesses, ushered in by severe and per- 
sistent pains, redness, and swelling of the affected part, often occur 
many months after the fever; and, in a case recently recorded by 
Buschke, forty-six years had elapsed since the occurrence of enteric 
fever, yet the typhoid bacillus found in the pus was capable of further 
growth and cultivation. In other cases the bone, instead of undergoing 
suppuration, becomes hypertrophic and deformed- hypertrophic osteitis. 
In children and young persons, after convalescence one occasionally 
notices an exaggerated growth of the bones. Sometimes a circumscribed 
periostitis is recorded, which comes on without any great pain, and may 
undergo complete absorption (Hutinel). 
The joint affections associated with or following enteric fever vary 
in their nature. 
1. Pain and swelling of one or more joints (the smaller joints, the 
ankle, wrist, and knee) is not a rare symptom in enteric fever, and may 
come on early in the disease. The symptoms generally subside during 
convalescence. As this is seen in pure and uncomplicated cases it is prob- 
ably more or less directly connected with the typhoid poison itself (31). 
2. The osteitis before described, when situated near the joint, may 
extend to the joint itself, and osteo-arthritis, with marked pain and 
swelling of the joint, and occasionally even suppuration, may occur. ENTERIC FEVER 
831 
3. Septic arthritis, usually with other pysemic symptoms, is seen in 
the mixed infection. 
4. Occasionally rheumatic arthritis, affecting several joints, may 
complicate and follow enteric fever, and set up endocarditis (94). 
Of other complications we have oidy yet to mention - 
Suppuration of the Thyroid Gland. - Golgi found the typhoid bacil- 
lus in the pus (17a). 
The Nutrition of the Body in Enteric Fever. - Emaciation is most pro- 
nounced, especially during the latter part of the attack. According to 
Robin (75), a person suffering from enteric fever eliminates more solids 
(52 grammes) than a healthy, well-nourished person (50 grammes). 
This, apart from many other factors, would explain the emaciation. The 
daily loss of weight is about 238 grammes. Klemperer's observations 
further show that during the fever the food albumin is not completely 
used up by the patient, who therefore gives up part of his body albu- 
min. Ziemec (102) found an average daily loss of body weight of 0'9 
per cent during the fever, a figure much lower than Robin's. 
[The subject of tissue metabolism in fever is set forth in the art. 
" Doctrine of Fever."] 
lielapse. - I have already spoken of a recrudescence of the pyrexia 
during convalescence from various causes. From this the true relapse 
must be distinguished, which is indeed a fresh attack of enteric fever, 
and in it appear many of the noteworthy symptoms, such as tympa- 
nites, diarrhoea often with slight hsemorrhages, a second series of roseo- 
lar spots, a further enlargement of the spleen, and pyrexia with marked 
evening exacerbations. These symptoms, of course, are not all con- 
stantly present. In the presence of the eruption and the renewed 
pyrexia, and in the absence of any local inflammation, the diagnosis of 
a true relapse must be based. 
Authors differ somewhat as to the frequency of relapse. Murchison's 
estimate is 3 per cent, Griesinger 6 per cent, whilst Shattuck gives over 
16 per cent. Men appear more liable to it than women. The duration 
of the relapse varies from nine to twenty-one days; thus it is shorter, 
and as a rule the symptoms are less severe than in the primary attack. 
In Shattuck's twenty-one cases of relapse there was only one death. 
The relapse may occur early or late during convalescence; in several 
cases I have seen it occur only a few days after defervescence; in most 
cases it occurs within the first fortnight of convalescence, whilst occa- 
sionally even a month or more may elapse before its occurrence. 
The first relapse may be followed by a second, and sometimes even 
by a third and fourth relapse, but as a rule the subsequent attacks are 
shorter in duration and milder in their symptoms. The cause of the 
relapse is most likely a reabsorption of the poison, and probably glands 
which escaped the typhoid bacillus during the primary attack of fever 
become affected; or it may be that some of the poison is retained in the 
spleen or some other organ, and is subsequently liberated and thrown 
into the circulation. 832 
SYSTEM OF MEDICINE 
Mixed Infection. - When describing the symptoms and complica- 
tions of enteric fever I have repeatedly drawn attention to the presence 
of other micro-organisms found in the diseased tissue, which must be 
looked upon as the cause of these complications; and we know now 
that in many of these complications not only in enteric fever, but in 
other infectious diseases, both acute and chronic (pneumonia, diphtheria, 
scarlatina, tuberculosis, etc.), mixed infection plays an important part. 
It is well to distinguish between double infection and secondary infection. 
In the first case the symptoms of the two different diseases are present 
and can be readily distinguished, their association often being only a 
coincidence, as, for example, enteric fever and tuberculosis, or enteric 
fever and typical diphtheria due to Lbffler's bacillus. The chief double 
infections which have been noticed in enteric fever are with tuberculo- 
sis - coming on chiefly after convalescence - scarlet fever, diphtheria, 
cholera, anthrax, erysipelas, and malaria. In the second case, the sec- 
ondary infection, the presence of one organism favours the development 
of the other. Thus it is now well established that the tubercle bacillus 
favours the growth and development of the streptococcus; many of the 
lesions and symptoms of phthisis are due to the latter and not to the 
former micro-organism. The same holds good for enteric fever, as 
the typhoid bacillus favours the growth of other micro-organisms, such 
as the streptococcus, the staphylococcus pyogenes, the bacterium coli, 
and the pneumococcus. There are various circumstances which may 
explain the development of these secondary micro-organisms, most of 
which may occur in the human body or its surroundings; as for example 
the weakened state of the system, the ulcerated condition of the intes- 
tines and other organs giving free access to the micro-organisms to the 
system, the presence of toxins in the blood, etc. The most common 
secondary infection is of septic nature, and due to the various patho- 
genetic cocci. It is not always easy to distinguish the septic complica- 
tions from the changes due to the typhoid bacillus itself, especially as 
it has been shown that the typhoid bacillus has pyogenetic properties, 
and may induce suppuration (71, 36, 7). Bacterioscopic examination 
of the blood will enable us sometimes to detect the pathogenetic cocci 
in the blood of the typhoid patient (83). Want of attention to the 
proper hygienic measures may easily lead to secondary infection. An 
instance in point is an observation by Korczynski and Gluzinski (48), 
in a ward previously occupied by many surgical cases wherein a number 
of patients affected with enteric fever were afterwards placed. Great 
mortality from septicaemia, pyaemia, phlegmonous inflammations, etc., 
ensued, and dust from the ward showed the presence of staphylococcus 
aureus, and the streptococcus pyogenes citreus and albus. After thor- 
ough disinfection of the ward these septic complications disappeared to 
a great extent. Cases of measles and of other acute infectious fevers 
in these wards showed no such complications. 
Varieties of Enteric Fever. -The diversity in the symptoms and course 
of enteric fever has led authors to distinguish certain varieties of enteric ENTERIC FEVER 
833 
fever. The usual classification, one which recommends itself from a 
clinical and practical point of view, is the following: - 
1. The Abortive Form. -The disease begins, like an ordinary attack 
of enteric fever, with high temperature, repeated shivers, enlargement 
of the spleen, diarrhoea and roseola, or some of these. Early in the 
second week the fever falls, and by the end of the week there may be 
complete defervescence. Relapses have been noticed. 
2. The Mild Form.-The symptoms are slight throughout the 
course of the disease, which lasts from sixteen to twenty-one days : the 
temperature does not reach 103°; diarrhoea, if present, is mild; the pros- 
tration not great. There is no great emaciation, and convalescence is 
usually rapid. 
3. Ambulatory Typhoid (walking typhoid, or latent typhoid). - The 
symptoms are here so slight that the patient follows his work, though 
more or less troubled with loss of appetite, diarrhoea and headache. 
Patients suffering from this form have often been known to walk to 
the out patients' room, where by the condition of the tongue, the tremor, 
and the temperature, the true nature of the case is recognised. In 
other cases violent delirium or profuse intestinal haemorrhage is the 
first symptom which brings the patient to the doctor; and if death 
occur soon after, as it often does, extensive intestinal ulcerations are 
found; or sudden death may occur from perforation (92). I remember 
one case of a workman who, whilst repairing the roof of a house, fell off 
and was killed by the fall; at the post-mortem examination, besides 
fracture of the skull, there were found typical typhoid ulcers in the 
ileum. At the inquest the wife of the deceased stated that her husband 
had complained of headache, lassitude, and giddiness for some days. 
4. The apyrexial form, which runs its course without any perceptible 
pyrexia. 
5. The grave form of enteric fever, characterised by high fever and 
grave nervous symptoms. According to the more prominent symptoms 
we distinguish under this head- (a) The Bilious Form (fievre bilieuse). 
Frequent and persistent vomiting of bilious matter, with severe and per- 
sistent headache; pulse quick and small; the case often ends fatally 
about the end of the second week from asthenia; delirium generally 
absent. (&) The Ataxic Form. - Delirium with hallucinations promi- 
nent, typhoid symptoms severe, and sometimes convulsions occur, 
(c) The Adynamic Form. -From the outset there are great prostration, 
very weak heart's action, abundant diarrhoea, low delirium, profound 
stupor: if these symptoms are associated with subcutaneous and internal 
hemorrhages the case is spoken of as the hemorrhagic form. 
Most of these severe forms are due to a secondary infection of septic 
nature. Pharyngo-typhoid, laryngo-typhoid, pneumo-typhoid, nephro- 
typhoid, cardio-typhoid, are often instances of mixed infection, as already 
mentioned. 
6. Spleno-typhoid occupies a somewhat different position. It is 
characterised clinically by a type of fever which in the excessive enlarge- 
VOL. I 
3 H 834 
SYSTEM OF MEDICINE 
ment of the spleen, and in the absence of intestinal symptoms, rather 
resembles that of relapsing fever (though spirilla are not found in the 
blood). The lesions in Peyer's patches are not well developed, only 
congestion and swelling being noticed (23). Moore (65) observed a case 
in which Peyer's patches were not even hyperaemic. 
7. Enteric fever in children is not rare. Some of the peculiarities 
observed in infantile enteric fever we have already noticed. In some 
cases the infection runs the same course as in the adult, in others the fever 
has a remittent type (infantile remittent fever), the evening temperature 
being 2° to 3° higher than the morning temperature. Abortive enteric 
fever is also noticed, likewise the bilious form. A respiratory or thoracic 
type has been described by some, the more prominent symptoms being 
quickened respiration, marked dyspnoea and cyanosis, and the presence of 
fine rales over one or both lungs. A meningeal type may be distinguished 
which sets in with headache, vomiting, and convulsions, and is followed 
by delirium, great prostration, and torpor. Diarrhoea and involuntary 
discharge of fseces is not infrequent, and the diagnosis from meningitis 
is often difficult. In these cases strabismus, inequality of pupils, 
injection of the conjunctivae, and even the hydrocephalic cry (8), may 
occur. Finally, a spinal type, with hyperaesthesia of the skin, contrac- 
tion of muscles and opisthotonus (26), is also described. 
8. Enteric Fever in the Aged. - Enteric fever is not common in 
persons after forty; but in epidemics old people are not infrequently 
affected. I have seen a typical case of typhoid in a man seventy-five 
years old.1 The affection usually commences insidiously with headache, 
loss of appetite, epistaxis; the fever is not very high, and rarely reaches 
103°; diarrhoea is present, but not usually profuse. Death sometimes 
takes place before the end of the third week from pulmonary oedema or 
failure of the heart. The mortality is high. 
9. Malario-typhoid. - See articles on Malaria and on Climate and 
Fevers of India. 
10. An epidemic atypical form of enteric fever, occurring only in 
those who shortly before had suffered from malaria, is described by 
Karlinski (45). It was observed in Bosnia, and called there dog-typhoid 
(Hunde-typhus). (The typhoid bacillus was found in the faeces in these 
cases.) 
Diagnosis. - The diagnosis of enteric fever is often made without 
difficulty; sometimes the diagnosis can only be made after watching the 
symptoms for some days, whilst in not a few cases it is impossible to 
arrive at a definite diagnosis. It is during the first week of the fever 
that the difficulty of diagnosing the disease is so great, and here Wunder- 
lich's propositions as to the temperature will be found a very useful 
guide; also such symptoms as severe headache, sleeplessness, epistaxis. 
Ehrlich's diazo reaction, though present in most cases, is also noticed in 
1 A well-marked and severe case occurred many years ago under my care in a vigorous 
old gentleman of eighty-two. By the labours of six nurses, working in pairs for eight 
hour watches, he was brought to recovery, but only to die during convalescence of a 
diaphragmatic hernia. -Ed. ENTERIC FEVER 
835 
other febrile affections, and being often absent during the first week, 
is of no great help in doubtful cases. Nor as yet can the detection of 
the typhoid bacilli in the stools be made of use for clinical purposes, as 
their isolation and distinction from the bacterium coli take much time, 
and are processes too elaborate to be clinically useful: moreover the 
bacilli have not been found in the stool before the eighth or ninth day 
of the fever. The same applies to the detection of the bacilli in the 
urine, though, according to some observers, they may be found earlier, 
which seems to me very doubtful; and in the blood, where they have 
only been found very rarely: we cannot countenance puncture of the 
spleen for the detection of the typhoid bacilli. In distinguishing enteric 
fever from other affections we must note the temperature curves, the 
intestinal symptoms, the characteristic rash, the enlarged spleen, and 
other less prominent symptoms. Thus, in typhus fever we have the 
typhoid state, and we may have diarrhoea, but the fever is less grad- 
ual in onset; it remains high during the whole time of the fever, 
and on the fourteenth day there is usually a crisis and a rapid fall to 
the normal.1 The rash in typhus appears earlier, generally about the 
fourth day, does not occur in successive crops, and persists to the end 
of the fever; the rash consists of spots of irregular form, red or dirty 
pink, which become reddish brown and then do not disappear on press- 
ure, they often become haemorrhagic, and they are more numerous and 
more widely distributed; besides the spots there is marked mottling of 
the skin of the abdomen. Violent delirium is much rarer in typhus 
than in enteric fever. 
In tubercular meningitis the temperature is rarely so high as in enteric 
fever with marked cerebral symptoms; the pulse if soft is no longer 
dicrotic, and may even be hard; persistent vomiting during the first 
few days occurs more frequently, and the abdomen is generally retracted. 
Optic neuritis, whilst extremely rare in enteric fever, is not uncommon 
in meningitis; the same may be said of the inequality of pupils, and of 
squint. Tubercle of the choroid would be, of course, a pathognomonic 
sign, but it is not often present in the latter disease. 
In acute general miliary tuberculosis we may have the history of pre- 
vious cough or pleurisy ; the temperature is not so high, the pulse is not 
dicrotic, the abdomen is retracted, roseola is rare, the examination of 
the stools may sometimes show the presence of tubercle bacilli, and 
emaciation is noticed early in the disease; yet in some cases the diag- 
nosis is impossible. A roseolar rash may occur, though very rarely, in 
miliary tuberculosis; I have seen it in three cases - two at the Fever 
Hospital, and one under the care of my colleague, Dr. Steell, at the 
Manchester Infirmary. Diarrhoea and even intestinal haemorrhage may 
be noticed, with tympanites and gurgling in the right iliac fossa, while 
the temperature curve may be very much like that of enteric fever (79). 
1 It is generally stated that in typhus the fever terminates abruptly in a crisis. Ac- 
cording to Dr. Steell's observations (83a) this is not correct; the defervescence is gradual, 
lasting two days, and the fall of the pulse during the period of defervescence is also 
gradual. 836 
SYSTEM OF MEDICINE 
The much quicker pulse and the absence of dicrotism appear to me to 
be very significant distinguishing features in acute miliary tuberculo- 
sis, and also the aspect which is usually alert and even excited; not 
oppressed, not apathetic, save towards the end; rarely even indifferent. 
Tubercular peritonitis may simulate enteric fever. I recall two cases 
admitted into the Mon sail Hospital as enteric fever, in which for several 
weeks the symptoms much resembled it. In one of the two cases large 
tumour masses in the abdomen could be detected about the fourth week 
of illness, and in the other case, after some weeks of pyrexia, fluid was 
discovered in the abdomen; in both cases the pulse was over 130 for 
many days. 
The gastro-intestinal form of epidemic influenza may closely simulate 
enteric fever. We may have a roseolar rash (though this is very rare, 
and when it does occur is more widely distributed, and does not appear 
in successive crops), tympanites, gurgling (which, however, is not con- 
fined to the right iliac fossa), a markedly enlarged spleen, and profuse 
diarrhoea. The sudden onset of the fever, which often in less than 
twenty-four hours reaches 103° and 104°, and the subsidence of the 
fever symptoms before the end of the second week, will help us to dis- 
tinguish influenza from enteric fever, so will also the condition of the 
tongue and pulse. In some cases of influenza the pyrexia persists for 
several weeks, but diarrhoea and the other symptoms have then subsided 
(57). If there be cough with expectoration, the examination of the 
sputum for influenza bacilli, which can be easily recognised without any 
cultivation, will assist us materially to a correct diagnosis. I must, how- 
ever, here observe that enteric fever and influenza may occur together. 
1 have seen two undoubted cases of enteric fever immediately following 
an attack of epidemic influenza: in one the diagnosis was verified by a 
post-mortem examination, and in the second there was a distinct relapse 
after the enteric fever. Both cases occurred in adults; several mem- 
bers of the family were affected with typical influenza at the time, and 
in both cases a subsidence of the influenza symptoms had taken place, 
when the temperature again rose, and gradually all the prominent 
symptoms of enteric fever were manifested. 
We have already spoken of pneumonia complicating typhoid, and of 
typhoid pneumonia. There is, however, a form of pneumonia-the cere- 
bral pneumonia- where the symptoms for a few days very much resem- 
ble those of enteric fever. There may be no rigor, no pleuritic pain, the 
onset of the fever may not be sudden, and on physical examination of 
the chest no signs of pneumonia may be noticed for several days, that is 
to say, until the pneumonic process has reached the periphery of the lung. 
Pycemic and septiccemic affections, such as ulcerative endocarditis, osteo- 
myelitis, idiopoXhicpyo-septicoemia, and puerperal septicaemia, may produce 
a train of symptoms very much like those of enteric fever, including a 
roseolar rash, tumefaction of the spleen, and diarrhoeal tympanites. Thus 
three members of one family had lived in a cellar dwelling, which had 
been under water at a time of an extensive flood, and being attacked with ENTERIC FEVER 
837 
febrile symptoms, they were sent to the Monsall Fever Hospital. Their 
symptoms closely resembled those of enteric fever, and one of them 
presented on the third day of admission marked roseolar spots, and had 
slight intestinal haemorrhage on the fifth day ; the temperature showed 
marked evening exacerbations ; the patient died from exhaustion on the 
fourteenth day after admission (about the seventeenth day of the fever), 
and on post-mortem examination the intestines appeared healthy. I could 
quote several other similar cases. Puerperal septicaemia may sometimes be 
indistinguishable from enteric fever. Thus in a case reported by Leu (59), 
a roseolar rash, tympanites, enlarged spleen, intestinal haemorrhage, and 
a pyrexial curve like that of enteric fever were noted. In most cases of 
puerperal septicaemia, however, we notice, apart from any local symptoms, 
a high temperature early in the disease. There is from the first and 
often throughout the course of the disease vomiting and profuse diarrhoea; 
the pulse from the first is quick, and not dicrotic; the spleen is found 
slightly enlarged from the first, and shows no further increase as the 
disease progresses; epistaxis and deafness are absent. The puerperal 
septicaemia often ends fatally after a few days - from four to ten days - or 
if recovery take place, the fever symptoms subside at an earlier date than 
is the case in enteric fever. In doubtful cases bacteriological examination 
of the blood will not help us much, as there may be a mixed infection of 
enteric fever and septicaemia. Some of the most difficult cases are those 
in which during or after some pelvic inflammation or mild septic poi- 
soning enteric fever gradually supervenes as an independent event. 
Acute gastro-intestinal catarrh may, if the fever be high, and remain 
so for a few days, as not infrequently happens in the young and in chil- 
dren, give rise to symptoms like a mild or abortive attack of enteric fever. 
'The difficulties of diagnosis become especially great at the time of an 
epidemic of enteric fever, when many mild and abortive cases are about. 
The malarial affections which occur in this country can scarcely be 
mistaken for enteric fever; in the remittent type of the severe malarial 
affections as they occur in tropical climates the presence of the plasmo- 
dium in the blood would form a pathognomonic sign. 
Other affections with which enteric fever may occasionally be con- 
founded are - acute rheumatic arthritis (especially during the first week, 
when severe pains in the joints may be present), mania, pentyphlitis, 
haemorrhagic colitis, pelvic cellulitis, epidemic cerebrospinal meningitis, 
extravasation of urine, acute trichiniasis. 
Tn discussing diagnosis, we may remark that sometimes patients 
present themselves for treatment with symptoms of sequelae of enteric 
fever, in whom the enteric fever had not been diagnosed. The case of 
Intestinal obstruction already quoted is an instance in point, and other 
cases, especially some with prominent nervous symptoms, could be cited. 
Pathological Anatomy. - We have to distinguish between the lesions 
which are characteristic of enteric fever, those which are common to 
most acute febrile infections, and those which are the result of secondary 
infection or complication. 838 
SYSTEM OF MEDICINE 
The characteristic changes are seen in the intestines, mesenteric 
glands, and spleen. 
Intestines. - The lower part of the ileum is the portion affected, and 
here the parts close to the ileo-caecal valve are more markedly affected 
than those higher up. In some cases the large bowel may show a few dis- 
eased patches, and occasionally the jejunum and even the duodenum may 
be the seat of the characteristic lesions. The affection is to a great extent 
confined to the follicular apparatus - the solitary follicles and Peyer's 
patches - and consists at first in a hyperaemia, followed by an infiltration 
of the glands with cell elements; the infiltrated patches then undergo 
necrosis, the typhoid slough forms, and becomes detached, and an ulcer- 
ated surface is left behind which undergoes cicatrisation. Considering 
these several stages more in detail, we have first, and for a few days 
only, marked hyperaemia of the affected part, the mucous surface appears 
swollen and red, and is covered by an abundant secretion of mucus. 
As cell infiltration takes place the hyperaemia disappears, the blood- 
vessels becoming compressed; the mucous surface is now paler, and the 
follicles and Peyer's patches stand out prominently. This is the stage of 
infiltration, which reaches its height from the 8th to the 12th day. Micro- 
scopic examination with the usual staining agents (eosin and haema- 
toxylin) shows the follicle filled with cells of the type of leucocytes, 
many having one large, well-stained nucleus; in others the nucleus is 
badly stained and pale, and this infiltration extends slightly into the 
neighbourhood of the follicles; the walls of the blood-vessels show infil- 
tration, and are compressed; the lymphatic vessels are dilated and filled 
with cells, and we see in them large ovoid cells with large nuclei - the 
proliferating endothelial cells. In a section stained with aniline dyes 
for the detection of micro-organisms, large numbers of typhoid bacilli 
are seen, most numerously in the centre of the follicle where the cell 
nuclei appear less stained; we notice them also collected in large num- 
bers in the lymphatic vessels of the follicle, and can trace a few into 
the submucous tissue. When this stage has reached its height (10th-12th 
day) we may have in mild cases a gradual resolution; the cells which 
infiltrate the follicular apparatus undergo necrosis or fatty degeneration, 
and become absorbed. This process may be unaccompanied by ulcera- 
tion, or by a few superficial erosions only with slight haemorrhage. In 
most cases, however, as the swelling of the gland is considerable, the 
necrosis of the cells (which is a true coagulation necrosis) leads to the 
formation of smaller or larger sloughs, which are of yellowish or grayish 
colour, soft, and raised at the edges; these when microscopically examined 
are found to consist of granule cells, detritus, fibrin, red blood corpuscles 
and sundry micro-organisms. The slough gradually becomes detached 
and an ulcer is left (third week of fever). The ulcer is either round 
(solitary follicle or partial necrosis of Peyer's patch) or oval (Peyer's 
patch), with its long axis corresponding to the long axis of the intestines; 
the floor is usually smooth, and consists of the exposed muscular coat; 
sometimes the floor is irregular and shreddy, but it is not hardened or ENTERIC FEVER 
839 
much infiltrated; the edges are not indurated, they are often undermined, 
and float when the ulcer is held under water. The depth of the ulcer 
varies according to the extent of the necrosis. The serous surface of 
the intestine shows no changes. 
Microscopic examination of a section of the affected part shows that 
the tissue of the intestinal wall adjoining the follicles and floor of the 
ulcer is filled with mononuclear cells and blood corpuscles; it presents 
all the appearance of embryonic tissue. 
The number of ulcers varies considerably. I have twice seen a 
solitary ulcer, situated near the caecum; in ordinary cases they are more 
numerous near the ilio-caecal valve, and farther from this site they 
become smaller, and often more shallow. 
In a few cases the lesions of enteric fever have been found, with the 
exception of intestinal ulcers; the Peyer's patches in these cases presented 
swelling and congestion only. Death in the cases reported had occurred 
at a date (after the 21st day) when the ulceration ought to have been 
well marked (69). We may assume that in these cases little phagocytic 
action is opposed to the typhoid bacilli in the walls of the intestines, 
and that they pass through to the mesenteric glands. 
Cicatrisation of the ulcer occurs in the last stage; small granulations 
form, which gradually become changed into firm fibrous tissue. From 
the neighbouring part of the mucous surface an epithelial covering 
extends, and the glands may to some extent become regenerated. The 
cicatrix scarcely ever tends to narrowing of the lumen of the gut; it is 
smooth, depressed, and pigmented, and may be often recognised years 
after the occurrence of the enteric fever. 
Mesenteric Glands. - Here we observe a process very similar to that 
seen in the follicles. At first the glands are slightly enlarged by hyper- 
semia, especially in their peripheric part; then they swell considerably, 
and become paler and softer (cell infiltration). The infiltrated cells then 
undergo fatty degeneration and become absorbed, and the gland gradually 
diminishes and becomes firmer. Occasionally the gland may undergo 
suppuration, which is probably due to a septic infection, though the 
typhoid bacillus may cause suppuration; the pus may burst into the 
peritoneal cavity, causing peritonitis, or it may become inspissated, and 
eventually form a calcareous mass. A man, who two years before had 
passed through a severe attack of enteric fever, came under my care for 
intestinal obstruction; the symptoms pointed to an obstruction of the 
small intestine, and an operation was performed: the cause of obstruction 
was then found to be a large mesenteric gland which had become adherent 
to a part of the small intestine, and had dragged in a portion of the wall 
of it, causing marked diminution of the lumen. 
The spleen shows similar changes. It gradually increases in volume, 
and by the end of the third week may be three to four times its normal 
size and weight; the swelling is less marked in old people. During the 
first week there is hypereemia. The capsule becomes stretched, and on 
section the spleen has a cherry-red colour, and the stroma is indistinct; 840 
SYSTEM OF MEDICINE 
gradually the pulp becomes softer, bulges forward, and the Malpighian 
bodies appear distinct and larger (third week); with the fourth week, or 
sometimes later, diminution begins, the pulp appears pale or brownish, 
the consistence of the spleen becomes increased, and later still the stroma 
becomes more fibrous. Histologically we find at the height of the disease 
an infiltration of leucocytes, some of them degenerated, large endothelial 
cells with one or more nuclei, and large cells containing several red blood 
corpuscles. The typhoid bacilli are found disseminated through the 
spleen, and are often found in clumps. 
The tonsils and the glands in the pharynx are found enlarged and 
infiltrated, but as this affection is seen in other acute infective fevers, it 
cannot be looked upon as a lesion specific to enteric fever. 
The medulla of bone resembles in its structure the pulp of the spleen, 
and as in certain maladies (Hodgkin's disease, leucocythamiia) the glands, 
spleen, and medulla of bone are often alike implicated, some observers 
have laid stress in enteric fever on changes in the medulla of bone com- 
parable with those of the spleen. These changes, however, have been 
found in other affections accompanied by profound disorders of the blood, 
and have nothing specific in character. Yet a close connection between 
the typhoid bacillus and bone is suggested by the frequent occurrence of 
osteitis, osteoperiostitis, or abscess of bone, which so often follow in the 
wake of the disease, and in them the typhoid bacillus has been found 
(see section on Symptomatology). 
I will now briefly touch upon the lesions found in the other organs 
in enteric fever, omitting those affections, the nature and appearance of 
which is sufficiently evident during life, and a description of which will 
be found under Symptomatology. 
Digestive Tract. - The stomach is often the seat of catarrh. Cornil 
(18) describes cell infiltration of the adenoid tissue, and compares it to 
the intestinal lesion. Handford (37) noticed similar changes and haemor- 
rhages. The caecum and colon may occasionally show enlargement of the 
solitary glands and there may be ulceration also of the appendix; the rest 
of the large intestine is often the seat of catarrh, and occasionally ulcers 
are noticed, which may go on to perforation, which is less serious than per- 
foration of small intestines; perforation of the rectum has been found 
with formation of recto-vaginal fistula. I have once seen marked haemor- 
rhagic infiltration of the greater part of the large intestines. The liver is 
not found enlarged, it is pale in colour and the gall-bladder is moderately 
filled with light coloured bile. Histologically we find more or less marked 
granular degeneration of the liver cells, and small necrotic areas; the 
capillaries are sometimes found dilated, and when death has taken place 
at a late period of the fever we find slight perilobular cell infiltration in the 
portal canals. Chantemesse describes small foci of cell infiltration in the 
central part of the lobule with degeneration of the adjacent liver cells. Ty- 
phoid bacilli are often seen in large numbers filling up the capillaries (56). 
Acute yellow atrophy of the liver and abscess of the liver may be 
cited as very rare complications. The gall-bladder and large bile-ducts ENTERIC FEVER 
841 
may be the seat of catarrh. We may have, as rare complications, sup- 
puration, ulceration, and perforation of the gall-bladder; more commonly 
the catarrh of the gall-bladder leads to the formation of gall-stone. 
The spleen may be the seat of infarcts which may form pysemic 
abscesses; in persons who have died after many weeks from exhaustion 
owing to long-continued suppuration (bed-sores, empyema), lardaceous 
degeneration of the spleen and other organs may be found. 
Lungs. - Besides the affections mentioned under symptoms, we notice 
at times haemorrhagic infarcts in the lungs and occasionally gangrene 
or pysemic abscesses. 
Heart. - The heart is flabby, pale in colour, and soft in consistency, 
sometimes almost friable. Microscopic examination reveals a variety of 
changes; in some cases no noteworthy alteration in the myocardium is 
found, in others there are changes in the muscular fibres, interstitial 
tissue, and blood-vessels. The muscular fibres may show fatty degenera- 
tion and occasional waxy degeneration; in some cases of sudden death 
segmentation of the muscular elements (myocardite-segmentaire of Renaut) 
has been noted; in cases in which the fever has run a more protracted 
course, small pigment granules in the neighbourhood of the muscle nuclei 
have been observed; hyaline (Zenker's) degeneration is rare; inter- 
muscular cell infiltration is occasionally seen, and the small arteries of 
the myocardium may be the seat of endarteritis (77). Chantemesse and 
Widal have found typhoid bacilli in the heart-muscle. The endocardium 
and pericardium are not often found affected, though occasionally there 
may be both the vegetative and ulcerative form of endocarditis. 
The Kidneys. - The changes in the kidney are manifold, and are not 
always in proportion to the renal symptoms exhibited during the disease. 
In some cases in which during life there was persistent albuminuria with 
casts, no noteworthy changes have been found; but in most cases, even 
with but slight albuminuria, we observe cloudy swelling of the epithelium 
of the convoluted tubes; in cases in which during life there have been 
signs of hsemorrhagic nephritis, or in which from the first there have 
been grave renal symptoms, the changes are marked. The kidneys are 
enlarged, especially the cortical part; the epithelium of the convoluted 
tubes is granular. Renaut describes a distension of the glomerular 
cavities and adjacent renal tubes with an albuminous material. Peri- 
vascular cell infiltration may also be noticed. In cases with septic 
complications there are sometimes small cell accumulations round the 
blood-vessels in various parts of the kidney. These have been specially 
noticed by Wagner, and have been compared to multiple lymphomata: 
they represent, however, only microscopic abscesses, and may eventually 
lead to small visible abscesses. They are found more often in scarlet 
fever and diphtheria than in enteric fever. The typhoid bacillus and 
bacill. coli commun. have both been found in sections of the kidney. 
Muscles. - The changes observed here have been noticed in other 
febrile affections, though perhaps more frequently found in enteric fever. 
Some of the muscles (recti abdominis, adductors of the thigh, pectorales, 842 
SYSTEM OF MEDICINE 
diaphragm) appear pale and waxy to the naked eye, and microscopically 
examined show Zenker's hyaline degeneration. A muscle so affected 
may rupture and give rise to haemorrhagic extravasation. Other 
muscles show fatty degeneration, especially when fever has continued 
for weeks. Another change consists in a proliferation of the muscle 
nuclei. According to Metschnikoff, this appearance is due to an infiltra- 
tion with leucocytes (phagocytes) rather than to a nuclear proliferation. 
Nervous System. - Most of the nervous symptoms during the fever 
are due to the toxic products of the typhoid bacillus, which give rise to 
no anatomical changes; yet certain alterations have been found, such as 
oedema of the membranes and of the brain itself and distension of the 
ventricles, pigmentations of the ganglion cells, infiltration of the perivas- 
cular spaces with leucocytes, and of the spaces round ganglion cells, fatty 
degenerated nerve fibres and haemorrhages (meningeal and cortical). 
Meningitis rarely complicates enteric fever. The pathological anatomy 
of the nervous affections occurring during convalescence (peripheral 
neuritis, sclerosis, etc.) need not be described here. 
Pathological Physiology. - Much on this subject is still very obscure. 
The bacilli, after they have reached the intestines, multiply, penetrate 
into the mucous and submucous coats, invade the lymphatic tissue, 
and pass thence through the lymph channels into the mesenteric glands. 
Some of the bacilli reach the blood and pass to internal organs, princi- 
pally the spleen. The bacilli produce various poisons, at present hardly 
known; some of these have a pyrogenetic action, and thus produce 
the fever. As a result of their irritant action and that of their products 
we get the intensely inflammatory signs in the intestines leading to 
necrosis. 
The fever during the first eight to ten days is most likely due to the 
direct action of the bacilli and of their toxins. During the second and 
third weeks, when the intestines are ulcerated, another factor concerned 
is probably the absorption of some septic material into the blood, 
co-operating with the specific poison; the various complications which 
so often accompany enteric fever probably also add their quota. The 
diarrhoea is partly due to the irritation produced by the ulcers, but 
chiefly to catarrh of the large intestine with increased peristalsis. As 
it has been distinctly proved that typhoid bacilli may by themselves give 
rise to suppuration, we have an explanation of the occurrence of abscesses 
during or more especially after the attack. Lastly, as has already been 
pointed out, both when considering the etiology and the symptomatology 
of enteric fever, some of the symptoms, and especially many of the 
complications, are to be traced to other micro-organisms, which find a 
favourable soil for growth and development in the tissues and organs 
of the patient whose resistance has been much reduced by the fever. 
As yet the numerous experimental investigations with injections of 
typhoid bacilli, of bacterium coli, of serum from immunised animals, etc., 
have not helped us much in clearing up the pathology of the disease, 
nor has the chemical examination of affected organs led to a clearer ENTERIC FEVER 
843 
understanding. Fenwick (25) extracted from the spleen of typhoid 
cases three varieties of chemical substances: albuminoses, alkaloids and 
fatty bodies; the injection of the albuminoses into lower animals caused 
a rise of temperature for thirty hours, with anorexia and emaciation, but 
no further changes of importance were noticed, whilst the injection of 
the alkaloids and fatty extracts was unattended by any results. 
Prognosis. - Enteric fever, even in its mildest form, must be looked 
upon and treated as a serious disease; for even in mild cases death may 
occur from perforation, or from haemorrhage, and sudden death without 
any premonitory symptoms, and for which no adequate cause can be 
found on autopsy, is occasionally seen. Perforation may occur during 
convalescence. As a relapse may occasionally be fatal, and as serious 
complications may occur during convalescence, the patient cannot be 
considered out of danger till convalescence is complete. We have fur- 
ther to bear in mind that however mild the fever may appear during the 
first and second weeks, grave symptoms are none the less likely to ap- 
pear before the third week; no case therefore, however slight the symp- 
toms at first, should be lightly treated. Some general propositions, 
however, may be stated as regards prognosis. As regards age, we may 
say that the older the subject the more unfavourable the prognosis: as 
regards sex authors differ somewhat; according to many the affection is 
more serious in women than in men. The prognosis is less favourable 
in stout than in lean people, and very unfavourable in drunkards, in 
persons who have undergone great privation and fatigue (soldiers in 
war), in persons with weak or dilated hearts or who are affected with 
valvular affections of the heart, or who have incipient phthisis or dia- 
betes ; the prognosis is also grave in pregnant and puerperal women. 
In persons of marked neurotic disposition, acquired or inherited, the 
nervous symptoms and sequelae are to be feared; and in those affected 
with renal disease aggravation of this disease and uraemic symptoms 
are apt to occur. Septic complications are to be feared in those who 
suffer from surgical diseases, especially suppurating wounds; and in 
those who live in unhealthy or insanitary districts. It is also a well- 
known fact that in hot weather the disease is often more serious than 
in cold weather. During the decline of epidemics of enteric fever, as 
in other infectious diseases, the cases become less and less serious. 
Certain families show a particular disposition to enteric fever, several 
members of the same family may be attacked at the same time, and 
other members readily contract the disease (see Pfeiffer, Wagner). 
Recently with Dr. Wm. Sellers, junior, of Radcliffe, I saw two cases in 
the same family: in this family no less than five members had been 
attacked by it at various times; one contracted it by assisting in the 
laying out of the body of a relation who had died of enteric, and an- 
other had had it twice. 
Apart from these general considerations, we are guided in our 
prognosis - 
1. By the pulse: a slow, regular pulse indicates a favourable course; 844 
SYSTEM OF MEDICINE 
an irregular and intermittent pulse, even if not high, is a grave omen, as 
it may denote myocarditis; a very quick and small pulse, except in 
young children, is an equally unfavourable sign, and if the pulse reach 
140 or more in an adult, the issue is almost always unfavourable; a 
short and weak first sound, at the apex of the heart, or disappearance 
of the first sound, is a grave symptom; a soft systolic bruit, limited in 
extent and not due to previous endocarditis, is of no special significance. 
2. By the temperature: in young, strong subjects a high tempera- 
ture, say 104-5°-105°, if it only last for a few hours and rapidly fall to 
a lower temperature, and if the pulse be not very quick, is of no serious 
importance: if, however, the temperature remain high for some time, 
and especially if the fever be accompanied by nervous symptoms, and 
not quickly reduced by antipyretics, it is to be looked upon as very 
serious. Hyperpyrexia is a very unfavourable symptom, especially if 
after the application of cold the temperature does not fall much and 
rises very quickly afterwards; sudden fall of temperature, with the 
pulse remaining high, often denotes haemorrhage or collapse. 
3. By the nervous symptoms : low, muttering delirium, subsultus 
tendinum, convulsions (in adults), and incontinence of faeces and urine 
are of very grave omen. 
4. By the intestinal symptoms: diarrhoea only becomes serious 
when it persists and is very profuse. Of the gravity of haemorrhage 
and perforation we have already spoken. 
Such complications as extensive pneumonia, pulmonary oedema, 
oedema of the glottis, haemorrhagic nephritis, and symptoms of septic 
infection, are of serious import. 
Special attention has been drawn to sudden death in enteric fever; 
it occurs in about 4 per cent of the fatal cases, and generally about the 
end of the third week. Excluding sudden or rapid death from perfora- 
tion, in about two-thirds of the cases changes have been found post- 
mortem, such as embolism or thrombosis of the pulmonary artery, 
myocarditis, and degenerative changes in the myocardium, sufficient to 
account for the sudden death; in about one-third no such changes could 
be found. Some think that death is due to syncope caused by reflex 
influence from intestinal lesions, others (Laveran) attribute the death 
to cerebral ansemia. The premonitory symptoms are sudden dyspnoea, 
irregularity of the pulse, and syncopal attacks (20). 
Mortality from Enteric Fever. -Numerous statistics exist on this sub- 
ject (see Table II., Appendix). I will allude here only to a few of the 
more important points. The mortality per population has markedly 
decreased in England, but the mortality of the number of persons at- 
tacked with typhoid, or (to apply a term used by continental observers) 
the mortality compared to the morbidity, is still for England as high 
as it was in Murchison's time, namely, about 17 per cent. From 1848- 
1870 it was 17-26 per cent, according to the return of the Registrar- 
General, and also according to the report of some of the larger fever 
hospitals (see table for Monsall Hospital return, Appendix). Tn ENTERIC FEVER 
845 
the Cork Fever Hospital the mortality (1871-1890) was 8-6 percent; 
the mortality in the Glasgow Fever Hospital was 17-29 per cent. The 
statistics of some of the larger continental hospitals when compared with 
those of English hospitals, show in many, like those of Berlin and Paris, 
a mortality slightly less; thus in Paris for 1882-88 it was 14-1 per cent, 
though since then it has risen to 20'6 per cent; in Berlin it was 14-5 per 
cent; in Leipzig (for 1880-1893), 12-7 per cent, whilst other places (such 
as Hamburg) show a much smaller mortality. To establish anything 
like a mean mortality in enteric fever is most difficult; it varies from 
year to year, and it varies with the age and sex of the patient. Con- 
trary to Murchison's views, most observers (Griesinger, Gesenius) are 
agreed that amongst very young children the mortality is high ; in per- 
sons from ten to thirty years of age it is much less, but it increases 
again in persons over thirty. The mortality is higher in women than 
in men ; thus, according to Hayem, the mortality in Paris for 1888-1893 
was of men (over fifteen years of age) 19 per cent; of women (over fif- 
teen years) 22-5 per cent. In pregnant women (91) the mortality was 
17 per cent, abortion occurring in 66 per cent; on the introduction of 
the cold bath treatment it fell to 6 per cent, with 55 per cent abortions; 
in puerperal women the mortality is nearly 50 per cent. The mortality 
amongst soldiers, as given in the reports of the various military hos- 
pitals, is better fitted for statistical purposes, inasmuch as the reports 
deal with persons in the prime of life and living under the same condi- 
tions. The mean mortality (from 1875-1891) in the French army, as 
given by Brouardel, was 12-2 per cent, and during these seventeen years 
it only varied between 11 per cent and 14 per cent. 
It is of great importance to know how far the various methods of 
treatment affect the mortality. To arrive at a satisfactory conclusion 
we must not consider results obtained from a limited number of cases in 
one locality or observations made during one epidemic. The evidence 
appears now to be conclusive that the hydropathic treatment carried out 
strictly after Brand's method has considerably lessened the mortality. 
Thus in the Prussian army the mortality fell from 25 per cent to 8 per 
cent, and in the various hospitals, both in Germany, France, and America, 
where this system was rigidly carried out, equally satisfactory results 
were obtained (93). Thus - 
Per cent 
Drasche (Vienna) found a reduction from . 16-2 to 9-3 
Tripier and Bouveret (Lyon) found a reduction from 25 to 7-5 
Osler (Baltimore) ,, ,, ,, 21-8 to 7-4 
Thompson (New York) ,, ,, ,, 19 to 7- 
And lastly, Vogi (Munich garrison) gives the following statistics: - 
Per cent 
For 1841-1860 ........ 21 
,, 1860-1875, treatment, partly expectant, partly by cold bath . 15-2 
,, 1875-1881-2, treatment by bath and combined . . . 6-5 846 
SYSTEM OF MEDICINE 
It must, however, be noted that the cold bath treatment in some of 
the larger German hospitals has not reduced the mortality to so low a 
level as in the list given above. 
The antiseptic treatment, so much recommended of late by some 
clinicians in England, has not as yet produced any marked diminution 
in the mortality of typhoid; but 1 do not know how far it is adopted 
in the larger fever hospitals. At the Monsall Fever Hospital at Man- 
chester, where the mean mortality is about 17 per cent, the mortality 
fell during one year, when this treatment was extensively used, to 13 
per cent; and some physicians, like Dr. Caton of Liverpool, dealing with 
a smaller number of cases, have recorded even a much lower mortality. 
Treatment. -We have as yet no specific treatment of enteric fever. 
We do not know of any drug which destroys the typhoid bacillus, or 
checks its growth in the intestinal glands and other organs; nor of any 
agent to counteract or neutralise the action of the toxins of the bacillus 
circulating in the blood. (The treatment recommended by Simmonds 
is mentioned further on.) In our treatment we must therefore try to put 
the organism into a state in which it can successfully withstand the 
action of the poisonous products, and maintain it there; we must also 
try to prevent, if possible, the ingress of septic organisms into the sys- 
tem, and of toxic bodies which result from abnormal fermentation proc- 
esses in the intestines. 
In speaking of the treatment of enteric fever it is well to consider, 
first, the management of the patient as regards hygienic conditions, diet, 
etc., and then to review special treatment by drugs, baths, etc. 
Hygienic Measures and Management of the Patient.-The patient 
should be put to bed as soon as the symptoms show themselves. The 
bedroom should be large, airy, and well ventilated; it should be in a quiet 
part of the house; it should not contain too much furniture, and should 
have no carpets or bed-hangings. It is well to have two beds in the room, 
so that the patient may be changed from one to the other; especially is 
this useful when the patient is treated with the cold pack. The patient 
should rest on a spring mattress, and a mackintosh be placed beneath 
the sheet; he should only be lightly covered, and the temperature of 
the room be kept between 60° and 65°. In hot weather the tempera- 
ture of the room may be artificially reduced. The patient should not 
be allowed to get up, and should be made to use bed-pans; he should be 
as little disturbed as possible, and not examined oftener than necessary, 
the right iliac region in particular should be rarely and gently handled; 
to prevent hypostatic congestion his position should be changed. The 
trunk and limbs should be sponged with vinegar and water (at 85°-90° 
F.) night and morning; the mucous membrane of the mouth kept 
clean, and gargled with boracic acid, or with the following mouth- 
wash (Acid boracic 3j., Potass, chlorate 3j., Glycerini §j., Aquam ad |vj.), 
or the parts painted with boroglyceride; for the teeth the same wash 
may be used. Special care should be taken to prevent the formation 
of bed-sores by washing the nates and adjacent parts with weak spirit or ENTERIC FEVER 
847 
spirit of camphor. As soon as erythema appears water or air cushions 
should be used, and the parts dusted over with boracic acid or salicylic 
acid and prepared chalk. The patient should not be left alone, and if 
there be any active and violent delirium he should be treated with 
consideration and yet with firmness; he should never be strapped 
or otherwise fastened down, put into jackets, or otherwise restrained. 
Under urgent circumstances, and for a short time, the sheet may be 
tightly drawn over him and fastened on both sides; but the proper 
means is to add to the number of the trained nurses. The window 
should be stopped so as to open no more than six inches, or a heavy 
table may be put in front of it. 
Diet. - The diet should be nourishing, yet easily assimilable and non- 
irritating, and the food given often; the secretions of saliva, gastric 
juice, pancreatic juice, and bile being diminished, and the intestines 
ulcerated, we have to be very careful in the selection of the diet. Milk 
is an excellent food in enteric fever; it is as a rule well borne, and should 
be given throughout the whole course of the illness. Two to three pints 
in the twenty-four hours is a sufficient quantity; patients will often take 
more, but then the milk may be seen partly digested in the stool. The 
stools should be inspected, and the quantity of milk reduced if many 
curds are found. It is well to give it diluted with lime water or soda 
water, or other aerated water, and administered about every two hours. 
Or it may be given in weak tea, or in the form of custard, or whey 
or junket beaten up with egg. Some people cannot take milk, then 
peptonised milk, Benger's food, or arrowroot may be given instead. 
Besides milk the patient may take broth, such as chicken or mutton 
broth, beef-tea, chicken jelly, and some of the other jellies, artificially 
prepared extracts, or cold meat or chicken juice, made by macerating 
finely chopped lean meat or chicken in water; some hydrochloric acid 
and a little salt being added, and the whole strained through a cloth. 
If there be much diarrhoea beef-tea or even mutton broth had better 
be avoided. Fruit is inadvisable especially if there be diarrhoea; but 
occasionally grapes, with skins and seeds removed, are much enjoyed 
and help to clean the tongue. As a beverage give pure water (which has 
been especially recommended in very large quantities by recent writers) 
or barley water, or toast and water, or water containing the white of 
raw egg strained through a cloth; weak tea to which milk is added, 
or iced coffee may be given, especially when the stomach is irritable, 
and the pulse flagging; aerated waters also may be allowed, except in 
those cases in which there are much flatulency and tympanites. 
Alcoholic stimulants need not be given unless there are special indica- 
tions for it: such as failure of the heart, pulmonary oedema or congestion, 
insomnia, low muttering delirium, threatening collapse, or very high 
temperature. In tipplers stimulants are often necessary from the first, 
and should be given to avert some of the graver symptoms which so 
often threaten them. When the cold bath is given or the ice pack, 
alcohol may be required before and after especially if the patient be 848 
SYSTEM OF MEDICINE 
very weak or feel exhausted or faint. Alcohol is also needed when 
certain complications arise, such as perforation or haemorrhage, which 
lead to collapse. The best form of stimulant is brandy or whisky; 
the quantity depends on the age of the patient and the gravity of the 
symptoms; three to four ounces in twenty-four hours usually suffice for 
adults. When the pulse becomes small and thready much larger doses, 
even ten to twelve ounces or more, may be necessary. Alcohol should 
be given soon after some food is taken; or it may be taken in the milk 
every two or three hours; in critical cases every hour. Its effects should 
be watched and the large doses diminished as soon as the desired effect is 
produced; of this the pulse is the best index, which should become 
stronger and slower. In some cases in which brandy is disliked we may 
give champagne or good claret. Alcohol should be withheld if signs of 
haemorrhage from bowel or kidney appear, or if the urinary secretion 
become very much diminished. 
Medicinal Treatment.-In mild cases, when the temperature does 
not exceed 102-5°, no medicine maybe needed; some physicians give 
small doses of hydrochloric acid and quinine, and if the patient come 
under treatment before the 9th day, several doses of calomel (gr. ij. to 
gr. v.) over two or three days. This administration of calomel, recom- 
mended by Wunderlich, Liebermeister and others, appears to prevent a 
further rise of the fever, and to diminish the diarrhoea during the sub- 
sequent period; I have tried it also with good effect in the Monsall 
Fever Hospital. In the severer cases many physicians still follow an 
expectant treatment, and only treat such grave symptoms as pyrexia, 
profuse diarrhoea, etc., as they arise; others follow a particular line of 
treatment, which in its conception is either antipyretic or antiseptic, or a 
combination of both. 
Antipyretic Treatment.-We have varipus means of lowering febrile 
temperature, and I would distinguish particularly between the antipy- 
retic treatment by means of the cold bath or allied methods, and that by 
means of antipyretic drugs. 
A certain amount of pyrexia is an essential element in fever and is 
looked upon by many persons as beneficial; it probably does interfere 
somewhat with the further growth, development, and action of the 
typhoid bacillus and its products, and it is said to increase the resistance 
of the organism. On the other hand, we know that a high temperature 
in itself is directly injurious to many organs, and occasionally the 
cause of severe nervous disturbances, though many of the grave nervous 
symptoms may occur with moderate temperature. Most observers are 
agreed that a high febrile temperature requires active interference. 
Now the method of reducing the temperature is by no means a matter of 
indifference. Abstraction of heat without much diminishing the pro- 
duction of heat, which to a large extent is caused by the oxidation of 
the tissues and by increased tissue metabolism, is the safest and best way 
of reducing the temperature; and the application of cold, especially in 
the form of the cold bath, best fulfils the requirements. There can be ENTERIC FEVER 
849 
little doubt that whenever this treatment can be applied it is far 
preferable to antipyretic treatment by drugs; and a comparison of the 
mortality statistics of the cases in which the cold bath treatment is carried 
out, with those of cases in which antipyretic drugs are administered, 
clearly shows the superiority of the former method of antipyretic treat- 
ment (12 to 16 per cent compared to 6 to 10 per cent). Some of the best 
English clinicians, like Sir Win. Jenner and others, are not in favour 
of the cold bath treatment. Yet a glance at the tables published by the 
Registrar-General, and by the several Hospital Boards in England, 
must satisfy every one that, whilst the mortality is much diminished, 
the mortality from enteric fever per case rate in England, in spite of 
better hygienic conditions and management, is still very considerable. 
The cold bath treatment, first recommended by Currie in 1787, is now 
extensively used, especially on the Continent. Its reintroduction is due 
to Dr. Brand of Stettin (1861), who showed how the mortality of enteric 
fever was lessened by its adoption; and his method was soon followed 
in a more or less modified form by other observers. In England Dr. 
Cayley has most strongly advocated the use of the cold bath in enteric 
fever (12). Brand recommends it to be used whenever the temperature 
is over 102° (measured in the rectum), and this treatment he adopts 
from the very beginning. 
Before the patient is put into the bath the face and chest may be 
sponged with cold water, and if the patient be weak and exhausted he 
receives some stimulant. The temperature of the bath varies from 70° 
to 65° F., the bath is placed close to the bed, and the patient is lifted 
into it and so immersed that the water covers the chest; the back of 
the patient is supported by a water cushion, and a sheet or napkin is 
folded round the loins. The head and forehead are now covered by a 
cloth wrung out in cold water, and whilst the patient is in the bath cold 
water (of lower temperature than that of the bath) is applied to the head 
every three to four minutes, whilst the limbs and thorax are rubbed 
during the whole time of the immersion. While in the bath the patient 
has some cold water to drink. The duration of the bath is from ten 
to fifteen minutes as a rule; the patient is then lifted out and dried 
gently, except over the abdomen, put into bed lightly covered, and hot 
bottles are placed at the feet. A second dose of some stimulant, such 
as whisky and hot water, is then given to him. During the bath the 
state of the patient must be carefully watched; with the fall of the 
body temperature he begins to shiver; but if the temperature before 
the bath has been very high, he may still be left for some minutes longer 
whilst the limbs and thorax are more vigorously rubbed. If the pulse 
be very weak, and the patient become cyanotic, he should be removed 
from the bath at once. After the bath the patient may take some food, 
and he generally then falls into a quiet slumber; if not, Brand recom- 
mends the application of compresses wrung out in cold water to the 
chest and abdomen. Half an hour after the removal from the bath the 
temperature is taken; it is usually found to have fallen 1° to 3° F., 
VOL. I 
3 i 850 
SYSTEM OF MEDICINE 
and if in two or three hours the temperature again exceeds 102-2° the 
bath is renewed. Brand has given as many as eight baths in the twenty- 
four hours, but usually four to six suffice. The good effects of the cold 
bath are readily seen: the pulse becomes slower and the tension of the 
artery is increased, the number of respirations diminish, the tongue 
becomes moist, and the appetite improves; the nervous system is 
especially relieved, the delirium disappears for a time, the patient 
appears much calmer, and the sleep becomes more natural. The ad- 
vantages claimed for the cold water treatment are: that the fever runs 
a less protracted course, that grave nervous symptoms are less apt to 
occur, that the heart and pulse remain strong, that the tongue remains 
moist and the appetite good, and that the diarrhoea, if not lessened, is 
certainly not increased: statistics show that the mortality is less. The 
cold bath is contra-indicated when the pulse is irregular and intermittent, 
and when we suspect myocarditis or pericarditis; also in intestinal 
haemorrhage occurring during the later stage, in peritonitis, and in old 
people. On the other hand the puerperal state, pregnancy, broncho- 
pneumonia, pneumonia, intestinal haemorrhages during the first week, 
and albuminuria, are no contra-indications (Chantemesse). Relapses 
appear, however, to occur more frequently with the cold bath treatment. 
Brand's system of treatment is still carried out by a good many 
medical men, especially on the Continent. Many physicians, however, do 
not bathe the patient unless the temperature reach 103° or 103-5°: many 
also advise the use of water of 80° R, the temperature of which is gradu- 
ally lowered to 70° or 65°; this plan appears to have many advantages, 
but it does not give quite as good results as the stricter method of Brand. 
For the five years ending 15th May 1895, systematic hydrotherapy 
- the method of Brand with certain minor modifications - has been used 
in the Johns Hopkins Hospital at Baltimore. Each patient receives a tub- 
bath of twenty minutes at 70° every third hour, if the rectal temperature 
be at or above 102° 5'. Prof. Osler (67a) says: "Two advantages are 
claimed for hydrotherapy in typhoid fever - a mitigation of the general 
symptoms of the disease and a reduction in the mortality. Our experi- 
ence during the past five years bears out these claims." Osler adds that 
the beneficial action is " not so much special and antipyretic as general 
tonic and roborant. The typhoid picture is not so frequently seen." 
About 6 to 8 per cent more lives are saved. While continuing its use 
the author says that he prays for a method which, " while equally life 
saving, may be, to put it mildly, less disagreeable." 
In certain cases it is well to place the patient in a warm bath and 
to lower the temperature gradually by the addition of pieces of ice; these 
are cases of threatening syncope, or cases in which the breathing is very 
much oppressed from emphysema or laryngeal complications, or in which 
there is profuse sweating. 
As the cold bath treatment is difficult to carry out in private practice, 
other modifications of applying cold to the body have been recommended; 
such as the wet pack, the ice pack, sponging the body with iced water, or ENTERIC FEVER 
851 
with cold water and vinegar, placing a cradle over the patient in which 
buckets containing pieces of ice are suspended (Fenwick), or Leiter's 
tubes, with iced water running through them, which are placed over 
various regions of the body, head, chest or abdomen. None of these pro- 
cedures, except perhaps the ice pack, reduce the temperature so effectively 
as the cold bath. 
Many physicians combine the cold water treatment with medicinal 
treatment. Jurgensen recommends the cold bath when the temperature 
reaches 104°, and gives quinine. Liebermeister gives calomel when the 
patient is seen early; he recommends a bath of 70° F. when the tem- 
perature in the axilla is over 102-2° F., and moreover large doses of 
quinine (20 to 40 grains in the evening). Bouchard combines antiseptic 
treatment with the baths, but the initial temperature of the bath is only 
about 5° F. lower than the temperature of the patient and is gradually 
reduced to 85°. 
Partly as antipyretic, but more as hydropathic treatment, must be 
mentioned the prolonged immersion in a tank bath, recommended by Dr. 
Janies Barr of Liverpool (5). 
The temperature of the bath, which varies from 90° F. to 98° F., is 
regulated according to the temperature of the fever patient, that is, the 
higher his temperature the lower the temperature of the bath; the patient 
is kept in the water for days (six to thirty-one days), and passes all his 
discharges into the bath. Dr. Barr claims all the good effects produced by 
the cold bath for his immersion treatment, which, on the other hand, 
avoids the objections usually urged against the cold bath: out of forty 
cases treated by him in this way only one died. 
In England, and to some extent also on the Continent, the cold water 
treatment is principally confined to cases of hyperpyrexia, and for 
ordinary cases of enteric fever one or other of the antipyretic drugs is 
given when the temperature reaches 103° or 103-5°. Quinine is still much 
used; it should be given in one or two large doses daily, and only at 
those times of the day when there is a natural fall in the temperature, 
that is, evening and forenoon: the dose for an adult should be from 
15-30 grains, for a child 3-5 grains. Antifebrin (4-8 grain doses) 
and phenacetin (10-15 grains) are now much preferred to antipyrin 
(10-20 grains), as the latter may cause the temperature to fall too rapidly, 
and induce symptoms of collapse and irregularity of the pulse. Salicy- 
late of sodium (15-30 grains) was formerly given largely in enteric 
fever. At the Monsall Fever Hospital some years ago the late Dr. 
Tomkins, then resident medical officer, tried salicylate of sodium in a 
very large number of cases; but the depressing effects, the unpleasant 
accidents (such as delirium, vomiting, dyspnoea, etc.), and the tendency to 
hiemorrhage from the intestines which it produced, made us abandon its 
use. The antipyretics - anti pyrin, antifebrin, and phenacetin - are given 
when the temperature is over 103° F., and repeated after some hours 
when the temperature has again risen. A combination of phenacetin with 
2-5 grains of quinine is now very much used. Apart from the therapeutic 852 
SYSTEM OF MEDICINE 
effect, it must be noted that a rapid fall of temperature after the ad- 
ministration of any of these antipyretics is as a rule a good prognostic 
sign. Quite recently two new antipyretics, malakin (44) and lactophe- 
nin (90) have been described, and the action of lactophenin in typhoid 
is much praised by v. Jaksch. Among other drugs which were formerly 
preferred, but which are now rarely applied as antipyretics, are digitalis 
and veratria. Kairin and thallin have marked antipyretic properties, 
and thallin is still occasionally used (78). 
Antiseptic Treatment. - Of the various antiseptic remedies calomel was 
the first to be used, and is still largely used by some physicians. It was 
not given in the first instance on account of its antiseptic properties, but 
because under its use the duration of the fever seemed to be lessened, and 
its course to be milder. Of its antiseptic virtue there can be no doubt, and 
experimental investigations have shown that it readily kills bacteria, that 
it prevents butyric acid fermentation, - a fermentation brought about by 
micro-organisms, - that it checks the formation of products of decomposi- 
tion usually found in the digestive tract (indol, skatol), and that it does 
not interfere with the action of the unorganised ferments of the saliva, 
gastric and pancreatic juices (Wassiljeff). 
Perchloride of Mercury (-|- to 1 drachm of the solution of perchloride 
of mercury, with 1 or 2 grains of quinine, given every four hours for 
several days) has been highly recommended by Sir W. Broadbent; 
especially when the motions are very offensive and accompanied by much 
gas, the abdomen much distended, and the fever high. Calomel or 
perchloride of mercury are only to be given for a few days; but 
within the last few years more thorough antiseptic treatment has been 
advised, and numerous drugs have been recommended, not so much with 
the object of checking the action of the typhoid bacilli which have 
already passed the intestines and reached internal organs, as with that of 
acting on any toxins as yet unabsorbed, and particularly of checking 
fermentation and the action of the numerous micro-organisms found in 
the alimentary canal, the growth and development of which are favoured 
by the presence of the typhoid bacillus, and the products of which may 
be absorbed through the ulcerated surface of the intestines. 
One effect of the antiseptic treatment which is often apparent is that 
the dejections become less offensive, sometimes quite odourless; bacterio- 
logical examination of the faeces, however, shows that they still contain 
a very large amount of living micro-organisms. Diarrhoea is often 
diminished, the temperature reduced, and some of the graver nervous 
symptoms are said to be prevented. Whilst some speak very highly 
of the effects of the antiseptic treatment, and record a very low mortality, 
others have seen but little benefit from the treatment. My own experi- 
ence from a number of cases in which the various antiseptics have 
been tried makes me think well of this treatment, though it is certainly 
inferior to the cold water treatment. 
Of the various antiseptics which have been recommended we may 
mention - ENTERIC FEVER 
853 
/3 Naphthol, is given either alone in powders or capsules (5-10 grains 
every four hours), or mixed with salicylate of bismuth. 150 grains of 
P naphthol are mixed with 75 grains of salicylate of bismuth and 
divided into thirty powders. From three to twelve of these are given in 
the twenty-four hours. Teissier recommends besides, that four enemata 
with cold water be given daily to aid diuresis, and one enema containing 
15 grains of quinine and an infusion of valerian (33). In cases in which 
constipation exists, salicylate of magnesium (50-100 grains daily) has 
been recommended. 
Salicylate of quinine I have often given (10-15 grains) with good effect. 
Salol (40-60 grains in twenty-four hours) has come much into use 
of late. It is usually well borne, produces in these doses no toxic 
effects, deodorises the stool, and often relieves flatulence and tympanites. 
Betol, or salicylate of naphthol, naphthalin, and benzoate of /3 naph- 
thol, or benzo-naphthol, have been highly spoken of by French observers. 
Hydronaphthol was recommended by Clarke; magnesium benzoate by 
Klebs; dermatol (17) by other observers. 
Carbolic Acid. -2^-3 grains in keratin pills, or in the following mixt- 
ure (14), Acid carbolic liquefact. (Calvert) n^xij., Tr. iodi. (B. P.) fAxvj., 
Tr. aurant. 3iss., Syrup simpl. 3iij., Aquse 5 viij.; 5 j. may be given every 
four hours for the first fourteen days, or till the urgent symptoms yield, 
and then three times a day (Moore), or creasote may be used, in pills or 
capsules, 1 to 2 minims; or paracreasotic acid (51). 
Turpentine acts both as an antiseptic and as a stimulant, it checks 
tympanites, and is especially to be recommended in haemorrhage. It 
must be given cautiously if nephritis be present. A dose of 5-15 minims 
given in capsules, or emulsified with yolk of eggs, I have often found 
well borne, or a mixture of the same with spirit of nitrous ether and 
spirit of chloroform (Moore). 
Chlorine is highly recommended by Burney Yeo. Into a twelve- 
ounce bottle put 30 grains of powdered potassium chlorate, and pour on it 
40 minims of strong hydrochloric acid. Chlorine gas is at once liberated. 
Fit a cork into the mouth of the bottle, and keep it closed till it has 
become filled with the greenish yellow gas. Then pour water into the 
bottle, little by little, closing the bottle, and well shaking at each addi- 
tion, until the bottle is filled. To 12 oz. of this solution 24-36 grains of 
quinine are added, and 1 oz. of syrup of orange-peel. Dose, 1 oz. every 
two, three, or four hours, according to the severity of the case. 
Camphor is recommended by Janeway; Thymol has been also used 
(89). 
Chloroform may be given internally, 1 part of chloroform in 150 of 
water (84, 98). Chloroform rapidly destroys typhoid bacilli. 
Quinine must also be grouped with the antiseptic remedies. 
Besides the antiseptic treatment of enteric fever we have yet to 
mention the administration of potassium iodide, which was very much in 
vogue on the Continent, as a remedy throughout the fever period, and is 
spoken of very highly; also the administration of large quantities of water 854 
SYSTEM OF MEDICINE 
by the mouth (74), or in the form of enemata: Cantario recommended 
large enemata of cold water and gallic acid (5 to 100 of water). 
The antitoxin treatment, successfully applied in diphtheria and 
tetanus, finds as yet no place in the treatment of enteric fever. E. 
Frankel (28) in more than fifty patients suffering from enteric fever 
used subcutaneous injections of sterilised, attenuated cultures of typhoid 
bacilli, grown on beef-tea made from thymus gland; the injections 
which produced a distinct reaction were repeated several times. Frankel 
states that the treatment shortened the duration of the fever, and altered 
the continued into a remittant form. This treatment can scarcely be 
looked upon as a specific treatment, for Rumpf obtained results 
similar to Frankel's by using the products of other bacteria, such as 
the bac pyocyaneus. Local haemorrhagic infiltration round the typhoid 
ulcers, the probable result of this treatment, has been noted by Kraus 
and Baswell. 
Treatment of Special Symptoms and Complications. -I can only refer 
here to a few of the more important. 
Hyperpyrexia. - All authors are agreed that there is but one plan of 
treatment for this event, namely, the cold bath. Where this is inappli- 
cable, the ice-pack or cloths wrung out in iced water are to be applied to 
the limbs and trunk of the body, the cloths to be repeatedly changed 
till the temperature of the body is sufficiently reduced. At the same 
time large doses of quinine, 30-40 grains, may be given. This plan I 
found successful in two cases in which the temperature had reached 
106-5° and 107° respectively. 
For the adynamic form of fever subcutaneous injections of ether, 
caffein (subcutaneously or by the mouth, 1-3 grains), musk, or camphor 
may be used. 
In the petechial form large doses of quinine, perchloride of iron, lime 
juice are prescribed. 
Constipation. - Constipation lasting only a few days, and not accom- 
panied by much tympanites and flatulency, need not be treated medici- 
nally ; an admixture of beef-tea and milk diet may be tried. If the con- 
stipation be more obstinate glycerine enemata or cold water enemata 
may be given; should these produce little effect, and the constipation 
have gone on for five days or more, small doses of castor oil (one to two 
teaspoonfuls in milk) may be given, and repeated after some hours if 
necessary. 
Profuse Diarrhoea. - This may have to be treated if the alvine dis- 
charges amount to more than eight in the twenty-four hours, and if the 
patient is thereby rendered weak and exhausted. A starch enema, to 
which 20-30 drops of laudanum are added, often suffices to keep the 
diarrhoea within bounds; it causes diminished peristalsis in the large 
intestines, and often the diarrhoea is due more to a catarrh of the large 
bowel than to the ulcerated state of the small intestines. Nitrate of 
bismuth, salicylate of bismuth, and mistura cretae are equally efficacious; 
but if they fail one need not hesitate to give opium, either alone or in ENTERIC EE VER 
855 
combination with acid, (sulphuric acid preferred), or with acetate of lead 
or sulphate of copper. There is no objection to giving the opium with 
the lead or copper salt in the form of a pill; but it is better, perhaps, 
to give it in fluid form, so as to avoid mechanical irritation of the 
ulcerated surface in case the pill should not dissolve before it reach the 
affected part. As I have said, antiseptics, such as ft naphthol, often 
subdue the diarrhoea quickly. 
Persistent Vomiting. - Food should be given in small quantities and 
often. Milk and lime water or Benger's food may be tried, or some of 
the prepared foods, or cold meat juice with acid. Bismuth in powder 
(10 grains) with cocaine hydrochlor, (gr. |), given three to four times 
daily, I have often found very efficacious. A sinapism to the epigastrium 
may also be applied. Ingluvin in 5 grain doses has been recommended. 
Pain in the abdomen may be relieved either by cold or hot applica- 
tions to the abdomen. The latter, either as fomentations or poultices, 
are highly spoken of by some English observers. 
Tympanites. - Often a troublesome symptom. Enemata with tur- 
pentine or tincture of valerian often give decided relief. Turpentine 
may be given internally in capsules of 10 minims. If there be much 
flatulence, carbolic acid, or creasote or sulphocarbolate of soda (15 grains) 
may be tried. The application of ice to the surface of the abdomen is 
highly recommended by Cayley. If the tympanites do not yield to any 
of these drugs, the introduction of a long tube may give passage to 
much flatus; but this operation has to be repeated, as its effects are 
often very temporary. 
Haemorrhage from the Bowels. - We have already spoken of the 
gravity of intestinal hamiorrhage when it occurs aftei- the first week, and 
when it is profuse. The patient must be kept quiet in the recumbent 
posture, and a small dose of morphia (| grain) should be injected at once. 
Ice should be applied to the abdomen (the ice may be placed between 
flannel, or small pieces of ice may be placed in a kind of square dish 
made out of a piece of mackintosh). The patient should suck small 
pieces of ice, and all his food should be iced. Milk should be stopped, 
or given with carbonate of soda, or in the form of alum whey, that is, 
mixed with finely powdered alum and the curds separated from the 
serum (21a). Ergot was formerly in general favour, but has fewer ad- 
vocates now; it is best given as a subcutaneous injection of ergotin - 1 
to 3 grains. Of much more service are large doses of acetate of lead, 
given every two to three hours, or gallic acid and opium. Turpentine in 
10 minim capsules (1 drachm given two to three times a day) has given me 
by far the best results. It is also contained in the mixture recommended 
by Murchison. (Acidi tannici gr. x., Tinct. opii ^x., Spirit, terebinthini 
ntxv., Mucilag. 3ij., Tinct. chloroform, co. ^Txv., Aquam menth. pip. ad § j.; 
this dose to be taken every two hours.) Ice-water injections have also 
been tried with success. Opium enemata are to be recommended. 
The profound anaemia which accompanies or follows profuse haemor- 
rhage is best treated by subcutaneous injections of ether, and if the 856 
SYSTEM OF MEDICINE 
pulse become very frequent and small a large quantity of normal salt 
solution is to be injected into the subcutaneous tissue. The salt solution 
is contained in a tin or glass vessel held or suspended at some height 
from the patient, and connected by means of an indiarubber tube with a 
fine aspirating needle; this is inserted into the skin below the scapula, 
where the subcutaneous tissue is loose. As the salt water flows into the 
tissue under a high pressure, a large quantity, half a pint or more, can 
thus be easily injected. The operation can be repeated on the other 
side after a little time. A very marked improvement follows the 
injection, though too often it is but temporary. 
In peritonitis, whether due to extension of inflammation or to per- 
foration, large doses of opium are given and poultices applied locally; 
if accompanied with symptoms of collapse alcoholic stimulants should 
be given freely, ether injected, and heat applied to feet and legs. 
As perforation is almost always fatal, and the medicinal treatment of 
little value, surgical interference (that is, laparotomy, washing out of the 
peritoneal cavity, suturing the intestines, or the establishment of an arti- 
ficial anus) has been suggested. Van Hook (43) records one recovery 
out of four cases in which he operated. When he wrote nineteen 
laparotomies with four recoveries were recorded. It is very difficult to 
give the indications which render an operation likely to be successful. 
Those cases in which there is no great collapse, or in which the collapse 
and the more acute symptoms have passed off, but all the signs 
of peritonitis with exudation exist, appear the most favourable for 
operative interference. 
Some of the various symptoms may require special treatment: 
Persistent Insomnia. - Sulphonal, or trional in 15-25 grain doses 
rarely has much effect. Chloral and bromide act better, but should not 
be given if heart's action is weak; small doses of morphia may often 
be given with advantage, and without producing any ill effects; or 
paraldehyde. 
In Delirium. - Ice to the head, a sinapism to the back of the head, 
and morphia with quinine; if of low muttering character, stimulants 
may be given. 
Delirium tremens is best treated by large doses of paraldehyde, and 
occasionally morphia may be necessary. 
Weakness of the heart's action, indicated by the pulse, and due to 
change in the myocardium or to general prostration, is best treated 
by digitalis, ether, citrate of caffein, and by subcutaneous injections 
of strychnia (A7 of a grain). Digitalis may also be given with ad- 
vantage in the form of digital in subcutaneously, or in granules, but its 
effects on the pulse must be watched. Ziemmsen recommends subcu- 
taneous injections of camphor dissolved in olive oil (camphor 1 gramme, 
olive oil 5 grammes). 
In acute dilatation of the heart, if it occur in plethoric subjects, and 
especially if associated with pulmonary complications, cyanosis, and 
marked distension of the veins, venesection may be resorted to. ENTERIC FEVER 
857 
Bed-Sores. - These can be prevented by proper attention to the 
patient, as I have already said. The nurses should be able to lift the 
patient easily, he must not remain a moment wet or soiled, the buttocks 
must be washed (if danger threaten) once or twice a day with warm 
soap and water, and the skin disinfectetl with boracic acid and lanoline 
or other means. If the skin become rough, reddened, or show slight 
abrasions, the part may be washed with boracic acid solution or weak 
perchloride of mercury solution, and some ointment, such as zinc or 
boracic acid ointment, or iodoform powder, may be applied to the 
abraded part. If a slough have formed antiseptic and stimulating 
dressings, such as carbolic acid (1 in 40), or compound tincture of 
benzoin, or balsam of Peru are required. Over the lint, which ought 
to fit exactly into the ulcer, a piece of gutta-percha tissue is applied, 
and outside this again some folds of lint, and the whole fixed by a 
strip of diachylon plaster. When the slough is large it is best to 
dust it over with iodoform, or iodol, or aristol; this is covered by 
gutta-percha tissue, and over this lint dipped in an antiseptic or 
stimulating lotion is placed. The best preventive against bed-sores 
is to warn the head nurse that she will be superseded if they occur. 
[See article on "Nursing."] 
It would be beyond the scope of this article to speak of the treat- 
ment of the many complications and sequelee of enteric fever, such as 
pneumonia, pleurisy, nephritis, etc., as these subjects will be dealt with 
in the several articles on these affections. 
Treatment during Convalescence. - Considering the nature of the 
lesion in enteric fever, and that the healing process can be but slow, the 
patient's progress during convalescence should be most carefully watched, 
and strict injunctions given as to rest, diet, and general management. 
The temperature should still be taken for a fortnight, so as to judge 
of the progress of the case or foretell an impending relapse. The patient 
should keep to his bed for some days after the subsidence of the fever 
and till he feels sufficiently strong to get up; if there have been any 
heart symptoms he should keep to the recumbent posture even longer. 
Usually we may allow the patient to sit up for a short time about a 
week after convalescence has begun. 
With the beginning of convalescence the stimulant should be at once 
reduced, and in young subjects may soon be stopped altogether. The 
diet for eight to ten days should still be chiefly of milk; soft boiled eggs 
may be allowed, and soups, milk puddings, and custards: if the diar- 
rhoea continue during convalescence, even a longer period - about a fort- 
night - must elapse before the patient is allowed solid food; and then 
he should only be allowed to eat at first fish (whiting, sole), then such 
light food as chicken, pigeon, sweet-bread, tripe, before reaching beef 
and mutton. Stale bread or biscuits, and a small amount of vegetables 
(rice, mashed potato), and stewed fruit may be allowed with the solid 
food. Drugs are rarely necessary during convalescence. If diarrhoea 
persist, bismuth, opium and lead may be given; if on the other hand 858 
SYSTEM OF MEDICINE 
constipation, occur, cold water taken in the morning fasting, or a cold 
infusion of senna-pods, or stewed fruit, will often overcome it: if these 
be insufficient, mild laxatives (Hunyadi Janos, Carlsbad salts, etc.) 
should be administered. When the patient's recovery is very slow, 
and he suffers much from anaemia and weakness, the mineral acids, 
with quinine or nux vomica, may be given, followed by mild iron prepa- 
rations. Change of air materially helps to complete the convalescence, 
but the patient should not leave his home for a month after the subsid- 
ence of the fever lest a relapse occur. 
Prophylaxis of Enteric Fever. - Knowing the cause of enteric fever, 
the vehicles which convey it, and the factors which aid in its develop- 
ment, much can be done, and a good deal has been done (1) to check 
outbreaks of enteric fever, and (2) to prevent the spread of the disease. 
With the first of these two propositions sanitary science has occu- 
pied itself for many years and with very good results; many of the 
epidemics have been traced to a contaminated water or milk supply. 
Defective drainage and impure water may play an important part in 
the production of enteric fever, but, as explained in the chapter on 
Etiology, they chiefly act by preparing, as it were, a favourable soil for 
the growth and development of the specific bacillus, and by rendering 
the body less resistant to its action. When enteric fever breaks out, it 
is advisable to boil drinking water and milk, and to skin fruit before 
eating it. As in many places on the Continent the sanitary arrange- 
ments as to drainage and water-supply are still far from satisfactory; 
and as travellers and new residents are more apt to be attacked with 
enteric fever in places where enteric fever is endemic, than the inhabi- 
tants of the district, who appear to acquire immunity from it, it is well 
that travellers to continental towns should abstain from drinking water 
and unboiled milk, and when eating raw fruit should remove the skin of 
the fruit. 
To prevent the spread of the disease, when it occurs in an endemic 
form, from the patient to those who come in contact with him, is no diffi- 
cult matter if proper care be taken; for it is well established that the faecal 
discharges and perhaps the urine are the only excretions which contain 
the active agent. Sputum, if there be any, should also be disinfected. 
The following measures should be adopted: the dejections (both urine and 
faeces) are to be received into a bed-pan containing a strong disinfectant 
(1-20 carbolic acid), and a sufficiently large quantity of the disinfectant 
is to be added to the discharge and well mixed with it. The nates must 
be well cleaned with paper, or with linen moistened with dilute carbolic 
acid; this refuse is burnt or added to the contents of the bed-pan. The 
bed-linen, blanket, and body linen of the patient should be changed at 
once when soiled; they should be placed in a sheet soaked in carbolic 
acid (1 in 40), and afterwards kept for some hours in carbolic acid solu- 
tion of the same strength: before they are sent to the laundry they should 
be well boiled. The feeding utensils are to be cleaned in dilute carbolic 
acid, and afterwards with boiling water. The nurse after attending to ENTERIC FEVER 
859 
the alvine discharges or changing the linen, and always before she takes 
her meals, should wash her hands in corrosive sublimate solution (1 to 
1000). Every precaution should be taken after the death of a patient 
as regards the bed-clothing, sheets, etc. Mattresses, pillows and clothes 
should be sent to a disinfecting oven, when this is feasible. 
Instead of carbolic acid as a disinfectant some use strong commercial 
hydrochloric acid or corrosive sublimate. Chloride of lime is an excellent 
disinfectant which quickly destroys typhoid bacilli, and it may be used to 
disinfect the faeces. 
If there be any expectoration the sputa are to be dealt with in like 
manner. 
Julius Dreschfeld. 
[Appendix. 860 
SYSTEM OF MEDICINE 
APPENDIX 
Table I. - Annual Mortality per Million Persons living from Fever. 
Period. 
England. 
London. 
Typhus. 
Enteric. 
Ill-defined. 
Typhus. 
Enteric. 
Ill-defined. 
1838 
1228 
1839 
1010 
1840 
1089 
1841 
932 
1842 
1004 
620 
1843 
1075 
1844 
849 
1845 
641 
1846 
873 
1847 
1807 
1474 
1848 
1266 
1647 
1849 
1044 
1125 
1850 
865 
875 
1851 
997 
1000 
1852 
1022 
901 
1853 
1008 
1064 
1854 
1015 
1125 
1855 
875 
966 
1856 
847 
1045 
1857 
988 
833 
1858 
918 
716 
1859 
806 
675 
1860 
652 
531 
1861 
767 
656 
1862 
919 
284 
1863 
S74 
988 
1864 
960 
1278 
1865 
1089 
1074 
1866 
986 
884 
1867 
778 
708 
1868 
895 
786 
1869 
193 
390 
239 
225 
337 
194 
1870 
147 
388 
233 
147 
303 
177 
1871 
121 
371 
186 
118 
267 
133 
1872 
80 
377 
145 
52 
242 
97 
1873 
70 
376 
132 
82 
269 
96 
1874 
74 
374 
130 
91 
256 
98 
1875 
62 
371 
108 
37 
235 
78 
1876 
48 
309 
81 
45 
217 
57 
1877 
45 
279 
78 
44 
251 
54 
1878 
36 
306 
71 
41 
283 
54 
1879 
21 
231 
58 
19 
229 
43 
1880 
21 
261 
58 
20 
186 
35 
1881 
21 
212 
44 
24 
254 
35 
1882 
36 
229 
39 
14 
252 
24 
1883 
33 
228 
36 
14 
247 
26 
1884 
12 
236 
28 
8 
284 
20 
1885 
12 
175 
24 
7 
150 
20 
1886 
9 
184 
22 
3 
154 
18 
1887 
8 
185 
18 
5 
151 
11 
1888 
6 
172 
15 
2 
169 
9 
1889 
5 
176 
. 15 
4 
130 
10 
1890 
5 
179 
13 
2 
146 
9 
1891 
5 
168 
11 
3 
132 
10 
1892 
3 
137 
8 
3 
102 
5 ENTERIC FEVER 
861 
Table II. - Death-rate from Enteric Fever per 1,000,000. 
Year. 
England. 
London. 
Manchester.1 
1871 
371 
267 
450 
1872 
377 
242 
400 
1873 
376 
269 
460 
1874 
374 
256 
390 
1875 
371 
235 
440 
1876 
309 
217 
420 
1877 
279 
251 
290 
1878 
306 
283 
310 
1879 
231 
229 
180 
1880 
261 
186 
260 
1881 
212 
254 
170 
1882 
229 
252 
250 
1883 
228 
247 
200 
1884 
236 
234 
190 
1885 
175 
150 
170 
1886 
184 
154 
290 
1887 
185 
151 
310 
1888 
172 
169 
330 
1889 
176 
130 
310 
1890 
179 
146 
270 
1891 
168 
132 
370 
1892 
137 
102 
240 
1893 
161 
250 
1 The rates for the years previous to 1891 are for the Township of Manchester, and 
the Unions of Chorlton and Prestwich, which have been taken to approximately repre- 
sent " Manchester." 862 
SYSTEM OF MEDICINE 
Table III. - Enteric Fever : Monsall Fever Hospital, 
26^ August 1884 to 25th August 1894. 
Males. 
Females. 
Males and Females. 
Age. 
Admitted. 
Died. 
Per 
cent. 
Admitted. 
Died. 
Per 
cent. 
Admitted. 
Died. 
Per 
cent. 
Under 
5 years. 
39 
2 
5'13 
31 
5 
16-13 
70 
7 
10-00 
5 years 
and 
under 10. 
151 
moribund 1 
152 
8 
_1 
9 
5'29 
5'92 
151 
9 
5-96 
802 
moribund 1 
308 
17 
J. 
18 
5-62 
5-94 
10 years 
and 
under 15. 
200 
moribund 4 
204 
15 
4 
19 
7'50 
9'31 
183 
moribund 1 
IS 
17 
J 
18 
9-29 
9'78 
388 
moribund 5 
888 
82 
37 
8-35 
9-53 
15 years 
and 
under 20. 
274 
moribund 4 
278 
88 
_4 
42 
13'86 
15'10 
150 
moribund 1 
151 
29 
J 
30 
19-83 
19-86 
424 
moribund 5 
429 
67 
£ 
72 
15'80 
16-78 
20 years 
and 
under 25. 
224 
moribund 5 
229 
41 
_5 
46 
18'30 
20-08 
128 
moribund 1 
129 
19 
1 
20 
14-84 
15'50 
352 
moribund 6 
358 
60 
_6 
66 
17'04 
18-43 
25 years 
and 
under 30. 
144 
moribund 1 
145 
40 
_1 
41 
27-77 
28'27 
98 
moribund 5 
103 
18 
_5 
23 
18'36 
22-83 
242 
moribund 6 
248 
MM 
58 
2 
64 
23'96 
25'80 
30 years 
and 
under 40. 
118 
moribund 6 
124 
34 
_6 
40 
28-81 
32-25 
77 
moribund 2 
79 
IS 
2 
20 
28'87 
25'31 
195 
moribund 8 
203 
52 
_8 
60 
26'66 
29'55 
40 years 
and 
under 50. 
39 
moribund 3 
42 
13 
_3 
16 
33-33 
38-09 
40 
moribund 3 
43 
14 
17 
35-00 
89-58 
79 
moribund 6 
85 
Ml 
27 
_6 
33 
34-17 
38'82 
50 years 
and 
under 60. 
3 
1 
33-33 
11 
3 
27'27 
14 
4 
28'57 
Over 60. 
1 
2 
3 
All Ages. 
1193 
moribund 24 
1217 
192 
24 
216 
16-07 
17-74 
871 
moribund 13 
884 
182 
_13 
145 
15'15 
16-40 
2064 
moribund 87 
2101 
824 
87 
361 
15-69 
1718 ENTERIC FEVER 
863 
REFERENCES 
1. Alessi. Cbl. fur Bakteriol. 1894.-2. Anderson. Glasgow Medical Journal, 
1894. - 3. Ballet, Ply, and Angel Meadow. Lancet, 1885, vol. ii. p. 842. - 4. 
Barie. Soc. med. des hopitaux, 1890, feb.-5. Barr, Dr. James. Lancet, 1891, vol. i. 
p. 690.-6. Barry, Dr. Report on Typhoid Fever in the Tees Valley. - 7. Belfanti. 
Estrate dal Gior. della R. Acad, di Med. 1890, Nos. 1, 2. - 8. Boginsky. Virchow's 
Archiv, xlix. p. 52. - 9. Bouveret. Berl. klin. Woch. 1886, No. 14. - 9a. Brieger. 
Ueber Ptomaine. - 9b. Brieger and Wassermann. Charite Annalen, 1892. - 9c. 
Brouardel and Thoinot. La fievre typhoide. Paris, 1895. -10. Brit. Med. Journal, 
1895, vol. i. -11. Buschke. Fortschritte der Med. 1894, No. 15. -12. Cayley. 
Croonian Lectures, 1880, p. 7; Dr. Murchison's Treatise on Fevers, 3rd edit. -13. 
Cantario. Il Morgagni, 1891, No. 1. -14. Chatteris.-Brit. Med. Jour. 1892, Dec. 
31. -15. Clarke. Practitioner, 1890, July. -16. Coats. Brit. Med. Jour. 1882, 
vol. i. p. 421. -17. Colsanto and Dutto. Berl. klin. Wochen. 1892, No. 34. - 17a. 
Colgi. Spermentale, 1891, 15th March. -18. Cornil. Gaz. Hebdom. 1880. -19. 
Cygnoeus. Ziegler's Beitrage, z. path. Anat. Bd. viii. Heft 3, 1890.- 20. Dewevre. 
Arch. g€n. de mAd. Oct. 1887.-21. Dreschfeld, Prof. Practitioner, 1893; Brit. Med. 
Jour. 1894, vol. i. - 21a. Duckworth, Dyce. Internal. Clinic. 1895, vol. ii.- 
21b. Dunbar. Deutsch, med. Wochen. 1895, p. 138.-22. Eberth. Virchow's Archiv, 
vol. Ixxxi. p. 58; vol. Ixxxiii. p. 486. - 23. Eiselt. Verhand. d. Xten. Internal. Med. 
Congress, Berlin, vol. ii. p. 210.-24. Eisenlohr. Deutsch, med. Wochen. 1893, p. 122. 
- 24a. Eschebich. Fortschritte der Medicin, 1885, Nos. 16, 17. - 25. Fenwick. RriL 
Med. Jour. 1895, vol. i. p. 801.-26. Fitz. "£tude clinique des divers symptomes 
spinaux observees dans la fievre typhoide," These de Paris, 1864.-27. Flugge. 
Hygiene, 3rd edit. p. 542. -28. Frankel, E. Deutsch, med. Woch. 1887, No. 5; 1893, 
No. 41. - 29. Frankel and Simmonds. Die Etiologische Bedeutung des Typhus 
bacillus. Hamburg and Leipzig, 1886. - 30. Frantzel. Zeitsch. f. klin. Med. 1880.- 
31. Freyhon. Berliner Klinik, 1891, Heft 42.-32. Gaffky. - JfiMbeiZ. aus dem 
Kaiserb. Gesundheits amt, vol. ii. p. 372. - 33. Gaz. med. de Paris, 1890, No. 33.-34. 
Gerhardt. Charite Annalen. - 35. Gerloczy. Pester Med.-Chir. Presse, 1891, No. 3G. 
- 36. Gilbert and Girode. Comp. rend, de la soc. de biologic, 1891, No. 16.-37. 
Handford. Lancet, 1891, vol. ii. - 38. Henscherl. Centralb. f. klin. Med. 1892, 
p. 1058. - 39. Hesse. Zeitschrift f. Hygiene, vol. v. p. 527.-40. Hewetson, John. 
Johns Hopkins Hop. Rep. vol. iv. No. 1, p. 115.-41. Huppe. Berl. klin. Wochen. 
1889, Nos. 46, 47. - 42. Hoelscher. Munch, med. Wochen. 1891, p. 43.-43. Hook. 
Medical News, 1891, No. 21.-44. Jacquet. Corres. bl. f. Schweizer Arzte, 1893, No. 
18.-45. Karlinski. Berl. klin. Wochen. 1888. - 46. Klein. Brit. Med. Jour. 
1894, vol. xi.-47. Koch. - Mittheil. aus dem Kaiser I. Gesundheits amt, vol. plates 
ix., x. -48. Korczynski and Gluzinski. Centralb. fiir klin. Med. 1892, p. 829.-49. 
Kraus and Baswell. Wiener, klin. Wochen. Nos. 31, 32. 1894.-50. La Semaine 
medicale, 1894, p. 215. - 51. Lancet, April 1892. - 52. Landgraf. Charite Annalen, 
vol. xiv.; Deutsch, med. Woch. 1889, No. 23. - 53. Landouzy and Siredey. Revue 
de mAdecine, 1885 and 1887.-54. Lassurie. These de Paris, 1890. - 55. Latham, 
A. C. Lancet, 1893, vol. i. p. 462.-56. Legry. - La foie dans la fievre typhoid. Paris 
1890. - 57. Lemoine. Semaine medicale, No. 51.-58. Levy. These de Paris, 
1890. - 59. Leu. - Charite Annalen, vol. xvi. 1891, p. 315.-60. Loeffler. Cbl. f ur 
Bakteriol. vi. p. 109. - 61. Luff. - Brit. Med. Jour. 1889, vol. ii. p. 193.-62. Luning. 
Arch. f. klin. Chir. vol. xxx. p. 225. - 63. Lustig.-Diagnostik der Bacterien des 
Wassers, translated by Teuscher, 1893. - 64. Mendelsohn. American Journal of 
Medical Science, Oct. 1883. - 65. Moore. Trans. Royal Acad, of Med. in Ireland, 1889, 
vol. vii. p. 10; Eruptive and Continued Fevers, p. 422.-65a. Moser. Arch. f. klin. 
Med. vol. lii. p. 601. - 66. Neumann. Centralb. f. klin. Med. 1890, p. 465. - 67. Osler. 
Johns Hopkins Hosp. Rep., vol. iv. No. 1, on "Typhoid Fever."-67a. Osler. Johns 
Hopkins Hosp. Rep. vol. v. - 68. Peter. Semaine medicale, June 1890. - 68a. Pfeiffer, 
R. Deutsch, med. Wochen. 1894. - 69. Phillips, Sydney. - Trans, of Clinical Society, 
London, 1891, p. 104. -70. Pisenti and Biancho-Mariottl Centralb. f. Bacteriologie, 
vol. xvi. 699.-70a. Polguere. These de Paris, 1888. - 71. Poloff. Centralb. f. Bakteriol. 
1890, p. 366. - 71a. Raimondi. Gaz. des Hop. 1894, Sept. 20.- 72. Raymond. Revue 
de medecine, 1885.-73. Renon. Gaz. des Hopitawx,, 1892, Aug. 2. - 74. Rimini. Wiener 
med. Blatter, 1893, No. 5. - 75. Robin. - Le<;on de clinique et de thArapeutique medicale, OF MEDICINE 
864 
1887.-75a. Ross and Bury. Peripheral Neuritis.-76. Rumpf. Deutsch, med. Wochen. 
1893, No. 41. - 77. Romberg. - Arch. f. klin. Med. 1891, vol. xlviii. p. 369. - 78. Schmid. 
Corresp. blatt.fur Schweiz. Arzte, 1892, No. 17. - 79. Senator. - Charite Annalen, vol. 
xvii. 1892, p. 272. - 80. Shore. Barth. Hosp. Rep. vol. xxiii. - 81. Silvestrini. 
Centralb. f. Bakteriol. vol. xvii. p. 476. - 82. Sirotinin. Zeitsch. f. Hygiene, 1886, vol. 
i. Heft. 3.-83. Sittmann. Deutsch. Arch. f. klin. Med. 1894, p. 348.-83a. Steell. 
Practitioner, 1890, pp. 347, 401.-84. Stepp. Munch, med. Wochen. 1890, No. 45-.- 
85. Stern. Deutsch, med. Wochen. 1892.- 85a. Strpolansky and Stroganoff. 
Wratch, 1887, No. 22.-86. Sultan. Deutsch, med. Wochen. 1894, p. 675.-87. 
Taylor, F. Lancet, May 4, 1889. -88. Terray. Zeitsch. f. klin. Med. 1894, p. 346. - 
89. Testi. Allgem. Wien. Med. Zeitung, 1889, No. 9.-90. Therapeut. Monatshefte, 
July 1894. - 91. Veniat. Lyon med. Dec. 3, 1893. - 92. Vestes. Centralb. fur klin. 
Med. 1892.-93. Vogl. Munch, med. Wochenschrift, 1895, Nos. 12, 13.-94. Wagner, 
Deutsch. Arch. f. klin. Med. vol. xxxvii. - 95. Wassermann. Zeitsch. f. Hygiene, 
1892.-96. Weil. Pest. Med.-Chir. Presse, 1891, No. 23. - 97. Wendland. Cbl.f. 
klin. Med. 1892, p. 1103.-98. Wenner. Peters, med. Wochen. 1891, May 13.-99. 
Wyssokowitch. Zeitsch. f. Hygiene, vol. i. Heft 1, p. 45. -100. Whipham. Clinical 
Society's Transactions, vol. xvi. p. 150. -101. Yeo. Burney. Treatment of Typhoid 
Fever. London, 1891. -102. Ziemec. Virchow and Hirsch's Jahresbr. 1890, vol. ii. 
p. 36. 
Some of the references not included in the above Bibliography will be found in 
the larger treatises on enteric fever, which the author has consulted in the composition 
of this article. Besides the treatises of Murchison and Moore these are: - Zuelzer's 
article " Typhus " in Eulenberg's Real Encyclopaedic der gesammler Heilkunde, Lieber- 
meister (article "Typhoid Fever" in Ziemssen's System of Medicine), Chantemesse 
(article "Fievre typhoide," in vol. i. of Traite de medecine, edited by Charcot, 
Bouchard, and Brissaud, 1891), and Brouardel and Thoinot {La fievre typhoide. 
Paris, 1895). 
J. D. 
CHOLERA ASIATICA 
Nomenclature. - The Hippocratic term cholera was originally employed 
to indicate bilious diarrhoea. It has come, in course of time, to be ap- 
plied to any violent intestinal flux; such adjectives as simplex, biliosa, 
nostras, infantilis, serosa, spastica, perniciosa, epidemica, etc., being used 
to distinguish varieties. The qualifying adjective commonly added to 
the word cholera, in order to denote the disease which is the subject of 
this article, is founded on the circumstance that in some parts of Asia - 
•or, more strictly, of India - it is perennially present; and that, when it 
makes its appearance in other countries and continents, it can always be 
traced back to its Asiatic birthplace and home. It is by this geographi- 
cal title that serous, spasmodic, pernicious, epidemic cholera is known 
in all the languages of Europe. In India it is usually denominated 
by the vernacular term haiza (Hindostanee); other Eastern names are 
Enerum Vandee (Tamil), Ookal Julab (Deccan), Vantee (Telegoo), Duba 
(Arabic), Ho-louan (Chinese), Visuchika (Sanscrit). 
Definition. - Cholera Asiatica may be defined as " a specific and 
communicable disease, probably due to a specific organism, prevailing 
endemically in some parts of India, and from time to time diffused 
epidemically throughout the world; it is characterised by violent vomit- CHOLERA ASIATIC A 
865 
ing, purging, cramps, collapse, and suppression of urine, followed by 
febrile reaction-; case mortality about 50 per cent." 
History and Geography. - The authentic history of Asiatic cholera 
dates from the year 1817, when it broke out violently in Lower Bengal, 
and became the subject of close and exact observation. There is every 
reason to believe that previous to that date the disease prevailed in 
India, and spread at intervals throughout Asia as it does now; but it is 
very doubtful whether it overstepped Asiatic limits. Certain passages 
in Sanscrit, Chinese, Arabic, and Greek medical literature have been 
supposed to refer to it; but the descriptions of all writers before 
our own century are vague, and vary as the colliquative, spasmodic, 
febrile, or prostrating features of the malady chiefly arrested attention. 
Cullen, for example, placed the disease among spasmodic neuroses, and 
it cannot excite surprise that physicians less learned and accurate than 
he should have seized upon partial aspects of it to name, class, and 
describe it, thus creating difficulties of identification. It seems cer- 
tain, however, that Portuguese, Dutch and English physicians found 
the disease prevailing in India and its dependencies in the fifteenth, 
sixteenth, seventeenth, and eighteenth centuries; and when the outbreak 
of 1817 occurred it was recognised as a severe manifestation of a familiar 
scourge. Since 1817 Asiatic cholera has been watched with keen 
interest wherever it has prevailed; and the facts relating to its prevalence 
in India and elsewhere have been recorded with great minuteness and 
care. Voluminous as these records are, the story of cholera is a very 
simple and singularly interesting one. It presents the pictures of a 
deadly disease prevailing perennially in certain parts of India, which 
have been recognised as its home or field of endemic lodgment, where 
it waxes and wanes, but never altogether disappears; and of a dread 
epidemic taking its departure from its endemic habitat, after a re- 
crudescence of more than usual severity, and diffusing itself along the 
ordinary routes of commerce and pilgrimage throughout the inhabited 
world. The history of cholera is thus a tale of repeated invasions, pre- 
senting a remarkable similarity. It is not easy to define with exactitude 
the endemic centre from which these invasions have proceeded: some 
authorities assert that there are several such centres in India; the 
principal one is undoubtedly the delta of the Ganges and the vast 
creek and river-netted alluvial plain which lies south of its confluence 
with the Brahmaputra. How far the endemic area extends up the 
Gangetic and Assam valleys it is difficult to say; or whether other 
deltaic regions in India, as of the Godaveri and Kaveri rivers, are also 
endemic areas. It is important to note that, even in its endemic 
haunts, cholera presents most of the features which characterise its 
epidemic facies. It rises and falls, and travels; and if we carefully 
study particular tracts of country, we shall find that the disease pre- 
sents a succession of outbreaks and an aspect of grouping very similar 
to what is observed in Europe when the disease visits a susceptible 
place and people in a favourable season. 
3 K 
VOL. I 866 
SKSV'AJf OF MEDICINE 
It is observable that every departure of cholera beyond Indian limits 
has been preceded by an outbreak in India of marked and unusual 
violence. Its westward diffusions have naturally attracted most atten- 
tion ; but eastern diffusions have also occurred - to the Straits Settle- 
ments, Siam, China and Japan-which have not been so carefully 
investigated. The western invasions have taken place by three routes, 
namely, (1) through Afghanistan, Persia and Central Asia, to Eastern 
Russia, along trade routes crossing or bordering the Caspian Sea, and 
thence into the interior of Russia along the Volga; (2) by the Persian 
Gulf to Turkish Arabia and Persia; thence to Turkey in Asia, and 
along or across the Black Sea to Constantinople and the Danube; and 
(3) by the Indian Ocean and Red Sea to Aden and Mecca, thence to 
Egypt and the countries bordering the Mediterranean. The disease 
prefers 'a land route to a sea route, and has sometimes travelled west- 
wards by more than one route. 
Seven distinct invasions of Europe have taken place in the present 
century. The outbreak of 1817 reached, but did not enter Europe. It 
covered India in 1818; found its way to Mauritius and Burmah in 
1819, reached Arabia, Siam, Malacca, and China in 1820, prevailed in 
Persia and Asiatic Turkey in 1821, and got as far as Tiflis and Astra- 
khan in 1823. There its westward march ended. 
The first European invasion covers a period of thirteen years - 
1826-39. During the first three years India was extensively overrun 
by it; in 1829 the disease was carried by the Central Asian route through 
Kabul, Herat, Bokhara, Khiva, and Orenburgh, as far as Nijni-Nov- 
gorod; in 1830 it travelled through Persia and by Resht, Tabriz, Tiflis, 
and Astrakhan to Southern Russia, eventually reaching Moscow. Russia 
and Poland were then occupied, and in 1831 Northern and Central 
Europe; in 1832 it invaded the United Kingdom and America, and in 
1833 France, Spain, and Portugal; in 1834 Italy and North Africa 
suffered, and the disease lingered in Europe till 1839. 
The second European invasion commenced in 1840 and ended in 
1851 - eleven years. Cholera was carried to China by our troops, and 
after raging severely in that empire, was conveyed by trade routes 
into Burmah, Yarkand Turkestan, and other parts of the Central 
Asian plateau. It broke out in Persia in 1845, in Arabia and Turkish 
Arabia in 1846, it reached Eastern Russia in 1847, and in 1848 it spread 
through Europe, visiting the United Kingdom, and reaching America 
via New Orleans from Havre. This epidemic subsided in 1851. 
The third European invasion covered nine years -1848-57. It is 
thought by some authorities to have been a recrudescence of the cholera 
of 1840-51. During 1848-50 the disease ravaged India extensively; in 
1851-52 it spread through Turkish Arabia and Persia, and reached 
Russia; in 1853 Asiatic Turkey and Northern Europe suffered; in 
1854-55 the rest of Europe, Great Britain, and America were invaded. 
This outbreak, which died out in 1856-57, was the cholora from which 
the army of the Crimea suffered; and it was during this Epidemic that CHOLERA ASIATIC A 
867 
certain celebrated observations were made npon the agency of water in 
cholera diffusion. 
The fourth European invasion of 1863-67 took place through Arabia 
and Egypt as well as by way of Persia, the Black Sea, and the Caspian. 
The disease occupied Europe in 1865, and in 1866 it prevailed in 
Britain and America. 
The fifth European invasion commenced in India in 1867 - the year 
of the celebrated Hurdwar outbreak - and lasted till 1873. Europe was 
reached by the Persian and Turkish-Arabian route, and during the years 
1870-73 the disease raged in Europe and also in America, which was 
reached through New Orleans from Jamaica. 
The sixth European invasion, dating from 1879, took place via 
Mecca (1882) and Egypt (1883). The countries bordering the Medi- 
terranean suffered first and most, and the disease lingered in these till 
1887. Indeed an outbreak in Paris in 1892 is considered to have been 
a survival of this epidemic. It was in Egypt, in 1883, that Koch 
discovered the bacillus which has formed so prominent a feature of 
cholera research in recent years. 
The seventh European invasion of 1891-95 is remarkable for the 
unprecedented rapidity with which the disease travelled westward and 
overspread Europe. Beginning in Bengal in 1891, it raged in Upper 
India in 1892, and in the same year ravaged Kashmir and Kabul, 
travelling rapidly through Persia and Central Asia, and spreading over 
Northern and Central Europe. There was a violent outbreak at 
Hamburg, which has so frequently endured severe visitations. Cases 
occurred in English seaport towns, but the epidemic did not penetrate 
inland. In 1893 sharp outbreaks occurred at Hull, Grimsby and Yar- 
mouth, and in many adjoining inland localities; but this country as a 
whole escaped. 
From this cursory sketch it is evident that human intercourse and 
agency are the cardinal factors in cholera propagation: and the main 
question which has agitated the public mind, and engaged the attention 
of conferences and commissioners during these years, is whether the 
progress of cholera can be stayed by stopping communication between 
infected and non-infected places by means of a system of quarantine. 
This question resolves itself into two subsidiary questions, namely, 
whether quarantine be feasible and effective; and, if so, whether the 
disturbance of social life and interruption of commerce which it implies 
be justifiable. Unfortunately these questions have been chiefly debated 
on theoretical grounds, and have mainly turned on whether the disease 
be personally communicable or the reverse. Sufficient experience has 
now been gained to render a solution of the question possible on the surer 
basis of natural experiment. As regards inland quarantine, the experi- 
ence gained by numerous trials in India and Europe has resulted in almost 
uniform failure; and when the difficulties of imposing a rigid quaran- 
tine and the chances of evasion are considered, together with the possibil- 
ity that dissemination may be effected by other agencies than human -• 868 
SYSTEM OF MEDICINE 
by animals, birds, and insects, or by wind and water - it is not strange that 
the disease has so often overstepped the most rigid cordons. Maritime 
quarantine presents easier postulates, and has been attended with more 
success ; but ships, unless crowded with emigrants, pilgrims, or soldiers 
under unsanitary conditions, are not such good porters of cholera as 
caravans, armies, hordes of pilgrims, and unsavoury travellers by road 
and rail. The policy of detaining masses of men in unwholesome 
lazarettos, subject to infection by new arrivals, has certainly proved 
disastrous; and a system of accurate and early information, careful 
inspection, isolation of the sick and suspected, and sanitation general 
and special, has been productive of greater benefit than any wholesale 
attempt to hinder the movements of men and merchandise. 
There are certain parts of the earth's surface, more or less insulated, 
which have not been visited by cholera. The most remarkable are the 
Andaman Islands in the Bay of Bengal, Reunion, Australia, New 
Zealand, and other islands of the Pacific, the Cape of Good Hope and 
West Coast of Africa, St. Helena, Ascension, the Azores, Bermudas, 
West Coast of South America, Orkney and Shetland Islands, Iceland and 
the Faroe Islands. This list is, moreover, by no means exhaustive. 
There are certain localities in all countries which have seldom or never- 
been visited, while epidemics have prevailed around; and in any out- 
break even in India, the places and persons attacked are always a 
minority of the whole. Even in Calcutta, the head centre and perpetual 
home of cholera, there is a quarter of the city which possesses as com- 
plete an immunity from the disease as Iceland. No better illustration 
than this could be given of the power of sanitation to extirpate cholera. 
Cholera literature is immensely voluminous, and from time to time 
many theories have been advanced to explain the nature, origin and dif- 
fusion of the disease. These speculations, putting aside the purely 
mythical, have concerned themselves with every possible influence - 
cosmic, sidereal, telluric, climatic, septic, ochlotic, etc. - to account for 
cholera visitations. A study of statistical aggregates and too exclusive 
an attention to " broad " views have begotten vague and fatalistic gen- 
eralisations, as of mysterious forces and pandemic waves, which have of 
late years become discredited. General causes do not produce except- 
ional, limited, erratic, and contingent results; and a closer study of 
cholera on a more rational basis has made it clear that so specific a mal- 
ady must have a specific cause. The microbic agents investigated by 
Koch and others have now for eleven years been subject to criticism, 
experiment, and research, and year by year his theory has gained sup- 
port from clinical, pathological, bacteriological, and epidemiological stud- 
ies. The theory which offers a key to the bewildering mass of cholera 
literature which the present century has produced, is that which finds 
the causation of cholera in a disregard of the laws of health, and in the 
presence of an organic (microbic) poison, capable of conveyance under 
favouring circumstances by man himself. 
K. M. CHOLERA A SI A TIC A 
869 
Etiology and Epidemiology. - Seeing, then, that cholera is due to a 
living contagium - Koch's cholera bacillus - which, growing in the 
intestines of the patient, causes death partly by the effect of the toxins 
produced by it and partly by the profuse purging which it sets up, the 
further etiology of the disease resolves itself into two factors: first, the 
means by which the microbe gains access to the body; second, the con- 
ditions which render the body susceptible to the microbe. Of the first 
of these we know much, of the second little. 
Mode of Access. - It is certain that cholera is not contagious in the 
ordinary sense of the word. Cholera cannot be caught by contact, and 
although nurses and those who attend to the sick are often affected in 
larger proportion than others, this is readily explained by the fact, that 
unless constant care is exercised in regard to cleanliness of hands and 
utensils they are much more exposed than are others to the known and 
recognised mode of infection, which is by the mouth. All evidence goes 
to show that the infection of cholera to take effect must be swallowed. 
Now, as in all zymotic diseases, the materies morbi- the contagium 
vivum - greatly increases within the body of the patient during the 
progress of his malady. During the disease a minute amount of infec- 
tious material grows into an amount capable of giving the infection to 
thousands; and, in the case of cholera, this infectious material finds its 
exit from the patient's body in the discharges caused by the disease. 
The study of the etiology of cholera, then, is to a large extent a 
study of the steps by which matter which has left one patient so gains 
access to some article of food as to be swallowed by some one else. 
It is conceivable that in the presence of a great abundance of the in- 
fection it might be inhaled in the form of dust. Of this, however, there 
is no evidence, nor is it probable unless it be in the case of those who 
have slept in cholera-soiled bedding; the cholera bacillus is so readily 
killed by desiccation that such a mode of transference is in the highest 
degree unlikely. It is with food and drink that it commonly gains 
access to the human body. 
Well-authenticated instances are related in which flies have appeared 
to carry the infection from cholera dejecta to milk and various articles 
of diet; and M. Haffkine has detected cholera bacilli in specimens of 
sterilised milk, exposed in new vessels, to which flies were permitted 
free access during an outbreak of cholera (1). 
The use of cholera-infected water for washing cooking utensils and 
articles used in the preparation of food is another mode of local distri- 
bution ; especially in regard to the spread of the disease by milk. 
In the case of nurses and those who attend to the sick, or have charge 
of the dead, the cholera poison may, as a result of want of strict cleanli- 
ness, be transferred to the mouth by the fingers, either directly or by 
means of the food they touch. 
But the great, the persistent, and the almost universal mode by which 
the cholera germ gains access to the body is in the drinking water. 
This is now so well recognised that it is unnecessary to go again over 870 
SYSTEM OF MEDICINE 
the evidence by which the fact has been proved to demonstration. It 
may, however, be well to refer to a few of the classical examples of this 
mode of cholera distribution.1 
A full account of the case of the Broad Street pump, which was in- 
vestigated by Dr. Snow, is to be found in the Report of the Committee 
for Scientific Inquiries into the Cholera of 1854. The relation between 
the incidence of cholera and the source of the water-supply to different 
parts of London is described in the Report of the Royal Commission on 
Water-Supply, 1869. The outbreak of cholera in the East End of Lon- 
don in 1866, which was traced to the supply of specifically contaminated 
water, is described by Mr. Netten Radcliffe in the Report of the Medical 
Officer to the Local Government Board, 1866; and the great outbreak of 
cholera in Hamburg is described with full statistical detail in the Report 
of the Medical Officer to the Local Government Board, 1892-93. 
There is a good deal of evidence to show that water does not act 
as a mere diluent and distributor of the cholera poison, but that under 
certain conditions the cholera bacilli grow and for a short time increase 
in virulence during their sojourn in this medium. In the presence, how- 
ever, of sunlight and ordinary water-bacteria they are either rapidly 
destroyed or soon cease to multiply. The persistence of cholera in a 
district is indicative of more than a single pollution of the water-supply, 
and generally points to a persistence of some insanitary conditions which 
favour repeated infection. 
It is not always the case, however, that the infection is conveyed 
directly from man to man by means of water. Where we find sudden out- 
bursts of disease affecting large numbers of people drawing their water- 
supply from a common source, some direct and wholesale fouling of the 
supply is generally the cause of the mischief. But much more commonly, 
especially near its endemic home in India, cholera does not occur in great 
outbursts; small local epidemics arise, die down, and then recur. The 
cholera bacillus, in fact, grows in the foul soil, is now and again 
washed into the wells, and so sets up disease in those that draw their 
water from them. The key, then, to this side of the etiology of cholera 
is to be found in the habits of the people, and the degree of care or 
want of care they exercise in the protection of their water-supplies. 
The natural home of cholera is a land of foul water. In Lower 
Bengal, where cases are reported every month in every year, an inquiry 
into the habits of the people, and the condition of the tanks from which 
they largely draw their water-supply, is sufficient to show how constant 
are the opportunities both for food and water, especially the latter, to 
be exposed to faecal contamination. 
In many of the towns of Southern Europe, also, which have most 
markedly suffered from the ravages of cholera (among these Naples and 
Marseilles may be specially mentioned), it has been demonstrated that 
1 In how wide a sense the term " drinking water " may properly be applied is indi- 
cated by the alleged dissemination of the cholera poison by means of oysters which had 
been exposed to the affluence of sewage. CHOLERA ASIATIC A 
871 
while the water-supplies had been contaminated, the habits of the people 
had intensified the evils resulting from this cause. On the other hand, 
our own practical immunity during the epidemics which have broken out 
in Europe since greater attention has been given in England to the secur- 
ing of pure water, compared with our great mortality from cholera in 
earlier epidemics, together with the great lessening of the cholera mor- 
tality in those towns in India which have obtained pure water while 
epidemics have continued as of old in surrounding districts, both tend 
to show that when the habit of drinking water which has been exposed 
to chances of faecal defilement is once broken cholera fails to take root. 
Individual Susceptibility.- We do not, however, completely explain 
the etiology of cholera by the statement that it depends on the ingestion 
of cholera-infected water; another condition is also necessary, namely, 
the susceptibility of the individual. 
Considerable differences exist in the habits of the various members 
of every community; thus it often happens that even where the habits 
o'f the majority are foul, a few are protected from receiving the infec- 
tion by the greater cleanliness and propriety of their lives. Yet 
many fail to sicken, although they are known to have swallowed the 
very infective matter which at the same time is producing cholera in 
others. We have proof of this in every wide-spread water epidemic; 
the number of those who swallow the poison must in these cases vastly 
exceed the number of those who are attacked by the disease. Mac- 
namara gives an instance in which a vessel of drinking water was acci- 
dentally polluted with fresh cholera excreta, and after being exposed to 
the sun all day the water was partaken of by nineteen persons ; of these 
five only subsequently suffered from cholera. 
It seems clear that the inhabitants of the areas in which cholera is 
frequently present, notwithstanding habits which expose them continu- 
ally to chances of infection, are much less frequently attacked than new 
arrivals in the districts, much less, for instance, than Europeans, although 
when attacked they succumb more readily. How far this immunity is 
racial, or how far it is the result of a frequently repeated small infec- 
tion, creating and maintaining an artificial immunity (as is presumed by 
some to occur in the case of yellow fever), is a question which cannot at 
present be decided. There is, however, much in the progress and rapid 
recession of cholera epidemics to favour the opinion, that exposure to the 
influence, if it does not produce the disease, does induce some temporary 
immunity. 
On the other hand there is a good deal of clinical evidence - of a 
nature, however, that can hardly be brought to the test of statistics 
- to show that any disturbance of the balance of the digestive organs, 
especially the dyspepsia common among drinkers, and the looseness of 
the bowels often brought on by eating over-ripe or decomposing fruit, 
distinctly tends to leave the patient open to the cholera infection - that 
in fact an active gastric digestion and a healthy intestinal mucous surface 
form a considerable bar to attacks of cholera. 872 
SYSTEM OF MEDICINE 
The predisposing influence of poverty and bad food partly consists, 
no doubt, in such disturbances of the digestive organs; while the thirst 
and consequent ingestion of large quantities of water common among 
the labouring people may cause indigestion, and do expose them to in- 
creased risks of cholera when the water is infected. 
So far we have considered the etiology of cholera as it affects the 
individual. We have shown that although the condition of the patient 
has an influence on the effect of the attack, the immediate factor in the 
production of cholera is the swallowing of an infection which has come, 
directly or indirectly, from the dejecta passed by another patient suffer- 
ing from the same disease; thus we have demonstrated that cholera 
may properly be called a filth disease: not that filth, unless infected 
with cholera, can cause the disease, but that, without the filthy habits 
which bring about the consumption of food or drink befouled by man's 
dejecta, cholera cannot be transmitted. 
Epidemic Prevalence. - This view, however, of the etiology of cholera 
by no means explains the occurrence of epidemics, nor the tendency of 
these epidemics at varying periods to spread beyond the normal confines 
of the disease, to extend into areas which for long series of years 
had been entirely free from it, to advance stage by stage, and thus to 
march around the globe; then to retire, and for an uncertain period 
either to lie latent or to be confined within the endemic area. 
To understand this peculiarity of cholera, it is necessary to bear in 
mind the various factors which aid in the dissemination of the disease, 
and to recognise that it is the coincidence of many factors which sets 
cholera on the march. 
Within certain areas in India cholera is endemic, especially in the 
country of the Lower Ganges. There " the air, the water, and the soil 
are never cold, the ground is often damp, and when it is dry the tanks 
are foul, so that there is always a fit breeding-place for the contagion, 
and the habits of the people in every way facilitate its entry into their 
systems "(2). 
The habits of the people and the condition of the water-supply in 
many Indian villages are such that, if one did not bear in mind that 
a necessary factor in the etiology of cholera is the susceptibility of the 
individual, one might expect the whole mass of the inhabitants to perish 
rapidly of that disease. If, however, we examine more carefully the 
incidence of cholera within the endemic area, it becomes obvious that, 
although in every district deaths from it may be reported every year and 
every month in every year, still the incidence of this mortality is by no 
means evenly distributed; even within the endemic area cholera wanders 
about, one village after another being attacked and then left at peace for 
a time. It seems as if there were the same tendency for these outbursts 
to die down within the area as there is outside it; but that in consequence 
of the great facilities for reimportation, and of the condition of the soil, 
which makes it possible for the germ to maintain its vitality and carry 
on the saprophytic phase of its existence for a considerable time, the CHOLERA AS/AE/CA 
873 
disease frequently crops up again - whenever, in fact, there is a suffi- 
ciency of susceptible people for it to prey upon, and whenever accident 
introduces it afresh into the drinking water. 
It is important to bear in mind the somewhat curious fact, that the 
highest mortality from cholera does not occur in the parts in which the 
disease is permanently endemic; this points strongly to the probability 
that dwellers within the endemic area attain some degree of immunity 
from the infection. 
The Spread of Epidemic Cholera. - One of the most striking peculiari- 
ties of epidemic cholera, when it oversteps the bounds of its endemic 
area, is its tendency to advance along fairly definite tracks; to go from 
town to town, from country to country; to attack each fresh district 
with enormous virulence at first; then, in a short time, to become 
much modified in intensity, subsiding altogether in about three months 
to return again the next year, and perhaps the year after; then again 
to die out entirely till it is introduced afresh, passing on meanwhile to 
some other place where the same course is repeated. The study of the 
epidemiology of cholera thus involves that of the modes by which the 
disease is carried from place to place, the influences which favour its dis- 
semination, those which favour or retard its taking root in fresh locali- 
ties, together with those curious periodic variations of intensity which, for 
the sake of a phrase, are sometimes attributed to " epidemic influence." 
There can no longer be any doubt that cholera is disseminated by 
human intercourse. The march of cholera coincides with the march of 
man, and it is carried from place to place either by infected man or by 
cholera-tainted clothing. There seems no practical limit to the distance 
to which it would be possible to transmit the infection in a bundle of 
imperfectly dried rags soiled by cholera excreta; man, however, can but 
carry the disease so far as he is able to travel between receiving the 
infection and being laid low. 
What we find, then, on comparing the march of the earlier epidemics 
of cholera with those that have occurred in more recent years, is that 
whereas when travel was slow the disease swept steadily forwards, 
occupying the land as it advanced; in later times it has bounded forward 
with long strides, occupying outposts far ahead of infected areas by 
means of railway and steamboat communication, and then, from these 
outlying foci of infection, has spread in both directions, coalescing per- 
haps at a much later date with the main body of the epidemic which 
has slowly advanced across country from the earlier centres. 
Certain as it is, however, that man is the porter by whom cholera is 
introduced to any place, it must not be forgotten that its development 
in that place depends on insanitary circumstances, the chief condition 
necessary being the liability of the drinking water to be contaminated 
by infected excreta. Hence it has happened again and again that 
cholera has proved the touchstone to the sanitary deficiencies of towns 
and districts, leaving unharmed those with pure water, and ravaging 
those whose water-supply was open to defilement. 874 
SYSTEM OF MEDICINE 
It will thus be readily understood why cholera is so apt to be spread 
in epidemic form by wars and pilgrimages. Cholera may and often 
does travel along the tracks of ordinary trade ; but it never advances far 
unless along its path there be places where the sanitary conditions enable 
the disease to take root and start upon its course afresh. When, how- 
ever, as in the case of wars or pilgrimages, great bodies of men are 
camped out without any proper means of dealing with their excreta, or 
any assurance that their water-supply remains untainted; and especially 
when, as is the case in the great religious pilgrimages which are recruited 
from within the endemic home of cholera, the men who form these 
camps carry with them those habits and customs which, within that 
area tend to make cholera permanently endemic, then we find every con- 
dition fulfilled for the epidemic propagation of the disease. 
Accepting the view that when cholera is introduced into new dis- 
tricts it is carried thither by cholera-infected rags, cholera-infected food, 
or cholera-infected man, it becomes a matter of great importance to 
determine whether the last (namely, cholera-infected man) can carry 
with him the germs, deposit them in fresh places, infect water-supplies, 
and set up epidemics, without himself suffering from cholera and be- 
traying its symptoms. Till a few years ago this question would have 
been unhesitatingly answered in the negative; and in fact it is in the 
belief that a man cannot carry cholera unless he himself suffers from it 
that the modern substitute for quarantine is founded, namely, the sys- 
tem of medical inspection and detention of invalids. Modern travel is 
conducted on so vast a scale, and the numbers moving from place to 
place are so enormous, that efficient quarantine is obviously impossible. 
It has been hoped, however, that if those actually ailing be sorted out 
the rest may safely be allowed to pass. Hence the modern system. 
The more recent investigations of Koch and others tend, however, to 
throw some doubt upon the efficiency of such measures; and although 
they have appeared successful in preventing the disease from taking root 
in England, it is quite possible that the greater attention which of late 
years has been given to the purity of the water-supply of our towns may 
have had a much larger share than our port sanitary inspection in giv- 
ing us the exemption we have enjoyed. Koch has shown (3), and it has 
been shown repeatedly at the observation stations which were established 
in Germany at the time of the epidemics in Hamburg in 1892 and 1893, 
that among those who had been exposed to the possibility of cholera 
infection, and who yet remained apparently healthy, there were indi- 
viduals whose fseces although hardly diarrhoeic -•nay, quite normal - 
yet, nevertheless, contained cholera-bacteria. " It is now certain that 
among a number of persons who have been exposed to cholera infection 
the resultant cases may show the whole scale from the severest and 
rapidly fatal cases down to the mildest imaginable, demonstrable only 
by bacteriological investigation." 
The determination of this point goes far to explain outbreaks of 
cholera in which the first apparent sufferers could be shown not to have CHOLERA ASIATIC A 
875 
entered any infected district. The very first case has, in fact, not been 
recognised, maybe the patient has not known that he was ill; his dejecta 
have nevertheless obtained access to the water-supply, and thus given rise 
to the outbreak. It seems only in this way possible to explain some of the 
isolated sporadic cases which have occurred in England, cases in which, 
notwithstanding the entire want of evidence of any connection with 
any known focus of the disease, the typical micro-organisms have been 
discovered. 
Conditions determining Character of Outbreak. - When the cholera 
germs have once been introduced into a district their fate will depend 
on various conditions. If they chance to gain access to a public water- 
supply they will, as has been shown again and again, set up a sudden 
and wide-spread epidemic among the consumers of the water - an 
epidemic which breaks out simultaneously in different parts of the dis- 
trict, rages violently for a time, and if the infected water be cut off, 
stops almost as suddenly as it had begun. 
If, however, the germs do not gain access to a general water-supply, 
but are deposited in the neighbourhood of the dwellings of the people, 
they will only set up small and localised outbreaks ; in one part after 
another of a town, in one town after another, cholera will arise and 
soon die out, only to crop up again in neighbouring places, or even in 
the same place again; and thus an epidemic, never perhaps severe, may 
continue so long as to cause serious loss of life. The continuance of an 
outbreak of this latter sort depends upon local conditions; and it is 
obvious that, although a general water-epidemic has a sudden rise and a 
sudden fall, one occurring in a district which favours the development of 
foci of cholera, although it may rise as suddenly, will not terminate so 
quickly: it will rather set up a multitude of centres from which it will 
continue to spread as in the second mode, the mode in which it mostly 
shows itself in countries in which it is endemic during non-epidemic 
times - countries in most parts of which no such thing as a public 
water-supply, in the modern sense of the term, exists. It becomes then 
very important to inquire into the causes other than the infection of 
public water-supplies which favour the development of epidemic cholera; 
for it is certain that " in many districts of greater or less extent, the 
cholera has never reached any considerable or strictly epidemic devel- 
opment notwithstanding repeated importations of the poison " (4). 
Conditions favouring the Development of Cholera Epidemics. - Hirsch 
says, "As there are certain local peculiarities which furnish the con- 
ditions for the endemic disease, so also there are certain factors re- 
siding in the circumstances of place or season, which are necessary to 
give potency to the cholera poison beyond its native habitat; " and he 
quotes Hergt as saying, " The rise of the cholera epidemic at any one 
place implies, besides importation of the contagium, certain local con- 
ditions of atmosphere and of soil as well. These conditions must be 
able at a given place to generate themselves and to disappear again." 
The latter is an important qualification, for it appears certain that 876 
SYSTEM OF MEDICINE 
among the causes necessary for the development of cholera in an epi- 
demic form, except when widely distributed by water, are some which 
are purely temporary, as for example those which are connected with 
season; and that a locality, which at one time may be capable of devel- 
oping cholera in a most virulent form, may at other times be, compara- 
tively speaking, protected from its attacks. Putting then on one side 
infection of public water-supply, which is capable of creating an epi- 
demic in any place and in any season, we have to consider the factors 
in the production of an epidemic not arising from that cause. 
According to Dr. Davidson (6) they may be classed as - Local con- 
ditions : Seasonal influences: Predisposing conditions: Facilities of in- 
tercourse : Race proclivities: Epidemic influences. 
Of these the " predisposing conditions " and the " racial proclivities " 
have already been dealt with; and after what has been said regarding 
the mode of dissemination of cholera, the importance of facilities for 
intercourse is obvious. "Epidemic influence," again, and the curious 
tendency of cholera, like other infectious diseases, to rise into epidemic 
importance at moderately regular intervals of time, must be regarded 
as due to the coincidence of several causes, each emphasising the impor- 
tance of the other. It remains then to consider the conditions of place 
and of season which influence the occurrence of epidemic cholera. 
(a) Altitude. -Elevated districts often remain exempt from cholera; 
on the other hand valleys and low-lying areas are much more apt to 
suffer: in towns situated on a slope, or occupying different elevations, 
it is usually found that within the same town the higher districts are 
least affected. On the other hand, cholera has occurred at very consid- 
erable altitudes, and even sufficiently often in the higher parts of towns 
to make it clear that the cause of the apparent variation of cholera with 
altitude must be sought elsewhere, probably in its relation to tempera- 
ture, water-supply, and movement of ground water. 
(&) Relation to Rivers. - It has constantly been observed that not 
only does cholera follow rivers, which it should be noted are also com- 
monly lines of traffic and centres for the aggregation of large popula- 
tions, - two main factors in the dissemination of the disease, - but 
that it attacks places on the banks of rivers and even of small streams 
with special severity. This again probably has relation to conditions 
of soil and density of population, as well as to the double function of 
rivers as drains and sources of water-supply. 
(c) Character of Soil. - Cholera attains its greatest intensity on soils 
which are permeable to water, but not sodden with it, and are at the 
same time capable of retaining a certain degree of moisture within their 
interstices. 
The relation then of altitude, neighbourhood of rivers, and character 
of soil may all resolve themselves into this - that cholera is most likely 
to take on its epidemic character on a soil which is porous, more or less 
charged with decomposing organic matter, moistened with water, and 
having its interstices filled with air. On such a soil complete dryness, as CHOLERA ASIATIC A 
877 
was seen in the famine districts in India, or complete saturation as is seen 
in the rainy season in certain districts, are inimical to cholera: while a 
falling ground water, leaving the soil moist, full of air, and charged with 
organic matter from the surface, disposes to cholera; not only by favouring 
the saprophytic growth of the cholera bacillus, but also by facilitating its 
access to wells. 
(d) Seasons and Weathers. -In like manner the influences of season 
and of weather can be reduced to those of temperature and rainfall. A cer- 
tain temperature is necessary for the development of the cholera bacillus 
outside the body; but cholera is not always most prevalent in the hottest 
weather, nor is it always stopped by winter. It seems probable, however, 
that in those cases in which cholera has occurred in winter there has 
either been a direct infection of a water-supply, as in the case of the 
outbreak at Nietleben in January 1893, described by Koch (7), or the 
infection has gained access to the soil under houses which, as in Russia, 
have been kept continually at a high temperature, and has thus reached 
the drinking water indirectly. In temperate climates the great mortality 
from cholera takes place in the warm weather; in England August and 
September are the most fatal months. In India, however, the greatest 
prevalence of cholera is by no means synchronous in the different parts 
of the country, nor does it uniformly accord either with greatest heat or 
with the maximum or minimum of rainfall. Along with heat there must 
be moisture of soil for cholera to prevail. On the other hand the soil 
must not be sodden with water, as in some places is the case in the rainy 
season; thus it happens that in some districts with dry soil the rains 
by introducing the moisture necessary for its development and by wash- 
ing the infection into the water-supply, seem to bring cholera; while 
in other districts, in which there is usually a certain moisture of soil, the 
rains will stop an epidemic by filling up the pores and removing the 
aeration of the soil necessary for the continuance of the saprophytic 
growth of the bacillus. Heat, moisture, aeration, and the presence of 
decomposing organic matter in the soil are then the conditions favourable 
to the local development of cholera when once introduced; and the 
more of these conditions which coincide in any place and time the more 
likely is cholera in its epidemic form to prevail at that time and place. 
(e) Habits of Inhabitants. - Even amidst the conditions of soil and 
climate most favourable or most inimical to cholera, its prevalence largely 
depends upon the habits of the people; however largely present its 
contagium may be it is harmless unless swallowed. Thus among all the 
influences making for cholera, the most important are those habits of 
carelessness as to the cleanliness of food and drink which make it easy 
for either the one or the other to be tainted with faecal material. 
(/) General Sanitation. - As is the influence of the habit of cleanly 
living to the individual, so is that of general sanitation to the body 
corporate. Good drainage and good water-supply keep cholera at bay 
by making it impossible for the faeces of one person to gain access 
to the drink or food of another. 878 
SYSTEM OF MEDICINE 
This brings us back to the key-note of the etiology and epidemiology 
of cholera, namely, the ingestion of infected water or infected food. 
The act of swallowing the living contagium derived from the excreta 
of a previous sufferer from the disease is the immediate cause of cholera 
in the individual; while the means by which facilities are given for the 
growth of this contagium outside the body, for its wide-spread dissemi- 
nation, and for its introduction into the food or drink of man, are the 
causes of cholera epidemics. 
Ernest Hart. 
Solomon Charles Smith. 
Bacteriologv of Cholera 
It is a difficult task to give a comprehensive and impartial sketch of 
the bacteriology of cholera. Opinions have constantly changed since 
Koch's discovery of the comma bacillus, and from the very outset his 
conclusions have been strongly opposed. More recent experience has 
led to changes of opinion, and, however impartial our endeavour, we 
cannot at present find a satisfactory solution of the matter. We shall do 
our best to present it in a more or less historical order. In this conflict 
of opinions there are two distinct periods: the first, dating from Koch's 
discovery of the comma bacillus in 1883 until the recent appearance 
of cholera in Europe; and the second, beginning with the cholera 
epidemic in 1892. During the first period Koch was the central figure, 
and the study of the cholera organism was more or less restricted to 
laboratory research: on account of the scarcity of choleric material 
general criticism was impossible. On the return of cholera to Europe 
pathologists and bacteriologists were enabled to make independent ob- 
servations, and a general exchange of opinions became possible. 
First Period 1883-1892. - In 1883 Koch separated a characteristic 
curved organism from the dejecta and intestines of cholera patients, 
the comma bacillus; this he declared to be absent from the stools and 
intestinal contents of healthy persons, and of persons suffering from other 
affections. The organism was said to possess certain morphological and 
biological features which readily distinguish it from all previously de- 
scribed organisms. It was absent from the blood and viscera, and was 
found only in the intestines ; and in the greater number, it was said, the 
more acute the attack. Koch also demonstrated an invasion of the mucosa 
and its glands by the comma bacilli. The organisms were found in the 
stools on staining the mucous flakes or the fluid with methylene blue or 
fuchsin, - and sometimes alone: by means of cultivation on gelatine 
they were readily separated from the stools. During his stay in India, 
in Egypt, and at Toulon, Koch had examined more than a hundred cases, 
and other investigators confirmed his statements. Numerous control ob- 
servations, made upon other diarrhoeic dejecta and upon normal stools, 
were negative ; the comma bacillus was found in choleric material only, 
or in material contaminated by cholera. Soon other observers, however, CHOLERA ASIATIC A 
879 
described comma-shaped organisms of non-choleraic origin; Finkler and 
Prior, for instance, found them in the diarrhoeic stools of cholera nostras, 
Deneke in cheese, Lewis and Miller in saliva. All of these organisms, 
however, differed in many respects from Koch's comma bacillus; and 
gradually the exclusive association of Koch's vibrio with cholera became 
almost generally acknowledged. In 1886, indeed, Fliigge maintained that 
the comma bacilli must be regarded as the cause of cholera, because they 
occur constantly and exclusively in this disease. 
Koch described his vibrios as short, curved organisms, often arranged 
as spirals; the curvature of the individuals varies greatly, the latter being 
sometimes almost straight, and at other times nearly semicircular. Two 
commas may be attached so as to form an S; spirals, even of great length, 
may indeed be found. They possess the power of spontaneous movement 
in a marked degree, and readily undergo involution, becoming round and 
coccoid or irregular in appearance. Htippe assumed these coccoid forms 
to be arthrospores; his observations, however, are by no means convincing. 
On the surface of a gelatine plate the growth, as described by Koch, 
is characteristic during the early stages, the colonies appearing as small, 
whitish, refractive points, so that the gelatine seems to be sprinkled 
over with delicate glass splinters; as the liquefaction of the nutrient 
medium progresses this appearance is lost. Stab-cultures in gelatine are 
equally characteristic: there is a whitish growth along the needle-track 
with gradual liquefaction, which at first is most marked near the surface, 
so that a funnel-shaped depression is formed which appears to contain 
an air-bubble. Liquefaction is comparatively slow, but after six days 
it has progressed so far as to destroy the appearance just described. 
On agar-agar we have a superficial slimy growth, offering no special 
features; growth occurs on potato at a raised temperature only; milk 
is not coagulated. Koch's vibrio is capable of thriving in very dilute 
broth or peptone solution; it is a facultative anaerobe, and grows best 
between 30° and 35° C.; drying, acids, and most disinfectant solutions 
destroy it quickly. 
Animal experiments, in so far as their aim was to reproduce a typical 
choleraic lesion, were not successful in Koch's hands; nor can those per- 
formed by Nicati, Rietsch, and Van Ermengem be considered convincing. 
Subcutaneous inoculations and feeding led to no result; direct inoculation 
into the duodenum, with or without previous ligature of the bile duct, 
frequently produced fatal diarrhoea with abundant vibrios in the dejecta, 
but since this result seemed to depend to a great extent on intestinal 
injury they are not free from doubt. Koch himself, indeed, asserted that 
he had induced a choleraic process by feeding guinea-pigs with pure cult- 
ures, after previous neutralisation of the gastric contents and injection 
of tincture of opium into the peritoneal cavity, in order to paralyse the 
intestinal peristalsis. Yet as other vibrios act in the same manner these 
animal experiments have not established the specifically pathogenetic 
power of the comma bacillus. The sterile products of choleraic cultures 
administered to a guinea-pig will cause distinct intoxicative symptoms 880 
SYSTEM OF MEDICINE 
or death, as first shown by Nicati and Bietsch; these symptoms, how- 
ever, do not differ from those produced by many other bacterial toxins. 
We shall refer to human experiments later. 
Lbffler demonstrated that the cholera vibrio possesses a single terminal 
flagellum, but others have shown that it may possess more than one. Of 
more interest, however, is a peculiar chemical reaction which Koch 
pronounced to be characteristic, the so-called cholera-red reaction. On 
adding pure hydrochloric or sulphuric acid to a culture in peptone solu- 
tion or in peptone broth, a pink or red colour (cholera-red) appears. This 
reaction was discovered by Pohl, Bujwid, and Dunham in 1886 and 
1887, and was explained by Salkowski, who at the same time proved it 
to be of no specific value. It depends merely on the formation of indol 
from the albuminous substances in the culture medium. Many organisms 
give the same reaction: some on the addition of nitrites, others without 
this addition; the latter possess the power of converting the nitrates 
contained in the broth or peptone into nitrites first. This the cholera 
vibrio can do, but many other vibrios and bacilli do likewise. 
This short description of Koch's comma bacillus must suffice. He 
considered it to be the one specific cause of cholera, and to be constant 
in its characters: any vibrio which did not agree in its features with the 
one discovered by himself was at once put aside as non-choleraic. This 
ban fell upon the various vibrios described by Finkler-Prior, Deneke, 
Gamaleia (vibrio Metschnicovi), and others. 
The specific germs - Koch's comma bacilli - are shed in the stools 
from the body during the first days of the disease; and only these, or mat- 
ter contaminated by them, as for instance the bed linen, vessels, latrines, 
soil or drinking water, can be sources of infection. Since the vibrio is 
readily destroyed by drying, only freshly-contaminated objects are dan- 
gerous. Yet it has been shown that the vibrio, when kept moist, may 
retain its vitality for a considerable time. It follows, therefore, that the 
disease to be carried from an endemic area must either be uninterruptedly 
transmitted from one individual to another, or must pass by a general 
source of infection, as for instance a contaminated water-supply. Aerial 
infection is excluded; hence there must be either direct contact with 
choleraic material or the consumption of contaminated food or unclean 
water. Moreover, some personal disposition, brought about perhaps by 
dyspeptic conditions, or by the general debility of poverty, starvation, and 
overcrowding, may or must co-operate with the specific agent. Nor are 
locality and season without moment. In some localities the disease seems 
never to occur; and the exemption finds an explanation in a difference 
of water-supply, of hygienic and economic conditions, and is independent 
of the particular state of the soil. So far as the seasons are concerned, the 
cholera epidemics in the temperate zones reach their climax during the 
late summer and in autumn; that is, during those months when insects 
abound, when raw food is copiously consumed, and when gastric derange- 
ments are common. Such in brief is the mechanism of infection as it was 
explained by the contagionistic school which believed in a single specific 
cholera vibrio. CHOLERA ASIATIC A 
881 
Pettenkofer was one of the earliest opponents of this school; and 
until now he has defended the " localistic " view against those of Koch 
and the contagionists. He too believed in a transmissible virus (a?), but 
that an epidemic cannot arise without concomitant conditions which de- 
pend on differences of locality and season (y); so that, although x alone 
may cause an individual case, an epidemic can only appear when x and 
y coincide. Pettenkofer sought and still seeks y more particularly in 
special conditions of the upper layers of the soil which affect x in such a 
way as to render it infective. He denied formerly that Koch's bacillus is 
x, because of its lack of resistance to external influences. Koch's adher- 
ents maintained that Pettenkofer's explanation did not apply to cholera 
epidemics generally, and that the recent outbreaks especially failed to 
satisfy his conditions. Although Pettenkofer has now accepted Koch's 
vibrio as the factor x, he still adheres to the unknown y on epidemiologi- 
cal evidence. After the Hamburg epidemic he reminded us that the 
cholera germs may often remain quiescent, so that the epidemic appear- 
ance of cholera depends not so much on the presence of comma bacilli or 
a personal disposition, as on certain associated states of locality and sea- 
son. He complains that contagionists do not pause to consider why certain 
localities and areas are not visited by an epidemic, although sporadic cases 
of cholera are constantly present in them. He alleges that, in spite of 
railways and steamers, cholera does not spread quicker or more generally 
than formerly, and this with him is a strong argument against the con- 
tagionist theory. Cholera epidemics, he asserts, appear only in places 
with a local disposition. 
The staunchest opponent of Koch's school has been Dr. D. D. Cun- 
ningham, who is not yet reconciled to the opinion that the "comma 
bacillus " is a specific element. In 1890 he claimed to have demonstrated 
that several distinct species of vibrio occur in association with cholera in 
Calcutta, the home of the disease; so that, according to him, no one 
species, and least of all Koch's which he never found, can be regarded as 
the cause of the disease. He agreed with Koch that, as regards the vast 
majority of cases, the presence of large numbers of vibrios in the intestines 
is characteristic and even diagnostic. But he has seen " undoubted " cases 
of cholera without comma organisms; and he has further observed that 
the vibrios separated from other cases were not of one, but of various 
species: in fact, from sixteen cases he obtained no less than ten distinct 
species, distinct morphologically, biologically, and chemically. He there- 
fore concluded that Koch's theory of cholera, as primarily due to the 
access of a specific comma bacillus to the interior of the intestinal tract, 
must be abandoned; and if comma-shaped organisms are to be regarded 
as entering into the causation of cholera, it must be as members of a 
group of various species. In one case he separated three distinct species 
- a fact which suggested to him that the special morbid condition existing 
in choleraic enteritis is the cause of the presence of the comma bacilli. 
Cunningham has followed up his observations for some years, and he is 
confirmed in his opinion that the vibrios which he found in association 
VOL. I 
3 L 882 
SYSTEM OF MEDICINE 
with cholera are not of one kind, nor even varieties of one species, but 
are of different species. He has continued to cultivate the forms obtained 
for long periods under equal conditions, and has found that they remain 
distinct, and that there is no approximation in morphological and biologi- 
cal characters. He states that some of his choleraic vibrios differ from 
others as much as the organism of Finkler-Prior differs from Koch's 
comma bacillus, or as the B. subtilis from the anthrax bacillus. As no one 
regards the latter bacilli as varieties of the same species, there is no justi- 
fication for regarding the various choleraic vibrios as aberrant forms of a 
common stock. Cunningham is indeed disinclined to admit that cholera 
is due to the access of a member of a group of vibrios; he sees in cholera 
a disease caused by a ptomaine which produces certain changes in the in- 
testinal tract favourable to the growth and development of sundry vibrios. 
Until recently Cunningham's views as to the multiplicity of vibrios 
associated with cholera were either left unnoticed or generally opposed; 
but Dr. Klein has fully confirmed Cunningham's statements as to the 
permanently different cultural characters of various forms of choleraic 
comma bacilli; though he does not discuss their specific affinities. Klein 
himself, however, until recently, based his doubts as to the causal rela- 
tion between cholera and Koch's comma bacillus chiefly on animal 
experiments. He accepted then, as he does now, the fact that vibrios are 
almost always found in large numbers in cholera; but he considered that 
experimental proof was wanting. It had been asserted by Koch and his 
school that comma bacilli, when introduced into the small intestine in a 
living state, are capable of setting up an acute illness resembling Asiatic 
cholera. We need not give Klein's arguments in full, because it is now 
generally acknowledged that the lesions produced in guinea-pigs and other 
animals by subcutaneous, intraperitoneal or intestinal inoculations have 
no specific characters, and may be caused by many other organisms besides 
the so-called cholera vibrio. It is evident, then, that since choleraic 
symptoms cannot be produced in animals, and since lesions identical with 
those following on inoculation with choleraic vibrios are called forth by 
many organisms, the animal experiment cannot be used in support of 
Koch's thesis. Intraperitoneal inoculations are followed by fatal peritoni- 
tis, but this does not differ from that produced by similar inoculations with 
the bacillus prodigiosus, the vibrio of Finkler-Prior, typhoid germs and 
other micro-organisms. Nor can it be maintained that the intestinal in- 
oculation has any specific character, for identical phenomena may follow if 
we use other vibrios, such as the spirilla of Finkler-Prior and of Deneke. 
According to Klein, then, animal inoculation cannot be said to have proved 
the causal relation between Koch's vibrio and Asiatic cholera. Klein has 
always agreed with other observers that vibrios are extremely common, 
and almost constantly found in the intestinal contents in cholera, 
although he could not confirm Koch in the assertion that the more 
acute and severe the case the more numerous are the comma bacilli 
in the lower ileum; he did not find this definite relation, and indeed 
the assertion is now generally withdrawn. His attitude has always been CHOLERA ASIATIC A 
883 
one of reserve, which is justifiable, and indeed imperative, so long as the 
chain of evidence is incomplete. 
Second Period. - The second period is characterised by energetic 
investigation of the morphology, biology, and etiological importance of 
the cholera vibrios. It soon became evident that from stools derived from 
cases clinically recognised as cholera various forms of curved micro- 
organisms can be obtained, which morphologically as well as in artificial 
cultivations often do not even resemble Koch's comma bacillus, and 
differ greatly one from another, or at least sufficiently so, to raise the 
suspicion in our minds that in cholera we are dealing with more than one 
kind of vibrio. Even the unwavering supporters of Koch's views became 
aware that there is more than a grain of truth in Cunningham's observa- 
tions on the variability in form. Klein's cholera studies in England, the 
only complete ones in this country, have clearly shown that several 
varieties of vibrios are associated with cholera-a point upon which most 
observers are now agreed. The burning question is whether these forms 
are merely varieties of one choleraic vibrio, or are different species. If 
the latter be the case, and we find that the numerous forms associated 
with cholera are specifically different, one vibrio in particular cannot 
any longer be regarded as an invariable antecedent. This difficulty 
has been felt by all who are acquainted with the bacteriology of cholera. 
These inquirers are now divided into two camps : (1) those who believe 
with the majority that cholera is due to one organism which may show 
certain variations - in other words, that cholera is a strictly specific 
disease; (2) those who contend that, as suppuration may be caused by any 
one of a certain number of micrococci, so likewise may cholera be caused 
by more than one vibrio. The present confusion therefore is great, and 
much ingenuity has been manifested by the adherents of the one view to 
overthrow the assertions of those who accept the other. As yet we 
have not reached the solution of the problem. 
Those who, amid numerous existing varieties believe in the unity of 
the choleraic vibrio, employ special tests whereby we may decide whether 
we are dealing with the specific vibrio or with one resembling it; seeing 
that a number of vibrios have been found in water or elsewhere, for which 
places may readily be found in the long series of the varieties of the 
cholera microbe. Artificial cultivation on ordinary nutrient media, under 
usual or unusual conditions, has shown that these choleraic vibrios are 
highly pleomorphic, and that they readily change morphologically and 
biologically, chemically and physiologically. Thus Dunbar, a firm 
believer in the vibrionic unity of cholera, admits that typical comma 
bacilli when kept in water vary and differ more from one another than 
non-choleraic water vibrios. True vibrios may become so altered as to 
belie their origin altogether. This extraordinary variability, which 
readily leads to permanent changes, is a property which must not be left 
out of sight; it must make us cautious in our criticism, for it is more than 
probable that what a few test-tube processes can effect nature and disease 
can do far more thoroughly. The collected observations of the last few 884 
SYSTEM OF MEDICINE 
years, if they remove a great part of the force of Cunningham's opposi- 
tion, have impressed, upon us the difficulty of the bacterioscopic diagnosis 
of the choleraic vibrios. Koch for his diagnosis relied on microscopical 
preparations, growth in peptone solution, on gelatine and agar-agar plates, 
on the indol reaction, and on the positive animal experiment; but it was 
soon found that few, if any, of these tests could be relied upon. 
(a) Gruber, after patient work, came to the conclusion that the only 
certain criterion is the appearance of the colonies in a gelatine plate. 
He points out that the attempts to formulate characteristic differences 
in the microscopical appearances between Koch's and the other comma 
bacilli are vain; seeing that one and the same race of Koch's or other vibrio 
may present morphological characters varying as the conditions of growth 
and the age of the cultivation. The difference in the microscopical 
appearance between individual races and cultivations is often greater than 
that between different species; so that it is impossible by this method to 
distinguish the cholera vibrio. Gruber admits that the variety of cholera 
vibrio, first described by Pasquale in an epidemic in Massowah, differs in 
the most remarkable way from that of Koch. These differences have 
been maintained for a year and a half in cultivations on various media, 
and after passing it through the body of animals. Further, the Massowah 
vibrio possesses from four to six flagella: Koch's generally has one only; 
but in cover-glass preparations some were always found to possess two or 
three, so that this feature is not a constant one, and it is possible to regard 
the Massowah vibrio simply as a variety and not as a distinct species. 
For a long time it was considered that the rapidity and manner of 
liquefaction of gelatine would constitute a simple method of diagnosis. 
But it was found that the different generations of the cholera vibrio show 
wide differences in the property of liquefying gelatine; some liquefy it 
almost as rapidly as does the vibrio of Finkler-Prior, some hardly 
liquefy it at all: as most of the allied species of vibrios lie within these 
limits Koch himself has abandoned this test. Gelatine plate cultiva- 
tions, according to Gruber, are of much more value. Here it is impor- 
tant that the composition of the gelatine should be constant, and that the 
temperature be kept at or about the same level - 20° to 22° C. being the 
most suitable. The thickness of the layer of gelatine on the plate, 
the depth of the colonies, the number of the colonies, the presence of 
other bacteria, all are factors which influence the appearance of colonies; 
and, finally, the distinguishing characters of different species only make 
their appearance at certain stages of development, so that the observation 
must be repeated at definite intervals of time. 
The superficial and the deep colonies of the cholera vibrio differ in 
appearance. The superficial colonies of Koch's vibrio in 45 to 48 hours old 
gelatine plates differ from all other known vibrios except Deneke's cheese 
vibrio: (1) The superficial colonies of the earlier stage present an irregular 
(never simply round or oval) shape, and have either a coarsely granular 
or a furrowed or striated appearance; while the colonies of all other 
vibrios, with the exception of Deneke's, have a rounded shape, and appear CHOLERA A STATIC A 
885 
quite structureless, or at most finely striated. (2) The deep-seated 
colonies, even in sparsely-sown plates, present at an early stage an irregular 
shape and a wavy, uneven appearance. In the case of old and attenuated 
cultivations this irregular, uneven appearance may be but slightly marked, 
yet it is always present. 
On the other hand, all other vibrios (excepting Deneke's), especially 
in thinly-sown plates, appear rounded, quite structureless, and with a 
smooth surface. On thickly-sown plates the deep and superficial appear- 
ances of these colonies present a great similarity to that of the cholera 
vibrio; so that the difficulties surrounding this procedure are many, and 
Gruber admits that after all the test is not conclusive. 
With certain cholera vibrios these characteristic appearances may be 
only slightly marked or altogether absent. Thus some cholera vibrios 
liquefy very slowly, and the superficial colonies have then quite an aber- 
rant appearance - in fact, an appearance so distinct from the classical 
appearance that one might be tempted to describe two kinds of cholera 
vibrios simply on the ground of these differences. 
Yet further study has convinced Gruber that it is possible by gelatine 
plates to distinguish all vibrios from that of Koch, except Deneke's vibrio. 
But seeing that external conditions have so great an influence, and 
that the variations in mode of growth of a particular species are so great, 
this method of determining the species, as Gruber admits, is extremely 
difficult and perhaps uncertain; and seeing that Gruber's test breaks 
down with Deneke's vibrio, for this reason alone it must be regarded as 
useless. Recently Gruber himself has confessed that although we know 
with certainty that the vibrios which are associated with the choleraic 
processes cause the symptoms and lesions of the disease, yet we cannot 
diagnose the true nature of these vibrios with like certainty; hence, at 
present, we cannot definitely state whether those which have been sepa- 
rated from genuine cases of cholera belong to one or several species, or 
whether they are identical all over the world. The fact which he now 
also accepts - that copious proliferation of these vibrios may occur in 
the intestinal tract without leading to serious disease - while it com- 
pels him to assume the co-existence of certain unknown factors necessary 
for the appearance of cholera in the individual or in a locality, renders 
his position somewhat paradoxical. 
(6) Pfeiffer, who has never doubted the correctness of Koch's observa- 
tions and deductions, recognising, nevertheless, that none of the proposed 
tests vouchsafe a certain diagnosis, introduced a novel method of dis- 
tinguishing between true and false cholera vibrios. It was based on the 
fundamental proposition expressed by Behring, that the serum of a pro- 
tected animal is specific in its action; that is, if injected into an animal 
it confers on it an immunity only from the lesion against which the 
original animal had been protected. Pfeiffer, therefore, rendered animals 
proof against a cholera vibrio, and then used their serum as a test. Its 
action being specific, it can counteract the effects only of one species of 
vibrio, and must be impotent against all others. His method of proced- SYSTEM OF MEDICINE 
886 
ure is as follows: he injects a mixture of anticholera serum with the 
suspected, organism: if the animal succumb, the organism in question can- 
not have been a cholera germ; if the animal survive, our suspicions have 
been justified. Those who dissent from him object that this argument 
entirely begs the question as to the true choleraic vibrio. Pfeiffer selected 
at the outset a comma bacillus obtained from Hamburg, and used it as the 
genuine form before he had demonstrated its specific value. The dis- 
senters, therefore, refuse to accept his test: it may distinguish between 
varieties or species, but it does not prove the specific nature of the vibrio 
under suspicion. Curiously enough it led to the confession, on Pfeiffer's 
part, that the Massowah variety with which he had worked for some 
time, and which had formed the basis of his cholera studies, is an impostor; 
yet this vibrio had been used in most laboratories, and its specific nature 
had never been doubted by bacteriologists. On the other hand, a vibrio 
separated by Ivanoff from a case of typhoid fever was declared to be 
genuine, although formerly it was excluded from the group of cholera 
vibrios. Before Pfeiffer's method can be convincing, it must be shown 
that cholera is specific in the sense that it is caused by one form of vibrio, 
and only one. If this be so, and if, under such conditions, Pfeiffer was 
fortunate enough to secure this one vibrio, then the immunity test might 
become absolute ; if the specificity of protective serum within Pfeiffer's 
narrow limitation can be accepted. 
Sanarelli objects that Pfeiffer and Issaeff themselves have shown 
that normal horse's serum is as active as that of cholera-immune ani- 
mals ; and Roux maintains against Behring's law that antitetanic serum 
can destroy the lethal effect of snake poisons. Further, Sanarelli's own 
serum tests led to results very different from those of Pfeiffer; for he 
obtained reciprocal action between many choleraic and non-choleraic 
vibrios: he concludes that " it is established that the serum of an 
animal vaccinated against a pathogenetic organism is endowed with pro- 
tective action, not only with regard to varieties of the same species, but 
also with regard to organisms belonging to a different species. The 
bacteriological diagnosis of the choleraic vibrio by means of anticholera 
serum, therefore, is a practice not warranted by results." 
Dunbar and Klemperer agree with Pfeiffer in regard to the specificity 
of the cholera serum and its value as a diagnostic test; nevertheless the 
former acknowledges that a true vibrio may become so altered in its 
properties that it will eventually react negatively. C. Frankel and Gruber 
are neither of them willing to accept the absolute validity of this test. 
Bordet, however, applying the serum test in a manner differing from 
that of Pfeiffer, that is, by studying the antimicrobic power of the 
serum outside the body, to some extent disagrees with Sanarelli, and 
asserts that this power of a serum is always more marked towards 
identical vibrios or towards varieties of a species. But yet, we find from 
his researches that the " Massowah serum " reacts on a Calcutta vibrio, 
but not on vibrios obtained from Constantinople, Hamburg, East Prussia, 
and Casino; and that the " East-Prussia serum " reacts also on the CHOLERA ASIATIC A 
887 
Hamburg and Constantinople varieties, but not on the Massowah vibrio. 
Bordet believes that the preventive action of the cholera serum is 
specific to the same extent as its germicidal action. Pfeiffer has asserted 
that if vibrios inoculated into the peritoneal cavity of a cholera proof 
guinea-pig become transformed into granular masses, or if the same result 
follow a similar injection of a mixture of vibrios with specific serum, they 
are genuine comma bacilli. This granular transformation is called Pfeif- 
fer's phenomenon. Bordet states that the same phenomenon can be ob- 
tained outside the animal body on a glass slide, if a little of the suspected 
culture and normal serum be mixed with a few drops of anticholeraic 
serum: theiiif we are dealing with true vibrios they are at once changed 
into a granular mass. Those vibrios which do not respond to Bordet's 
reaction fail to respond to Pfeiffer's test; and Bordet therefore proposes 
his method as a quicker and readier procedure, and also as a less expen- 
sive one, since it requires fewer animals. A vibrio which gives a posi- 
tive reaction may be considered genuine; and Bordet acknowledges that 
a negative reaction must be accepted with reservation, because some vibrios 
are more resistant than others. Mr. H. E. Durham, simplifying the test, 
has recently come to the same conclusion; but he also confesses that the 
limits of the absolute value of this serum test for the diagnosis of cholera 
vibrios has yet to be determined, and he adds that a series of gradations 
in intensity of reaction between serum and vibrios has been observed. 
It is evident, then, that at present we are surrounded by contradictions, 
and must suspend our judgment. 
Metschnikoff criticised both Gruber's and Pfeiffer's tests adversely; 
the latter, because it leads us to paradoxical results. Of Gruber's test 
he says that it is precisely the regularity and circular appearance of 
young colonies of Deneke's vibrio which have always been taken to dis- 
tinguish this vibrio from the cholera vibrio: yet in young colonies of 
Deneke's vibrio we find among the symmetrical colonies others of irregular 
contour; and among the varieties of cholera vibrio, on the other hand, we 
find some which present a regular contour. Here then we find no way 
out of our difficulties. But we may state that the validity of Pfeiffer's 
tests can hardly be accepted, unless it be shown that morphological and 
cultural variation is never accompanied by chemical variation. 
Metschnikoff is also of the opinion that among the water vibrios 
found independently of any cholera outbreak there are choleraic vibrios. 
Of these we shall now speak. 
(c) Sanarelli discovered a number of vibrios in water, which often 
could not be immediately traced to any epidemic of cholera, present or 
past; these he pronounced to be choleraic vibrios, altered or modified by 
saprophytic conditions of life. We must premise that he accepts the 
researches of those who maintain that there are varieties of comma bacilli, 
and who doubt the exclusive specificity of Koch's original organism. 
This doubt he considers still more justifiable in the light of Rumpel's 
and Metschnikoff's discoveries of cholera vibrios in the faeces of healthy 
persons, to which we may add similar observations by Cunningham, SYSTEM OF MEDICINE 
888 
Pasquale, Lesage, and Macaigne. He rejects the criticisms of Hiippe 
and Friedrich, who attempted to show that all these various forms 
are merely physiological varieties of one and the same species, and he 
rejects Koch's six tests also, namely, (1) microscopical examination; (2) 
cultivation in peptone solution; (3) appearances on a gelatine plate; (4) 
appearances on an agar-agar plate; (5) the nitros-indol reaction; and 
(6) the animal test. Sanarelli obtained altogether 32 water vibrios of 
extreme variability, many of which satisfied even Koch's conditions; 
and his conclusion was that, in the absence of an epidemic, vibrios may 
be found which are identical with the true choleraic germs. Now an 
animal protected against any one of these varieties is not necessarily 
proof against the others. Sanarelli abandons the narrow conception of 
morphological and biological uniformity; he believes there are different 
races of vibrio all capable of causing true cholera; and that we must 
consider many of the non-pathogenetic forms as varieties which under 
special conditions may become virulent. Yet since, taken collectively, 
they resemble one another in many respects, it is very probable that all 
the varieties obtained from choleraic stools or from water have a common 
origin, their differences being caused by the saprophytic conditions which 
they find in water. 
In continuing his researches, Sanarelli, after having produced diarrhoea 
in normal guinea-pigs, separated 12 vibrios from their intestinal tract, 
which also he regarded as choleraic forms. Pfeiffer's serum test, as 
already mentioned, he declares, more or less on the same grounds as 
Metschnikoff, to be utterly inadequate. Sanarelli also disagrees with 
Pfeiffer in regard to certain varieties which, in his own hands, by means 
of the serum test, reacted as true choleraic organisms, though Pfeiffer 
on the strength of the same test had considered them to be non-choleraic; 
he goes further than this, for he denies, from experiments of his own, 
the specificity of protective serum, since he succeeded in conferring an 
immunity on guinea-pigs against choleraic infection by means of anti- 
typhoid serum, and again by means of a serum obtained from an animal 
inoculated against the vibrio of Metschnikoff, which is generally acknowl- 
edged not to be choleraic. It is not quite easy to follow all Sanarelli's 
arguments, but it seems that, although he believes in a common origin of 
all the various choleraic vibrios, he is an opponent of those who insist on 
a specific comma bacillus ; for in his last paper he thus expresses him- 
self : "Nous pouvons conclure qu'il y a des races diverses de vibrions 
choleriques inegalement virulents." 
(d) In connection with Sanarelli's work we may consider that of Mr. 
Hankin, who regards the many varieties of vibrios as degenerate forms 
of Koch's organism. In his opinion the discoveries of vibrios in the water 
and elsewhere throw doubt rather on the tests for the cholera microbe 
described by Koch, than on the authenticity of the cholera microbe as the 
cause of cholera. He summarises his results, obtained in India, as follows: 
In a large number of localities, situated often under very different climatic 
and other conditions, microbes resembling that of cholera are extremely CHOLERA ASIATIC A 
889 
rare, except in places in which cholera has recently existed. During the 
epidemic, according to his experiments, they generally show virulence, 
power of giving the indol reaction, and other characters regarded as typi- 
cal of the cholera microbe. After the cessation of the epidemic they are 
greatly diminished in virulence for guinea-pigs; and in their limited abil- 
ity of growing on agar-agar they betray a diminution of vitality, which 
he regards as an indication of diminished virulence. Such degenerated 
vibrios show a great tendency to die out in ordinary cultures, so that 
it is difficult to keep them alive for any long time. The conclusion 
he draws is that these vibrios are the cholera microbe in various states 
of degeneration. The cessation of an epidemic is due to a weaken- 
ing of the microbe. Whether the degenerate microbes can under any 
conditions regain their virulence, and thus again become capable of start- 
ing an epidemic, is a question he leaves unanswered. Such a view is 
simple, but it is too simple; and Hankin evidently relies on a guinea-pig 
test, which all other workers consider unsatisfactory. We cannot allow 
that all the varieties described by Cunningham and others can on such 
evidence be neglected as degenerate forms of one and the same microbe. 
It is manifest that at present the argument is extremely involved, and 
that it is impossible to come to a definite decision. It appears that most 
observers who have studied the question associate comma bacilli closely 
with cholera: some of these uphold the unity of the vibrio, others accept- 
ing this unity declare that its forms are manifold; and forms which 
some regard as varieties of one species of organism, others describe as 
distinct species. Rumpf sums up his experiences gathered during the 
Hamburg epidemic in the former sense, and concludes that undoubtedly 
Koch's comma bacillus is the cause of Asiatic cholera, and that its home is 
the Ganges. Human intercourse diffuses it, but a phase outside the human 
body, that is, an ectanthropic period of existence and development there 
must be. This phase is frequently passed in the water where the comma 
bacilli experience changes in infective virulence. Long seasons of warmth 
favour their development, rains and cold inhibit it; but beyond India 
they cannot gain a permanent footing, although they may survive for 
months and years under suitable surroundings, gradually losing their 
original features; these, however, they may regain under given conditions 
and for a given time. Carried away by the rivers and streams, they 
reach the digestive tract through the water, in some cases perishing at 
once, in others passing away harmlessly, and inyet others producing lesions 
varying in intensity from diarrhoea to typical cholera. Personal disposi- 
tion in this connection is of far reaching importance. These views are evi- 
dently a modification of those originally held by the contagionist school, 
but years must elapse before a complete solution of the problem is found. 
A few matters still remain to be discussed in the light of recent 
knowledge: these are (1) the pathogenetic properties of the comma 
bacilli; (2) their chemistry; (3) the production of immunity in animals 
and in man; and (4) the vitality of the vibrios outside the human body. 
1. The Pathogenetic Properties of the Comma Bacilli. - (a) We have 890 
SYSTEM OF MEDICINE 
already referred, to earlier animal experiments on the pathogenetic proper- 
ties of the cholera vibrios. These, however, were hardly convincing, and, 
a few exceptions apart, it has generally been admitted that it is impossi- 
ble to produce a true choleraic state in animals. Recent researches have 
shown that intraperitoneal inoculation of guinea-pigs is generally fol- 
lowed by death; and this reaction at one time was thought by Koch and 
Pfeiffer to be characteristic of the true vibrios: we now know, however, 
that no reliance can be placed on this test. It was further thought that 
the results following such intraperitoneal inoculation are specific, and 
therefore of great value for the purpose of diagnosis. But Klein has 
conclusively demonstrated that the same symptoms and the same ana- 
tomical changes follow intraperitoneal injections of other bacterial forms, 
such as the vibrio of Finkler-Prior, the bacterium coli, the bacillus 
prodigiosus, proteus, and others; and his observations have been con- 
firmed by Sobernheim, Gruber, and others. Hence there is nothing 
specific in this animal reaction. Sanarelli likewise maintains that the 
enteritis which may be produced by infection with choleraic vibrios is 
not specific, and is identical with that produced by other organisms 
or their toxins. According to Gamaleia, on inoculation a disease not 
unlike cholera appears in dogs, writh the symptoms of vomiting, diarrhoea, 
convulsions, cold and cyanosis. 
In considering the immunity of man under certain conditions of 
season and locality, the two factors especially dwelt upon by Pettenkofer, 
the question arose in the mind of Metschnikoff whether the presence of 
other micro-organisms in the intestinal tract may co-operate in this result. 
Kitasato had worked at this problem in 1889: using artificial media, he 
found that the growth of cholera vibrios was generally not arrested by 
the presence of other micro-organisms - on the contrary, that cholera 
vibrios checked and even destroyed a variety of bacilli in a few days. 
Kitasato, however, found some exceptions to this general statement; the 
bacillus pyocyaneus, for instance, is stronger than the cholera vibrio. 
Metschnikoff was able to confirm this latter statement, and found, by 
culture on artificial media, that cholera vibrios are extremely sensitive 
to the presence of other organisms, and when subject to these conditions 
undergo certain developmental and morphological changes. He then 
proceeded to inquire whether the immunity of animals against intesti- 
nal cholera could be explained by postulating some action of intestinal 
micro-organisms antagonistic to the cholera vibrios. 
For this purpose Metschnikoff used suckling rabbits, in whose intes- 
tinal canal micro-organisms are scanty and of few kinds. By experi- 
ments on artificial media he found that certain species of torula and 
sarcina were favourable to the development of cholera vibrios. On 
infection by the mouth with the Massowah vibrio, together with a torula 
and a sarcina, four rabbits, aged 4 to 8 days old, were attacked with fatal 
cholera; but death did not occur for 7 to 9 days. In a second series of 
experiments he used a combination of cholera vibrios, as arcina, a torula, 
and a bacillus (related to B. coli); of twenty-eight rabbits two only sur- CHOLERA ASI A TIC A 
891 
vived, and death frequently occurred in 36 to 48 hours. On section the 
small intestine, especially the ileum, was hypersemic, and the caecum was 
distended with a fluid which often recalled the characteristic appearance 
of the watery stools in man. Microscopically the small intestine more 
especially contained the cholera vibrios; in the majority of cases in pure 
culture. The caecum, while also presenting numerous vibrios, always 
contained other bacilli besides. By examining animals at various 
stages of the process it was found that the torula, sarcina, and colon 
bacillus, originally added, disappeared in a few hours; so that the result 
was not a mixed infection, but possibly one similar to that seen in inocu- 
lations with the tetanus bacillus which requires the association of other 
organisms or of its own toxin to produce the fatal spasms. Nor can the 
process be regarded as a simple intoxication; for Metschnikoff describes 
thirteen cases of spontaneous infection among broods of rabbits suckled 
by the same mother. Here the quantity of infective material had been 
small, too small to account for the fatal result on the hypothesis of intoxi- 
cation. These results were only obtained with suckling rabbits; when 
the young had fed on green food they were no longer susceptible. 
Of young guinea-pigs similarly treated thirteen out of seventeen 
died; but diarrhoea was a rare occurrence, and the post-mortem appear- 
ances were far less pronounced. On the other hand the vibrios were 
found in the blood of the heart in thirteen cases. 
Dunbar maintains that the specificity of Koch's cholera vibrio has 
actually been proved by the experiments of Sabolotny who, like Metsch- 
nikoff, asserts that he has produced true cholera in animals. He fed 
Marmots {SpermOphilus guttatus) with common bacilli, and thereby pro- 
duced an infection presenting the classical symptoms of Asiatic cholera; 
of this malady 50 per cent of the animals died. They became prostrate, 
refused food, their temperature fell from 38° C. to 32° C., clonic spasms 
and cyanosis appeared, and after death the gut was filled with fluid, often 
sanguineous, and containing white flocculi, which consisted to a great 
extent of cholera vibrios. However interesting these observations of 
Metschnikoff and Sabolotny may be, they carry less conviction on account 
of the very special nature of the animals used. It is practically useless 
to look to inoculations of rodents or dogs or of any animal for positive 
proof. Inoculations of pigeons by some observers are stated to be a dis- 
tinguishing test between true and spurious cholera vibrios, the former 
having no effect on these animals. Sawtschenko and Weichselbaum, how- 
ever, showed that though generally immune, pigeons succumb occasion- 
ally ; and Salus found that they can frequently be infected with the true 
cholera vibrio as readily as with Metschnikoff's vibrio: herein he is 
confirmed by Rumpel, Weibel, and others, so that this test also, once 
vaunted, had to be abandoned. 
(5) Experiments on man have contributed much towards establishing 
the infective nature of the cholera vibrios. Pettenkofer, Emmerich, 
Metschnikoff, and Hasterlik collectively report observations made on 
eighteen persons, who swallowed pure cultures of vibrios. In some cases 892 
SKS'T'A/J/ OF Al ED I CINE 
severe symptoms followed, in others none, in others again slight diarrhoea. 
The cases described by Macnamara, who saw five persons out of nineteen 
fall victims to cholera after drinking water which had been contaminated 
with choleraic dejecta; the well-known case of Orgel of Hamburg; Koch's 
equally famous case; as well as that of Freymuth and Lickfelt, where 
cholera had been acquired in the laboratory; or the experiments of Boche- 
fontaine and Klein, cannot be used as arguments for or against the question 
under discussion: there is no evidence that pure cultures had been used in 
these cases. We may ask, indeed, whether the other cases are convincing ? 
The doubtful critic may maintain with some justice that they are not, for 
amongst the eighteen persons not one succumbed to the infection. Yet 
Metschnikoff, whose opinion is of great value, declares that in at least 
one case he observed the symptoms of true cholera to follow the drink- 
ing of a pure culture of Koch's vibrio; and that, in spite of the variability 
of the comma bacillus, there is no reason to doubt that it is the specific 
cause of cholera. We must refrain from expressing a positive opinion, 
for evidence based on young sucklings and marmots, and on a few cases 
of diarrhoea is insufficient, although it brings us nearer to a solution of 
this vexed question. Pettenkofer, indeed, who for more than ten years 
was an avowed opponent of Koch's views, has been constrained, on the 
strength of the observations of the last three years, to acknowledge the 
vibrio as the specific organism of cholera. 
We must also point out that Haffkine's patient anticholeraic vaccina- 
tions in India have contributed much to establish this hypothesis. Haff- 
kine is firmly convinced that the cause of cholera is one variable vibrio; 
and for the purpose of vaccination he uses living cultures of that which 
he considered to be the choleraic vibrio. He originally prepared two vac- 
cines, a weakened first virus and a strengthened second virus; so that the 
principle of his inoculations is the same as that practised in the case of 
anthrax. Now if his operations have been accompanied by adequate 
success, it may be argued that they will go far to establish the specific 
action of the cholera vibrio, and also to prove that we are dealing writh 
one organism of protean shapes. His results up to this date have been 
very satisfactory. Thus in Calcutta he found that the mortality among 
the inoculated was 17-24 times less, and the incidence of cholera 19-27 
times less than among the non-inoculated; so that the present evidence is 
certainly in favour of the anticholeraic vaccination. If further observa- 
tions confirm the results already obtained, we can hardly any longer 
doubt the specificity of the cholera vibrio. The test of experience on 
man is therefore that best calculated to carry conviction. 
2. Chemistry of the Cholera Vibrio. -A few words on the nature of 
the cholera toxin will suffice, since our knowledge of it is still very im- 
perfect. Scholl obtained from cultures in eggs a toxic peptone which, 
however, according to Gruber and Wiener, can be obtained from unin- 
fected eggs. Emmerich and Tsuboi explained cholera as a nitrate in- 
toxication, but their fallacies were disproved by Klemperer, who showed 
that cholera vibrios which have lost the power of forming nitrites remain CHOLERA ASIATIC A 
893 
virulent nevertheless. Pfeiffer assumed that the poison is protoplasmic, 
and contained in the bacterial cells; others assumed that this poison is not 
specific, but is a substance common to many bacteria (a protein, Klein's 
intracellular poison). Brieger, it may be remarked, had formerly sepa- 
rated six ptomaines from impure cholera cultures; and Gamaleia had 
anticipated Pfeiffer when he described two poisons belonging to the 
group of nucleins and nucleo-albumins which he had extracted from 
the bodies of the vibrios: while Wesbrook showed that the nature of 
the cholera products varies with the medium in which the vibrios grow. 
Passing over the numerous observations made by various writers, it may 
suffice to say that none of the substances separated so far, whatever 
their nature may be, is capable of producing in animals the symptoms 
characteristic of the disease in man; the chemical identity of the prod- 
ucts formed in the body of choleraic individuals and of those developed 
in artificial media has not yet been proved. It must be remarked, how- 
ever, that with most of the substances mentioned, different as their 
nature may be, an artificial immunity may be produced in the animal. 
3. On Artificial Immunity little need be said since, as we have seen, 
animal experiments have not as yet been of much assistance; indeed, 
they have contributed rather to our confusion. Haffkine, as already 
mentioned, employed Pasteur's method of vaccination with attenuated 
and strengthened living virus. Immunity by means of living cultures 
may be produced by subcutaneous or intraperitoneal injections, but also 
by means of the introduction of vibrios through the mouth; indeed, some 
observers maintain that the highest degrees of immunity are obtained by 
feeding. With regard to the methods of protection there exist two views 
of the pathogenesis of cholera. Some consider the lesions naturally occur- 
ring in man, and artificially produced in animals, to be due to intoxication; 
so that in order to produce an immunity all that is required is to render 
the body toxin proof: the seat of infection is of secondary importance. 
Others believe that the locality where the vibrio thrives cannot be 
neglected; and that an immunity of the skin or peritoneum, for ex- 
ample, does not imply an immunity of the intestinal tract. The latter 
experimenters assert that guinea-pigs, immune on subcutaneous or intra- 
abdominal inoculation, are still susceptible to an infection by the mouth. 
There is, however, considerable diversity of opinion on this point. 
Metschnikoff, experimenting on man, was inclined to believe that the 
intestinal tract cannot be rendered cholera proof by any form of arti- 
ficial infection; while Sanarelli, maintaining that cholera is a toxic 
enteritis, contends that a cholera immunity must depend on an acquired 
tolerance of the cholera poison by the intestinal walls. Sabolotny agrees 
with Metschnikoff that subcutaneous or intraperitoneal treatment does 
not, in the case of marmots at least, protect against gastric infection. 
It is important to know whether one form of choleraic vibrio protects 
against all others. According to Pfeiffer, the action of all true comma 
bacilli is reciprocal, but there is no reciprocity in protection between the 
true and false vibrios. An immunity established by intraperitoneal in- 894 
SYSTEM OF MEDICINE 
jection of one organism may lead to a merely transitory immunity from 
another and different organism, but to a lasting immunity from identical 
organisms. An animal protected against the cholera vibrio is still sus- 
ceptible to the vibrio of Metschnikoff. This is the fundamental principle 
of his serum test. On the other hand, Sabolotny asserts that artificial 
immunity procured with one variety does not necessarily imply protec- 
tion against others; and many observers - such as Salus, Weibel, and 
Sanarelli - maintain that there is a reciprocal protective action between 
the vibrios of Metschnikoff and the true cholera vibrios. This seems 
to be so well established, that, if we accept the theory of the unity of 
the vibrios, we are almost forced to find a place for this organism in 
the long series of choleraic forms; an admission hardly calculated to 
make matters easier, but nevertheless the logical outcome of laboratory 
observations. Haff kin e's experiment in India seems to show that by 
means of one variety of the comma bacillus an immunity can be pro- 
duced in man against all other true vibrios. Thus once more we come 
face to face with contradictions which may find their natural explana- 
tion in the variable conditions of experiment. 
Numerous experiments have also been made with serum, and the 
fact is established that an animal may be protected against a cholera 
peritonitis by means of a specific serum. Klemperer and others showed 
that the serum obtained from individuals who have recovered from 
cholera has a marked protective action, and that the serum of arti- 
ficially protected animals is equally potent. These observations ought 
to be regarded as an additional proof of the specificity of the comma 
bacillus; but Metschnikoff and others have shown that normal serum 
is frequently thus active, and we have said that horse's serum, accord- 
ing to Pfeiffer and Issaeff, possesses similar protective power. Never- 
theless it is generally accepted that to confer an immunity from cholera 
upon an animal is to render its serum anticholeraic; and experiments 
have further shown that by gastric inoculations also this result can be 
obtained. We have referred above to the conflict of opinion on the 
specificity of the serum of protected animals, and we do not wish to 
reopen the matter. Whether a therapeutic serum will ever be found for 
cholera must be left to the future; suffice it to state here that Behring 
is firmly convinced of its possibility, and is at the present time striv- 
ing hard to secure it. The various views held from time to time with 
regard to a natural cholera immunity need not detain us further than 
just to allude to the ingenious explanation put forward by G. Klem- 
perer, who believes that it depends on the nuclein substances of the 
intestinal epithelium which possess marked antimicrobic power. 
4. Vitality of the Cholera Vibrio. -If we assume that the vibrios are 
the cause of cholera, we are forced to meet the objections of those who 
deny their eetiological importance on the ground of their want of resist- 
ance to external influences. If we are to accept the opinion mentioned 
above, that the various water vibrios are but degenerated or altered 
forms of one species, we shall find less difficulty in explaining outbreaks CHOLERA A SI A TIC A 
895 
or sporadic cases of cholera. But, apart from this unproved hypothesis, 
recent observations have shown that the choleraic vibrios are more 
resistant than is generally supposed, (a) These organisms may find an 
abode in persons actually or apparently healthy. Thus during the 
winter epidemic of 1892-1893 the presence of Koch's vibrio was demon- 
strated in the Hamburg Hygienic Institute, in twenty-eight healthy 
persons; and also in the members of certain families similar observa- 
tions were made. These twenty-eight persons had been in contact with 
cholera patients, and their stools were solid or semi-solid. Abel and 
Claussen found vibrios in the faeces of 13 out of 17 healthy persons 
who had been in daily intercourse with cholera patients. (6) In the 
stools of convalescents from cholera vibrios were found after 50, 47, 27, 
16, 10, and 8 days; and (c) it has been shown that they may remain 
alive and capable of proliferation in choleraic dejecta for a considerable 
time. Thus Gruber isolated vibrios from a stool which had been kept 
for 15 days; Karlinski from stools 52, 37, and 28 days old; while 
Dunbar succeeded in the same search after 76, 143, and 163 days, and 
occasionally even after 8 months, (d) As regards artificial cultivation, the 
cholera vibrio has been shown to be highly saprophytic. Thus, according 
to Frankel, it thrives in solutions of 0-4 per cent aspartate of sodium, and 
in water it will also remain alive for some time; on potato boiled in salt 
solution it grows well at the ordinary temperature, and even at 8° C. 
In ordinary milk it survives 12 hours to 6 days; on fruit and fish for 
some days, (e) From flies fed on choleraic material the vibrios could be 
separated after 14 days; on silk threads they remained in a vital con- 
dition for 13 to 86 days, and dried on glass for 120 days. (/) Even 
severe degrees of cold can be resisted for a few days; the concurrence of 
saprophytes, according to Kitasato, has but little influence on them; but 
acids soon destroy them, (g) In water they remain alive for many days; 
in sterile distilled water for 73 days to a year; in sterile well-water for 
months, but in unsterilised water for from 4 to 25 days. Orgel, indeed, 
succeeded in keeping them alive in ordinary Elbe water for almost a year. 
Hence these vibrios are possessed of no little tenacity; and, if they be the 
cause of cholera, there is no difficulty in explaining the spread of an 
epidemic, so that Pettenkofer's early objection - already withdrawn by 
himself - falls to the ground. 
Summary. - If we now review shortly our position with regard to 
the bacterial aetiology of cholera, we find that (1) vibrios are so con- 
stantly associated with the disease that their absence may justly be taken 
as an error in observation; (2) vibrios are frequently found in pure 
culture to the exclusion of other organisms. (3) These vibrios are pos- 
sessed of great variability, both morphologically and biologically; so 
that new forms, widely different from the original stock, can readily be 
produced in the laboratory. We have, therefore, some justification in 
regarding the various kinds of vibrios obtained from cholera dejecta 
as descendants of one species; but we have as yet no means of proving 
this assumption. (4) None of the various tests, taken singly, suffice to 896 
•S'ySZZ.'JZ OF MEDICINE 
establish the unity or specificity of the vibrios; but the circumstantial 
evidence is fairly strong - indeed, so far as our present knowledge goes, 
almost convincing, (a) Pfeiffer's test, with its modifications, although 
not an absolute one, has proved the true nature of a very large number 
of vibrios obtained from undoubted cholera cases, or from sources where 
contamination had taken place; though in some instances it has broken 
down. (/3) Further, there is the evidence of Klemperer that the serum 
of persons who have recovered from cholera has protective powers against 
inoculations of animals with cholera vibrios; and that, conversely, the 
serum of animals rendered immune by means of choleraic vaccination 
displays the same powers. True, normal serum often has the same action, 
but certainly to a less degree, (y) Within certain limits this action of 
the serum of protected animals is specific. (3) Lastly, there are the 
observations of Haffkine in India, who finds that the subcutaneous inocu- 
lation of a true vibrio will protect man against Asiatic cholera. The 
various lines of argument all then converge towards one point, namely, 
the unity and specificity of the choleraic vibrios. Time will show how 
far this classification is final. 
We shall conclude this account with directions to guide the physician 
in the bacteriological diagnosis of cholera; but we must premise that, 
comparatively simple as this is in skilled hands, it cannot be under- 
taken by persons unfamiliar with bacteriological methods. 
Bacterial Investigation of Bowel Contents and of Dejecta. - The 
methods here summarised were those used by Dr. Klein in his examination 
of reputed cholera material during the occurrence of cholera in England 
in 1893. The cases may be classified broadly in two kinds: (1) Those in 
which microscopical examination showed crowds of comma bacilli in the 
mucous flakes; and (2) Those in which at the outset comma bacilli, as com- 
pared with other bacilli, were in a small minority. It is in cases of the latter 
kind, which present the greater difficulty, that the value of Method 3 is 
recognised. On the other hand, when the comma bacilli are 'originally 
present almost in pure culture, other methods are equally good. 
Method 1. - A flake from the dejecta is placed in peptone broth, and 
incubated at 37° 0. In 24 hours an abundant crop of vibrios is found in 
the superficial layers of the broth. This pellicle consists of a practically 
pure culture, or at any rate is a culture which easily allows of pure sub- 
cultures being obtained. 
Method 2. - A flake is placed in sterile salt solution or broth; it is 
shaken up, and from this gelatine or agar tubes are inoculated, and plates 
are made. In agar plates incubated at 37° C., numerous colonies may be 
found in 20 to 30 hours. In the gelatine plates, after 2 to 3 days' 
incubation at 20° to 22° C., numerous typical colonies can be got. 
Method 3. -A flake is placed directly into Dunham's peptone salt solu- 
tion (1 per cent peptone, 0'5 per cent sodium chloride), or the Dunham's 
solution is inoculated after previous dilution of the material. The peptone 
solution, after 6, 8, to 10 hours' incubation at 37° C., shows a definite tur- 
bidity, due to the rapid growth of the comma bacilli; and the cholera-red CHOLERA ASIATIC A 
897 
reaction may be obtained. For speedy diagnosis this method is most 
valuable: in 6 to 12 hours, or at latest in 16 hours, comma bacilli can be 
found in the superficial layers of the peptone solution, so that in 24 
hours pure sub-cultures and the cholera-red reaction can be obtained in 
secondary peptone tubes. Also a positive result may be got by this 
method in cases in which the microscopical examination has failed to 
give definite evidence of the presence of vibrios. 
A. A. Kanthack. 
J. W. W. Stephens. 
Clinical, Pathological, and Therapeutical Aspects of 
Asiatic Cholera 
Symptoms of Cholera. - In different epidemics and different indi- 
vidual cases these present considerable variation. It will be most con- 
venient to describe, in the first place, the phenomena of an ordinary 
seizure - the form of disease most frequently met with; and then briefly 
to delineate those less common manifestations which are seen during 
the course of epidemic outbreaks, and seem to owe their exceptional 
character to variations in the strength and amount of the poison, or 
to peculiarities in the constitution and proclivities of individuals who 
have been subjected to its influence. 
The Ordinary Form. - In a characteristic case of cholera it is always 
possible to distinguish certain well-marked stages which have been desig- 
nated by their most striking features. A premonitory or incubative 
stage can be recognised in a large proportion of cases, followed by the 
stage of evacuation, of which purging, vomiting and muscular cramps 
are the most prominent phenomena; to this succeeds a stage of collapse, 
characterised, as the name implies, by profound depression of all the 
functions of the body; finally, a stage of reaction, in which more or less 
febrile excitement is manifested, ends, in favourable cases, in recovery. 
The stage of incubation is that which intervenes between the recep- 
tion of the poison and the manifestation of serious and characteristic 
disturbance of health. Its duration varies from a few hours to a few 
days, probably not exceeding ten. Three to six days appear, inferen- 
tially, to be the usual length of this stage; though precise and positive 
knowledge is wanting, owing to the lack of exact information as to what 
enters the body and how and when it effects an entrance. The symp- 
toms of deranged health which may be felt or observed during this 
period are referable to gastro-intestinal irritation, and to a disturbed or 
depressed condition of the nervous system. Diarrhoea is the most common 
precursor of cholera: it may last for hours or even days, and is apt to 
be copious and watery, motions being passed three or four times a day; it 
may be painless or accompanied with griping. There is often a feeling 
of weight or oppression at the pit of the stomach, and there is reason to 
believe that in this stage the function of digestion is seriously impaired 
(Chevers). The nervous symptoms take the form of malaise, depression 
VOL. I 
3 M 898 
SYSTEM OF MEDICINE 
of spirits, pallor, anxious expression, exhaustion, giddiness, tinnitus and 
headache. 
In most cases premonitory symptoms are not noticeable or are very 
transient; and the disease sets in without warning, with violent purging 
and vomiting, speedily followed by cramps and progressive exhaustion. 
These are the essential phenomena of the stage of evacuation, which 
may last from two to twelve hours or longer - the duration depending 
probably on dosage and vital resistance. The purging is frequent, copious 
and watery. The earlier stools are feculent, the later pale, resembling 
whey or water in which rice has been boiled - a flocculent or curdy sedi- 
ment being deposited on standing. Later motions are sometimes sanious. 
Successive evacuations should be received in separate vessels for observa- 
tion and comparison. There may be griping or abdominal pain; more 
frequently there is neither. The bulk of material passed in this stage 
is often very large. Vomiting generally begins later than purging: 
the contents of the stomach are first expelled; and it has been observed 
that these are often undigested, though they have been in the stomach 
for some time. The later rejections are watery and copious, emitted with 
force, and occasionally tinged with blood. Vomiting is easily excited by 
ingesta, and these are generally returned sooner or later. In some cases 
distressing and exhausting retching occurs without much result. The 
reaction of the vomited material varies; it is sometimes very acid. 
Muscular cramps are a painful feature of this stage; they may begin 
with the purging, and be prolonged into the next stage. The legs are 
their most frequent seat; but the muscles of the abdomen and back, and 
in some cases the whole muscular system may be affected; the cramped 
muscles feel hard and knotty, and in many cases the pain is very severe. 
The temperature of the body falls somewhat as this stage proceeds, the 
surface becoming cold, dusky, clammy, or covered with sweat. The 
features are drawn, eyes sunk, expression anxious or blank, fingers and toes 
shrivelled, tongue white and cold. There is great thirst and much rest- 
lessness. The breathing is not thus far much affected, but the pulse rises 
in rate and loses in force. The patient becomes greatly exhausted, and, 
though generally sensible, is apathetic. Recovery may take place in this 
stage by cessation Of purging, vomiting and cramps, and gradual restora- 
tion of strength; but in the majority of cases a more profound depression 
of vitality sooner or later supervenes. This is the stage of collapse, into 
which the patient may lapse gradually or suddenly. It may last from 
two or three to forty-eight hours, or even more, the attention being 
withdrawn from the evacuations, and arrested by the signs of alarming 
exhaustion. Liquid, colourless motions may still be occasionally passed 
involuntarily; or the presence of watery material may be detected in 
the intestines by palpation or succussion. Vomiting or attempts to vomit 
may persist, and cramps are often present, sometimes terribly painful. 
But these symptoms are overshadowed by the evidences of failing power: 
the pulse flickers and fails at the wrist, and is sometimes imperceptible 
in the brachial and almost so in the femoral arteries; its rate, always CHOLERA ASIATIC A 
899 
accelerated, may rise to 120 or 140, or even higher. The heart sounds 
get less distinct, especially the first: in some cases strange murmurs and 
friction sounds are detected in this stage (Wall), which betoken disturbed 
and inco-ordinate contraction of its walls or the existence of clots in its 
cavities. 
The capillary circulation* becomes slow and feeble, the surface gets 
livid; respiration is quick and shallow, painful and often paroxysmal 
dyspnoea arises, compelling the sufferer to struggle for breath; the ex- 
pired air is cold and deficient in carbonic acid. The face presents the 
characteristic choleraic expression - features pinched, skin drawn, eye- 
balls sunken and surrounded by a dark areola, lids half closed, pupils 
contracted, mouth open, teeth covered with sordes, tongue cold, counte- 
nance apathetic. The general surface is cyanotic and clammy or be- 
dewed with cold sweat: the fingers and toes are wrinkled. There is great 
restlessness and profound debility. The intelligence is clouded, the 
senses impaired, the muscular power diminished: in some cases sense 
and sensibility and capacity of movement are retained; in others coma 
or a semi-comatose state exists. The voice is husky and feeble, or the 
patient can speak only in faint whispers. Thirst is imperative, and a 
feeling of coldness is felt. The urine is suppressed; the bladder is 
generally emptied in the preceding stage, and no further accumulation 
of urine takes place. The temperature of the surface and mouth is 
greatly and, in fatal cases, increasingly depressed, and may fall below 
90° F.; the temperature of the axilla is higher, but yet below normal, 
readings of 95° to 97° F. being not uncommon in this stage; the rectal 
temperature may be slightly subnormal or normal, but in time it shows 
a tendency to rise above the normal. 
In this stage a peculiar and characteristic odour may be detected in 
the breath and from the skin. The motions are devoid of smell unless 
they are retained, in which case they quickly become offensive. It is 
in this stage of cholera that death most frequently occurs; and the 
fatal event may happen early or late, very suddenly or after some 
lingering hours while life and function are slowly waning. Death may 
occur by apnoea, asthenia or coma. 
The stage of reaction is, generally speaking, characterised by a 
gradual restoration of power and resumption of function. The pulse 
returns to the wrist, feebly and fitfully at first; but there is, in favour- 
able cases, a progression in steadiness and strength. The breathing 
becomes easy and the patient tranquil. Blueness, coldness, shrinking 
and clamminess of the skin give way to roundness and warmth. Tem- 
perature is normal or slightly raised. The stomach regains its tone, and 
food is retained. The stools resume their proper colour ; some looseness 
may persist, but the motions are less frequent and less watery, and ex- 
hibit successively deepening tints of gray and brown. Urine is passed, 
though its reappearance may be delayed for many hours; it is at first 
scanty, high coloured, of strong smell and high specific gravity, albumi- 
nous, and containing indoxyl and casts ; then it becomes watery and 900 
SYSTEM OF MEDICINE 
copious. Mental activity and muscular power return, and complete 
recovery may take place within a few days. 
So happy a result is, however, by no means invariable. In a con- 
siderable proportion of cases (from 10 to 25 per cent) events occur dur- 
ing the stage of reaction which constitute a serious departure from the 
normal sequence, and prolong the illness or cause death. 
The variations which take place in the symptoms and course of 
cholera are numerous and well marked, and have led to the distinction of 
several forms of the disease. These varieties of cholera are apt to pre- 
sent themselves more or less prominently in different epidemics and at 
different periods of the same epidemic; and, for purposes of diagnosis 
and treatment, it is highly important to take them into account. They 
are best described in the order of succession of the phases of the ordi- 
nary disease. 
1. The disturbance of health may be slight and transient. During 
an epidemic of cholera many persons complain of slight malaise, anorexia 
and looseness of bowels which pass off with or without treatment. This 
is the so-called ambulatory form. The disease appears to be arrested or 
abortive in the incubative stage. 
2. In other and more frequent cases the diarrhoea is more pronounced 
and persistent - painless, accompanied, perhaps, with nausea or vomit- 
ing, and sometimes with cramps. The stools are copious and watery, 
inclining gradually to the rice water type. There is no suppression of 
urine. Cases of this kind occur in anticipation of or during an epidemic, 
and contribute to that excessive prevalence of diarrhoea which statistics 
indicate as generally concomitant with cholera. With or without the 
aid of medicine recovery usually takes place within twenty-four hours; 
but not unfrequently such cases, especially if untreated, lapse into true 
cholera. This form of disease has received the name of choleraic diarrhoea 
or cholerine, and appears to represent an arrest in the stage of evacuation. 
3. On the other hand, this stage may seem to be absent, patients 
passing quietly into fatal collapse without either vomiting or purging. 
Cases of this sort have been described as occurring at Karachi in the 
year 1846, and at Teheran in the same year. On post-mortem examina- 
tion, however, the characteristic lesions and evacuations of cholera are 
found in such cases. The absence of evacuation and the rapid prostra- 
tion have been attributed to the large dose or special virulence of the 
poison which rapidly overpowers vital resistance and energy. This form 
of disease is very rare; it has been called cholera sicca. 
4. The stage of collapse is very short; death takes place suddenly 
from apnoea, with symptoms of gravely disturbed cardiac action and 
impeded circulation through the lungs. This may depend on spasm of 
the pulmonary arterioles, on the difficulty of transmission of the inspis- 
sated blood from the right heart into the lungs, or on the formation of clots 
in the right cavities. Dr. Wall has described murmurs and friction sounds 
which he attributes to this cause: the condition is not necessarily, though 
frequently fatal. It may be called the embolic form or phase of cholera. CHOLERA ASIATIC A 
901 
5. On the other hand the cold stage may be prolonged up to thirty- 
six or forty-eight hours. Recovery sometimes takes place in such cases, 
but the unfavourable contingencies of the reaction stage are more likely 
to occur under these circumstances. 
6. The intelligence of the patient - in other words, the activity of the 
brain and nervous system - is in some cases marvellously keen during 
the stages of evacuation and collapse; but a condition of growing pros- 
tration and apathy is the rule. In some instances the clouding of the 
intellect and dulling of the senses are early and profound, and out of 
harmony with the other symptoms. This primary choleraic stupor has 
been attributed to the direct effects of the choleraic poison on the nerve 
tissue (Wall). 
The varieties of cholera depending upon variations in the phenomena 
and course of events in the stage of reaction are numerous and important. 
7. The reaction may be imperfect. Some revival from collapse may 
occur, but the temperature remains subnormal, purging and vomiting 
continue, the pulse does not regain power, exhaustion is progressive, and 
the patient in time sinks from asthenia, or may pass into a fatal typhoid 
phase. 
8. In other cases, after temporary amelioration, there is a relapse of 
the purging or vomiting, and death by exhaustion sooner or later ensues, 
though recovery from the relapse is possible. The relapse may be in- 
duced by the use of purgatives or indiscretion in diet. 
9. A very serious variety of cholera is the hyperthermic form, in which 
during collapse the rectal temperature is found rising to 100° F. and 
over. The axillary temperature soon follows suit, and a very high degree 
of heat (as much as 107° F. in the axilla, and 109° F. in the rectum - 
Wall) may be reached. Such cases are very fatal. 
10. During the stage of reaction patients not unfrequently lapse into 
a typhoid state. This does not depend on excessive temperature or on 
suppression of urine, but seems to correspond rather with the state of 
"prostration with excitement" met with under other circumstances. 
The symptoms are those of the typhoid condition however caused - 
moderate elevation of temperature (101° to 102° F.), excitement of pulse 
and respiration, failing power, restlessness, delirium, subsultus, dry 
tongue and lips, sordes, stupor merging into coma, and in prolonged 
cases purpura and bed-sores. This condition is generally, but not nec- 
essarily fatal. Convalescence is very slow in the non-fatal cases. There 
are cases which seem to occupy an intermediate position between the 
hyperthermic and the typhoid cases; in these mild fever of an inter- 
mittent or remittent form complicates and delays recovery. 
11. In these febrile states eruptions sometimes make their appearance. 
The more common are urticaria and erythema: the latter may be bright 
in colour and widely diffused. Roseola, maculae and bullae have been 
described. The eruption in such cases may perhaps be considered a 
sort of exanthem. 
12. Suppression of urine, and the consequent urcemia, constitute the 902 
SYSTEM OF MEDICINE 
most important and anxious feature of an abnormal reaction. The re- 
appearance of urine is sometimes delayed for many hours or even days 
without serious results; but such delay is always a cause of anxiety, 
and in most cases of prolonged suppression cerebral symptoms attest the 
retention of waste matters in the blood. Stupor with restlessness, mut- 
tering delirium, spasmodic contraction of muscles, bloodshot eyes, con- 
tracted pupils, dry lips and tongue, sordes, vomiting, slow pulse are 
the chief symptoms; the patient often relapsing into fatal coma. The 
bowels may remain relaxed; this is favourable and should not be checked. 
Vomiting of grass green material has been noted in this state. The 
secretion or discharge of bile may be suspended, and this adds to the 
gravity of the case. Chevers has described this dual suppression as 
cholouraemia. On the re-establishment of the urinary secretion the 
alarming symptoms may subside and convalescence proceed. 
The Sequelae of Cholera. - A number of untoward events may arise 
during the stage of convalescence; they may be classified as follows: - 
1. Functional.-Under this head are included anaemia, debility, 
nervous depression, jaundice (a rare but dangerous complication), gas- 
tric irritability, persistent hiccough, insomnia, dementia, paraplegia, 
anasarca, irregularity of bowels and chronic diarrhoea. In pregnant 
women abortion is almost invariable; the child dies during the algide 
stage and is sooner or later expelled. Signs of cholera are often found 
in the foetus (Wall). 
2. Inflammatory. - (Edema of the lungs, bronchitis, pneumonia and 
pleurisy are not unfrequently met with, especially in conjunction with 
suppression of urine. Meningitis, conjunctivitis, arthritis and parotitis 
have also been described. The parotid inflammation sometimes ends in 
abscess. Dysentery is an occasional complication of convalescence, but 
it is mild in type and amenable to treatment. 
3. Destructive. - Ulceration of the cornea is not uncommon. Bed- 
sores sometimes form in low cases of typhoid character and uraemia if 
the nursing be defective. Gangrene of the nose, ears, penis and scrotum, 
more rarely of the fingers and toes, are also met with, especially among 
natives of India. The dead parts, if limited, may be separated and cast 
off, but extensive gangrene is generally fatal. 
Pathology and Pathological Anatomy. - The morbid changes dis- 
closed by post-mortem inspection of cholera cases vary with the stage of 
the disease in which death took place. As a general rule alterations in 
blood distribution are the most prominent feature of early deaths. 
Epithelial disorders of mucous tracts and evidences of glandular irrita- 
tion occur later; and in more protracted cases, indications of more 
serious structural changes - inflammatory or necrotic - may be seen. 
The morbid anatomy of typical cholera is characteristic and constant. 
The surface of the body retains the peculiarities already described, which 
need not be repeated. Post-mortem rigidity appears early and lasts 
long. In some cases muscular contractions occur soon after death and 
cause distortions of the body. CHOLERA ASIATIC A 
The digestive tract reveals signs of grave disorder which are usually 
most marked towards the termination of the ileum. The stomach is 
generally empty; its lining membrane is usually congested, the degree 
of hypersemia varying; ecchymoses are occasionally seen and, rarely, 
haemorrhage into the cavity; a state of catarrhal inflammation is some- 
times found; the contents may be acid, neutral, or alkaline; the duo- 
denum and jejunum usually exhibit hypersemia, either continuous or 
patchy, arborescent or capillary. The lining membrane is generally 
swollen and sodden, and a pulpy material can be scraped off it, which 
consists mostly of granular cells and amorphous protoplasmic masses. 
Enlargement of Brunner's glands has been described (Griesinger), and 
denudation, often extensive, is frequently seen. Whether this shedding 
of epithelium be the result of a necrotic process during life or a post- 
mortem detachment is a subject of doubt and dispute. 
The ileum participates in the changes occurring higher up, but the 
last twelve or eighteen inches of it exhibit them more strongly and 
sometimes this portion shows special signs of diseased action. The 
solitary glands are enlarged and stand out prominently, and Peyer's 
patches are congested and swollen. This portion of the gut may also 
be covered with a croupous or diphtheritic pellicle, more or less adherent 
to the surface, and flocculent processes may project into the lumen of 
the tube, and may occasionally fill and obstruct it. Separation of this 
material may give rise to excoriation or even to ulceration. Ecchymoses 
of the walls and haemorrhages into the cavity of the small intestine 
sometimes occur. 
The large intestine is generally less seriously diseased than the small. 
Congestion and catarrhal inflammation may occur, and in rare cases 
ulceration giving rise to haemorrhage. 
The walls of the intestinal tube are generally thickened, and the 
lumen contracted. The peritoneal surface is injected, and presents, as 
Dr. Wilks has observed, a characteristic rosy colour. The peritoneal 
cavity contains no fluid. The mesenteric glands are enlarged, hyperaemic, 
and infiltrated with a whitish granular exudation (Aitken). 
The contents of the intestines vary in quantity according to the 
amount of vomiting and purging during life; they vary in quality accord- 
ing to the stage of the disease and intensity of the morbid process. 
The cholera stool is a turbid, gray or grayish white liquid, resembling 
water in which rice has been boiled. On standing, a granular, curdy or 
flaky material subsides, leaving a whey-like supernatant fluid. The 
reaction of the material is alkaline, and its specific gravity from 1005 to 
1015. The material found in the intestines after death resembles the 
sediment which settles from the evacuations passed during life. The 
solid elements in a motion amount to from 10 to 30 parts per 1000, the 
soluble salts from 5 to 10, and albumin and extractives from 2 to 20 
(Parkes). The amount of albumin is small, but of salts - sodium and 
potassium chloride, sodium phosphate, carbonate and sulphate - con- 
siderable. Nitric acid sometimes gives a red reaction. Considered as a 
903 904 
SYSTEM OF MEDICINE 
derivative from the blood the cholera evacuation accounts for a large loss 
of water, a large loss of soluble salts, and a moderate loss of albumin 
and animal matter. 
The microscopy of the intestinal discharges and contents has been the 
subject of laborious investigations. The objects found are embraced in 
the following categories : - 
1. Debris of food. 
2. Results of epithelial proliferation and glandular irritation-amor- 
phous, granular, and protoplastic masses, granular cell forms, and cloudy 
epithelia. The amount of epithelial cells found in the contents after 
death exceeds that discovered in the stools during life. 
3. Red blood cells and leucocytes. Much of the protoplasmic gran- 
ular material which forms so large a proportion of the solid constituent 
of the stool is held to be derived from changes which have taken place 
in white cells that have migrated from the blood (Lewis). 
4. Organisms; some peculiar to cholera, others incidental to it. The 
bacteriology of the disease has been already described. 
The liver is generally affected with venous congestion, the colour being 
dark, and venous blood escaping on section. The gall bladder is full of 
bile, which in later stages is thin and watery. Shedding of the epithelium 
of the bile ducts has been described. There is no mechanical impediment 
to the discharge of bile through the ducts. 
The spleen is not enlarged; on the contrary it presents signs of con- 
traction and expulsion of liquid. 
The kidneys exhibit evidence of grave pathological disturbance. They 
are increased in size and much congested. Ecchymotic spots and patches 
are sometimes seen beneath the capsule and throughout the parenchyma. 
The tubes are blocked with a granular and protoplastic material. The 
epithelial cells are cloudy and swollen, their contents granular, and in 
later stages fatty. In advanced cases the tubes are devoid of epithelial 
covering. The cells undergo, in fact, an acute process of degeneration 
and destruction. 
• The state of the urine accords with these conditions. The secretion 
is at first suppressed, then scanty, of high specific gravity, albuminous, 
and containing casts - epithelial, granular and hyaline; and ultimately, 
in prolonged cases, abundant in quantity, watery and devoid of albumin. 
The proportion of saline materials is greatly diminished in the urine of 
cholera, and of urea somewhat. Indican is a conspicuous constituent 
(Crombie). Bright's disease is a rare sequel of cholera. Temporary 
glycosuria is sometimes met with. The bladder is generally found empty 
and firmly contracted in cases fatal during the early stages of the disease. 
The circulatory system and blood undergo serious and characteristic 
changes in cholera. 
The heart is not altered in structure, but in some cases haemorrhagic 
spots and patches may be observed. The right cavities are generally 
distended with dark tarry blood; the left, as a rule, are empty. The 
distension extends into the venae cavae and into the pulmonary arteries as CHOLERA ASIATIC A 
far as the lungs. In a considerable proportion of cases white clots are 
found in the right cavities, and extending into the pulmonary arteries: 
detached thrombi have also been found in the latter. Dr. Wall con- 
cludes from clinical and post-mortem observations that thrombosis is a 
common incident of the collapse stage of cholera, and that the clots in 
the heart and vessels undergo liquefaction, fragments of them sometimes 
remaining as pulmonary emboli and infarcts. The pulmonary veins are 
found empty and contracted in cases fatal during the stage of collapse. 
The distribution of blood in the body is abnormal, the veins and their 
tributaries are distended with thick dark blood, and the arteries and 
capillaries empty. The solid organs exhibit well-marked venous con- 
gestion. In the later (reactive) stages of the disease these conditions 
of the circulation undergo change; also when recourse has been had to 
warm saline intravenous injections - the change being towards a restora- 
tion of the ordinary distribution and balance of the blood. 
The physical, chemical and microscopic conditions of the blood have 
been made the subject of elaborate research. Three osmotic processes 
appear to exist during the progress of choleraic disease: 1st, an exos- 
motic effusion from the vessels into the intestinal canal; 2nd, an exos- 
motic current from the corpuscles into the surrounding fluid; and, 3rd, 
an endosmotic transit of fluid from the tissues into the vessels. By these 
processes the blood becomes profoundly altered physically and chemically. 
The outflow of constituents has been determined by Schmidt to take 
place in the following order: the water transudes before the solids of 
the serum, the inorganic before the organic solids, the chlorides before 
the phosphates, the salts of soda before the salts of potash. The same 
law applies to the other currents which, however, are smaller and later, 
and fail to replace the material which has escaped. The blood in acute 
cholera is therefore found to be of high specific gravity, very dark and 
inspissated, and deficient in water and salts. Cells and albumin are in 
excess, but authorities differ as to the amount of fibrin factors and the 
coagulability of the blood. The amount of oxygen in the blood cells is 
seriously diminished. The blood regains its brightness on exposure to 
air in thin layers, and on contact with the intestinal discharges (Parkes). 
Urea has been found in it in cases fatal in the algide stage. Detach- 
ment of the epithelium of the vessels and adhesion of the blood to the 
denuded surface have been described (Thudichum). 
An excess of leucocytes was discovered by Virchow, and confirmed by 
Lewis and Cunningham, who found the red corpuscles diffluent; they 
observed that the leucocytes underwent a series of changes - becoming 
granular, rounded, still, and then vacuolated - and ultimately discharged 
their granular contents. The empty cell walls constitute, according to 
these observers, the peculiar hyaline vesicles which are found in the 
evacuations. Much of the protoplasmic granular material which forms 
so large a proportion of the latter is held to be derived from the blood, 
through the agency of leucocytes, which undergo after transit the changes 
described. No special organism or material of the nature of virus or 
905 906 
SYSTEM OF MEDICINE 
poison has been detected, in the blood of cholera either by the microscope 
or by chemistry. 
The lungs in a case of death in the collapse stage are found to be light, 
dry and shrunken. There is a deficiency both of blood in the vessels 
and of air in the alveoli. These are the characteristic cholera lungs; 
but in later stages they may be congested, oedematous or collapsed. 
The pleura, are usually healthy. 
The brain and its membranes exhibit venous congestion. Signs of 
meningitis are sometimes present in advanced cases. 
The tissues are dry, doughy, and shrunken from removal of water. 
The muscles are also dry and contain an unusual amount of urea. They 
are sometimes found ruptured. 
Theory of Cholera. - The phenomena observed during life and the 
appearances seen after death undoubtedly indicate that the choleraic 
process is due to the entry into the system of a poison which causes, in 
the first instance, violent functional disturbances; then sets up serious 
organic disorders, and finally results, if life be prolonged, in important 
structural changes. This poison has not as yet been isolated, but there 
is every reason to believe that it is of organic constitution, and a 
strong probability that it is elaborated either within or without the 
body by a microbe, and recent research points to this microbe being 
a vibrio. The early incidents of cholera cases - more particularly the 
varying duration of the incubative stage, the general occurrence, but fre- 
quent absence, of initial signs of intestinal irritation and nervous dis- 
turbance and depression - would suggest that the disease may be due 
either to ingestion of a poison elaborated elsewhere, in which case the 
invasion would be sudden, and the effects depend on the dose; or to the 
reception into the intestinal tube of a microbe under circumstances fa- 
vourable for its multiplication; in the latter case symptoms of intestinal 
derangement, of longer or shorter duration, would precede the general 
poisoning by absorption of the elaborated product. 
This theory would also account for the failure to find a specific organ- 
ism in a certain proportion of cases - a fact attested by good authority 
- as well as for isolated outbreaks on board ship and elsewhere, which 
might be due to conveyance of a limited quantity of the elaborated 
product. 
The phenomena of cholera, especially of its later stages, constitute a 
remedial reaction; and the disease has with plausibility been likened to 
a febrile paroxysm with a severe and prolonged algide stage. Cases and 
outbreaks of malarial fever have been observed which it was found al- 
most impossible to distinguish from cholera. On the other hand, in some 
cases and outbreaks of the latter disease the febrile phenomena assume 
a marked prominence. The poison seems to exercise a special influence 
- deleterious and destructive - on the epithelial elements of the intesti- 
nal and urinary tubes, and on the gland sacs and follicles of the former; 
but a strong impression on the nervous system, leading to contraction 
of arterioles and disturbance of the balance of the circulation, with pre- CHOLERA ASIATIC A 
907 
ponderance towards the venous side, is a very early effect of the poison 
in the blood, which soon undergoes important dynamical, organic, and 
chemical alterations. Many of the later incidents of cholera are due, no 
doubt, to absorption from the tubes and tissues of secondary poisons of 
bacterial or degenerative origin. The theory that the intestinal disturb- 
ance is sufficient to account for all the other phenomena of cholera as 
secondary and consequential effects is no longer tenable; and the chol- 
eraic process cannot be satisfactorily explained otherwise than as the 
effect of one of those organic poisons which constitute a very early stage 
of decomposition of proteids, or result from the metabolism of these by 
the agency of micro-organisms. 
When the virulence of the poison has been spent, or its removal 
effected, the primary disturbances set up by it are very soon and com- 
pletely recovered from. The secondary changes occurring during the 
stage of reaction are more serious and prolonged; but these likewise 
very seldom leave permanent structural defects. 
Diagnosis. - The maladies which most closely resemble cholera are 
ptomaine poisoning; mushroom poisoning; certain varieties of diarrhoea; 
and some rare malarial fevers, with intestinal complications, and a pro- 
found and prolonged algide stage. The identification of Asiatic cholera 
turns upon clinical, epidemic and bacteriological considerations. The 
clinical features which mark an ordinary case of cholera are: the copious, 
painless passage of watery motions, devoid of bile colouring, resembling 
rice water and exhaling a characteristic odour; the profound nausea and 
frequent vomiting of watery material; the suppression of urine; the mus- 
cular cramps; the cyanosis and shrinking of skin; the cold breath and 
whispering husky voice; the dyspnoea and restlessness; the prostration, 
torpor and failing pulse; the cold sweats and depression of the surface 
temperature, with a tendency to rise of internal temperature. These con- 
stitute a group of symptoms which may be imitated, but are seldom if ever 
identical with those of any other flux. If cholera is known to prevail 
in the locality or neighbourhood, or circumstances permitting or favouring 
importation exist, suspicion naturally attaches to all bowel complaints; 
even if they do not present the extreme form just pictured. Similarly, 
cases of diarrhoea, however mild, arising in the midst of an epidemic of 
cholera are viewed with apprehension. If numerous seizures occur in 
groups, and the mortality equals or exceeds 50 per cent, the identi- 
fication is rendered more easy and certain. Cases of ptomaine and 
muscarine poisoning, which most resemble cholera, generally occur singly, 
or in small groups; and usually follow the eating of fish, shell-fish, tinned 
provisions or mushrooms; fragments of mushroom may be found in the 
stools. The association with prevalent malarial fever, the absence of 
epidemic cholera in the place or vicinity, the periodicity, the better 
marked febrile stage, the lower mortality, and the amenability to 
quinine, serve to distinguish the cases of malarial fever which, in the 
algide stage, may assume a choleraic character. The suppression of bile 
and urine, the cyanosis, cramps, collapse and cold, and the high mortal- 908 
SYSTEM OF MEDICINE 
ity, are the chief circumstances which distinguish cholera from other 
diarrhoeas. The bacteriological conditions are also important. The 
detection of Koch's vibrio in the evacuations constitutes, according to our 
present knowledge, a means of separating cholera from every other disease. 
The negative, however, is not true. In a certain, though small, propor- 
tion of cases the vibrio cannot be found. It is also alleged that several 
varieties or species of spirillum, exhibiting different morphological and 
physiological characters, develop in the intestinal discharges of cholera 
(Cunningham). These matters are at present the subject of keen and 
searching investigation, and a detailed discussion of them would be 
premature and unprofitable. [ Vide section on Bacteriology.] 
Prognosis. - The death-rate of cholera varies with the character of the 
epidemic and the period of the outbreak. Fifty per cent may be accepted 
as an average death-rate, but it is often exceeded in specially severe 
outbreaks, and in the early stage of any outbreak. The very young and 
very old succumb more readily than the middle aged; sucklings are seldom 
attacked. Women are rather less frequently seized than men ; pregnancy 
is a dangerous complication. Organic disease of the kidneys is a specially 
unfavourable condition, and organic disease of the liver almost equally so. 
Drunkards are bad subjects of cholera; so are persons of feeble and 
damaged constitution; ill health, however caused, is an unfavourable 
introduction to the choleraic struggle. During the progress of a case 
signs of good or evil omen are observable at every step. 
Evil signs, in the order of the stages, are - Sudden seizure, early pros- 
tration, early stupor, quick advent of collapse, restlessness and fighting 
for breath, failing pulse, great depression of temperature, prolonged cold 
stage, hyperpyrexia, severe abdominal pain, blood in vomit and stools, 
persistent suppression of bile and urine, permanent muscular contrac- 
tions, jaundice, lung complications, recurrent purging and vomiting, 
delayed restoration of body heat, typhoid symptoms and indications of 
uraemia or cholo-uraemia, insomnia and delirium. 
Good signs are - Maintenance of pulse during collapse, moderate 
depression of temperature, early and not excessive reaction, return 
of colour in the motions, cessation of cramps, restoration of urinary 
secretion, resumption of warmth and dryness of skin and normal colour 
and plumpness of face, quiet breathing, tranquillity, sleep. 
The violence of vomiting and purging in the early stages are not 
necessarily indicative of a severe seizure, but their persistence is apt to 
result in delayed convalescence or fatal exhaustion. 
Treatment.-The fact that about one-half of those attacked with 
cholera recover, with or without treatment, indicates that processes 
antagonistic to the poison and curative of its effects arise within the 
organism, and are effective in that proportion of cases. What the precise 
nature of these processes may be it is impossible, in the present state of 
science, to affirm. Whether the poison of cholera lose its power by lapse 
of time, or be diluted, eliminated, or destroyed; or whether there be formed 
in the tissues or blood or intestinal tube some antagonistic principle-an CHOLERA A SI A TIC A 
909 
alexin or antitoxin, to adopt the language of modern bacteriology - we 
know not: in our ignorance of the process of natural cure it is impos- 
sible to formulate a rational system of treatment in imitation and 
furtherance thereof. Two principles may, however, be confidently stated, 
namely, (1) that it is obviously irrational and improper unduly to 
interfere with or thwart processes which, though apparently morbid 
and injurious, result, as a matter of fact, in restoration to health in a 
moiety of seizures; and (2) that, in estimating the value of any system or 
method of cure, the law of natural and unaided recovery must be taken 
into account, allowing for the character and period of the outbreak. 
Prevention. - The sanitary measures by which a community may be 
protected from cholera, by which its entry may be prevented, its spread 
controlled, its incidence and mortality minimised, are discussed in the 
section relating to the history and etiology of the disease considered 
epidemiologically. 
Personal prophylaxis, however, constitutes an important item of the 
treatment of cholera as affecting individuals. Certain circumstances and 
conditions have been recognised as rendering persons specially liable to 
attack. The chief of these are - bodily fatigue, mental worry, panic, 
disorder of stomach caused by consumption of raw fruits and vegetables 
(melons, cucumbers, and the like have been specially blamed), decompos- 
ing animal food, particularly fish and shell-fish, excessive use of alcohol, 
drinking impure water or milk, the use of purgative medicines especially 
salines, exposure to cold, and generally anything tending to depress the 
general vigour and derange health. The conduct and regimen necessary 
to avoid these risks need not be detailed. 
On grounds of reason and experience the most efficient preventive of 
cholera, both for individuals and bodies of men, is removal from the 
infected locality to another place, higher and drier if practicable, where 
the disease is not prevalent. New comers to infected places are specially 
prone to attack. Although the disease does not appear to be often, if 
ever, communicated directly from person to person, avoidance of associa- 
tion with the sick is advisable, because such association may involve 
exposure to the morbific conditions surrounding the sick. 
Chemical disinfection of excreta and discharges, and of articles which 
have been soiled thereby, is obviously advisable; and the free use of such 
agents as carbolic and sulphurous acids highly commendable. Protec- 
tion against attack by the administration of drugs, such as quinine and 
the mineral acids, has been tried without satisfactory results. 
Anticholeraic Vaccination. - Various attempts have been made to ren- 
der the system immune to choleraic infection by the injection of anti- 
toxins. The latest is the method devised by M. Haffkine. It has been 
amply proved that the use of the weak virus, prepared by his method, 
mitigates, both in animals and men, the local and general effects sub- 
sequently produced by the strong; and that an immunity against the 
latter may be thus produced. Extensive inoculations of human subjects 
have been carried out by M. Haffkine in India. Upwards of 42,000 SYSTEM OF MEDICINE 
910 
persons have been vaccinated without accident or harm. Evidence has 
been gained that recent inoculations are protective; but the experience 
is as yet too meagre and incomplete to justify final conclusions as to the 
merits and uses of the system. 
Medicinal Treatment, Nursing, and Dieting. - The drugs and com- 
pounds which have been administered empirically in cases of cholera are 
legion. It is safe to assert that not one of them has established a claim 
to cure the disease. It were useless, therefore, to catalogue or discuss 
them. Four plans of treatment stand out prominently among others as 
possessing some basis of reason, and offering some promise of success; 
namely, the astringent, the eliminative, the antiseptic, and the stimulant. 
To these may be added the antispasmodic and the counter-irritative. 
The astringent plan contemplates the choleraic process as a hypercathar- 
sis, and its danger as depletion; rice water evacuations being regarded 
as potentially haemorrhage (Chevers). Astringents, mineral and vege- 
table, in combination with opium, antispasmodics and stimulants, 
have, in accordance with this view, been administered by mouth and 
rectum, in the hope that if the dangerous flux be checked, the 
margin of recuperative power thus saved will suffice to avert fatal 
exhaustion and to restore health. It is possible, however, that the 
results thus to be prevented or cut short - the tremendous drain of 
serum, corpuscles and salts from the veins into the intestinal tube, the re- 
versal of the normal currents, and the abeyance of absorption - may have 
a salutary purpose, and within limits a curative function; it is doubtful 
whether the checking of these discharges is, as a dominant principle, a 
sound basis of action. Still the principle has its place in that scheme of 
treatment which, as we shall presently show, experience has sanctioned. 
The eliminative plan, on the other hand, looks upon the flux as 
adjuvant - as a means of conveying the cholera poison out of the system, 
and seeks to aid it by administering purgatives. But, apart from the 
well-established fact that purgation is of itself exhausting, especially 
so in the early stages of cholera when it ought to be most effective and 
beneficial, it is questionable whether it is wise to remove materials 
artificially from the intestinal tube - such, perhaps, as leucocytes or 
their alexins, or innocuous bacteria - which may tend to neutralise or 
destroy the poison of cholera. As a matter of fact, Sir George Johnson's 
castor oil treatment has been extensively tried and found wanting. 
Stimulation of the kidneys by diuretics has also been tried under the 
guidance of this hypothesis, and found to do more harm than good. 
The antiseptic plan aims at neutralising the poison in the intestinal 
tube, or setting up conditions there which may render its elaboration 
impossible. Acids and germicides of many kinds have been administered 
with this view; but this plan may simply result in adding poison to 
poison, or irritant to irritant; in hindering a process of salutary decom- 
position, or in destroying the leucocytes or innocuous organisms and 
their products which may be doing good work. Practically, the plan 
has failed to cure cholera. CHOLERA ASIATIC A 
911 
The stimulant or restorative plan simply endeavours to avert death 
from exhaustion, and to sustain the flagging vital powers under circum- 
stances of terrible depression. Alcohol, ammonia and ether administered 
by mouth or rectum, or hypodermically, are the favourite remedies of 
this class, supplemented by strong soups and nutrient enemata. Even 
this method is not without its drawbacks. Gastro-intestinal irritation 
may be increased, mischief may arise during the reactive stage, or per- 
haps undue disturbance of the collapse stage may be hurtful. These con- 
siderations suggest caution in the use of stimulants. 
The antispasmodic plan is based on the fact that the muscles of the 
intestines, arterioles, bile ducts, limbs and trunk are thrown by the 
action of the poison into violent contraction; pain and exhaustion 
tending to death are thus caused. The clamping of the pulmonary 
arterioles, impeding the circulation and banking back the blood - hinder- 
ing, that is, its aeration in the lungs, the nutrition of the brain, the 
action of the kidneys and skin, and promoting flux - is considered 
specially perilous. Warm baths, chloroform inhalation, sedative and 
antispasmodic drugs, nitrite of amyl and nitro-glycerine, and warm 
intravenous injections, have been given to relieve spasm. This treat- 
ment has proved useful as a means of relieving some symptoms. 
The use of counter-irritants is intended to remove morbid action 
from within to the surface, where it may be less hurtful and more under 
control. Measures of this kind may be useful as auxiliaries. 
It may be asserted with confidence that in the present state of our 
knowledge no single principle or plan of treating cholera has met with 
much success. It is possible, nevertheless, to lay down certain rules of 
action which, as experience has taught us, may aid the patients in under- 
going the terrible struggle for life which the choleraic process entails. 
These will be briefly stated as they apply to successive stages of the 
disease. 
1. Check the Preliminary Diarrhoea. - All authorities are agreed as 
to the advantage of this measure, which promptly cures mild cases and 
prevents others from becoming dangerous. Combinations of opium 
with astringents and antispasmodics constitute the favourite formulae. 
The remedy may be given in pill or mixture. The "cholera pill" of 
India consists of opium, assafoetida and black pepper. Goodeve used 
acetate of lead and opium. Chevers preferred vegetable astringents. 
The cholera tinctures, which have often proved so serviceable, are 
generally composed of laudanum or liquor opii sedativus with catechu or 
kino, compound tincture of lavender or cardamoms and chloric ether. 
Chlorodyne, with or without brandy, according to the state of the patient, 
is an admirable remedy of similar composition, fulfilling the same end. 
The dose and frequency of repetition must depend on the age and 
condition of the patient, the degree of irritability of the stomach, and 
the effect of the remedy. The practitioner must exercise a careful 
observation and judgment on these points; it is inexpedient to lay 
down precise rules or formulee. If the stomach be very irritable a 912 
SYSTEM OF MEDICINE 
mustard poultice or chloroform should be applied to the epigastrium, and 
lumps of ice given to suck. If medicines are still rejected the hypo- 
dermic injection of morphia may be resorted to. It must be clearly under- 
stood that the treatment now recommended is applicable to the pre- 
liminary and evacuatory stages only. When collapse has fairly set in 
opium and astringents must be stopped; for absorption being now in 
abeyance they are useless, and in the stage of reaction, when absorption 
again sets in, they may do harm. 
2. Maintain Physical and Physiological Rest. - The patient must be 
kept in bed and the evacuations received in a bed-pan. Fussy changing 
of clothes and bedding must be avoided. Violent rubbing, rough lifting 
into baths and other beds, transfer to another room or house, and, above 
all, a journey are dangerous. Medicines, food and stimulants shoidd not 
be forced on an irritable stomach; they provoke vomiting, excite irritation, 
and increase exhaustion. The indication is to refrain from anything 
that may add to the wearing effect of a most weakening malady. 
3. Restore a Failing Circulation. - If the pulse be maintained in the 
collapse the less done the better. If the pulse gradually lose volume 
and power, and become feeble and thready, a mild stimulant should be 
given - iced champagne and soda water, weak brandy and water (iced) - 
in teaspoonfuls, or ammonia or chloric ether well diluted. Should the pulse 
respond nothing further is needed. If, however, the pulse become 
imperceptible at the wrist, and hardly perceptible in the brachial and 
femoral trunks - if, at the same time, cyanosis and dyspnoea are well 
marked- the condition is one of imminent danger. Hypodermic injec- 
tions of sulphuric ether, or cautious doses of nitrite of amyl or nitro- 
glycerine, followed up by champagne or brandy, may restore the pulse; 
but nothing effects this so speedily and surely as the. intravenous injec- 
tion of warm saline solutions. Sixty grains of sodium chloride and 30 
of sodium carbonate are dissolved in 1 litre (about 35 ounces) of distilled 
water. The fluid should be sterilised by boiling, and injected slowly at 
a temperature of about 98H0 F., with strict antiseptic precautions, into 
one of the veins of the arm. A reservoir containing five or six litres 
should be kept ready and placed on a stand about four feet above the 
level of the patient's head. The injection flows by gravitation through 
a flexible tube, by pressure on which the rate of flow is regulated. The 
rate of entry should be slow, say one litre in twelve minutes. The 
amount injected will depend on the effect; one to three litres may be 
required in different cases to restore the pulse (Wall). 
In most cases the fluid leaves the blood-vessels and passes into the 
intestinal tube, and the symptoms of collapse recur. They may neverthe- 
less be removed again and again by a repetition of the injection, and in some 
cases a permanent cure results. Experience has, however, shown that the 
proportion of recoveries has not been materially increased by the use of 
saline intravenous injections. Still, distress is for the time relieved, life 
is undoubtedly prolonged, some cases seem to be saved; and in the face 
of impending death anything that offers the faintest hope of rescue is CHOLERA ASIATIC A 
913 
justifiable. Intravenous injection of milk and transfusion of blood have 
been tried without much benefit, if any. It has been sought to restore 
fluid to the blood by injecting saline fluids and plain water into the 
cellular tissue, peritoneum, bladder and rectum. No harm has resulted 
from such procedures, and little if any good. The fluid is readily 
absorbed, but as readily passes away through the intestines. It is 
possible that these artificial means of restoring water and salts to the 
blood simply keep the exosmotic current flowing, which might otherwise 
cease or be reversed through the altered specific gravity of the blood. 
It has also been sought to remedy stagnation of the circulation by the 
warm bath and mild rubbing of the limbs. These measures should be 
applied with the utmost gentleness. Rubbing with dry powdered ginger 
is a routine practice in India; clamminess and moisture of skin are thus 
removed, and mild stimulation of the cutaneous vessels and nerves 
attained. The practice, if cautiously followed, does no harm, and prob- 
ably does some good. 
4. Conserve the Body Heat. - The great depression of surface tempera- 
ture which takes place in the collapse stage of cholera is no doubt due to 
many causes - amongst them the direct effect of the poison on the nerve 
centres, the disturbance of circulation, and the loss of fluids from the 
intestinal and cutaneous surfaces. It is probably more a sign than a 
cause of exhaustion. Still, it seems desirable to prevent the evitable 
escape of body heat. The temperature of the room should not be 
allowed to fall below 70° F., and the air in the immediate vicinity of the 
patient should be warmed by a few hot bricks or bottles: this is better 
than loading him with bedding. Ventilation should be free, but draughts 
avoided; in hot climates the punkah should be gently pulled. The 
surface should be kept as dry as possible, and gentle wiping with soft 
cloths or rubbing with dry ginger powder resorted to. The warm bath 
also tends to restore the surface temperature. 
5. Allay Thirst. - The craving for fluids in cholera is astonishing, 
and ought to be gratified; but large draughts excite violent vomiting 
and so lead to exhaustion. Giving lumps of ice to suck is perhaps the 
best method of quenching thirst; still small quantities of iced soda water, 
iced champagne and soda, barley or arrowroot water, milk and soda, or 
teaspoonfuls of cold jelly or clear soup may be administered at short 
intervals. The injection of fluids into cavities and tissues tends indirectly 
to fulfil the same indication. 
6. Reiieve Distress and Pain. - The cramps undoubtedly constitute the 
most painful symptom of cholera, and it is not easy to relieve them. 
Probably the opiates administered in the early stages exercise an 
analgesic effect. Hot applications, the warm bath, gentle frictions with 
anodyne liniments, or even moderate counter-irritation with chloroform, 
turpentine, or mustard may be tried; but nothing relieves cramps so 
well as moderate and intermittent chloroform inhalation. Camphor 
has been recommended internally, externally and hypodermically. For 
the severe abdominal pains which are sometimes met with, hot applica- 
VOL. I 
3 X SYSTEM OF MEDICINE 
914 
tions and counter-irritation with chloroform or mustard give relief. In 
early stages a moderate dose of liquid extract of opium may be injected 
over the seat of pain. The relief of general distress is best accomplished 
by warm baths and intravenous injections, but these must be used with 
caution and judgment. Dr. Lauder Brunton has recommended the 
hypodermic injection of atropine in cholera, but rather on the ground 
of its known antagonism to muscarine, which causes symptoms closely 
resembling cholera, than on account of its anodyne properties. Suffi- 
cient trial has not as yet been made of the drug to warrant its confident 
recommendation. 
7. Check Persistent Diarrhoea. - Persistent or recurrent purging, caus- 
ing exhaustion and delaying recovery, sometimes occurs in the stage of 
reaction. Vegetable astringents or mineral acids may be given in small 
doses well diluted, but the large, warm, astringent rectal injections 
recommended by Catani are more efficient. Twenty grammes (308 
grains) of tannic acid and as much gum-arabic are dissolved in one litre 
of water. The injection is made very slowly by gravitation to such 
amount as the patient can comfortably bear. Blood heat is the best 
temperature, and the material should be retained as long as possible 
(Wall). 
8. Check Irritability of Stomach. - This may be manifested as obsti- 
nate vomiting or incessant hiccough; or signs of severe gastritis, induced 
perhaps by injudicious administration of food and stimulants, may be 
present. There is no special cure for this condition, which is to be 
treated on ordinary principles. 
9. Reduce Excessive Temperature. - It is extremely difficult to fulfil 
this indication; and this is the more to be regretted inasmuch as the 
hyperpyretic form of cholera is very fatal. Ice sucking and the slow 
injection of bulky cold enemata may be tried; antipyretics should be 
avoided. Tepid baths gradually cooled may be resorted to, but great 
caution is necessary in any such adventures. 
10. Restore the Secretion of Bile and Urine. - As regards the bile, very 
little if anything can be done to promote its secretion or evacuation; 
in most cases, fortunately, nothing need be done. Usually, when the 
cold stage has passed and spasmodic closure of the ducts is relaxed, the 
flow is resumed. Sometimes the outpouring of the imprisoned bile is 
excessive and gives rise to bilious vomiting. In those cases in which the 
function of the liver has been so much impaired that a watery material 
is poured into the ducts instead of bile, no means have been discovered 
of correcting the condition. Calomel has been given in large and small 
doses, with the intention of stimulating the secretion and discharge of 
bile. Large doses are undoubtedly injurious, and small doses, even 
when combined with soda, are of very doubtful value. 
The restoration of the urinary secretion is a more important object; 
its prolonged suppression is fatal. Dry cupping, hot fomentations 
and poultices may be applied in cases of delayed return; and water, 
milk and water, barley water, etc., freely given. Diuretics should be CHOLERA A STATIC A 
915 
avoided. When head symptoms are severe and the bowels confined, 
mild enemata, or even a little castor oil emulsion, may be given; but 
great caution is necessary in the use of such measures. The bladder 
should be examined by catheter occasionally if necessary. 
Special symptoms, complications, and sequelae are treated according to 
the appropriate methods, always bearing in mind the great strain to 
which the system has been subjected by the choleraic process, the spe- 
cial danger of re-exciting gastro-intestinal irritation, or of putting addi- 
tional stress on the damaged liver and kidneys, on whose restoration to 
healthy function life so greatly depends. 
In most cases of recovery from cholera health and strength are 
rapidly regained, and the patient in a few days seems none the worse 
of his attack. In some cases anaemia, emaciation, debility, deranged 
stomach and bowels, and general enfeeblement and bad health of a 
persistent and intractable description, ensue. Change of air is the best 
means of combating this state. Tonics and careful dieting and regimen 
are also necessary. 
The dieting of cholera subjects is a difficult task. The simplest 
possible liquid food should be given in small quantities during the 
attack, and ordinary food be very gradually resumed during convales- 
cence. It is needless to catalogue here the articles of diet which may 
be administered [yid. art. on " Dietetics and Sick Feeding These 
directions must be left to the discretion of the practitioner, but fatal 
relapses have not infrequently been caused by injudicious dieting. 
Finally, it may be asserted with confidence that, although no " cure " of 
cholera has as yet been discovered, careful attention to the state of the 
patient with a view to the fulfilment of the needs which I have indi- 
cated above, will relieve much suffering and save many lives. 
Kenneth Macleod. 
REFERENCES 
1. Macrae. " Flies and Cholera Diffusion," Indian Medical Gazette, 1894, pp. 407, 
412. - 2. Hart, Ernest. Nurseries of Cholera, p. 4. Smith, Elder, and Co.-3. 
Koch, Professor. The Cholera in Germany during the Winter of 1892-93, translated by 
George Duncan, M. A., p. 79.-4. Hirsch. Geographical and Historical Pathology .trans- 
lated by Creighton, vol. i. pp. 439.-5. Hirsch. Op. cit. p. 438.-6. Davidson. Geo- 
aravhical Patholoau. vol. i. d. 436. - 7. Koch. Op. cit. p. 119 et seq. 
E. H. 
s. c. s. 
1. Abel and Claussen. Centr.f. B. undP. xvii. 3,4. - 2. Bordet. Pasteur's Annales, 
June 1895. - 3. Cunninghan, D. D. Scientif. Mem. by the Medical Officers of the Army 
of India, 1885, 1886, 1890,1894. -4. Durham, H. E. Proc. Royal Soc. London, 1896.- 
5. Dunbar. Deutsch, med. Woch. 1895 and Ergebnisse der allg. Aetiologie (edited by 
Lubarsch and Ostertag) 1896, i. p. 804, where a useful list of references will be found. 
- 6. Emmerich and Tsuboi. Milnchener med. Wochenschr. 1893, Nos. 25 and 26.- 
7. Flugge. Die Mikroorganismen; Verbreitungsweise u. Abwehr der Cholera. Leipzig, 
1893. - 8. Frankel, C. Hygienische Rundschau, 1892, 1894, and 1895.-9. Frank- 
land and Frankland. Micro-organisms in Water, 1894. -10. Gruber and Wiener. 
Wiener klin. Wochenschr. 1892, and Arch. f. Hyg. ~kn. 1892.-11. Gruber. Munch, 
med. Woch. 1895, 13, 14.-12. Gunther. Einfiihrung in das Studium der Bakteri- SYSTEM OF MEDICINE 
916 
ologie, 1895, where also useful references will be found. -13, Haffkine. Brit. Med. 
Journal, 1895, Dec. 21, and Anticholera Inoculation, Calcutta, 1895. -14. Hankin. 
Indian Med. Gazette, March 1895. -15. Karlinskl Centr. f. B. und P. xvii. 5, 6. 
-16. Klein, E. Treatise on Hygiene and Public Health (Stevenson and Murphy), 
1893, chapter xxi. p. 172; Brit. Med. Journal, 1893, i. p. 632; Local Government Board 
Report and Papers on Cholera in England in 1893, Appendix B.-17. Klemperer. 
Zeitschr. f. klin. Med. xxv. 5, 6. -18. Koch, R. Zeitschr. f. Hygiene, xiv. p. 319. -19. 
Metschnikoff. Various articles in Pasteur's Annales, 1893-95.-20. Pettenkofer. 
Miinchener med. Wochenschr. 1892, 46, 96, and 1894, 12; Arch. f. Hygiene, xviii. 1, 
p. 94.-21. Pfeiffer. Numerous papers in the Zeitsch. f. Hygiene, xi. xiv. xviii. 
xix. and xx.-22. Pfeiffer and Issaeff. Zeitschr. f. Hyg. xvii.-23. Rumpf. Volk- 
mann'sche Vortr. N. F. 1894, 109, 110.-24. Sabolotny. Centr. f. B. und P. xv. 
pp. 150-157. - 25. Salus. Arch. f. Hyg. xix. 4.-26. Sanarelll Pasteur's Annales, 
1893-95.-27. Simpson, W. J. Cholera in Calcutta, 1894. - 28. Sobernheim. Hyg. 
Rundschau, 1893, p. 916. -29. Sternberg. Manual of Bacteriology, where also numer- 
ous references are found. - 30. Uffelmann. Berl. klin. Wochenschr. 1892 and 1893. 
- 31. Weibel. Arch. f. Hyg. xxi. - 32. Wesbrook. Hyg. Rundschau, 1895; Pasteur's 
Annales, 1894. - 33. Kanthack and Wesbrook. Brit. Med. Journal, 1893, vol. ii. 
A. A. K. 
J. W. W. S. 
The following works may be consulted with advantage as regards the aspects of 
cholera presented in the foregoing article: - 1. Jameson, J. Report on the Epidemic 
Cholera Morbus as it visited the Territories subject to the Presidency of Bengal in the 
Years 1817-1818-1819. Drawn up by order of the Government under the superintend- 
ence of the Medical Board, Calcutta. Printed at the Government Gazette Press.- 
2. Annesley, J. Sketches of the most Prevalent Diseases of India, comprising a 
Treatise on the Epidemic Cholera of the East. 8vo. London, 1825. - 3. Macpherson, 
J. Cholera in its Home, with a Sketch of the Pathology and Treatment of the 
Disease. 8vo. London, 1866. Annals of Cholera from the Earliest Periods to the 
Year 1817. 8vo. London, 1872.-4. Macnamara, C. N. A History of Asiatic 
Cholera. 8vo. London, 1870 and 1876. Also articles in Quain's Dictionary of 
Medicine and Davidson's -Ht/.t/iene and Diseases of Warm Climates. - 5. Parkes, 
E. A. Researches into the Pathology and Treatment of the Asiatic or Algide Cholera. 
8vo. London, 1847. Also British and Foreign Medico-Chirurgical Review, 1848, i. 236; 
London Journal of Medicine, February 1849, on the " Intestinal Discharges of Cholera," 
and numerous articles in the Reports of the Army Medical Department. - 6. Goodeve, 
E. " Epidemic Cholera," in Reynolds' System of Medicine. - 7. Schmidt, C. Beitrag 
sur Lehre von der Cholera. 8vo. Wurzburg, 1837. Charakteristik der epidemischen 
Cholera gegenuber verwandten transsudations-anomalien. Leipzig und Mitau, 1850. - 
8. Murray, J. Report on the Treatment of Epidemic Cholera. Calcutta, 1869.- 
9. Lewis, T. and Cunningham, D. D. Numerous papers on the Microscopy and 
Pathology of Cholera appended to the Reports of the Sanitary Commissioner with the 
Government of India since 1870. -10. Koch and Gaffky. Report of the German 
Cholera Commission of 1883-1884. Also numerous papers by Koch in German 
medical periodicals.-11. Wall, A. J. Asiatic Cholera: its History, Pathology, 
and Modern Treatment. 8vo. London, 1893. -A more extended bibliography will be 
found in Hirsch's Handbook of Geographical and Historical Pathology, and in the 
Index Catalogue of the Library of the Surgeon-General's Office, U. S. Army, vol. iii. 
K. M. PLAGUE 
917 
PLAGUE 
Synonyms. - Oriental Plague, Bubonic plague, Pestis, Pestilentia: 
Pali plague or Mahamurrie (in India). The Black Death (fourteenth 
century in Europe). 
Definition.-An acute infective febrile disease, accompanied by in- 
flammation of lymphatic glands; partly miasmatic, partly communi- 
cable, caused . by a micro-organism, the bacillus pestis. 
History of the Plague. - The first historical notice of a disease like 
bubonic plague records its occurrence in Libya in the third century 
before Christ, or earlier; but this notice is only contained in a fragment 
from the writings of a much later physician, Rufus of Ephesus (about 
100 a.d.), who also speaks of its occurrence in his own time in Libya, 
Egypt, and Syria. Whether it was clearly known to the classical Greek 
writers on medicine is doubtful, but Aretaeus speaks of /loySawes Xot/xw- 
8es, or pestilential buboes. The plague of Athens described by Thucyd- 
ides was apparently not this disease; nor was the destructive pestilence 
of the reign of Marcus Aurelius alluded to by Galen. We meet with 
bubonic plague again, however, in the great Plague of Justinian, which 
started from Egypt 542 a.d., and spread over a large part of Europe; 
it was described in Gaul as lues inguinaria. Epidemics succeeded one 
another in this and the succeeding century; but after that time it is 
difficult to follow the track of plague. Many European pestilences are 
spoken of in mediaeval histories, which may or may not have been 
bubonic plague; no sufficiently clear record remains. 
In the fourteenth century a new era began. All previous European 
plagues could be traced back, directly or remotely, to Africa, especially 
to Egypt; but now a new epidemic invaded Europe from Asia by way 
of the Crimea and the Black Sea, its origin being referred to Cathay or 
China. This terrible pestilence, afterwards known as the " Death," or 
the il Black Death," appeared in Southern Italy in 1346-47, and made 
its way over the whole of Europe. It reached England early in 1348 
and for several, probably five or six years, was prevalent in various 
parts of the country. Scotland and Ireland were affected in their turn; 
and no country in Europe seems to have escaped. A second epidemic 
occurred in 1361, and a third in 1368. The details of this great calam- 
ity have often been dwelt upon by historians and cannot be given here. 
It is calculated by Hecker that 25,000,000 of persons, one-fourth of 
the population of Europe, died of this disease. Although it has been 
doubted whether this was the true bubonic plague, as the first epidemic 
presented some peculiar features, yet it must now be accepted that the 
Black Death was that disease in a peculiarly malignant form. 
The great importance of this fact in epidemic history is that from 
this time forth, whether previously or not, plague was established as 
an endemic disease in England and other parts of Europe; though it 918 
SYSTEM OF MEDICINE 
is quite possible that, as Hirsch and others think, fresh importations of 
the virus from the East took place from time to time. The successive 
epidemics in Britain through the fifteenth, sixteenth, and seventeenth 
centuries are fully recorded in Dr. Creighton's History of Epidemics in 
Britain. Finally they culminated in that called the Great Plague of 
London in 1665, in which about 70,000 persons died, and which ex- 
tended widely over the country. Soon after that the disease vanished, 
never to recur on English soil. 
During these centuries most countries in Europe suffered from re- 
peated epidemics. It was noticed that the epidemic wave passed on the 
whole from East to West, or from the Mediterranean countries north- 
ward ; which led to the belief that many European epidemics were 
derived from more persistent foci of plague in Turkey, the Levant, and 
Egypt. Hence the system of quarantine, by sea and land, was intro- 
duced to stem the tide of infection. This belief, which is that of many 
epidemiologists, receives support from the fact that the disease died 
out earlier in Western than in Eastern Europe. Holland, France, 
Spain, and Italy became exempt, with one notable exception, a little 
later than England - about the end of the seventeenth century. East- 
ern Germany suffered somewhat longer, while in Poland, Russia, parts 
of the Austrian Empire, and the Danubian countries, epidemics were 
repeated throughout the eighteenth century. There was thus a general 
eastward recession; the chief exception to which was the great epidemic 
of Southern France, 1720-21. This was generally attributed to the arri- 
val, in the port of Marseilles, of a ship from Syria infected with plague, 
which then spread to the populous and insalubrious city. The invasion 
of islands like Sicily and Malta in the eighteenth century was clearly 
due to the same cause, namely, to a contagion imported by sea. 
During the first half of the nineteenth century plague prevailed in 
Turkey, and made occasional advances into the Danubian countries, 
to the shores of the Adriatic seas, and to the south of Russia. Being 
still almost constantly present in Egypt and Syria, it seemed to be a 
disease peculiarly of the Eastern Mediterranean, and thus acquired 
the name of Levantine Plague, which has lasted to our day; and the 
strictest precautions were still taken in all the Mediterranean ports to 
prevent its invasion. 
Finally in 1841 plague left Europe by its Eastern gate, Constanti- 
nople ; and in 1843-45 it became extinct also in Syria and Egypt, so that 
the old Levantine Plague seemed to have entirely vanished. It is clear, 
however, that in Asia Minor it did not die away, but only receded east- 
ward. At the beginning of this century, the Caucasus, according to Thol- 
ozan, was the centre from which epidemics radiated; but in the latter half 
of the century that centre has been shifted to the mountains of Kurdistan. 
Good authorities still held that the disease was probably not extinct; 
and these suspicions were confirmed by accounts received at Constanti- 
nople, in 1853, of an outbreak in the Azir district of Arabia already men- 
tioned : this outbreak has been followed repeatedly by others at intervals PLAGUE 
919 
of some years; the last was in 1889. In 1858 the same disease was heard 
of in Benghazi, where it must have prevailed at least two or three years 
before; and there it appeared again in 1874, and possibly again later. 
The plague also in the province of Tripoli so lately as 1837, has recurred 
in the form of epidemics which were relics of the former wide distribu- 
tion of plague along the whole northern coast of Africa. 
The more recent accounts of plague in the Kurdistan district, on the 
frontiers of Turkey and Persia and Mesopotamia, begin with 1863; but 
it must not be supposed that this was the first appearance of the disease 
in that part of the world - Baghdad and the neighbourhood had suffered 
severely at the beginning of the century, and for all we know to the 
contrary, for centuries before that. 
The chief known recent epidemics of Persia and Kurdistan were in 
1863, in 1870-72, and in 1876-77; in 1877 a terrible epidemic occurred 
also in the town of Resht on the Caspian, which is an important occurrence 
in relation to the epidemic of 1878 on the Volga. The latest recorded 
appearance of plague in Persia was in 1885; but it was probably not 
the last. 
In Mesopotamia (Irak-Arabi), from 1856 onward for several years, 
there prevailed what is now known to have been the mild form of plague. 
In 1867 a definite epidemic was recorded; in 1873-74 another extending 
over a much wider area; and in 1876-77 one still more extensive, and 
very severe. A further outbreak occurred in 1880-81, which is said to 
have destroyed one-quarter or one-third of the population; and another 
in 1884. 
The above short record is of interest as showing how plague may 
extend its area in successive epidemics; and also as leading up to the 
comparatively small epidemic on the Volga in 1879, which caused so 
much alarm. 
As has been shown, in the years 1876 and 1877 the plague was very 
active. In June 1877, and also in the two years following, a febrile 
malady accompanied by buboes appeared in Astrakhan on the northern 
shore of the Caspian, a place in direct communication with Resht on the 
Persian shore, and it extended to neighbouring villages. Though it was 
of a mild type and caused but few deaths, it was certainly the mild or 
minor form of plague. In October 1878, a similar but more severe 
epidemic broke out in the Cossack settlement of Vetlanka, 130 miles up 
the Volga; and by December it assumed the character of the most 
virulent plague. The epidemic lasted in this village till 24th January 
1879; but in December it had already spread to other villages, in which 
nearly every patient died. The last death in the district occurred on 
9th February. Though affecting a small population it was very fatal, 
causing 382 deaths in a population of 1700. The mortality was nearly 
90 per cent. 
This is the simple history of the epidemic which caused a panic 
through Europe. It is easily explained when we see its filiation with 
the mild epidemic of Astrakhan and the severe one of Resht; and the 920 
SYSTEM OF MEDICINE 
general prevalence of plague in Persia in previous years. A minor epi- 
demic in 1877 at Baku, on the western shore of the Caspian, furnishes 
another link. Why the disease was so mild in Astrakhan and so viru- 
lent in Vetlanka we cannot tell; but a like sudden development of the 
severe out of the mild form of the disease is frequently observed. 
History of Plague in India. -Plague has been little known in India; 
the climate generally seems too hot for it: three centres have, however, 
been known in this century. In 1815 an outbreak, following a famine, 
occurred in Cutch, Guzerat and Kattywar. The next year it reappeared, 
but went away in 1820. In 1836 an epidemic which broke out in Pali 
in Rajputana became known as the Pali plague, but it ceased in 1837. 
In a different locality, the districts of Gurwhal and Kumaon on the 
south-west of the Himalayas, a disease known locally as Mahamurrie 
(which is undoubtedly bubonic plague) has recurred several times since 
1823. The last great epidemic was in 1876-77, but it recurred in 1886 
and 1888. No connection can be traced between the above-mentioned 
localities of plague, nor between them and any other. 
In 1883-84 a malady was observed in Candahar (Afghanistan), which 
presented some features of plague, but was not certainly identified. 
History of Plague in China. - The first definitely known epidemic of 
plague in Yunnan was about 1860; but it is believed to have existed 
there at least since 1850, and probably long before, as it has all the 
characters of an endemic disease. It is said to have recurred nearly 
every year up to 1893. In Pakhoi it is also frequent, but was absent 
from 1884 to 1893. Some think the epidemics of Pakhoi were derived 
from Yunnan. It is impossible to trace the derivation of the disease 
from any other district. From Pakhoi it must in some way have found 
its way to Canton, where it broke out in 1894. Dr. Rennie of Canton 
thinks it passed by land, since in 1891 a severe epidemic occurred in the 
district of Kaochao, lying to the north of Pakhoi; and in the spring of 
1894 it prevailed in towns to the south of Canton. From Canton to 
Hong-Kong it was carried by numerous persons suffering from the 
disease, or in the stage of incubation. 
General Pathology of Plague.-Plague occupies an intermediate posi- 
tion between the miasmatic or malarial diseases proper, such as ague, 
and the true contagious fevers; there is clear evidence that its virus 
may be acquired both direct from the soil, and from infected persons 
and objects above the soil. It will be convenient, therefore, to consider 
it in this twofold relation, as an endemic soil-disease and as a communi- 
cable epidemic. Under both conditions its existence and propagation are 
explicable by the recent discovery of a micro-organism. 
The Bacillus of Plague. - The phenomena of plague can hardly be 
accounted for except on the hypothesis of a living organic cause, one 
capable of living in the human body, and also in some way outside the 
body also. Great interest, therefore, attaches to the recent discovery, 
in Hong-Kong, by Kitasato, confirmed by Yersin, of a micro-organism PLAGUE 
921 
which seems to fulfil all the conditions required by the problem, and is 
probably the specific cause of the disease. 
Kitasato found in the bodies of patients with plague a short, rather 
thick bacillus, which stains, with various dyes, in such a way that the 
poles are deeply coloured, while the central part is pale; thus it some- 
what resembles a diplococcus. Yersin's description precisely corresponds 
with that of Kitasato. This bacillus may be grown on ordinary cultiva- 
tion mediums - especially agar-agar, with glycerine, blood serum, and 
bouillon - temperatures from 97° to 102° F. being the most suitable. 
It is killed in thirty minutes by a temperature of 170° F., and in a few 
minutes by 212° F. According to both observers the bacillus is most 
abundant in the lymph glands; the pulp of softened buboes is indeed 
little more than a pure cultivation of the bacillus ; it is almost equally 
abundant in the spleen. But few are found in the blood, and then chiefly 
in very severe cases of plague (Yersin). Kitasato detected them in the 
blood of twenty-five out of twenty-eight patients, but says that the detec- 
tion is difficult, and, except in the hands of a skilled observer, does not 
furnish a satisfactory means of diagnosis. Cultivation from the blood, 
however, is more satisfactory. 
Inoculation of matter from buboes into rats, mice, guinea-pigs, or 
rabbits gives them a febrile disease (temperature 105° F., Kitasato), fatal 
in from one to five days. The bodies show characteristic enlarged glands, 
and bacilli are present in large numbers in the glands and spleen, and a 
few in the blood. Yersin passed the disease by inoculation from one 
animal to another with increasing virulence. Inoculation of cultures of 
the bacillus produces the same result, and bacilli are found in the organs 
after death. It is thus clear that the organism is the cause of the disease 
in animals, and that this disease is the same as the human disease. The 
bacillus thus fulfils all the conditions required to prove it to be the true 
pathogenetic organism of plague. 
The channels of reception of the bacillus are, according to Kitasato, 
the respiratory organs, the digestive tract, and inoculation. According to 
Yersin rats and mice, especially the former, fed with fragments of organs 
of animals dead of the disease acquired plague, and died with character- 
istic lesions and bacilli in their organs. It is also stated that bacilli are 
found in the faecal dejections of patients, showing a mode of infection in 
plague previously unsuspected: indeed the bacillus is not known to leave 
the body by any other channel. Y ersin established contagion of plague by 
keeping inoculated rats and healthy mice in the same place. All the 
latter, as well as the former, died with numerous bacilli in their organs. 
Under certain circumstances a remarkable diminution of virulence of 
the bacillus was observed by Yersin. Some colonies in cultures were 
observed to grow much more rapidly than the others, and if cultivated 
separately were found to be much diminished in virulence. Bacilli 
obtained from convalescent patients were also of comparatively low 
virulence. These observations are interesting as bearing on the spon- 
taneous decline in virulence and the cessation of plague epidemics. SYSTEM OF MEDICINE 
922 
Ectogenic Existence of the Bacillus. - Yersin was able to cultivate and 
isolate a bacillus from earth of an infected house, four to five centimetres 
below the surface, which precisely resembled that from buboes, but was 
not virulent. Kitasato found in one instance that dust from an infected 
house communicated plague by inoculation. Yersin found that flies die 
from the disease, their bodies containing the bacillus; and by inoculation 
of material contaminated with a dead fly he conveyed plague to animals. 
The conclusion is that a bacillus has been discovered capable of 
parasitic existence in men and animals, capable of ectogenic life, showing 
spontaneous variability in virulence, and thus fulfilling all the conditions 
necessary to explain the observed phenomena of plague. 
Endemic Plague. -In discussing the existence of plague as an endemic 
disease, it is necessary to take into account its geographical distribution, 
and to some extent its history, together with the associated physical and 
social conditions. The localities where it is now known to occur, or to 
have occurred within the last twenty years, are as follows: - 
(1) In the district of Benghazi (the ancient Cyrenaica), in the prov- 
ince of Tripoli, Northern Africa, the most westerly station now known; 
last definitely recorded in 1874. 
(2) The district of Azir or Assyr, in South-western Arabia, bordering 
on the Red Sea, as lately as 1889. 
(3) A large area in Asia, comprising Persian Kurdistan and adjacent 
parts of Persia, Turkish Kurdistan, and parts of Irak or Mesopotamia on 
the banks of the Tigris and Euphrates, including Baghdad. From this 
area it has extended to Northern Persia on the shores of the Caspian 
(Resht) in 1877, to Baku on the western, and Astrakhan on the 
northern shore of that sea; and up the Volga to the village of Vetlanka 
and its neighbourhood in 1877-79. 
(4) The districts of Kumaon and Gurwhal in the north-west of India, 
on the slopes of the Himalayas, as lately as 1888. 
(5) In Southern China, the mountain district of Yunnan and the sea- 
port Pakhoi on the Tonkin Gulf. Apparently by extension from Pakhoi, 
plague has in the last two years invaded Canton and Hong-Kong in 
Eastern China. 
The five localities above named appear to be independent centres of 
the disease, since no communication can be traced between them; and 
plague is not known to exist in any other part of the world. 
These localities are all in the temperature zone, with the exception of 
the Azir district and Pakhoi, which lie just within the tropics; but they 
have hardly another physical feature in common. Plague prevails in 
Benghazi on a rocky plateau overlooking a marshy district liable to 
inundation; on the banks of the Tigris and Euphrates, and on part of the 
shores of the Caspian in low and marshy situations. But the mountains 
of Kurdistan are 5000 to 6000 feet high; and the Himalayan seat of 
plague approaches 7000 feet above the sea; while in Yunnan the disease 
is said to occur only at elevations of from 1200 to 7200 feet. These 
facts show the old belief that plague prevails only in marshy and PLAGUE 
923 
malarious districts to be unfounded. In fact mountain districts are 
perhaps the most persistent foci of plague now known. 
The social conditions of these localities are important, and will be 
referred to presently. 
Endemic Plague as a Soil Disease. - In all the places where plague 
is endemic, there is reason to believe that the virus resides permanently 
in the soil, and that human beings acquire it thence by certain channels 
of communication. Plague is therefore partially, though not wholly, a 
miasmatic or soil disease. It differs from malarial disease in that it exists 
only in the soil of inhabited places, and has never been acquired from 
mere telluric conditions. Since the living virus is a bacillus which exists 
in the affected subjects, it will pass from them back into the soil, and a 
mutual relation be thus established. The soil theory of plague is a popular 
belief in some parts of the world. It was dimly perceived by many older 
writers (by Boghurst in the seventeenth century); but was obscured by 
other less tenable hypotheses of infection of the air and epidemic con- 
stitutions. It was clearly recognised by Dr. C. R. Francis as the ex- 
planation of the Indian plague of Kumaon in 1853. It was suggested as 
possible by Liebermeister in the article on Plague in Ziemssen's Cyclo- 
pedia of Medicine, and adopted, subject to further evidence, by myself 
in the Encyclopedia Britannica and elsewhere: but it was first defi- 
nitely formulated, with the aid of Pettenkofer's theory of soil water, by 
Dr. Creighton in his History of Epidemic Diseases. It is apparently not 
held by most epidemiologists. 
The arguments in favour of this view are somewhat as follows: - 
(1) The remarkably limited geographical distribution of plague, so 
widely different from that of diseases caused by a floating or purely 
personal contagion, is hardly consistent with any other hypothesis. 
(2) In localities where the disease is permanently established ani- 
mals living underground are often affected in a peculiar way. Usually 
before the outbreak of an epidemic such animals, especially rats, 
perish in large numbers. They come out of their holes evidently very 
ill, and die, or are found dead under ground; so that this phenomenon is 
considered by the people in India and China, where it has been chiefly 
observed, as the sign of a coming epidemic. Recent observation in China 
has shown that the rats suffer not merely from poisoning, but from true 
bubonic plague. They have buboes, and their organs contain immense 
numbers of the plague bacilli. It cannot, therefore, be doubted that the 
virus exists under ground before it affects human beings. In some 
countries other animals are said to be affected, but this is less certain.1 
(3) Within an endemic area of plague the disease often occurs year 
after year, or in successive epidemics, precisely in the same spots, even in 
the same houses ; and springs up simultaneously in several independent 
1 In the older European epidemics it seems doubtful whether this death of rats was 
actually observed. The old books contain general statements of the same kind regarding 
animals which live in the ground, but they have the appearance of being traditional, and 
borrowed from the Arabian writers, especially from Avicenna, who is very copious on this 
point. 924 
SYSTEM OF MEDICINE 
foci. In London in 1665 it was said the disease " fell upon several 
spots of the city and suburbs like rain." 
(4) Of places apparently under the same conditions, and in free 
communication with one another, one is repeatedly affected, the other 
never. Dr. Francis observed in India two villages on the same mountain, 
with the same aspect, scarcely 500 yards apart, of which, at every visita- 
tion of plague, one always escaped, the other suffered. In old days, again, 
it was observed in Egypt that Alexandria might have a terrible epidemic, 
while Cairo entirely escaped: in another epidemic the converse relation 
might obtain; and this in spite of unchecked communication. 
(5) In cities, where a notable part of the population lives on the 
water in boats and barges, it has more than once been noted that such 
persons have entirely escaped the plague. It was so in London in 1665; 
and recently in Canton, where 250,000 people live and sleep on the 
water, this part of the population enjoyed almost complete immunity. 
(6) It has often been observed that while those who live on the 
ground floor of a house are seized with plague, the inhabitants of the 
upper stories may entirely escape; so that it used to be said, " Plague 
does not go upstairs." This has been signally confirmed in the late 
epidemic of Canton. 
(7) In a general way, the beneficial effects of local sanitary meas- 
ures, as compared with mere prevention of contagion, tell in the same 
direction; but the bearings of these facts can only be thus briefly 
indicated. 
It would appear from the above reasons that the endemic prevalence 
of plague is comparable to that of cholera or typhoid, and governed by 
somewhat similar laws; though in other respects it differs very much 
from those diseases. In the double infection of the soil and the organism 
it resembles anthrax. Along with infection of the soil there appears to 
be a passage of the virus in some form into the air, so that it has always 
been believed that the disease may be acquired by inhalation, like typhus. 
Scientific explanation of this method of receiving the virus is, however, 
still wanting. 
Production of Epidemics. - While remaining fixed in one spot, plague 
varies very much in prevalence and intensity. When confined to sporadic 
cases, or existing only in the mild form, it is spoken of as endemic. When 
affecting larger numbers, and in a severer form, it is called epidemic. 
The disease is particularly liable to recur in periodical outbreaks ; and in 
the countries affected popular belief has sometimes assigned a definite 
number of years, such as seven, for the interval. There is, however, no 
such regularity; sometimes a great epidemic is followed by several years 
of apparent immunity, sometimes the disease recurs several years in 
succession. The interval of apparent health is probably often filled, not 
so much with sporadic cases of severe plague, as with minor plague. 
The causes of the development of minor into severe plague, and of 
the production of an epidemic, are very obscure. For various reasons it 
cannot depend upon the number of susceptible persons in the population; PLAGUE 
the causes must be physical, affecting the biology of the plague bacillus 
whether in or out of the body. The best established fact is that epi- 
demics have often (but not constantly) been preceded by a long drought. 
Epidemic diseases among animals, failure of crops, great abundance of 
lower forms of life - such as flies - and numerous other physical inci- 
dents, have been also described as preceding or accompanying plague, 
but are of little moment. More important are social conditions. Many 
epidemics of plague have followed on famines, wars, and other calami- 
ties, which produce destitution and lowered state of health. Other 
fevers have sometimes been observed to prevail at the same time. 
Epidemics of plague always seem to terminate spontaneously, usually 
in from three to six months. Generally in each place they begin about 
the same season: this in northern countries is spring or early summer; 
and they are checked by the cold of winter. When prevalent in Egypt, 
plague used to begin in the autumn and end at the summer solstice, 
when hot south winds prevail. In Russia plague has on some occasions 
prevailed through the winter, being kept alive by the high internal tem- 
perature of houses. In Mesopotamia an air temperature of 86° F. at once 
checks an epidemic, and one of 113° absolutely stops it. 
Conditions favouring the continued Existence of Plague. - It has been 
seen that no physical conditions, except temperature, have much effect 
on the prevalence of plague. But certain social conditions have a great 
influence, and seem almost indispensable to an endemic seat of the 
disease. The first of these is uncleanliness. All the localities in which 
plague flourishes are conspicuously filthy. The villages in Mesopo- 
tamia were in an incredible state of filth (Colvill). The sufferers from 
Indian plague were filthy beyond conception (Francis); the habits of 
the poorer classes of Chinese in Hong-Kong and Canton are notori- 
ously of the same kind. A soil contaminated with faecal discharges 
and decaying animal matter of all kinds appears to be an essential con- 
dition for the vitality of the virus. Among other causes of contamina- 
tion must be placed cadaveric infection from bad customs of burial. 
This was notably observed in the Indian seats of plague, where the 
rocky nature of the soil offers obstacles to efficient burial; in Yunnan 
also, and formerly in Egypt. Dr. Creighton regards this as the domi- 
nant cause, but the general bearing of testimony hardly confirms his 
opinion. The burial among or within dwelling-houses of those who die 
of the plague has often, however, been a potent means of continuing the 
infection; such bodies contain bacilli in enormous numbers, and con- 
tagion from dead bodies is undoubtedly possible. Overcrowding of 
dwelling-houses (not necessarily correlative with density of population) 
and absence of ventilation are also powerful contributory causes. But 
of all social conditions poverty and general social misery seem to be the 
most influential. The poor are always the chief, sometimes almost 
the only sufferers, as shown by such epithets as miseries morbus, or 
" the poor's plague," often given to the disease. 
But since destitution and uncleanliness are prevalent in so many 
925 926 
SYSTEM OF MEDICINE 
parts of the world where plague has never been heard of, these must be 
regarded as favouring, or perhaps essential, conditions for the disease, 
rather than as accounting for its origin. A very moderate improvement 
in sanitary matters at once limits or eradicates the disease. 
Plague as a communicable Disease. - Unlike true miasmatic diseases 
- such as ague - there can be no doubt that plague is communicable, 
both from the sick to the healthy, and from an infected place to one 
previously uninfected; but the extent and nature of this communi- 
cability have been the subject of active controversy. 
Communication from the sick to the healthy does not take place 
especially by contact, as was formerly believed (and hence the word 
contagion, with its false connotations, is better avoided), but by the 
atmosphere of the sick-room, or of the house itself; and this may be 
largely, if not completely, obviated by abundant ventilation. It may be 
difficult to say in some cases whether the infection is acquired from the 
patient or from the house; but it is pretty clear that communication 
from one person to another in the open air, or by casual meeting, is 
very rare, if it ever occurs. The transmission of infection by clothing, 
bedding, or other objects, that is, in the old phrase, \yy fomites, can hardly 
be questioned, though many exaggerated statements have been made on 
the subject. 
Those who, like the French physicians in Egypt, denied contagion 
altogether, did so chiefly on the ground of their own personal immunity, 
though they attended thousands of patients, and performed many post- 
mortem examinations. One of them, Bulard, even wore the clothes of a 
patient who had died of plague, and Clot Bey tried in vain to inoculate 
himself with matter from a pestilent bubo. Many similar negative in- 
stances are on record; but much negative evidence is not so conclusive 
with regard to infection as a few positive cases. On the whole, the truth 
appears to be that during different epidemics and at different stages of 
an epidemic, plague differs immensely in its contagious property, as it 
does in its virulence; so that, broadly speaking, it is highly communi- 
cable at some times, and very slightly so, if at all, at others. 
In explanation of cases where communication cannot be traced, it 
should be noted that, besides rats and the like, domestic animals may 
convey germs of disease, and Yersin has lately shown that the same is 
true of house flies. 
Transmission of plague from one place to another not previously in- 
fected must also be regarded as well established; though, doubtless, this 
has often been wrongly assigned as the cause of purely local outbreaks. 
That this is possible by means of infected ships is clearly proved by the 
records of the Quarantine at Marseilles (quoted by Prus), when in several 
instances the infection was, so to speak, caught on the sieve - that is to 
say, the infected ships gave rise to cases of plague within the quarantine 
station, of which some were fatal. The like possibility on land has often 
been established, though doubted by the extreme school of anti-con- 
tagionists. For instance, in the London Plague of 1665, towns and PLAGUE 
villages in communication with London became affected, though they 
were previously healthy, and had not suffered from plague for many 
years, if ever. The infection is doubtless generally conveyed by persons 
either affected with the disease or in the stage of incubation. Such 
persons convert the house they occupy into a focus of infection, till 
possibly the virus passes into the soil, and a severe epidemic may result. 
Conveyance by means of infected objects is doubtless possible, but prob- 
ably much rarer.1 
With regard, however, to this mode of transmission, it should be 
observed that, according to old and sound tradition, the plague does not 
spread when it is sporadic, but only when it is in an epidemic form. 
Furthermore, its diffusibility varies as much as its contagiosity in the 
narrower sense, being very marked in great epidemics, very slight or 
self-limited in others. Many epidemics have burnt themselves out on 
the spot, or travelled but a few miles; others have spread over whole 
continents. Generally successive epidemics, if unchecked, cover each 
time a somewhat wider area. 
The rate of extension is also variable, but is generally slow. Plague 
has taken weeks or months to pass from one side of a city to another; 
it creeps along from point to point, so as to be compared by some to a 
drop of oil on paper. 
Such gradual extension suggests the slow progress of a virus in the 
soil itself, and probably that is in some places the explanation; but, 
obviously, only transmission through short distances can be thus ac- 
counted for. 
Transmission by the air cannot be said to be impossible, and was 
once much dreaded; but while this may be possible through distances 
measured by yards, it can hardly be so through distances measured by 
miles. 
Plague as an Epidemic Communicable Disease. - Clinical Forms of 
Plague. - It is now pretty clearly established that plague may occur in 
two distinct forms, each of which may prevail separately to the exclusion 
of the other: - 1. Pestis minor, abortive or larval plague. 2. Pestis 
major, severe or ordinary plague. Very fatal cases of the latter are 
927 
1 The instance of Eyam in Derbyshire (whither the infection was carried in a package 
from London) is well known; less well known is that of an isolated house (Oakhow) in 
Langdale, in which, as it is believed, every occupant died. A son of the house died of the 
plague in London in 1598 or 1665, and it is said that the infection was carried in his clothes, 
etc., which were sent home. Food was brought near the house by the neighbours, who, 
however, never entered it; the bodies were left where they fell, and it seems probable 
that the house was burned after the last death. A mound only remains, the site never 
having been occupied since. No cases occurred elsewhere in the immediate neighbour- 
hood, but the pest fell heavily upon the towns of Cumberland and Westmoreland. Upon 
the wall of Penrith Church is the following inscription: " a.d. mdxcviii. Ex gravi peste 
quae regionibus hisce incubuit obierunt apud Penrith 2260, Kendal 2500, Richmond 2200, 
Carlisle 1196. Posteri, Avertite vos et Vivite, Ezek. 18th, 32." Vide Lays and Legends 
of English Lake Country, by J. Bagen White, F.R.C.S., Carlisle, 1873; and Dr. Barnes' 
paper in vol. xi. Trans. Cumb. and Westd. Arch, and Antiq. Soc. p. 158. In those days 
the fresh rushes were commonly laid upon those of previous years which were already 
charged and saturated with filth and refuse. -Ed. 928 
SYSTEM OF MEDICINE 
sometimes called " fulminant," or Pestis siderans ; but as they do not 
constitute an epidemic by themselves this is hardly a distinct form. 
1. Pestis minor is characterised by the production of glandular swell- 
ings, with little fever and no severe general symptoms, lasting perhaps 
about fourteen days. It has been observed in Mesopotamia preceding 
severe epidemics of ordinary plague; in the city of Astrakhan in 1877 
(the year before the severe outbreak in that province), and elsewhere. 
A similar type was observed in London in 1664, the year before the 
great plague, though its existence was concealed. This form is rarely 
or never fatal, and hence has often been overlooked or misunderstood. 
It does not appear to be contagious, and is not certainly known to be 
transmitted from one place to another. It has therefore the characters 
of an endemic miasmatic disease. 
2. Pestis major may be developed out of the milder form. In 
endemic seats of plagues the mild form appears sometimes, probably 
from some change in the soil poison, to be rapidly transmuted into the 
severer form, which then appears as the epidemic form. Strange to say, 
gradations between the two forms do not seem to be generally observed, 
as the earliest cases of the true plague are usually the most severe. 
When the severe form is prevalent as an epidemic the disease is cer- 
tainly transmissible. The extent and conditions of this transmission 
will be discussed later. The following clinical account is that of ordi- 
nary or severe plague: - 
The Attack of Plague.1 - Incubation. - The latent period between the 
reception of infection and the commencement of symptoms is imperfectly 
known, but appears to be generally from three to five days, or at most 
one week. Observation for about eight days may therefore be taken as 
sufficient to show whether a suspected person is or is not infected. 
The symptoms of plague vary much in their intensity and rela- 
tive frequency in different epidemics; but the order in which they pre- 
sent themselves and the general course of the attack are tolerably 
uniform. 
Prodromal Stage. - Often the onset is quite sudden; but when pre- 
liminary symptoms (prior to the coming on of fever) are observed they 
are as follows : - The nervous system is chiefly affected. There is severe 
headache, vertigo, staggering gait, and appearance suggestive of drunken- 
ness passing into lethargy. Colvill says -" The patient appears absent- 
minded, moves along speaking to no one, enters his house mechanically, 
shutting the door, and drops on to his bed, as if in despair or wandering 
in his mind." The pallid face, the injected eyes, the vacant or stupefied 
expression of countenance, with inability or refusal to answer questions, 
often suffice for an experienced eye to make the diagnosis. With these 
are associated the usual symptoms of acute febrile disease, pains in the 
limbs, extreme muscular weakness, and intense malaise. The tongue at 
1 In this summary I have followed chiefly the accounts given by Dr. Cabiadis and Mr. 
Colvill of plague in Irak. I have referred also to Dr. Cantlie's observations in Hong- 
Kong, and, for special symptoms, to those of other observers. PLAGUE 
929 
the beginning is thickly coated on the dorsum, the edges being red; 
later it becomes extremely dry and of a mahogany colour. Bilious 
vomiting or haematemesis are occasionally the initial symptoms. The 
prodromal stage, when present, may last a few hours or a day, rarely 
longer. 
Febrile Stage. - Immediately after the above symptoms, concur- 
rently with them, or sometimes from the beginning, high fever comes 
on, ushered in by a prolonged rigor or repeated shiverings. The tem- 
perature may rise rapidly to 102°, 104°, or even to 107° F. and higher. 
The pulse is always rapid, from 90 to 120 or 130. It is described as 
sometimes very small and thread-like, at other times not especially weak. 
Dr. Cantlie speaks of it as very variable in force, frequency and character. 
The skin is at first extremely dry, not always very hot to the touch. 
There is excessive thirst, with a sense of burning in the throat and 
stomach. Constipation is the rule during this stage. From the extreme 
weakness the decubitus is dorsal. The nervous disturbances are mainly 
those already described; sometimes they pass into active delirium, more 
often into lethargy and coma. The duration of the febrile stage 
would appear usually to be from two to five days, but sometimes it is 
much longer. The fall of temperature is generally described as sudden, 
and it may not rise again; but Dr. Cantlie observed in some cases a 
recurrence of high temperature after three or four days. In some fatal 
cases the rectal temperature after death was found to be high. In cases 
which do well there is a gradual but irregular fall, and after fourteen 
days the temperature is often subnormal.1 
Buboes or inflammations of lymph-glands constitute the most impor- 
tant and characteristic feature of plague. They are rarely wanting, and 
then only in cases which are very rapidly fatal; though it is difficult 
to say in what proportion of cases they are absent, since in the panic of 
an epidemic they may be overlooked.2 The term " bubonic plague " is 
therefore in the main accurate. 
Buboes are in some instances the first symptoms to attract the 
attention of the patient, perhaps by a sudden lancinating pain. More 
usually they occur after the onset of fever, on the second, third, fourth, 
or even the fifth day of the disease. With the appearance of buboes 
there is often some abatement of the fever and general symptoms. 
The affected glands are generally extremely painful, but sometimes the 
enlargement is insidious, and only detected on examination. They may 
enlarge rapidly, more often gradually. Glands are usually affected in 
groups, but generally one is much larger than the rest. At first the 
glands are extremely hard, and in fatal or very severe crises may retain 
1 The temperature charts on pp. 930 and 931 are copied by permission from Dr. 
Cantlie's article, Brit. Med. Journal, 1894, vol. ii. p. 424. 
2 At Vetlanka in Russia, after the epidemic, I was informed by the relatives of those 
who had died of plague that there were no swellings, though there is reason to believe 
that such had occurred; the bodies were probably buried hastily in ordinary clothes and 
not carefully examined. In Mohammedan countries this would be less likely to happen 
in consequence of the ritual observances carried out after death. 
3o 
VOL. I SYSTEM OF MEDICINE 
930 
this character to the last; in other cases suppuration occurs, which is 
regarded as a favourable sign, and is often more prevalent during the 
decline of an epidemic. On the other hand, rapid softening, flattening, 
or even disappearance of a bubo during the height of the attack is some- 
times observed, and is a symptom of the worst omen, being speedily 
followed by death. It was so in London in 1665, and in recent 
Chart 10. - Temperature chart of an acute case, with temperature in rectum after death. 
epidemics in Irak. Sometimes the skin over the bubo becomes gan- 
grenous, forming a carbuncle. According to Dr. Cantlie great oedema 
surrounds the glands, converting the group into an elevated doughy 
mass, sometimes five or six inches in diameter. A bubo once formed 
usually lasts during the whole of the attack. In suppurative cases which 
recover the process may be prolonged for several days, or even for some 
weeks, and leave formidable scars, the diagnostic marks of a past attack 
of plague. PLAGUE 
The size of a bubo does not generally exceed that of an almond or a 
walnut, but may attain that of an egg or small orange. In the majority 
of cases (three-fourths or more according to some observers) only a single 
prominent swelling occurs: but Dr. Cantlie remarks that swollen glands 
are to be found in other regions if sought for. With regard to situation 
all observers agree that the inguinal group of glands is most frequently 
931 
Chart 11. -Temperature chart of a less rapid case. 
affected, such cases, according to Cabiadis and Colvill (if with these be 
included those of the femoral triangle), making 40-50 per cent of the 
total number; but where the femoral glands have been distinguished 
from the inguinal, the former appeared to be most frequently attacked. 
Next in frequency of attack come the axillary glands -in 25 or 30 per 
cent of cases, and in a larger proportion of female patients ; the cervical 
and submaxillary or other glands are only attacked occasionally. Some 
internal glands, especially the various abdominal groups, are always 
found inflamed on post-mortem examination. 932 
SYSTEM OF MEDICINE 
Of secreting glands the parotid is sometimes though rarely inflamed. 
Carbuncles. - Gangrenous patches of skin, called carbuncles, though 
evidently not anatomically the same as the ordinary carbuncles pro- 
ceeding from sebaceous glands, form another characteristic feature of 
plague. According to Cabiadis and Colvill, they occur, however, only 
in 2 or 2| per cent of the cases. Red patches appear on the skin, and 
become indurated and sometimes vesicular; then necrosis occurs, which 
spreads till the patch may attain a width of some inches. They may 
occur on any part of the surface of the body, and have sometimes been 
attributed to direct introduction of the virus of plague into the skin. 
Petechice. - Purpuric patches, due to ecchymosis, sometimes of small 
size (petechiae), sometimes larger, are often seen in severe cases. In the 
seventeenth century they were known as the " Tokens," and regarded 
as invariably indicating the approach of death. 
General pustular or vesicular eruptions have rarely been observed. 
Sweating is an extremely variable symptom. In certain epidemics 
very profuse sweats have been observed, in others this feature has been 
entirely wanting. 
Haemorrhage from various organs is sometimes observed in severe 
cases, and is much more frequent in some epidemics than in others. 
Epistaxis is a common form of it, but pulmonary haemorrhage, usually 
associated with congestion or inflammation, is regarded as of specially 
serious import. It was observed in the first epidemic of the Black Death 
in Europe (1348), in the epidemic on the Volga in 1879, and on many 
other occasions. The theory of Hirsch, that this symptom distinguishes 
a special Indian variety of plague, comprising the Black Death of the 
fourteenth century and the Indian epidemics, is virtually abandoned by 
its author, and may be entirely discarded. 
Haematemesis is sometimes so noticeable as to have been called 
" black vomit "; and intestinal haemorrhage produces black dejections. 
Urinary haemorrhage and metrorrhagia occur, and are generally or 
always fatal. The haemorrhagic form of plague, though not constitut- 
ing a distinct type, may be compared to the haemorrhagic forms of 
small-pox, scarlet fever, and so forth. 
The remaining symptoms will be best considered in relation to the 
various systems of the body. 
Nervous System. - The general features have been already described. 
There is profound poisoning, affecting especially the cerebrum, but with 
little disturbance of motor functions, except occasional convulsions, and 
the contraction of tendons seen in the last stages of many febrile dis- 
eases. Paralysis does not appear in the descriptions. The violent 
or maniacal delirium of older records has not often been observed in 
recent epidemics. 
Respiratory System. - The respiration is accelerated in the febrile 
state in proportion to the fever, perhaps more so. In some epidemics 
marked symptoms of engorgement of the lungs and pneumonia with pro- 
fuse haemoptysis are described, but no precise accounts of physical signs PLAGUE 
933 
are forthcoming. These cases have in some instances given occasion for 
the false diagnosis of an epidemic pneumonia. In Hong-Kong pulmo- 
nary symptoms were absent. These variations are probably connected 
with differences of climate and season. 
Digestive System.- Beside the condition of the tongue already noticed,, 
some cases give evidence of grave gastric disturbance, in the form of 
severe bilious vomiting; this is sometimes an early symptom, but it may 
occur at any stage. The bowels as a rule are constipated, but profuse 
diarrhoea sometimes occurs, and has been regarded (by Colvill and also 
by Cantlie) as a favourable symptom. The occurrence of gastro-intestinal 
haemorrhage has already been noted. 
Blood and Circulation.-No recent observations on the condition of 
the blood are recorded, but the French physicians in Egypt in 1835-36, 
a time when bleeding was customary, made some analyses, from which 
it appears that the blood coagulated imperfectly, and never formed a 
buffy coat. Its surface presented fatty globules, the serum was deeply 
coloured, and in some instances the reaction of free sulphuretted hydro- 
gen was obtained. The water was in excess. These results are evidence 
of profound decomposition and destruction of red corpuscles. Recently 
in China the characteristic bacillus has been occasionally found in the 
blood, but never abundantly. > 
The Circulatory disturbances have been described. 
The Urinary System presents nothing very notable. The urine is 
generally diminished, sometimes suppressed; but in the Hong-Kong 
epidemic it was normal. Hsematuria has already been mentioned. 
Duration of Attack. - Cases are sometimes fatal within a day, but in 
general the duration of fatal attacks is three to five days. Colvill, in 
Baghdad, found nearly one-fourth of his fatal cases died on the first 
day, about three-fifths within three days, and five-sixths within five; a 
very small number of such cases lived over a week. Hence if a patient 
lived as long as this, he was thought pretty certain to recover. On the 
other hand, cases in which suppuration of buboes occurs, and which 
recover, may be protracted to three weeks or a month. 
Mortality. - Plague is the most fatal of all known epidemic diseases 
affecting large numbers. At the beginning of an epidemic the mortality 
is often 80 to 90 per cent or more of those attacked, and this rate is 
maintained or increased at the height of the epidemic. In the epidemic 
on the Volga in 1879, in one group of villages visited by myself, every 
person attacked by plague had died. Towards the end of every epi- 
demic recoveries predominate over death, so that the average mortality 
falls: but in some limited epidemics in Irak three-fourths or more of those 
attacked have died. In the larger epidemics of Baghdad in 1876, the 
proportion of deaths was officially stated as 55-7 per cent; and at Hillah 
in the same country it was given by Cabiadis at 52-6 per cent. In other 
epidemics the percentage of fatal cases has not been more than 40 per 
cent, and in Egypt in 1834-35 about one-third. 
The total mortality has notoriously been in many instances very 934 
SYSTEM OF MEDICINE 
great both absolutely and. in proportion to the population, though older 
accounts may have been exaggerated. The Black Death is calculated to 
have carried off one-third of the inhabitants of Europe, and in some 
countries more than one-half, but these estimates must be uncertain. 
In modern times it is said that the plague of 1830-31 killed 60,000 of 
the 150,000 inhabitants of Baghdad. The epidemic of 1876 in Irak is 
stated to have destroyed one-eighth of the whole population. In 1881 
most of the villages affected lost a moiety or more of their inhabitants. 
As in such times a large part of the surviving population seeks safety in 
flight, it is easy to understand how villages may be entirely ruined and 
depopulated by the ravages of plague, as was the case also in our own 
country in the fourteenth century. 
Prognosis. - The most unfavourable symptoms are haemorrhage, in 
whatever form, and petechial eruptions or " tokens "; both affections 
are generally lethal prognostics. Profound affection of the nervous 
system is also an unfavourable sign. Suppuration of buboes is always 
of good omen. Sex and age appear to have little or no influence on the 
result. All observers agree that prognosis is generally very uncertain, 
and that cases apparently mild often terminate fatally. 
Diagnosis. - No acute febrile disease presents the peculiar affection 
of the lymph-glands. Nevertheless a casual lymphatic inflammation or 
an inflamed parotid gland may occur in rare cases of other diseases, 
especially in typhus, which was at one time thought to show in some 
cases a transition to plague. Modern observers, however, have found 
no difficulty in making the diagnosis; the longer duration of typhus 
(" the fourteen days' fever ") and the collective symptoms making a well- 
marked distinction. Malignant forms of malaria have sometimes been 
confounded with plague; but the absence of intermissions, or even of 
definite remission of the fever, and the inefficacy of quinine, are obvious 
distinctions. The aspect or facies of a malarious patient is also very 
different. 
Morbid Anatomy. - There is little satisfactory information on this 
head; the fullest accounts are still those which were made up by the 
French physicians in Egypt in 1834-35; but some valuable observations 
were made also in the recent epidemic at Hong-Kong. The bodies of 
plague patients undergo rapid decomposition, and this change, especially 
affecting the blood, must have been the cause of some of the appear- 
ances described in older accounts, such as red or black staining of the 
serous membranes, of the surfaces of internal organs, of the mucous 
membranes, and so forth. The central nervous system, especially the 
brain, is deeply congested; the brain substance in some instances is 
softened, and the blood-vessels, especially the veins, much engorged. 
The lungs are much congested, especially in their posterior parts, but 
evidently this was partly due to hypostasis before or after death. The 
pericardium contains an excess of fluid, frequently blood stained. The 
right side of the heart is dilated with black, imperfectly coagulated 
blood, and the whole venous system is engorged. The heart substance is PLAGUE 
935 
pale, and sometimes softened. The stomach and small intestines may 
contain blood-stained fluid, sometimes actual blood, the surface showing 
intense venous congestion; but Dr. Cantlie, in Hong-Kong, found no 
congestion of these parts. In a few cases superficial ulcerations have 
been noted; but the Peyer's patches are not specially affected. The 
large intestine is comparatively normal. The peritoneum is described as 
showing great vascular congestion, chiefly venous. The liver was found 
enlarged by the French pathologists, sometimes considerably; but Dr. 
Cantlie found no notable enlargement: its substance is pale and anaemic, 
and presents the appearance of cloudy swelling. Haemorrhage, intersti- 
tial or superficial, is found occasionally. The spleen, according to all 
observers, is greatly enlarged. The kidneys are sometimes enlarged, and 
occasionally present haemorrhagic patches; Dr. Cantlie describes their 
histological appearance as being that of cloudy swelling. 
The one characteristic sign is inflammation and swelling of the in- 
ternal lymphatic glands, a condition always present even when the 
external glands are not notably enlarged. All groups of lymph-glands 
may be affected so as to form continuous chains, the cervical being 
united with the mediastinal and bronchial; the inguinal with the groups 
surrounding the iliac vessels and aorta, and with the pelvic glands, and 
so on. The mesenteric glands are least frequently affected. Agglom- 
erated glands may form masses weighing as much as two pounds. In 
substance they are sometimes red, congested and hard, sometimes soft 
and discoloured, sometimes breaking down into a pulp. The surround- 
ing tissue is infiltrated with serous fluid. 
It is evident that, apart from the condition of the lymph-glands, there 
is nothing distinctive in the morbid anatomy of plague. 
Treatment.-Nothing is less satisfactory than the treatment of 
plague. In old days opinions were divided as to the value of bleeding, 
but the balance of experience was decidedly against it. The violent 
sudorifics used in the seventeenth century appear to have been useless. 
In modern times quinine has naturally been largely administered, but 
the general testimony is that it is quite useless. Antiseptics (such as 
carbolic acid, salicylic acid, etc.), antipyretics and cardiac stimulants have 
all been tried with no better results ; purging with calomel and magnesia 
was largely used in Hong-Kong, but with little benefit. In fact, nothing 
approaching to a specific or antidote in the way of drugs has ever been 
discovered. The general principles of treatment would seem to be, as in 
other asthenic fevers, to give the patient an abundant supply of fresh air, 
to avoid overcrowding, to use cold affusions or baths in the height of the 
fever, and to administer such cooling or other drinks as may promote his 
comfort. When the strength is failing, stimulants are of course indi- 
cated, but alcoholic stimulation appears to be of less value than in typhus. 
In the seventeenth century some good observers denounced the use of 
" strong waters " as positively pernicious. In a malady of such short 
duration the utility of abundant nutrition would appear to be of less 
importance than in more protracted illnesses. 936 
SYSTEM OF MEDICINE 
The local treatment of the buboes has received much attention. The 
general result of experience is that energetic treatment by caustics, 
mercurial inunction, or early surgical interference, is painful and fruitless. 
In early stages only soothing applications, such as poultices and anodynes, 
should be used. When softening or suppuration occurs, surgical treat- 
ment by incision and drainage is called for. There is no evidence of the 
value of thorough antiseptic surgical methods ; but in the epidemic of 
Hong-Kong the injection into the glands of solutions of perchloride of 
mercury and carbolic acid seemed to be of temporary benefit. 
Finally, it should be noted that Yersin, Calmette and Borel in the 
Institut Pasteur, claim to have worked out a system of serum therapeutics 
for plague like that used in diphtheria and other diseases. Repeated 
injections of virulent bacilli were made into a horse, and, after six weeks' 
preparation, its blood serum, when injected into rabbits, was found to be 
capable of producing, not only immunity against a subsequent virulent 
injection of plague bacilli, but also in larger dose the cure of animals 
previously submitted to a virulent injection. 
Prophylaxis and Prevention.-For individual prophylaxis against 
contagion a number of elaborate precautions were formerly recommended, 
which need not now be taken into account. The important rules seem to 
be that any person, medical or other, who is brought into contact with 
infected patients or dwellings, should, in the first place, keep himself in 
as good a state of general health as possible; and, in the next, remain 
in the sick-room or house no longer than duty requires. The risk of 
touching and handling plague patients is apparently very slight, and 
nurses and attendants in well-managed and airy hospitals incur no special 
danger. Doctors on the whole have rarely been affected; and in most 
instances have conspicuously escaped. When they have suffered (as was 
grievously the case in the short epidemic of Vetlanka) it has generally 
been because they lived in the same dwellings, and under the same con- 
ditions as the affected population; or, as in Hong-Kong, they have been 
engaged in investigations on the material of the disease. 
The prophylaxis of communities is a difficult matter, as it involves 
the question of quarantine, a system of regulations which has been 
elaborated chiefly to guard against this very disease; but the subject is 
too large to be fully discussed here. 
Since there is no doubt that plague, when in an epidemic form, does 
tend to spread to other places and countries by means of infected persons 
or objects, we have to consider the possibility of its being brought to an 
uninfected place. The first precaution, and probably the best, consists in 
making the place unfit to be the nidus of the disease. This precaution 
concerns the purity of the soil itself, the cleanliness and ventilation 
of dwellings, the prevention of overcrowding, of extreme poverty, of 
personal uncleanliness and other insanitary conditions. It is improbable 
that any healthy European city or population in good sanitary condition 
could be the seat of a serious epidemic of plague. Since, however, san- 
itary perfection is not universal, and a very intense plague infection PLAGUE 
937 
seems sometimes to spread even under good sanitary conditions, the 
question of exclusion cannot be disregarded. 
Total exclusion of persons and objects coming from an infected 
place, as common-sense shows, would be sufficient; but this is rarely 
practicable. The epidemic at Noja, in Italy, in 1815, was thus isolated 
by absolutely cutting off communication with other parts; and other- 
instances might be quoted. But for general application, modified exclu- 
sion or " quarantine " is the only possible method. Quarantine consists 
in subjecting all persons and objects coming from an infected country to 
a period of observation measured by the known period of incubation 
of the disease, and in requiring certain measures of disinfection before 
they are permitted to proceed. In marine quarantine all ports in 
communication with an infected port, unless they adopt the same 
regulations, are themselves regarded as infected; arrivals from such 
ports are therefore put under the same restrictions - a serious matter 
for the commercial relations even of countries which do not adopt 
the principle of quarantine. In quarantine on land these arrangements 
are complicated with a so-called " cordon sanitaire " along the frontier to 
prevent entrance by irregular channels. In recent times infected dis- 
tricts have been surrounded by double or triple cordons to prevent exit 
except under quarantine regulations. These are necessarily military 
arrangements. On the efficacy of. quarantine opinions have differed, 
though notwithstanding modern scepticism, it would be unreasonable to 
doubt that this system, as applied in former times in the Mediterranean 
ports, was of great service, especially as against infected ships. But 
early in this century the system became out of date, and even injurious 
through mal-administration. At the present time a modified system of 
quarantine against plague is still legally in force, and may be put in 
operation by an Order in Council; it is not, like other sanitary arrange- 
ments, subject to the Local Government Board. 
The land quarantines established in Asiatic Turkey and Persia are 
considered by most unbiassed observers to be so defective as to be use- 
less even if well designed. Some authorities, like Tholozan, deny their 
efficacy altogether, and regard the limitation of epidemics attributed to 
them as due to seasonal decline.1 
Dismissing quarantine in the old sense, attention should be directed 
to ships arriving from an infected country with cases of plague on board, 
an element of the gravest danger which no sanitary authority could 
11 can say from personal knowledge, that the limitations of the epidemic on the Volga 
in 1879 to a small district could not have been due to the elaborate cordons established by 
General Loris Melikoff, which in every newspaper were credited with the result. For two 
months the disease was confined to a single village, though communications on the main 
high road were open nearly the whole time. It then began to spread, but when the cordons 
were established it was already confined to a very few cases in another village. It is right 
to say that the villagers in their alarm established a sort of quarantine, or rather system of 
exclusion between one place and another. Much more credit is due to the radical measures 
of destruction carried out by the authorities. All infected houses (mostly of wood) and all 
suspected objects were burned; and it is highly probable that the disease was thus pre- 
vented from recurring in the next season or becoming endemic. 938 
SYSTEM OF MEDICINE 
meet otherwise than by absolute isolation, followed by radical disinfection, 
or even destruction where practicable. The persons on board should be 
removed to an isolation hospital, and observed for a period corresponding 
to the known incubation of the disease. Supposing plague to be intro- 
duced into or to break out in any place, its restriction must depend upon 
the measures usually applied to infectious diseases, with special reference 
to the dwellings which may retain the virus. The infected house should 
be emptied, patients should be removed to a hospital, and the other 
inmates isolated under observation. Under some circumstances the 
patient might be better isolated in his own house, the chief thing to be 
avoided being concentration of the virus. The dwelling should in the 
meantime be thoroughly disinfected, and all clothing or infected objects 
subjected to disinfecting agents, of which heat appears the most 
efficacious. On account of its usually low degree of contagiosity, plague 
would probably in a clean city be more easily controlled than small-pox 
or typhus. As contagion from the dead body is possible, interment 
should be carried out under special precautions. 
The only remaining question is whether the infection may be carried 
from an infected country to a distance by any kind of infected objects. 
As regards ordinary articles of merchandise, experience shows that the risk 
is slight or none; but the importation of rags or worn clothing might, as 
in the case of small-pox, be made subject to special restrictions. 
J. F. Payne. 
REFERENCES 
General History. 
1. Hirsch. Handbook of Geographical and Historical Pathology, translated by 
C. Creighton, vol. i. New Syd. Soc., London, 1883.-2. Haeser. Geschichte der 
Medizin und der epidemischen Krankheiten, 3te Auflage, Band iii. Jena, 1882. - 
3. Make. Article " Peste," Dictionnaire Encyclopedique des sciences medicales, vol. 
xxiii. p. 641. Paris, 1887 (with a very complete bibliography).-4. Creighton. 
History of Epidemics in Britain, 2 vols. Cambridge, 1891. - 5. Prus. Rapport a 
V Academic Royale de Medecine sur la Peste et les Quarantaines. Paris, 1846 (abridged 
translation by Galvin Milroy. London, 1846).-6. Payne. Article " Plague," Ency- 
clopedia Britannica, 9th ed. (historical summary). 
History of Special Periods. 
In Antiquity:-7. Oribasius. Collectanea, lib. xliv. cap. 17 ((Euvres de Oribase, 
ed. Busseinaker and Daremberg, Paris, 1851, vol. iii. p. 607).-8. Procopius. De 
Bello Persico, ii. 22, 23, and other authorities referred to by Gibbon, Decline and Fall, 
chapter xliii. Fourteenth Century (The Black Death):-9. Hecker. Epidemics of 
the Middle Ages. Trans, by Babington. Syd. Soc., London, 1844. -10. Guv de 
Chauliac. La Grande Chirurgie, ed. Nicaise, Paris, 1890, p. 167. -11. F. A. 
Gasquet. The Great Pestilence 1348-9. London, 1893.-12. J. F. Payne. "Plagues, 
Ancient and Modern," St. Thomas's Hospital Reports, vol. xvii. p. 103. 1889. 
Seventeenth Century:-13. Thomas Lodge. Treatise of the Plague. London, 1603. 
-14. Josephus Ripamontius. De Peste anni 1630. Milan, 1641, 4to. -15. Isbrand 
Diemerbroeck. Tractatus de Peste. Arnheim, 1646, 4to; 2nd ed., Amsterdam, 
1665, 4to. On the Great Plague of London in 1665 we have: -16. Nath. Hodges. 
Loimologia, sive Pestis nupere narratio. London, 1672, 8vo. English by Quincy. 
London, 1720. -17. Thomas Sydenham. In Observationes Medicse circa morborum 
acutorum historiam, etc. London, 1676. English edition (Sydenham Society). -18. PLAGUE 
939 
William Boghurst. Loimographia: an Account of the Great Plague of London in 
1665. Published from the MS. by the Epidemiological Society of London, 1894 (by 
far the best account of this epidemic, containing minute clinical records, and showing 
great independence of judgment). -19. Defoe. Journal of the Plague Year, an often 
reprinted fiction founded on facts, which will never lose its interest. The Journals of 
Evelyn and Pepys, with the Calendar of State Papers (Domestic Series), 1665-6, 
contain many important facts. Eighteenth Century:-20. Relation historique de la 
Peste de Marseille. Cologne, 1721. Translated into English: Journal of the Plague at 
Marseilles. London, 1721. -21. Chicoyneau, Verney, etc. Observations de la Peste. 
Marseilles, 1721. Also English, London, 1721.-22. Chicoyneau. Traits de la Peste. 
Paris, 1744.-23. D'Antrechaus. Relation de la Peste de Toulon en 1721. Paris, 
1756. - 24. Samoilowitz. Memoire sur la Peste en Russie 1771. Paris, 1783. - 25. 
Patrick Russell. Treatise of the Plague (Aleppo, 1760-2, etc.). London, 1791, 4to. 
Nineteenth Century:-26. Faulkner. On the Plague in Malta. London, 1820. - 27. 
Tully. History of the Plague in Malta, Gozo, Corfu, etc. London, 1821.-28. 
White. Treatise on the Plague (at Corfu). London, 1847. - 29. Gosse. Relation de 
la Peste en Grece 1827-8. Paris, 1838. - 30. Clot-Bey. De la Peste en Egypte. Paris, 
1840. - 31. Bulard. De la Peste Orientate. Paris, 1839.-32. Tholozan. La Peste 
en Turquie dans les Temps Modernes, Paris, 1880; Histoire de la Peste bubonique en 
Perse, Paris, 1874, (and other works).-33. Reports addressed to the Constantinople 
Board of Health on Plague in Asiatic Turkey, by Drs. Castaldi, Cabiadis, Bastoletti, 
and others. These are not easily accessible, but summarised in articles by Dr. 
Dickson in Trans. Epidemiolog. Society, London, vol. iv. p. 140, and in following: 
- 34. J. Netten Radcliffe. Report of Local Government Board 1875 to 1879-80; 
and Supplement 1881; also Papers on Levantine Plague presented to Parliament 1879. 
- 35. W. H. Colvill. "Plague in the Province of Baghdad," Trans. Epidem. Soc., 
vol. iv. p. 9; also Reports quoted by Netten Radcliffe, op. cit. On Indian Plague: 
- 36. Francis and Pearson. Indian Annals of Medical Science, vol. i. 1854.-37. 
C. R. Francis. Trans. Epidem. Soc. London, vol. iv. p. 391.-38. John Murray. 
Trans. Epidem. Soc. London, vol. iv. p. 129.-39. F. Forbes. On Plague in N. W. 
Provinces of India. Edinburgh, 1840.-40. Webb. Pathologia Indica. 2nd ed. 
Calcutta, 1848. On the Epidemic of Vetlanka:-41. Hirsch and Sommerbrodt. 
Pest-Epidemie 1878-9 in Astrachan. Berlin, 1880.-42. Cabiadis. See Dickson, 
Trans. Epidem. Soc. London, vol. iv. p. 446.-43. J. F. Payne. "On the Epidemic 
of Plague in Astrakhan, 1878-9," Trans. Epidem. Soc. London, vol. iv. p. 362. 
On Plague in China:-44. Reports of Imperial Chinese Customs: Manson, Series 2 
for 1878, 15th issue; Lowry, Ibid. 24th and 28th issue; also 47th and 48th issues, 1895. 
- 45. Netten Radcliffe. Op. cit. 1881. - 46. United Service Magazine, April 1895, p. 
60, and Reports quoted in the text.-47. Rennie. British Medical Journal, 1894, ii. 
615.-48. Yersin. Annales de I'Institut Pasteur, 1894, p. 662; lb. 1895, p. 589.- 
49. Kitasato. Lancet, 1894, ii. 428. - 50. "Report by James A. Lowson on 
Plague at Hong-Kong, 1894," Hong-Kong Government Gazette, 13th April 1895. 
On Contagion, Prevention, Quarantine, etc.:-51. Fracastorius. De Contagionibus; 
- Opera, Venice, 1555, 4to.-52. Cardinal Gastaldi. De avertenda et Profliganda 
Peste.-Bologna, 1684, folio. - 53. Muratori. Trattato del Governo della Peste. 
Modena, 1714. - 54. Mead. Discourse concerning Pestilential Contagion. London, 
1720, 8vo. - 55. John Howard. An Account of Lazarettoes in Europe, etc. 
London, 1789, 4to.-56. Report of Committee of House of Commons on Quarantine, 
1819. - 57. A. B. Granville. Letter on the Plague and Contagion. London, 1819.- 
58. John Bowring. Observations on the Oriental Plague. Edinburgh, 1838. - 59. 
Lorinser. Der Pest des Orients. Berlin, 1837. - 60. Charles Maclean. Evils of 
Quarantine Laws, etc. London, 1824 (and other works).-61. Make. Op. cit.- 
62. Prus. Op. cit. 
J. F. P. SYSTEM OF MEDICINE 
940 
RELAPSING FEVER, OR FAMINE FEVER 
Synonyms. -Five or seven days' fever; Five days' fever with, relapses; 
Remittent fever; Typhus recurrens; Figure a rechute; Epidemic fever 
of Edinburgh, of Ireland; Epidemic remittent fever; Relapsing synocha; 
Bilious relapsing fever; Bilious typhoid; Remitting icteric fever; Fam- 
ine fever; Die Hungerpest; Miliary fever; Typhinia. 
This fever, with enteric or typhoid fever, formerly confused with the 
larger group of typhous continued fevers, was separated and distinguished 
by a long series of researches and of more accurate observations in the 
first half of the present century. The essential character which distin- 
guishes it from typhus is the occurrence of the relapse; while from 
enteric fever it is distinguished by the absence of intestinal lesions. 
The following brief description has been given of it by Dr. Murchison: 
- "A contagious disease which is chiefly met with in the form of an 
epidemic during seasons of scarcity and famine. Its symptoms are: 
A very abrupt invasion marked by rigors or chilliness; quick, full, 
and often bounding pulse ; white, moist tongue, sometimes becoming dry 
and brownish; tenderness at the epigastrium ; vomiting and often jaun- 
dice ; enlarged liver and spleen ; constipation ; skin very hot and dry; 
no characteristic eruption; high-coloured urine; severe headache, and 
pains in the back and limbs; restlessness and occasionally acute delirium; 
an abrupt cessation of all these symptoms, with free perspiration about 
the fifth or seventh day; after a complete apyretic interval (during which 
the patient may get up and walk about), an abrupt relapse on the four- 
teenth day from the first commencement, running a similar course to the 
first attack, and terminating on or about the third day of the relapse; 
sometimes a second or even a third relapse; mortality small, but occasion- 
ally death from sudden syncope, or from suppression of urine and coma; 
after death no specific lesion, but usually enlargement of liver and spleen." 
With this description before us it is easy to see how relapsing fever might 
be confused with typhus, especially if cases of it were few; as the relapse 
might be either overlooked or attributed to some accidental or unex- 
plained conditions. But when cases became more numerous the points of 
difference would, as happens during epidemics, be forced into prominence, 
and the more so that during certain epidemics sometimes cases of typhus 
proper would predominate, and sometimes cases of the fever with relapse. 
When also it appeared, by and by, that patients who had been affected by 
the one form of fever contracted and went through a well-marked course 
of another, there could no longer be any doubt that two different kinds 
of fever were under observation. Dr. Henderson, of Edinburgh, was 
enabled in 1843 to advance arguments leading to the general acceptance 
of the view that relapsing fever must be distinguished as a separate 
disease from typhus fever. It appears now, in the light of further 
information, that relapsing fever is by no means a new disease. Dr. 
Spittai, of Edinburgh, stated in 1844 that Hippocrates described an RELAPSING FEVER, OR FAMINE FEVER 
941 
epidemic of relapsing fever as occurring under his own observation in 
the island of Thasos. The observations of Hippocrates are somewhat 
confused, some cases of doubtful character being described among many 
which may well have been instances of relapsing fever. Neither then 
nor now did cases run a perfectly definite course; but the accounts 
would lead us to believe that in most cases the disorder ran its 
course in seventeen days (De Morbis vulgar, lib. i.). Thus in two 
brothers who were attacked in the very same hour (the invasion having 
been therefore sudden), the phenomena were as follows: - In one the 
initial fever lasted seven days, in the other six; the intermission in 
one five days, in the other six; and the relapse in both five days, so 
that they recovered together (De Morbis vulgar, p. 956, see also 
pp. 953-956). In other cases the initial fever, intermission, and 
relapse lasted respectively five, seven, and five days; seven, seven, and 
three days; six, six, and five days; and again, six, seven, and four days. 
It will be seen that the addition of the three numbers in all these cases 
gives a total of seventeen days, which corresponds very well with the 
duration observed in modern epidemics. In Bradford, for example, 
during the course of the epidemic which I witnessed in 1869-70, the 
duration of the initial fever, intermission, and relapse respectively were 
seven, seven, and three days; eight, six, and five; five, eight, and four; 
five, eight, and five; six, seven, and four; six, eight, and three days, and 
so on. Out of sixteen successive and regular cases, omitting those in 
which a second relapse occurred, the whole duration of the disease was 
seventeen days in eight or one-half of, the cases ; in three cases the dura- 
tion was eighteen days; in three, nineteen days; and in two, twenty 
days. Hippocrates dwelt on four important phenomena, whose occur- 
rence at the period of crisis might be looked upon, separately or together, 
as of good prognostic omen. These were epistaxis, enuresis, diarrhoea, 
and dysentery. Sweating he also considered a favourable sign. That is 
to say, as we should put it, when secretion and excretion were free and 
abundant the cases did well; when otherwise, the reverse. The syriip- 
toms in his description are very characteristic. He mentions the splenic 
enlargement, the jaundice, the tendency of pregnant women to abort, as 
well as the frequent appearance of menstruation during the disorder. 
The first mention of the relapse is in these words: - " And about 
Arcturus " (the beginning of September) " many had the crisis on the 
eleventh day, and such had relapse without apparent cause." Some of 
the severe cases (many of which seem to have been fatal) appear, from 
the mention of the swellings, to have partaken of the character of plague. 
When suppuration occurred, such cases were always fatal. 
It is a remarkable fact that, so far as I am aware, no reference to re- 
lapsing fever seems to be known between these highly interesting records 
of Hippocrates, and the time when Rutty wrote in 1770 describing the 
weather, seasons, and diseases in Dublin from 1725 to 1765. It seems 
incredible that relapsing fever was absent during the long centuries that 
elapsed between these two dates, yet no references to its occurrence 
appear to be extant. 942 
SYSTEM OF MEDICINE 
Symptoms. - The invasion of relapsing fever is generally sudden. 
The patient is seized with rigors, headache, backache, and loss of 
strength; though the muscular weakness does not hinder patients from 
walking long distances to hospital, especially during the first day or two 
of the disease. In Bradford they would walk into the workhouse as late 
as the third or fourth day. I saw many cases, however, in which the 
symptoms appeared to set in gradually rather than suddenly. On the 
other hand, cases did occur very suddenly, like one I remember in a 
man, not himself a smoker, who was suddenly attacked while sitting 
among a number of smoking companions - the attack commencing with 
rigors, vomiting, and purging •, but such suddenness as this was, so far 
as my recollection goes, comparatively rare. More commonly the patient 
had been ailing for some time before giving in to the attack, and would 
present himself with a white, moist tongue, and complaining of general 
malaise, rheumatic pains in the limbs and joints, and headache. 
The invasion was not so gradual as to make it difficult to date the 
commencement, but it was rarely so sudden as, for instance, Dr. Murchi- 
son describes it to be - by no means so sudden as the onset of typhus or 
pneumonia. Still, on the whole, the writers who have recounted the 
symptoms seen in the various epidemics which have appeared in this 
country, especially those of 1819, 1826, 1828, and in the great epidemic 
of 1843, unite in the statement that the onset of the disease was sudden. 
The period of incubation has varied in different epidemics. Some- 
times the disease has broken out immediately after exposure to conta- 
gion; sometimes not till as many as fourteen days had elapsed. In 
Silesia in 1857 it was said to be longer - from a fortnight to three weeks. 
But whether the attack come on suddenly, or be preceded by a period 
of anorexia or malaise, it is generally ushered in by rigors which may be 
slight or more severe, though they are generally severe. After being put 
to bed the patients complain of headache, generally referred to the occiput 
and vertex, and not, as a rule, accompanied by delirium. Pains are also 
complained of in the back and limbs. The skin is hot and burning, and 
the patient is restless with a flushed face, although the rest of the skin 
generally shows a characteristically yellow hue. The temperature, dur- 
ing the first few days of the attack, is high, ranging from 102° to 105° F. 
or even higher. The pulse also is quick, and is said sometimes to 
reach even 140 on the second day. In my cases it usually rose at that 
period to 110-120, and it appeared to me to be higher during the re- 
lapse- when it might rise to 130, or 140, or even 160-than during 
the initial fever. These very high rates did not, however, seem to 
indicate any particular danger in the case. I saw very few deaths; 
but most of my patients were young adults, and, as will subsequently 
appear, they did not seem to have been much debilitated by hardship or 
starvation, and so were no doubt better fitted to struggle successfully 
with incidental illness. Although I did not observe any instance in which 
the pulse rose so high as 160 on the second or third day, I often saw 
a temperature of 104° F., and sometimes observed it as high as 105°. RELAPSING FEVER, OR FAMINE FEVER 
Generally there was no rash, but in a considerable minority of my cases 
a rose coloured rash was observed, not unlike the spots of typhoid fever, 
but individually smaller. This rash was never petechial. It appeared 
on the thorax, abdomen, and limbs. In one case a rash was seen twice 
during the attack; the spot was from one to two lines in diameter, was 
rose coloured, and scarcely distinguishable from that of typhoid fever. 
All these rashes disappeared in a day or two. The second appearance of 
the rash occurred just before the defervescence at the end of the relapse. 
Some interest attaches to the question of rash in relapsing fever. 
Dr. Murchison, who met with it in 8 out of about 600 cases, says it 
consisted of small spots, or of a reddish mottling: sometimes it resembled 
measles, but more often it was undistinguishable from that of typhus at 
an early stage; yet it always disappeared under pressure, and faded 
after a few hours, or within three or four days at the latest. It came 
out sometimes during the first attack, sometimes in the relapse, and 
either as early as the third day or immediately before the crisis. Pete- 
chise were not uncommonly present. It is suggested by Dr. Murchison 
that the rash in some cases was urticarial. What I saw, and not in one 
case only, but in many, was neither petechial nor urticarial. In the 
epidemic of relapsing fever in Silesia in 1857 a rose rash on the second 
or third day was the rule; and a considerable number of the cases seen 
in Bradford in 1869-70 showed the same feature, approximating, there- 
fore, in character to those seen in Silesia rather than to those seen in 
other epidemics in this country. 
The respiration is hurried, and varies from twenty-eight to forty a 
minute. A distressing cough is usually present, with rhonchus, sibilus, 
and harsh breathing on auscultation. I seldom saw expectoration, 
and in none of my cases did true pneumonia supervene; the symptoms 
indicated rather congestion of the tracheo-bronchial mucous membrane 
than congestion or inflammation of the lung itself. 
These symptoms continue for several days, five to seven as a rule, 
but in some cases I have known them persist for as many as nine, the 
patient complaining most of the nausea and sickness, and of pains in 
the limbs and joints. The skin remains persistently yellow, and it is 
found in nearly all cases that the area of hepatic dulness is increased, 
while that of the splenic is always so. In some of my cases the area 
of splenic dulness seemed to be actually continuous with that of the 
heart, the spleen appearing almost as large as another liver. Patients 
then complained of weight and tenderness at the part. Tenderness 
was also well marked over the liver in many cases, corresponding with 
the occurrence of jaundice, which was present in nearly every case. 
As the latter was so common, occurring as well in slight as in severe 
cases, I cannot agree with those observers who look on it as a formid- 
able symptom; but it is possible that different epidemics have shown 
widely different characters in this as in other respects. The jaundice 
has no necessary connection with head symptoms, and probably depends, 
as Dr. Murchison suggested, on functional interference by the fever 
943 944 
SYSTEM OF MEDICINE 
poison with the proper metamorphosis of the biliary products, which are 
retained in the blood instead of being eliminated by the liver. 
The rest of the digestive apparatus also shows signs of disturbance. 
Generally speaking the tongue remains moist, and covered with a 
yellowish white fur. It is frequently red at the tip, and occasionally 
the whole organ may be seen brown and dry as in typhus. Frequent 
and persisting vomiting of greenish yellow matter is often observed. 
This symptom is in some cases most distressing, and may remain con- 
stant during the whole of the primary fever, disappearing during the 
intermission and reappearing during the relapse. Thirst is also a com- 
mon symptom. The bowels are constipated as a rule, but in some cases 
diarrhoea occurs, and in others the bowels act every other day or so. 
Pregnant women almost always abort, but often not till the relapse 
occurs. 
After these symptoms have continued for five, seven, or nine days, 
the severity pursuing an increasing or climacteric course, and the patient 
complaining much of the nausea and sickness, and of the pains in the 
limbs and joints, a crisis suddenly occurs. A copious perspiration 
appears, or diarrhoea or epistaxis, or two or more of these phenomena 
concur, often ushered in by a rigor (during which I have known the 
thermometer to register a temperature as high as 105° F.), and im- 
mediately the patient feels quite well. The temperature may then fall 
from 7° to 10° F., and the pulse from 136 to 70 or so; and the patient 
who, a few hours before, was tossing helplessly in the height of the fever, 
perhaps even with paralysis of the sphincters and pharynx, suddenly 
declares himself quite well, and is with difficulty prevented from get- 
ting up. The rheumatic pains, vomiting, headache, and all the febrile 
symptoms having disappeared, he will profess great surprise if he is 
told that there is another period of illness in store for him. The crisis 
occurred almost always during the night. 
Although I might succeed in keeping my patients in bed for a fe-w 
days, yet they generally got up towmrds the close of the interval, and 
before the relapse, which often therefore came upon them with all the 
force of the onset of a new disease. As, however, by no kind of treat- 
ment did it appear possible to prevent the occurrence of the relapse, 
and as therefore no hope could be held out that rest in bed might save 
the patient from its onset, it appeared the less desirable to interfere 
with the patient's own inclinations. 
One of my patients had been out in India as a soldier, and had there 
suffered repeatedly from attacks of intermittent fever. He was quite 
certain that the illness from which he was suffering in 1870 was of the 
same character as the attacks with which he had been so familiar in 
India, and consequently felt quite incredulous wrhen I told him he 
would have a relapse. After the manner of people of his class, he 
offered to lay a wager that I was mistaken, and that he would have no 
relapse. The relapse came, nevertheless, as predicted. 
This incident is quite in keeping with what has been observed in RELAPSING FEVER, OR FAMINE FEVER 
other epidemics, and reminds us of the classic case of Dr. Hughes 
Bennett, who had relapsing fever in the epidemic of 1843, when he was 
attended by Dr., afterwards Sir Robert Christison. When the patient 
was told by his medical attendant that(i he was suffering from an attack 
of an old acquaintance " of Christison's, " whose face had not been seen 
for a good many years; that he had not yet done with it, and that he 
would have another attack, commencing with rigor, on the fourteenth 
day, Dr. Bennett expressed great astonishment." "Surprised," says 
Christison, " I will not say incredulous, Dr. Bennett replied that the 
relapse had no time to lose, as there were only two or three hours of the 
fourteenth day to run. It did, indeed, lose no time, for I must have 
scarcely reached home from his house before the rigor set in with 
violence." 
The period of exemption from febrile symptoms - the intermission - 
is of variable duration. In my cases it usually seemed to last longer 
in those who defervesced early after the primary fever, and a shorter 
time when the primary fever had lasted longer. Thus the intermission 
extended to between nine and ten days in a case where the primary 
fever endured only six days; and only six days when the primary fever 
lasted between eight and nine. In the former case, therefore, the re- 
lapse took place on the fifteenth day, or between the fifteenth and six- 
teenth ; in the latter between the fourteenth and fifteenth. But this 
rule is not invariable. The authorities state that the relapse generally 
occurs abruptly on the fourteenth day. It is ushered in by rigor. 
The duration of the relapse was from three to five days in the cases I 
saw. The usual duration appears to be three days. 
A relapse occurred, so far as my observation extended, in every case 
without exception. The symptoms, similar to those of the primary 
fever, were often more severe; and one sometimes saw the tongue com- 
pletely brown and dry as in typhus, and observed the pulse ranging at 
what, in other circumstances, would be considered the perilously high rate 
of 160. At the end of three or four days this set of symptoms usually 
came to a termination nearly, if not quite, as abrupt as that of the pri- 
mary fever, the thermometer indicating a fall of 6° or 7° F., rarely of 
10° F., and the pulse a corresponding diminution. The second crisis 
generally led to the establishment of complete convalescence, though 
sometimes a second relapse occurred. In such a case the symptoms were 
not so severe, nor the defervescence so sudden as before. 
In none of the cases which I saw did a third, fourth, or fifth relapse 
occur. 
It is worthy of remark that during convalescence, as well during the 
intermission as after the relapse, the temperature and pulse both invariably 
sank considerably below the normal standard, and gradually rose as con- 
valescence became more completely established until the normal was again 
reached. This sequence is observed no doubt in most of the acute diseases, 
being in accordance with the general law of action and reaction; but it seems 
to me that the temperature ranges lower after the elevation of the febrile 
945 
VOL. I 
3 p SYSTEM OF MEDICINE 
946 
stage of relapsing fever than in most other diseases. Thus a temperature 
of 96° F. was common at the commencement of the intermission; while 
in one of my cases, in which a second relapse occurred, the temperature 
during the second intermission was observed to be 94-5° F., 95-6°, and 
96° on successive days. Even lower temperatures may be registered. 
Two temperature charts are reproduced here. The first, that of R. D., 
set. 30 years, is more or less typical of the records of temperature (and 
Chart 12. - Case of relapsing fever (Eabagliati). 
pulse) found in relapsing fever. These ranges may be defined as two or 
more sets of high readings in temperature, alternating with periods of 
complete apyrexia. I have, unfortunately, no observations on the tem- 
perature at the very beginning of the fever (though I have one observa- 
tion of 103-5° F. on the second day), but the authorities state that it is 
very high, agreeing in this respect with the early stage of typhus, but 
differing from that of typhoid fever. In the two charts depicted, the 
temperature was 103-5° F. on the third day in one, and 104° and 105° 
on the fourth day in the other. The second chart, that of J. O'H., is 
introduced to show the very great fall of temperature which is sometimes 
observed during the intermission. There is no fallacy in the observations 
which record temperatures so low as 95° F. and 92-2° F., for I took much RELAPSING FEVER, OR FAMINE FEVER 
care to satisfy myself by repeated observations that these sublingual 
readings were correct. Between the highest and lowest recorded tem- 
peratures in the case of J. O'H. there is a difference of no less than 13° 
F.,- a state of things which, if not unique in medical thermometry, is 
at any rate extremely rare. Chart No. 1 (and indeed No. 2 also, except 
that the fall in the intermission is greater than usual) shows so well the 
947 
Name. J.O.H. Age. 20 Years. Disease. Relapsing Fever. Result.Recouerg. 
TEMPERATURE FAHRENHEIT'S SCALE. 
TEMPERATURE CENTIGRADE SCALE. 
Chart 13. - Case of relapsing fever (Rabagliati). 
course of the temperature in relapsing fever, that the reader may be 
spared a verbal description. • 
The pulse rate is also characteristic of the cases seen in the Bradford 
epidemic. The usual accounts, however, state the pulse rate as higher 
than is shown in the chart. Thus 140 is said to be not uncommon, 
while 160 is said to be occasionally reached. An interesting point is 
that, as I have said, these rates do not seem to imply danger to the 
patient, much less do they prove the forerunners of a fatal termination. 
As with the temperature, so with the pulse, a sudden and extensive fall 
occurs at the end of the primary attack, and also at the termination of 
the relapse. One of my observations records a fall from 148 to 80, or of 
no fewer than 68 beats a minute in the course of a few hours. A fall SYSTEM OF MEDICINE 
948 
from 120 to 60 in a night was quite a common occurrence. Like the tem- 
perature, the pulse also usually falls below normal before returning to 
its natural rate. Thus it remained for about a week at 60 a minute in a 
young fellow of eighteen, whose normal pulse rate was much higher than 
that. The pulse and temperature, as might be anticipated, usually rise 
and fall together, though this is not always the case. Sometimes the 
rise of one precedes that of the other, and may be symptomatic of the 
general fever about to supervene. Both temperature and pulse gradually 
reach normal as convalescence becomes established. 
The only fatal case which occurred in my practice was of an old 
woman of seventy. She died, like one of Hippocrates' cases, on the 
sixth day. As she did not live long enough to have the relapse, there 
was just that amount of doubt as to the diagnosis which must attach to 
every such case; but I had no doubt that the malady was relapsing 
fever. 
This course of the general symptomatology of relapsing fever is then 
very characteristic, and no one looking at these temperature charts could 
possibly mistake them, or confuse them with those of any other disease. 
No doubt anomalous cases occur. This is so in all epidemics, and not 
of relapsing fever only. In one case of mine the disease ran on for 
thirty-six days, and seemed to be a case in which typhoid and relapsing 
fevers were mixed together; although perhaps other explanations of it 
were possible. Yet the characters of the disease, as it was generally 
met with, were so striking and peculiar as to be readily separable from 
those of any other disease, and to leave no doubt on the mind of the 
observer as to their true character. 
Etiology. - Remoter Causes. - So far as I saw, the male sex was 
much more liable to relapsing fever than the female. Dr. Murchison 
gives the proportion as 116 to 104, but inclines to the opinion that sex 
has very little influence in the matter. If the male sex suffer more than 
the female, it is probably because men are more exposed to the exciting 
causes of the disease. As to age, relapsing fever (like other fevers) is 
especially a disease of early life. Most of my cases occurred in young 
male adults. Dr. Murchison gives the mean age as 24-4 years. As to 
occupation, almost all the cases were either among paupers or very poor 
persons. This has been the general rule in epidemics of the disease, a 
fact which is so notorious as to have given a name to the disease. At 
the same time, it must be said that careful inquiry in Bradford often 
failed to elicit the fact that the sick had had to undergo any special hard- 
ships, or to endure any special privations in food. Trade was then moder- 
ately good in the town, and the consequent demand for labour was pretty 
active. In Liverpool at the time of the epidemic of 1870, according to the 
Lancet report, " there was full employment for every able-bodied and in- 
dustrious man." The patients themselves did not show any signs of hav- 
ing been deprived of food. Of 522 patients of whom the inquiry was made, 
only 91 had been in the workhouse before, which shows at least that they 
did not belong to the habitual pauper class. Besides this, at the time of the RELAPSING FEVER, OR FAMINE FEVER 
949 
Liverpool epidemic, there were (1st) considerably fewer inmates resident 
in the workhouse, (2) considerably fewer families in receipt of outdoor 
relief; (3) considerably fewer patients suffering from zymotic diseases 
than in the corresponding period of the year preceding. From all these 
circumstances it appears as if the name of " famine fever " is not always 
an appropriate one. Other circumstances appear to enter into the 
causation of the disease. Mere overcrowding is not a sufficient cause, 
as some very overcrowded populations have suffered even less from it 
than others less densely packed. The Lancet report on the Liverpool 
epidemic in 1870 showed that there were at least three principal causes, 
namely, (a) the sites of the houses, which were frequently placed on 
decaying vegetable and animal matter and midden refuse; (&) insuffi- 
cient and imperfect drainage; and (c) the extensive prevalency of cellar 
dwellings in darkened and filthy courts. 
On the other hand, much evidence exists to show that there is as 
a rule some connection between the occurrence of relapsing fever and 
the existence of destitution among the population attacked. Contagion 
cannot explain the whole of the cases or the spread of epidemics. Not 
to mention the fact that in Bradford and Liverpool in 1869-70 the mass of 
the cases of the disease occurred among the pauper class, Dr. Murchison 
showed that in London 97-5 per cent of the cases investigated by him- 
self were paid for by the parochial authorities, and were totally destitute. 
Nine of the remaining cases (430 in all were investigated) were admitted 
free, and were also destitute. Not a single patient had been a servant 
in a private family, and in one instance only was a fee for admission paid 
by the patient's friends. It is probably, also, not without significance that 
the epidemics of 1817, 1818, and 1819 raged during a period notorious 
in British history for low wages, high prices of food, and general depres- 
sion due to the fall of the inflation of the markets caused by the great 
continental war; while the epidemics of 1843-4 and of 1847-8 occurred 
about the time of the great Irish famine, and during the general destitu- 
tion which played so great a part in causing the abolition of the corn 
laws, and in preventing their re-enactment. In 1826 Stokes described 
relapsing fever as famine fever, and in 1847 Corrigan's pamphlet bore 
the title, On Famine and Fever, as Cause and Effect in Ireland. When 
the epidemic occurred in Silesia, in 1847, the inhabitants, in consequence 
of a succession of bad harvests, had been reduced to subsist on clover, 
grass, mushrooms, and the roots of trees. The synonym " Hungerpest " 
points unmistakably to the connection, in German opinion, between 
relapsing fever and the existence of destitution. " Carter states that it 
was brought to Bombay in 1877 by the peasantry flocking into the city 
from famine-stricken districts" (Fagge). Dr. Murchison's view, as is 
well known, was that relapsing fever is due to destitution, while typhus 
is produced, he thought, by overcrowding and destitution combined. 
Immediate Causes - Contagion. - The question of the contagiousness 
of relapsing fever was very fully gone into by Dr. Murchison, who proved 
his position that it was an exceedingly contagious disorder in the same 950 
SYSTEM OF MEDICINE 
way that he did for typhus fever. Several facts in corroboration of his 
opinion came under my notice. Thus several cases were admitted to 
hospital from the same house or street under circumstances which left 
little or no doubt that some patients had been infected by others. In 
one case, again, early in the epidemic, and before I was accustomed to 
recognise and diagnose the fever, I ordered a patient suffering from it 
into the general ward, thinking he had rheumatism. It was not long 
before I had to order the removal both of him and of another patient, 
who lay beside him, to the fever hospital. Both had relapsing fever, and 
the other patient had been some time in the general ward. However, no 
nurses or attendants on the sick in Bradford took the disease from 
patients. I suppose this good fortune was due to the fact that our cases 
were not very numerous, and perhaps also to the further fact, that our 
fever hospital was roomy and airy, rather than that our cases were not so 
infectious as they have been in other epidemics. At any rate both in 1818 
and in 1843 relapsing fever appeared as a very infectious disorder. Thus 
Dr. Welsh says of the epidemic of 1818, that in the course of four months 
his three colleagues, two of the young men in the apothecary's shop, 
two housemaids, and thirteen or fourteen nurses, caught the disease; and 
the matron and one of the dressers died of it. In Queensberry House in 
1818 two medical men, the matron, two apothecaries in succession, the 
shop boy, washerwoman, and thirty-eight nurses were infected, and four 
of the nurses died. Of the epidemic of 1843-4 Dr. Wardell wrote: 
"Most of the medical officers connected with the Edinburgh Royal 
Infirmary, and additional fever hospital, were seized with it; eight of 
the resident and clinical clerks in quick succession became affected." . . . 
"The majority of the nurses and domestics took the disease, and of the 
former, at one time, no less than nineteen were labouring under it." 
And more to the like effect. The late Dr. Begbie, from his experience of 
the epidemic of 1847, arrived at the conclusion that relapsing fever, like 
typhus, was communicable from " the sick to the healthy ; that for this 
purpose actual contact with the sick was not necessary, the subtle poison 
of this form of continued fever, equally with that of typhus, being readily 
conveyed through the air surrounding the latter; and, lastly, that by 
means of fomites or clothes the disease may readily be propagated." 
A. R. 
Bacteriology. - Although Henderson of Edinburgh, in 1843, had dis- 
tinguished relapsing fever from other diseases with which it had been 
classed under the general term "typhus," it was not until 1873 that 
Obermeier, assistant to Professor Virchow in Berlin, demonstrated the 
presence of lively spirilla in the blood of patients suffering from the dis- 
ease. This observation has been generally corroborated by later observers. 
The micro-organism of relapsing fever is a long and slender spirillum, 
of varying length (1G to 40 /x), sinuous, or twisted spirally in 10-20 turns. 
In fresh blood the spirillum is seen to be flexible and very active. Its 
movements are progressive, with undulations passing wave-like along RELAPSING FEVER, OR FAMINE FEVER 
951 
from one extremity to the other. It is so fine that under a low power 
its presence is revealed only by the commotion among the blood cor- 
puscles, which by the rapid movements of the spirilla are thrust violently 
aside. The spirilla are much thinner than a cholera vibrio, and their 
ends are tapering and sharp. These thin tapering ends were formerly 
considered by some to take the place of flagella, but Koch has since 
demonstrated true flagella, which account for their rapid motion. The 
rapidity and intensity of the movements depend, according to Dr. Van- 
dyke Carter, directly on the number of the spirilla. 
Activity persists after the death of the diseased person, and can be 
studied for a long time in preparations in one-half per cent salt solution, 
or in blood serum. 
Heydenreich found that the vitality of the spirilla, as evidenced by 
mobility, could be preserved for a time varying from two and a half 
hours to fourteen days, according to the temperature at which they were 
kept; at a higher temperature the movements ceased sooner. 
The presence of the spirilla in the blood has been taken as evidence 
of their aerobic nature. 
Although it has been found impossible to cultivate the bacteria of 
relapsing fever in or on artificial media, Koch has observed the forma- 
tion of tangled masses, and an increase in the length of spirilla which 
had been placed in tubes of blood serum. 
The total disappearance of the spirilla from the blood after the 
pyrexial attack, together with their reappearance in the next paroxysm, 
led some bacteriologists to the probably erroneous conclusion that they 
produce spores, in which form they were assumed to remain dormant 
until the next relapse. 
Metschnikoff has shown, however, that, after the parasites have dis- 
appeared from the blood, masses of them may still be present in 
the spleen, where they are mostly enclosed in cells. Many of these 
cells seem to be undergoing degeneration, and it is possible that the 
contained bacilli may then escape in a condition capable of causing the 
relapse. On the other hand, those microbes which had not been en- 
gulfed, and had remained extracellular, may be responsible for the 
second febrile attack. 
The low temperature by which the infective nature of the blood of 
a patient is destroyed seems to point to the absence of spores, although 
Soudakewitch has described spirilla which showed distinct terminal 
swellings. Free globular bodies are also observed, which, from their size 
and appearance, may be these swellings detached from the spirilla. 
Carter had some years previously called attention to the irregular dotted, 
beaded, or clubbed appearance chiefly to be observed in dried specimens. 
From the spirillar nature of the organism it is highly improbable that 
it forms ordinary endospores; it is more likely that reproduction takes 
place by fission, the spirillum dividing into two equal parts. 
The organism stains readily with the ordinary basic aniline dyes, 
such as gentian violet, bismarck brown, and fuchsin. SYSTEM OF MEDICINE 
952 
The spirilla are to be found in the blood for some hours, or even one 
or two days before the crisis, but after the crisis they generally dis- 
appear quickly. 
The micro-organisms persist throughout a pseudo-crisis, and are not 
to be found in the non-febrile intervals between the true attacks. 
At the beginning of the pyrexia the spirilla are seen to increase in 
number until at the crisis, according to Carter, they may be in the pro- 
portion of one-twentieth to one-tenth the total number of red blood cells. 
There is then a diminution, until in a short time none is to be observed 
in the blood. 
The constant occurrence of this micro-organism in all of Obermeier's 
cases, and its invariable absence in other diseases similarly examined, 
point to its causative relation to the symptoms. That it has been found 
impossible to cultivate the spirilla in artificial media can hardly be con- 
sidered a serious objection when we consider the following facts: - 
Carter, working in India in 1879, while verifying the observation 
already made in Europe, gave the following as reasons for connecting 
the presence of the spirilla with the fever symptoms in the disease: - 
1. The blood infection is always followed by the characteristic fever, 
although an interval of some hours or even one or two days 
may intervene. 
2. With the advent and progress of pyrexia the spirilla increase in 
number, but there is no fixed relation between the type and 
intensity of the fever and the number of organisms present in 
the blood. 
3. They disappear with the cessation of fever, persisting, however, 
occasionally for a day or two, especially during pseudo-crises 
and slow defervescence. 
4. By inoculation of defibrinated blood removed during the period 
of pyrexia-and therefore containing the spirillar organisms - 
from a patient suffering from relapsing fever into a healthy 
person, the disease may be conveyed to new subjects. 
The disappearance of the spirilla from the blood in man during the 
apyrexial periods is as yet unexplained; though Metschnikoff's observa- 
tions have been taken as evidence that they are largely, if not altogether, 
destroyed by the phagocytes, which engulf them and carry them to the 
spleen. This organ is enlarged, and is the seat of the chief pathological 
changes in those cases in which death from the disease occurs; it is then 
seen to be filled with white cells containing the parasites. The liver 
and marrow of the bones contain foci of necrosis. 
Koch, Carter, Metschnikoff, and Soudakewitch, by inoculation experi- 
ments on monkeys, have produced symptoms which correspond to the 
disease in man; by this means they have thrown much valuable light 
on the pathology and bacteriology of the disease, and have established its 
specific nature. In these animals inoculation was followed by a sharp 
febrile attack, beginning usually in about three days. The disease ter- RELAPSING FEVER, OR FAMINE FEVER 
953 
minated, without relapse in recovery. Spirilla were observed during the 
pyrexia, but disappeared soon after the temperature had fallen; and in 
animals which had been killed ten hours after the crisis the parasites were 
found only in the form of debris, chiefly contained in the microphage 
cells in the spleen. 
An emulsion of spleen-pulp, containing the spirilla, produces, when 
injected into a second monkey, the same symptoms and fever. A monkey 
that had passed through an attack remained susceptible to a second in- 
oculation ; recovery is not followed by immunity. 
Although under ordinary conditions the monkeys invariably survived, 
Soudakewitch showed that on removal of the spleen the disease proved 
fatal to some of the monkeys. The temperature gradually subsided until 
death occurred. On examining such animals after death the blood was 
found to be swarming with spirilla; in one instance the inferior vena cava 
was nearly blocked by tangled skeinlike masses of these organisms. 
F. F. Wesbrook. 
Relation between Relapsing and Typhus Fevers. - Some interest at- 
taches to this subject. We have seen that Dr. Murchison thought that, 
in the matter of causation, there was some relation between these two 
diseases; he believed that relapsing fever was caused by destitu- 
tion, while typhus fever was due to destitution and overcrowding. 
In the matter of the bacteriology of the two diseases no such 
relationship appears to have been as yet determined. While the 
bacteriological cause of relapsing fever seems to have been made out, that 
of typhus fever has not. If ever the latter is discovered, it will be 
interesting to notice whether in genus or species it is related to the 
former. At any rate as regards the progress of the two disorders in 
different epidemics a well-marked relationship has been seen. The 
sequence has generally been that in epidemics of relapsing fever 
well-marked cases have been most numerous in the commencement of the 
epidemic, while cases of typhus were comparatively rare. As the epi- 
demic advanced the cases of relapsing fever have become comparatively 
fewer, while those of typhus have become comparatively more numerous. 
Towards the close of the epidemic, on the other hand, the cases of typhus 
have become much the more numerous, while those of relapsing fever 
have been comparatively rare. Even as early as 1826 the distinction 
between the two fevers had been observed, but in 1843 it was more 
particularly insisted on, especially by Dr. Henderson. In Glasgow 
Infirmary, for instance, there were admitted 2871 cases of relapsing fever 
in 1843, and only 142 of typhus. In 1844, 432 cases of relapsing fever 
were admitted, and 711 of typhus; while in 1845, only 37 cases of 
relapsing fever were received, and 266 cases of typhus, the mortality 
being, as might have been expected, much higher in the typhus than in 
the relapsing fever cases. In 1869-70 I saw a good many patients who 
first contracted relapsing fever, and in the course of a few weeks there- SYSTEM OF MEDICINE 
954 
after took typhus. I did not see any who took typhus first and had 
relapsing fever afterwards; and I doubt if there were any patients in 
Bradford in whom this sequence was observed. Such a sequence may, of 
course, have occurred in other epidemics. 
In those cases in which typhus fever followed relapsing fever in the 
same patient within a short interval of time, it seemed to me that the 
typhus pursued a milder course than it might have been expected to do 
had the patient suffered primarily from typhus. This is not altogether 
what might have been anticipated. We might rather have anticipated 
that the patient, debilitated by the previous occurrence of relapsing 
fever, would thus have been brought into greater danger on the sub- 
sequent occurrence of typhus. My observations were not perhaps 
numerous enough to allow me to generalise from them; but I confess 
that, such as they were, they did raise the question in my mind whether 
the two fevers might not have some causal relationship. May not the 
causes of relapsing fever and typhus fever be so closely connected, that 
the occurrence of one of them in a patient may modify the subsequent 
course of the other ? In vaccination and small-pox, for example, we 
have such a sequence of events, and without laying too much stress on it, 
it seemed to me that the facts of the Bradford epidemic might justify 
some such reflections. 
Be this as it may, a relationship between the numbers of cases of 
relapsing and typhus fevers has been observed as a rule in epidemics 
since the time when the two fevers were first distinguished. And 
even before this time an investigation into the mortality at the be- 
ginning, middle, and end of epidemics has rendered it almost certain 
that a similar incidence of cases of relapsing fever and of typhus fever 
has occurred. 
During the continuance of the visitation of epidemic diseases the 
mortality, as a rule, is highest at the onset of the epidemic, diminishing 
gradually as the epidemic advances. This may be because the most 
susceptible are first attacked, and take the disease in its most virulent 
form. " Increase of susceptibility " may be mistaken for " increased viru- 
lence " of disease, the former expression referring rather to the nature of 
the soil, so to speak, in which the disease finds a lodgment; while the lat- 
ter refers rather to the nature of the seed than to the characters of the soil. 
Another reason for the diminishing mortality observed as epidemics ad- 
vance in time may simply be that the disease assumes a milder form which 
we are unable to account for. In epidemics of relapsing fever, on the other 
hand, even before it was properly distinguished from typhus fever, we 
find records of a low mortality at the beginning of the epidemic, of an 
increasing mortality as the epidemic advanced, and of a mortality which 
was highest towards the close of the epidemic. This was particularly 
noticed in the epidemics of 1817-18, and in 1819; the most prob- 
able inference seems, therefore, to be that there was a mixture of cases 
of relapsing and of typhus fever, and that their relative frequency at 
different periods of the epidemic determined the observed mortality. RELAPSING FEVER, OR FAMINE FEVER 
If that were so, as it appears to have been in 1817-19, as it certainly 
was in 1826-28, when the distinction between relapsing and typhus 
fevers was first made, and in 1843 and onwards, when it was generally 
accepted by the profession through the labours mainly of Dr. Hender- 
son, it seems reasonable to suppose that, as a rule, relapsing fever and 
typhus fever have at other times borne to one another the relationship 
which has been shown to exist in those epidemics. 
Diagnosis. - The relationship already dealt with is to some extent 
helpful in the diagnosis of relapsing fever. As a rule, the severity of 
the onset is greater than in typhoid fever, and the absence of abdominal 
symptoms serves still further to distinguish it; although, of course, in 
some cases of typhoid, abdominal symptoms may be in abeyance, and on 
the other hand, in a few cases of typhoid the onset of symptoms may be 
both sudden and severe. As the cases progress the differences become 
more marked. Before the eruption of typhoid fever is due, a sudden 
defervescence will have revealed that the attack is one of relapsing 
fever. From typhus, again, the absence of rash in the majority of the 
cases of relapsing fever (though we have seen that in some cases a less 
characteristic rash has appeared both in this country and abroad) will 
serve to distinguish it. In both typhus and relapsing fever the onset 
may, of course, be sudden. But as between typhus and relapsing fevers 
the great and obvious difference is the sudden defervescence that char- 
acterises the latter at about the end of the first week; and this short 
convalescence will also serve to distinguish relapsing fever from pneu- 
monia, in which the onset is likewise often sudden. 
From small-pox the diagnosis is comparatively easy after the third or 
fourth day, the shotty eruption under the skin of the wrists and on the 
face in variola being never present in relapsing fever. In influenza - the 
epidemic which played such havoc with our people in 1891, and which 
has reappeared to greater or less extent every year since - the symptoms 
are as sudden as in relapsing fever; but they persist for a shorter time in 
mild'cases, while in severe cases of influenza, broncho-pneumonia almost 
always occurs. In influenza there is no sudden recovery and no subsequent 
relapse, the symptoms in influenza progressing pretty steadily to death 
or to some degree of convalescence. 
All these points of difference which serve to distinguish relapsing 
fever from other diseases, such as typhoid and typhus fevers, small-pox, 
and pneumonia, are open to the objection that time is necessary for their 
appreciation. Is there no character, it may be asked, which will enable 
us at an earlier period to say positively - this is or is not relapsing fever ? 
The demonstration of the microbe proper to the disease would do this; 
and Dr. Carter, of Bombay, says that no less than 25 per cent of his cases 
wrere irregular. In 1869 I was not aware of the existence of the microbe 
of relapsing fever, so that I was not able to use it for diagnostic purposes. 
If, however, a new epidemic were to attack us, I think it would be found 
that thq chief means of diagnosis would be time, as it has been in previous 
epidemics; especially as an observer might or might not think of relapsing 
955 956 
SYSTEM OF MEDICINE 
fever if he had not had to treat it before. The discovery of the Spirochaeta 
would make the diagnosis sure. 
Sequelae. - These are not common in relapsing fever; with the ter- 
mination of the attack itself the patient nearly always recovers, unless 
the illness occur in a very debilitated subject. In such persons as these 
the consequences, chiefly pulmonary, with which we are familiar in other 
fevers, may follow relapsing fever. Parotitis must be especially men- 
tioned, not because of its frequency in Great Britain, where on the con- 
trary it is very rare, but because in some epidemics - as in that which 
occurred in Russia about twenty-flve years ago - its comparative fre- 
quency has led to the rumour of plague. Parotitis is occasionally seen 
in typhus, and enteric fever likewise. 
Prognosis is greatly determined by diagnosis. In relapsing fever we 
know that the mortality is not more than 5 per cent, while in typhus it 
may approach 20. The cautious physician will judge of each case on 
its merits, and after he has diagnosed relapsing fever, as he will no 
doubt be on the lookout for cases of typhus fever in the later phases of 
the epidemic, he will remember that a much higher mortality may then 
be looked for, although of course it will still remain true that relapsing 
fever has a low mortality. The higher mortality will probably be due 
to intercurrent typhus fever, and not to relapsing. 
Morbid Anatomy. - Although the cases which I saw exhibited a 
very small mortality, and although, therefore, my opportunities for 
inquiry into the morbid anatomy of relapsing fever were almost nil, it 
has not been so in all epidemics. In Berlin, for instance, in 1872-73, 
not fewer than 100 fatal cases occurred in the Charite Hospital alone; 
and there were therefore numerous opportunities of making careful 
inquiry into the morbid anatomy. The organs in which the most 
marked changes were found were the spleen and blood, the liver, the 
heart, the kidneys, the bones, and the muscular tissues. The most 
important changes of all, both as regards structure and gravity of 
import to life, were those found in the spleen and heart. 
An alteration was commonly observed in the muscular tissue of the 
heart, so grave as frequently to account for the fatal issue. The organ 
was flabby, the muscular tissue throughout pale, of a dirty gray-yellow 
colour, and friable. The primitive muscular fibrils were in many cases 
found to be fatty. The fattiness and general degeneration found in 
the heart in relapsing fever equalled that seen in the most malignant 
septi csemic and. puerperal fevers, and in diphtheria. 
The spleen was very much enlarged, and at the same time softened 
and fatty. In different observations it is described as weighing (as com- 
pared with its normal 4 ozs.) in one case as much as'4| lbs. avoirdupois, 
in another over 2 lbs. (920 grammes), in another about 11 lb. (670 
grammes), in another 15 ozs., and again about | lb. (330 grammes). The 
enlargement of the organ was greater than occurs in any other affection 
except leukaemia, and consisted of two sets of changes, a diffuse gen- 
eral enlargement, usually accompanied with noticeable softening, on the RELAPSING FEVER, OR FAMINE FEVER 
one hand; and on the other the appearance of small yellow softened 
patches which in some cases reached the size of a horse bean. Some 
observers have believed these patches to be due to infarctions. The 
enlargement took place in all directions, the capsule being tightly 
stretched and shiny, the tissue substance softer than usual, though not 
exactly diffluent; the spleen-pulp dark blue-red, standing out strongly; 
the follicles considerably enlarged and often obliterated; their colour 
for the most part gray, though sometimes pure white or yellowish. 
The swelling of the spleen-pulp was mainly due to marked congestion 
of the vessels, and an abundant increase of the cell elements. 
As regards the morbid anatomy of the liver, some difficulty occurred 
in distinguishing the recent effects caused by relapsing fever from those 
frequently pre-existing effects caused by alcoholism in the same patients. 
But, so far as could be made out, the increase in the size of the liver 
was greater than has been observed in any other of the infectious 
diseases. In one case the liver weighed 3620 grammes - almost 8 
lbs. avoirdupois - an enormous increase. The organ was enlarged 
throughout, the lobules being also increased in size, so that their 
boundaries were rendered obscure; the cut surfaces were cloudy, and 
of a striking uniform gray-red colour. On microscopic examination 
there was found cloudy swelling of the hepatic cells with fatty in- 
filtration round their edges, and fine-celled infiltration along the portal 
vein. Jaundice did not seem to bear any relation to the gravity of 
the cases, being well marked in some slight cases. On the other hand, 
out of sixty-five fatal cases only sixteen showed the presence of this 
symptom. 
The kidneys, like the liver, were also much increased in size, some- 
times weighing even twice their normal weight. The parenchyma was 
found soft and flabby, the cortical substance widened and filled with 
cloudy swelling, the vessels and the Malpighian corpuscles for the most 
part pale. In other cases the cloudy swelling was found for the most 
part in the straight tubules. There were found, besides, more or less 
abundant dark red spots specially numerous near the surface ; and, 
converging thence in a radiating manner towards the papillae, they 
could be traced, as red or brown spots or stripes, deeply into the tissue 
of the pyramidal substance. On microscopic examination it was found 
that not only were the tubuli more or less fatty, but also that the lumen 
of the urinary tubuli was filled partly with transparent fibrinous material, 
and partly with haemorrhagic clots in the most diverse stages of colora- 
tion. For the most part these were met with in the under parts of the 
tubuli contorti and of the loops of Henle; the haemorrhages were often 
found also between the capsule of Bowman and the interlacings of the 
vessels of the glomeruli. And as, besides these conditions, an abundant 
infiltration of small cells was found in the interstitial tissue, all the ana- 
tomical conditions were evidently present for the subsequent onset of 
Bright's disease. 
In the lungs were found marks of hepatisation and pneumonic 
957 958 
SYSTEM OF MEDICINE 
infiltration; also in some cases bronchiectasis and bronchitis. In others 
old apical cheesy and chalky deposits were found which might or might 
not have been caused by the disease. 
The condition of the blood of patients suffering from relapsing fever 
was related to the organism found to be present in the disease, and has 
been dealt with under the bacteriology. 
The changes in the bones caused by relapsing fever were mainly a 
simple fattiness or reddening of the marrow. In some cases the diaphy- 
ses and epiphyses of the thigh-bones or humeri showed yellowish white 
infarcts of irregular spotty character and varying in size from that of a 
hemp seed to that of linseed. Sometimes they were discrete, sometimes 
united by thin bridges to coarser infiltrations. 
Treatment. - I think it may be taken as pretty certain that no remedy 
essentially modifies the course of the disease. Relapsing fever, appar- 
ently, has its invasion, its primary five, seven, or nine days' fever, its 
intermission, and its relapse, in spite of all the resources of art. Some 
symptoms may be modified, but not apparently the great features of the 
disease. Thus several antiperiodics were used, without enabling me to 
prevent the occurrence of the relapse. The headache and arthritic pains 
were very severe, and though both were sometimes relieved by alkalies, 
it was often necessary to have recourse to opium. Colchicum seemed to 
have no effect on the pains. The persistent and distressing vomiting was 
very difficult of alleviation. Sometimes the effervescing draught, with or 
without hydrocyanic acid, was of service; sometimes relief was obtained 
by the administration of small and frequent doses of ipecacuanha, some- 
times by sinapisms to the epigastrium; and in some cases all these 
resources were unavailing till the patient found relief in the natural issue 
of the disorder. 
A. Rabagliati. 
REFERENCES 
1. Rutty. Chronological History of the Weather, Seasons, and Diseases in Dublin 
from 1725 to 1765.-2. " Review on Epidemic Fever," Edinburgh Medical and Surgical 
Journal, xiv. 1818. - 3. Clutterbuck. Observations on the Prevention and Treatment 
of the Epidemic at present prevailing. London, 1819. - 4. Hartz. Historic Sketch of the 
Causes, Progress, Extent and Mortality, of the Contagious Fever in Ireland during the 
years 1817-19. Dublin, 1820.-5. Barker and Cheyne. Account of the Fever lately 
Epidemical in Ireland. London, 1821. - 6. Graves and Stokes. Description of the 
Yellow Fever at Dublin in 1826. - 7. Alison, W. P. "Observations on the Epidemic 
Fever now prevalent among the Lower Orders in Edinburgh," Edinburgh Medical and 
Surgical Journal, xxviii. 1827. - 8. Reid, John. "Statistics and Pathology of the 
Continued Fever of Edinburgh," Edinburgh Monthly Journal of Medical Sciences, 
1842.-9. Henderson, W. "On some of the Characters which distinguish the 
present Epidemic Fever from Typhus," Edinburgh Medical and Surgical Journal, 
1844.-10. Various articles in the Edinburgh Medical and Surgical Journal in 1843 
and 1844; also in the Scottish and North of England Medical Gazette for those years 
by H. D. S. Goodsir, Craigie, Alison, Arnott, W. Henderson, J. Rose Cormack, 
W. Reid, Gibson, Kilgour, Jackson, Spittal, Halliday Douglas, etc., etc.- 
11. Corrigan. Famine and Fever. Dublin, 1847. -12. Bottomley. Famine Fever 
at Croydon. -13. Die Hungerpest in Oberschlesien, Mannheim, 1848.-15. Jenner, W. 
" On the Identity or non-Identity of the Specific Cause of Typhoid, Typhus and 
Relapsing Fever," Med.-Chir. Transactions, vol. xxxiii., also Edinburgh Monthly 
Journal of Medical Sciences, 1849-50. -16. Zuelzer, W. Der Recurrirende Typhus RELAPSING FEVER, OR FAMINE FEVER 
959 
in St. Petersburg. Berlin, 1867.-17. Virchow. On Famine Fever. London, 186b. 
English Translation. -18. Harrier, E. Parasitologische Untersuehungen bei Masern, 
Hungertyphus, etc. Leipzig, 1868. -19. Murchison. "The Re-appearance of Relaps- 
ing Fever in England," Lancet, ii. 503, 1869.-20. Crark, H. "On Relapsing Fever 
in India," Indian Annals of Medical Science, January 1869.-21. Wyss and Bock. 
Studien iiber Febris recurrens. Berlin, 1869. - Obermeier, Pastau, Pribram and 
Robitschek, also Estlandrer, Huppert, Schurtzen and Riesenferd, all wrote on 
Relapsing Fever in 1869. In 1870, Liebert, Breslau; Frantzer, C. Muirhead, 
Edinburgh; Crymer, New York; Crark, New York; Parry, Philadelphia, wrote on 
this Fever. - 22. Murchison. "The Period of Incubation of Typhus, Relapsing 
Fever, and Enteric," St. Bartholomeio's Hospital Reports, vol. ii. - 23. G. P. Tennent 
on "Relapsing Fever," Glasgow Medical Journal, May 1871. - 24. Lyons, on Relaps- 
ing Fever. London, 1872.-25. Obermeier, O. " Vorkommen feinster, eine Eigen- 
bewegung zeigende Faden im Blute von Recurrens Kranken," Centralblatt fur Med. 
Wissensch. 1893, No. 10. Beside the above authors, various German writers wrote on 
Relapsing Fever in Silesia, Berlin, Breslau, etc., among whom may be mentioned - 
26. Dr. Ponfick. Anatomische Studien iiber den Typhus Recurrens; Virchow's 
Archiv, Bd. lx. Hft. 2, and Griesinger, Azema, Hermann and Kuttner, St. Peters- 
burg, 1865; Kernig, and Dr. Carter, Lancet, 1879 and 1880. 
A. R. 
1. Obermeier. Centralblatt f. d. med. Wissensch. 1873, No. 10; and Berliner klin. 
Wochenschr. 1873, No. 35. - 2. Koch. Deutsche med. Wochenschr. 1879. - 3. Vandyke 
Carter. Med. Chir. Trans. London, 1880, 2nd series, xlv. pp. 7, 148; and Trans. 
Internal. Med. Congress. London, 1881, p. 334.-4. Metschnikoff. Virchow's Archiv, 
cix. 1887, p. 176. - 5. Soudakewitch. Ann. de I'Inst. Pasteur, v. 1891, p. 545. - 6. 
Heydenreich. Der Parasit. des Riickfallstyphus. Berlin, 1877. 
F. F. W. 
P.S. -On Dr. Wesbrook's departure for Minneapolis, Dr. Kanthack 
most kindly undertook the revision and correction of the proof of the 
section on the Bacteriology of Relapsing Fever, and of the corresponding 
references. - Ed. LIST OF AUTHORITIES 
Abel, 895 
Abelous, 168 
Ackerley, R., 209 
Adami, 511 
Addison, T., 168 
Addison, W., 104 
Aitken, 903 
Alessi, 548, 801 
Alison, 792 
Allbutt, Clifford, 18, 688, 788 
Althaus, 687 
Anderson, 808 
Andrew, 264 (note) 
Araki, 187 (note) 
Aretseus, 731, 747 (note), 917 
Arloing, 254 
Armstrong, 652 
Arning, 536 
Arnold, 100 
Arnott, Neil, 307 
Aronsohn, 154, 754 
Avicenna, 923 (note) 
Babes, 563, 628 
Bakewell, R. H., 261 
Ballard, 656 
Balzer, 175 
Bamberger, 627 
Barfurth, 118 (note) 
Barker, Fordyce, 635, 662 
Barkley, 632 
Barlow, H. C., 791 
Barlow, T., 165, 371 
Barnes, H., 927 (note) 
Barr, James, 851 
Barry, de, 70, 129, 509 
Barthez, 220 
Bassier, 492 
Baswell, 854 
Bauer, 186 
Baumgarten, 88, 554 
Baxter, 27 
Begbie, 950 
Behring, 89, 563 et seq., 580 et seq., 717. 
754, 769 et seq., 885 
Belfanti, 820 
Bennet, Henry, 264 
Bennet, Hughes, 945 
Bergeon, 302 (note) 
Berkley, H. J., 109 
Bernard, Claude, 163,223, 302 (note), 495 
Berry, J., 401 
Bert, Paul, 273, 301 
Bertillon, 30 
Berton, 303 
Beumer, 801 
Bishat, 222 
Biden, 262 
Biggs, 632 
Billroth, 156, 615 
Binet, 37 
Birch-Hirschfeld, 554, 628 
Bischoff, 323 
Blagovestchewsky, 544, 552 
Blake, 223 
Blakeney, 25 (note) 
Blanche, 382 
Blocqui, 829 
Blunt, 254 
Blyth, Wynter, 657 
Bochefontaine, 892 
Boerhaave, 219, 601 
Boginsky, 755 
Bonom^, 603, 629, 675 
Booker, 723 
Bordet, 85, 886 
Bordier, 22, 32 
Bordone-Uffreduzzi, 675 
Borel, 81, 936 
Bouchard, 167, 562, 582, 793, 851 
Boudin, 22, 47, 492 
Bouillaud, 627 
Boulting, 690 
Bouveret, 821 
Bowditch, 24 (note), 255 
Bowles, 254 
Boxall, 637 
Bramwell, Byrom, 628, 782 
Brand, 347, 845, 849 
Brandt, 383, 792 
Braun, 681 
Brehmer, 276 
Bretonneau, 420, 701, 731, 791 
Brieger, 521 et seq., 588, 723, 766, 796, 
893 
Brissaud, 633 
VOL. I 
961 
3 Q 962 
SYSTEM OF MEDICINE 
Bristowe, 627 
Broadbent, W., 852 
Broca, 29, 32 
Brodie, Gregor, 212 
Brouardel, 845 
Broussais, 221 
Brown, 221 
Brown-S^quard, 168, 377 
Brunner, 770 
Brunton, Lauder, 377, 466, 495, 530, 914 
Buchan, A., 258 
Buchanan, G., 24 (noie), 255 
Buchner, 89, 254, 514 et seq. 
Budd, 791 
Buhl, 807 
Bujwid, 552, 880 
Bulard, 926 
Bunge, 164, 377 
Burdon-Sanderson, 55, 314, 589, 662 
Burkart, 631 
Buschelt, 800 
Buschke, 769, 800 
Butlin, 215 
Buzzard, 688 
Cabiadis, 928 (note) 
Cahn, 821 
Caiger, 585 
Calmette, 564 et seq., 936 
Canalis, 548 
Candolle, de, 27 
Canney, 267 
Canon, 694 
Cantlie, 929 et seq 
Card, 725 
Caretti, 782 
Carle, 759 
Carter, 949 
Castelnau, 601 
Caton, 846 
Cattani, 89, 551, 578, 760, 914 
Cayley, 628, 849 
Celli, 674 
Champneys, 751 
Chantemesse, 795 et seq. 
Charcot, 37, 172, 627 
Charles, 283 
Charrin, 129, 158, 548 
Chauffaro, 821 
Chauveau, 566 
Chervier, 32 
Chevers, 897 
Christison, Robert, 945 
Claussen, 895 
Clot Bey, 926 
Clanny, 307 
Clarke, Lockhart, 788 
Coats, 793 
Cobbett, 131 
Coen, 118 
Cohn, 523, 767 
Cohnheim, 65, 104, 172, 205 
Coley, 216 
Collignon, 29, 32 
Collins, Treacher, 197 
Colvill, 925 et seq. 
Cornil, 116, 620, 628, 633, 840 
Corrigan, 949 
Councilman, 70, 123 
Coupland, 631 
Coxwell, 552 
Creighton, 690, 701, 918 
Crombie, 904 
Crum-Brown, 225 
Cruveilhier, 601, 636 
Cullen, 220, 865 
Cunningham, D. D., 512, 521, 881 et seq. 
Curling, 776 
Currie, 792, 849 
Curt Braem, 795 
Cygnseus, 801 
Dalton, 301 
Damalix, 377 
Dance, 601 
D'Arcet, 602 
Darwin, 21, 555 
Davidson, 268, 876 
Dejerine, 172, 728 
Del^pine, 805 
Demoor, 80 (note) 
Deneke, 879 
Denison, 274 
Denman, 635 
Denys, 90 
Desplats, 627 
Desportes, 776 
Dessy, 628 
Devignac, 821 
Dickinson, W. H., 788 
Dietrich, 819 
Disselhorst, 106 
Donders, 377 
Downes, 254 
Drasche, 845 
Dreschfeld, 628 
Duchenne, 184 
Duclaux, 523 
Ducrest, 601 
Duenschmann, 81 
Dufourt, 824 
Dugues, 627 
Duguet, 821 
Dunbar, 808, 883 et seq. 
Duncan, Matthews, 486, 594 
Dunham, 880 
Durham, H. E., 887 
Dutrochet, 104 
Eberth, 792 et seq. 
Eccles, S., 377 
Edinger, 179 (note) 
Edwards, W. F., 253 
Egger, 273 LIST OF AUTHORITIES 
963 
Ehrlich, 77, 564 et seq., 771, 825 
Ehrenberg, 249 
Eichhorst, 818 
Eischel, 689 
Eisenlohr, 829 
Elsner, 798 {note) 
Emmerich, 891 
Engelmann, 58 
Eppinger, 818 
Erb, 184 
Erichsen, 609 
Ernst, 800 
Escherich, 789, 796 
Eulenberg, 382 
Everard, 80 {note) 
Ewald, 169 
Ewing, 729 
Faber, K., 760 
Fagge, 173, 811 
Farr, William, 13, 47 
Faure-Miller, H., 348 
Fayrer, 251 
Fehleisen, 216, 615 
Fenwick, Soltau, 782, 843 
Fermi, 549, 552 
Ferniteld, 631 
Ferrati, 798 
Ferult, 828 
Fiessinger, 631 
Filehne, 125, 155 
Finkler, 879 
Finlayson, 7 
Finsen, N., 254 
Fischer, 118 
Fitz, 175 
Flexner, 662, 665 
Flint, 823 
Fliigge, 554, 807, 879 
Foa, 211, 551, 675 
Fodor, von, 88, 563, 568, 711, 801 
Fonsangrives, 256 
Fosbroke, 713 
Fox, Wilson, 292 
Francis, C. R., 266, 923 
Frankel, 522, 570, 658, 723, 767 
Frankel, A., 801 
Frankel, C., 886 
Frankel, E., 628, 801 
Frankland, E., 148, 249, 529 
Fraser, 225, 564, 583 
Freund, 579 
Freymuth, 892 
Friedlander, 629, 658, 673 
Friedrich, 627, 888 
Friis, 674 
Frosch, 723, 726 
Fuller, 738 {note) 
Gabritschewski, 82, 729 
Gaffky, 793 
Galen, 635 
Galton, Francis, 37 
Gainaleia, 526, 725, 880 
Gartner, 555 
Gaspard, 588 
Gaule, 186 
Gautier, 350 
Gee, 756 
Geigel, 153 
Gergens, 110 
Gerhardt, 814 
Gerst, 377, 380 
Gervis, 676 
Gesenius, 845 
Gilbert, 628, 801 et seq. 
Girode, 801 
Giuffre, 674 
G15nard, F„ 347 
Gley, 167 
Glovetzky, 377 
Gluzinski, 832 
Goldscheider, 770 
Golgi, 181, 831 
Goltz, 169 {note) 
Gombault, 728 
Gompertz, 13 
Godall, 725 
Godell, 384 
Goodhardt, 377, 628 
Gordon, Samuel, 667 
Gottlieb, R., 155 
Gowers, 382, 687 
Graves, 681, 792, 823 
Grawitz, 70, 129 
Green, George, 696 
Greenwood, M., 57 
Gresswell, D. A., 705 
Griesinger, 823, 903 
Griffiths, Joseph, 118 {note) 
Grimshaw, 671 
Grohmann, 568 
Gross, 759 
Grosz, 579 
Gruber, 884 
Gubler, 826 
Gueniot, 639 
Gulland, 80 
Gumprecht, 769 
Gunther, 601 
Haeckel, 61 
Haffkine, 559, 869 et seq. 
Hahn, 166 
Hahnemann, 221 
Haller, Albert von, 220, 588 
Halliburton, 89, 174, 212 
Hamilton, 185, 192 {figs.) 
Hammer, 254 
Hanau, 207 
Handford, 840 
Hankin, 89, 522, 568, 576, 888 
Hanson, Armauer, 555 
Hardy, Ralph, 8 964 
SYSTEM OF MEDICINE 
Hardy, W. B., 60 et seq., 132 
Harley, John, 461 
Harvey, 636 
Hassall, 306 
Hasterlik, 891 
Havel, 90 
Haviland, 24 (note), 210 
Hayem, 340, 627, 845 
Hayne, Louis, 696 
Hayward, 756 
Hecker, 917 
Heiberg, 628 
Heidenhain, 96, 152 
Helmont, von, 218 
Henderson, 940, 950 
Hensch, 720 
Hergt, 875 
Hericourt, 582 
Herwerden, 675 
Heubner, 720 
Hewetson, 826 
Heydenreich, 951 
Higgens, 688 
Hildebrandt, 577, 800 
Hildsbrandt, von, 791 
Hippocrates, 46, 246, 635, 941 
Hirsch, 22, 658 et seq., 875, 918 
Hirschler, 628, 629 
His, 109 
Hoelscher, 823 
Hoffinger, 379 
Hoffmann, 219 
Hofmann, 97 (note) 
Hohnfeldt, 70 
Holz, 798 (note) 
Hook, van, 854 
Hooper, 500 
Houzd, 31 (note) 
Hovell, 624 
Huchard, 121 
Hunter, John, 122, 161, 601 
Hiippe, 509, 562, 879, 888 
Huppert, 146 
Hiiter, 55, 129 
Hutinel, 830 
Huxham, 691 
ISSAEFF, 886 
Jaccoud,631 
Jacob, 713 
Jacobs, 64 
Jackson, 304 
Jackson, Reeves, 383 
Jacobson, 154 
Jaffd, 674 
Jaksch, von, 852 
Janeway, 853 
Janowsky, 795 
Jenner, William, 315, 559, 791, 849 
John of Gaddesden, 254 
Johne, 555 
Johnston, Alex. Keith, 47 
Johnstone, J., 745 (note) 
Jones, Wharton, 77 
Josseraut, 628, 629 
Junod, 306 
Jurgensen, 851 
Kant, 36, 38 
Kanthack, 78, 132, 503 (note), 726, 756, 
773 
Karlinski, 800, 895 
Kaupp, 323 
Kernig, 666 (note) 
Kircher, Athanasius, 702 (note) 
Kirkes, 627 
Kirkland, 636 
Kitasato, 563, 694, 760, 797, 890, 920 et 
seq. 
Klebs, 110, 205, 566, 628, 702, 717, 808 
Kleen, 380 
Klein, 377, 507 et seq., 581, 655, 694, 
709 et seq., 797 et seq., 882 
Klemperer, 667, 831, 886 et seq. 
Klemperer, G., 894 
Klipstein, 764 
Koch, 156, 212, 254, 510, 544, 589, 615, 
759, 793, 878 et seq., 951 
Koester, 628, 633 
Kolisko, 723 
Kolliker, 198 
Komelevsky, P. A., 254 
Korczynski, 832 
Kossel, 90, 577 
Kowalewsky, 189 
Kraepelin, 37 
Krafft, 117 
Kraus, 192, 624, 854 
Kraus, F., 145 
Kronecker, 377 
Krukenberg, 57 
Kubler, 770 
Kiihne, 157 
Lacassagne, 256 
Ladenberg, 227 
Laennec, 303 
Lancereaux, 167, 627 
Landgraf, 818 
Landouzy, 554, 817 
Lange, 314 
Langlois, 168 
Larat, 350 
Lassar, 377 
Latham, A. C., 795 
Latham, P. M., 731 (note) 
Lavdowsky, 105 
Laveran, 844 
Lazarus, 798 (note) 
Leared, 260, 266 
Leber, 70 et seq., 521 
Leborius, 794 
Le Dantgc, 57 LIST OF AUTHORITIES 
965 
Lee, Henry, 304 
Lehman, 144 
Leichtenstern, 675 
Leitz, 800 
Leloir, 172, 196 
Lenhossek, 181 (note) 
Leopold, 638 
Lepp, 563 
Lesage, 888 
Letulle, 97 (note) 
Leva, 631 
Lewin, 818 
Lewis, 879, 904 
Leyden, 825, 829 
Lickfelt, 892 
Liddon, Edward, 35 
Liebermeister, 173, 816, 923 
Liebig, 324 
Limbeck, von, 132 
Ling, 335 
Lingard, 821 
Lion, 628 
Lion, G., 628 
Lister, Joseph, 103, 249, 592, 602 
Litten, 187, 193, 628 
Lloyd, E. L., 730 
Loeb, 60 
Loewy, 145 
Loffler, 509, 547, 702, 717, 880 
Lombard,-22, 377 
Longmore, 280 
Longstaff, 704 
Lotze, 38 
Low, Bruce, 710 
Lubarsch, 89, 560 
Luff, 796 
Lukomsky, 615 
Lustig, 805 
Macaigne, 888 
Macalister, D., 159 
Macfadyen, 513, 530 
Maclean, 492 
Macnamara, 759, 871 
Mafucci, 555, 557 
Magendie, 223 
Maggi ora, 377 
Makeham, 13 
Malibran, 631 
Mannaberg, 629 
Manson, 27, 503 (note) 
Maragliano, 152, 583 
Marcet, 260, 316 
Marchand, 118 
Marchesi, 761 
Marchiafava, 674 
Marie, 181 
Mariotti, Biancho, 802 
Martha, 631 
Martin, Ranald, 251 
Martin, Sidney, 121,189, 521 et seq., 634. 
717 et seq. 
Mason, 826 
Massa, 601 
Massart, 80 (note) 
Masson, 166 
Mathieu, 631 
Matthes, 158 
May, 147 
Mayer, 149 
M'Clintock, 577 
M'Dowell, 676 
M'Lean, Russell, 657 
Mehu, 97 (note) 
Meier, R., 628 
Meigs, V. A., 413 (note) 
Meisels, 800 
Melloni, 249 
Mering, von, 167 
Merkel, 554 
Mesnil, 78 (note), 91 
Metschnikoff, 57 et seq., 82 et seq., 211, 
237, 562 et seq., 842, 887 et seq., 951 
Meyer, 728, 729 
Mezger, 377 
Michel, L5vy, 256 
Miller, 879 ' 
Minkowski, 166 
Mirto, 675 
Mitchell, 522 
Mitchell, Weir, 294, 377, 397 
Moleschott, 253 
Montagu, Lady M. Wortley, 559 
Moore, J. W., 822 
Moos, 668 (note) 
Morax, 797 
Morgagni, 222 
Moritz, 88 
Morpurgo, 548 
Morris, 811 
Morse, 729 
Mosengeil, von, 377 
Moser, 816 
Mosso, 152, 377 
Mott, F. W„ 178 (note) 
Moxon, 171, 627 
Muller, J., 140, 554 
Murchison, 166,627, 792 etseq., 940 etseq. 
Murphy, Shirley, 708 
Murray, 303, 307 
Nageli, 504 
Naunyn, 146, 187 
Nencki, 166, 527 
Netter, 628, 629, 631 
Nettez, 674 
Neuhans, 800 
Neumeister, 523 
Newman, 800 
Nicolaier, 760 
Nicolle, 797 
Niemeyer, P., 256 
Nissen, 89 
Nikiforoff, 118 966 
SYSTEM OF MEDICINE 
Nissen, 563 
Noeggerath, 211 
Nothnagel, 154 
Nunneley, 613 
Nuttall, 88, 563, 568 
Obermeier, 950 
Oemler, 551 
Oergel, 892 
Oertel, 305, 316, 334, 702 
Oesterlen, 22 
Ogle, J. W., 627, 631 
Ogston, 677 
Oliver, G., 168 
Orth, 547, 630 
Osler, 348, 628 et seq., 813 (note) 
Page, David, 713 
Pagenstecher, 377 
Paget, James, 113 
Paltauf, 723 
Panum, 313, 588, 792 
Parti, Ambrose, 601 
Parkes, E. A., 140, 251, 460, 492, 903 
Parry, 778 
Parsons, H. F., 657, 692 
Pasquale, 884 
Pasteur, 125, 249, 549, 559, 566, 768 
Pawlow, 166 
Peiper, 801 
Pekelharing, 85 
Pembrey, 159 
Pepper, 661 (note) 
P6r6, 798 
Pernice, 548 
Perret, 629 
Perry, 791 
Peter, 631, 792 
Petruschky, 549, 798 
Pettenkofer, 248, 807, 881 
Pfeffer, 58 
Pfeiffer, 582, 694, 885 et seq. 
Pfeiffer, Ludwig, 211 
Pfeiffer, R., 92, 808 
Pfliiger, 250 
Pfuhl, 794 
Philippe, 738 (note) 
Phillips, Sydney, 382, 817 
Pisenti, 802 
Pitcairn, A., 218 
Pitres, 172 
Platen, von, 253 
Playfair, 377, 383 
Podwyssozki, 118 
Poehl, 880 
Port, 257 (note) 
Potain, 816 
Power, d'Arcy, 208 
Power, W. H., 705 
Prior, 879 
Profanter, 377, 383 
Prudden, 628, 795 
Prus, 926 
Purcer, 628 
Purjez, 813 (note) 
Puzos, 635 
Queyrat, 554 
Quincke, H., 253 
Rabot, 738 (note) 
Radcliffe, Netten, 870 
Ramon y Cajal, 181 (note) 
Ramsay, A. C., 49 
Randolph, 666 
Ransome, A., 254 
Rasori, 221 
Rattone, 759 
Recklinghausen, von, 615 
Regnard, 515 
Reibmayr, 379 
Reichert, 522 
Reinke, 57 
R^my, 797 
Rennie, 920 
Renzi, de, 555 
Reuss, 97 (note) 
Ribbert, 90, 602, 628, 696 
Richard, 795 
Richards, Percy, 189 (note) 
Richardson, Benjamin, 672 (note) 
Richet, 582 
Richie, 819 
Richmond, James, 793 
Richter, 155 
Rieder, 78 
Rindfleisch, 77, 101, 554 
Ringer, 146 
Roberts, William, 632 
Robin, 826 
Rochard, 256 
Rockwell, 371 
Rodet, 548, 629, 792 
Roehrig, 342 
Roger, 106, 111, 544 et seq. 
Rohden, 256 
Rolleston, 175 
Romberg, 109 
Rose, 782 
Rosenbach, O., 617, 628, 760 
Rossignol, 460 
Rotch, 416 
Rouget, 764 
Routh, Amand, 639 
Roux, 82, 254, 522 et seq., 628, 717 et 
seq., 766, 792, 886 
Roy, 123 
Rubner, 149 
Ruffer, 80 (note), 211 
Rufus, of Ephesus, 917 
Rumpel, 887 
Rumpf, 854, 889 
Riitimeyer, 110 
Rutty, 941 LIST OF AUTHORITIES 
967 
Sabolotny, 891 
Sacchi, 548 
Sachs, 154 
Saenger, 628 
Salkowski, 880 
Salmon, 560, 770 
Salsano, 549, 552 
Salus, 891 
Samuel, 110 
Sanarelli, 88, 801, 886 et seq. 
Sander, 546 
Sansom, 683, 690 
Saundby, 689 
Saunders, 279 
Saussure, de, 248 
Sawtschenko, 551, 891 
Scabia, 551 
Schafer, 168 
Scharrenbroich, 283 
Scheuer, 340, 346 
Schiff, 140, 167 
Schild, 798 
Schmelz, 818 
Schmidt, A., 85, 157 
Schmiedeberg, 236 
Scholl, 526, 892 
Schott, 335 
Schrbter, 819 
Schultze, Max, 77 
Schulze, 829 
Schwann, 249 
Scudamore, 303 
Seitz, 795 
Sellers, 843 
Selmi, 588 
Semmelweiss, 636 
Senator, 142 
Senftleben, 63 
Senger, 628 
Severini, 110 
Shattuck, 831 
Sherrington, 78, 130, 169, 178 (note) 
Siawcillo, 81 
Silvestrini, 815 
Simmonds, 801 
Simon, J., 460, 670 
Simon, R., 684 
Simpson, James, 637, 759, 769 
Sinkler, 377 
Siredey, 817 
Sirotinin, 801 
Smellie, 635 
Smith, Archibald, 275 
Smith, F., 560, 770, 797 
Smith, R., Angus, 252, 301 
Snow, 870 
Sobernheim, 890 
Soudakewitch, 211, 951 
Spittai, 940 
Sprague, 483 
Springthorpe, 391 
Stahl, 58, 219 
Steell, 631, 835 
Stembo, 315 
Stenhouse, 226 
Stephens, J. W. W., 723, 756 
Stern, 628, 808 
Stewart, 37, 791 
Stewart, T. Grainger, 689 
Stich, 792 
Stills, 661 (note), 665 
Stoerk, 223 
Stokes, 303, 792, 816, 949 
Stokvis, 20 
Stoll, 738 
Stott, 632 
Straus, 70, 129 
Stroganoff, 800 
Strpolansky, 800 
Strumpell, 623, 663 (noie), 666 
Stutzer, 415 
Sugg, 797 
Sultan, 800 
Sutton, Bland, 198 
Svensden, 254 
Swieten, van, 636 
Sydenham, 218 
Sylvius, 218 
Symonds, C. J., 401 
Taylor, F., 628, 826 
Teissier, 853 
Terray, 825 (note) 
Thayer, W. S., 817 
Thiroloix, 633 
Thomas, 123, 259, 283 
Thompson, 681, 845 
Thompson, Symes, 279 
Thomson, A. T., 303 
Thomson, Theophilus, 701 
Thorne, Thorne, 807 
Thucydides, 917 
Thudichum, 905 
Tizzoni, 89, 551, 578, 760 
Todd, 792 
Tomkins, 851 
Toner, J. M., 272 
Topinard, 29 
Toupet, 116 
Tourdes, 667 
Traube, 88 
Tripier, 845 
Trousseau, 613, 747 (note), 823 
Truchot, 352 
Tsuboi, 892 
Tubini, 253 
Tufnell, 400 
Tunnicliffe, 377 
Tyndall, 248 
Ughetti, 674 
Unna, 196, 254 
Uschinsky, 524 968 
SYSTEM OF MEDICINE 
Vaillard, 172, 552, 570, 585, 629, 764 
et seq., 817 
Vanderkindere, 31 (note) 
Van der Velde, 90 
Vaquez, 817 
Vaughan, 89, 577 
Velpeau, 613 
Viault, 273 
Vincent, 552, 764, 802 
Virchow, 95, 161, 177, 202, 556, 601, 627, 
905 
Vivenot, von, 256, 313 
Voges, 526 
Vogl, 845 
Voit, 186, 323, 392, 460 
Volkmann, 615 
Voltolini, 668 (note) 
Vulpian, 627 
Wagner, 821 
Waldstein, 730 
Wall, 899 et seq. 
Waller, 104, 162 
Walshe, 256 
Walton, 320 
Ward, Marshall, 254, 514 
Wardell, 950 
Warington, 529 
Washbourn, 674, 695, 725 
Wassermann, 796 
Wassiljeff, 852 
Waters, 269 
Watson, T., 698 
Watt, F. M., 387 
Webb, Law, 209 
Weber, 103 
Weber, E. H., 140 
Weber, Otto, 156 
Wedel, 628 
Weibel, 891 
Weichselbaum, 628 et seq., 658, 891 
Weigert, 174 
Weil, 813 (note) 
Weintrand, 820 
Weir Mitchell, vide Mitchell 
Weiss, J., 77 (note) 
Weissmann, 40, 558 
Welch, 530, 574, 721, 755 
Welsh, 950 
Wendland, 814 
Wernher, 613 
Wernicke, 563 
Wesbrook, 526 , 893 
Weyl, 766 
White, J. Bagen, 927 (note) 
Whittle, 676 
Widal, 674, 795 
Wilks, 171, 591, 627, 685, 903 
Williams, C. J. B., 315 
Williams, C. T., 250 
Williams, Roger, 35 
Willis, 218 
Winge, 627 
Winogradski, 529 
Winternitz, 340, 377 
Wood, H. C., 154, 495 
Woodhead, 793 
Wooldridge, 577 
Wratch, 800 
Wright, J. H., 723 
Wunderlich, 812 
Wundt, 38 
Wurtz, 798 
Wyssokowitsch, 547, 628, 808 
Yeo, B., 853 
Yersin, 522, 717 et seq., 920 et seq. 
Youatt, 21 
Zabludowsky, 377 
Zenker, 175 
Ziegler, 117, 192 
Ziemec, 831 
Ziemssen, von, 257 (note), 347, 377, 662 
et seq., 856 
Ziilzer, 822 
Zuntz, 144 INDEX 
Abscess, experimental, 71; metastatic, 
74 
Abscesses, multiple, 587, 610 
Acetonuria in inanition and fever, 146 
Acne, electric treatment of, 371; diet 
in, 411 
Addison's disease, diet in, 406 
Adipocere, 192 
Esophageal obstruction, feeding in, 401 
Age in dosage of drugs, 244 
Agenesis, 178 
Ainhum, 27 
Air, see Atmosphere, 247 
Albuminuria in diphtheria, 736; in en- 
teric fever, 826; in phthisis (climatic 
treatment of), 287 ; in life assurance, 
486 
Alcohol in diseases of children, 421; in 
enteric fever, 845 ; in puerperal fever, 
649 ; in dietetics, 389; indications for, 
in febrile states, 390 
Alcoholism, diet in, 408 
Alexins, 569, 576 
Amenorrhcea, compressed air bath in, 
315 
Amphophile cells, 79 
Anaemia, balneo-therapeutic treatment 
of, 334 ; climates for, 294; compressed 
air bath in, 315 ; dietary in, 405 ; hy- 
dro-therapeutic treatment of, 346 ; 
massage in, 378 
Aneurysms, dietary in, 400 
Angina, recurrent pellicular, 743 
Anorexia nervosa, diet in, 396 
Anthracosis, 197 
Anthropology and medicine, 21 
Anti-microbic substances, 573 
Antitoxins, 565, 573 ; specificity of, 574 
Antipyretics, 155 
Aplasia, 178 
Apoplasmia, 132 
Apoplexy, heat, see Insolation, 491 
Argyria, 197 
Arm-plethysmograph in fever, 156 
Arterial degeneration, dietary in, 400 
Arthritis, dietary in, 409 
Arthritis, traumatic, massage in, 379 
Arthrospores, 509 
Artificial serotherapeutics, 300 et seq. 
Asthma, climates for, 293; compressed 
air bath in, 316 ; diet in, 398 
Ataxia with reference to life assurance, 
486 
Atmosphere, composition of, 248; diather- 
mancy of, 249 ; humidity of, influence 
on climate, 252 ; qualities of, 247 
Atmospheres, artificial, 300 ; inhalation 
of, 301 ; varying in barometric press- 
ure, 306 
Atrophy, dietary in, 411; from disuse, 
178 ; from inherent defect, 179 
Atrophy of cell elements of glands, 184 
Bacilli, 507 
Bacteria, 506 
Bacterial activity in disease, 533 
Bacterial infection, general, 534; local, 
534 
Bacterial products, 517 ; in infective proc- 
esses, 538 
Balneo-therapeutics, 338; definition of, 
318 ; Courses of, 337 ; seasons for, 337 
Basophile cells, 79 
Baths, compressed air, 310 ; compressed 
air, influence of, on circulation, 313; 
influence of, on respiration, 313 ; elec- 
tric, 363, 368; mercury, 304; Roman, 
341 ; sulphur, 304 ; Turkish and Rus- 
sian, 341; varieties of, 340 
Bed-rests, 431 
Bed-sores, 432 
Bladder, chronic catarrh of, climates for, 
294 
Blastomycetes, 505 
Bleeding in insolation, 499 
Blood and tissues, acquired properties 
of, 169 ; inherited properties of, 169 
Blood, anti-microbic properties, 568 ; the 
nutrient fluid, 163; proteids essential 
to, 165 
Blood serum, bactericidal action of, 88 ; 
toxicidal action of, 94 
969 970 
SYSTEM OF MEDICINE 
Blood-vessels, their part in inflammation, 
100 
Boils, see Furuncle, 651 
Boils, diet in, 411 
Bronchitis, climates for, 293 ; compressed 
air bath in, 315 ; diet in, 397 
Broussais, his theory of disease, 221 
Brown, his theory of disease, 221 
Buboes in plague, 929 
Calcareous precipitation, causes of, 
194 ; results of, 195 
Cancer, distribution of, 22 
Cancer of the stomach, dietary in, 403 
Cancrum oris in enteric fever, 820 
Capillaries, formation of new, in chronic 
inflammation, 101 
Carbuncles, 654 ; diet in, 411 
Carcinoma, auto-infection of, 207 ; chem- 
istry of, 212; definition of, 203 ; Koch's 
postulates, 210 et seq.; transference 
of, 207 ; treatment of, 215 
Cardiac failure in diphtheria, 737 
Caseation, 175 
Catamenial irregularities, hydrothera- 
peutics of, 346 
Cataphoresis, 351 
Catarrh, common, diet in, 399; hydro- 
therapeutics of, 346 
Catheterisation, 437 
Cellulo-humoral theory, the, 89 
Cerebral exhaustion, climates for, 294 
Cerebral heat centres, 153 
Cerebro-spinal fever, see Meningitis, 
epidemic cerebro-spinal, 659 
Chemiotaxis, 58, 64; "negative," 86 
Chemiotropism, 64 
Chilblains, electric treatment of, 371 
Children, sleep of, 470 ; baths for, 419 ; 
teeth of, 465 ; clothing of, 463 ; diet 
and therapeutics of, 412 ; diet in dis- 
ease, 418 ; education of, physical, 467 
et seq.; food of, 464; cubic space for, 
460; habits in, 466; heights and 
weights of, 459, 465 ; somnambulism 
in, 467 ; country air for, 458 ; athletic 
sports, 472 ; work, effects of, on brain, 
468-470; residence for, 460, 462 ; 
physical training of, 461; hereditary 
taint in, 462 
Chlorosis, dietary in, 405 
Cholera Asiatica, aetiology and epidemi- 
ology, 869 ; artificial immunity from, 
893 ; bacterial investigation of dejecta, 
896 ; bacteriology, 878, 895 ; bibliog- 
raphy, 915; conditions of epidemics, 
875; definition, 864 ; diagnosis, 907 ; 
dietary of, 395,915 ; history and geog- 
raphy of, 865 ; hyperthermic form of, 
901 ; individual susceptibility to, 871 ; 
mode of access, 869 ; morbid anatomy, 
902; prognosis, 908; prophylaxis, 
909; sequelae, 902 ; spread of epidemic, 
873 ; symptoms, 897 ; theory of, 906 ; 
treatment, 908 et seq. ; varieties of, 900 
Cholera nostras, diet in, 403 
Cholera sicca, 900 
Cholerine, 900 
Chorea, 27 ; dietary, 396; massage, 382 
Chromatin, 165 
Cicatrices, massage for, 381 
Cilia, 509 
Cirrhosis of liver, as a fibrosis, 180 
Cleanliness of hospital, 424 ; surgical, 424 
Climacteric changes, climatic treatment 
of, 295 
Climate, home, 296 ; influence of forests 
on, 255 ; influence of mountain chains 
on, 255; in treatment of disease, 247 ; 
principal elements of, 248 ; treatment 
of phthisis by, 286 
Climates, coast, 258, 269; for invalids, 
285 ; inland, 271 ; inland, elevated or 
mountain, 271 ; inland, lowland, 280 ; 
marine, 257 /marine, humid, 259, 261 
Clinical thermometer, 428 
Closure tetanus, 357 
Cloudy swelling, 192 
Cold bath in enteric fever, 849 ; in inso- 
lation, 499 
Cold douche in insolation, 498 
Cold in inflammation, 125 
Colic, hepatic, hydrotherapeutics of, 345 
Colic, nephritic, hydrotherapeutics of, 345 
Colic, renal, diet in, 407 
Colitis, ulcerative, diet in, 403 
Coloboma iridis, inheritance of, 46 
Compressed air baths, 311-313 
Complexion, blonds, inferiority of, 27; 
relation to cancer, 35; relation to 
phthisis, 35 
Constipation, dietary in, 404 
Contagion, 539-547 ; direct, 540; indi- 
rect, 540 
Convalescence, tardy, balneo-therapeu- 
tics of, 332 ; climate in, 295 
Convulsions, infantile, hydrotherapeutics 
of, 347 
Corpuscles, diapedesis of, 104 
Coryza, diet in, 399 
Cradle, in nursing, 431 
Death-rates of American cities, dia- 
gram, 6 ; of various diseases, tables, 
14-17 ; in Jewish populations, table, 19 
Degeneration, atrophic, of nervous sys- 
tem, 181, 182 
Degeneration, calcareous, 193 
Degeneration, fatty, appearances of, 
190 ; experimental pathology of, 186 ; 
of the heart, 187 ; of muscle fibres, 
changes in, 191 ; of muscles, from 
toxins, 189; of nervous system, 181, 
188 ; senile, 188 INDEX 
971 
Degeneration, parenchymatous or gran- 
ular, 192 
Degeneration, pigmentary, 195 
Degeneration, waxy, of muscle, 175 
Delirium, hydrotherapeutics of, 347; in 
enteric fever, 827 
Delirium tremens, diet in, 408 
Dermatitis, exfoliative, diet in, 411 
Deutero-albumose, in tuberculin, 157 
Diabetes, balneo-therapeutics of, 335; 
climatic treatment of, 295; diet in, 
407; hydrotherapeutic treatment of, 
346 
Diapedesis, 104, 108 
Diarrhoea, tubercular, climate in, 287, 
291; dietary in, 403 ; in enteric fever, 
810, 821, 854 
Diarrhoea, choleraic, see Cholerine, 900 
Diathesis, haemorrhagic, inheritance of, 
44 
Diazo reaction in enteric fever, 825 
Dietary in disease, 397 ei se#. 
Dietetics in disease, general principles 
of, 385 
Diphtheria, 701; aetiology of, 703, 711 ; 
age in, 705 ; artificial immunity from, 
730; bacteriology, 717; bibliography, 
756 ; dietary in, 394 ; fomites, 708 ; 
history of, 702 ; in lower animals, 710, 
721; morbid anatomy, 726 ; pathology, 
722 ; prophylaxis, 714 ; season in, 704 ; 
sex in, 705; spread of, 705; topogra- 
phy, 704 ; treatment, 744 
Diphtheria, "chronic," 728 ; latent, 754 ; 
local forms of, 753 ; milk, 708 ; nasal, 
752 ; simple and malignant, 731 ; 
tracheal, 749 
Diphtheria, serum treatment of, 754; 
serum treatment, bibliography of, 757 
Diphtheritic croup, 745; course and 
symptoms, 747; diagnosis, 746, 750; 
dysphonia in, 746; prognosis, 748; 
treatment, 751 
Diphtheritic sore throat, 731; diagnosis, 
742 ; prodroma, 732 ; symptoms, 732 ; 
temperature in, 736 ; treatment, 744 
Diplococci, 506 
Disease, "change of type " in, 697 ; dis- 
tribution of, 48 
Diseases, race in, 28 
Dosage of drugs for children, 422 
Douches, 340 
Drag addiction, massage in, 384 
Drug therapeutics, bibliography of, 247; 
principles of, 217, 224 ; sources of fal- 
lacy in, 246 
Drugs, action of, on inflammation, 237 ; 
analgesic, 242 ; antitoxin, 237 ; cumu- 
lative action of, 246 ; dosage of, 244 ; 
hypnotic, 242 ; idiosyncrasy in, 245 ; 
limit of action of, 236, 246 ; modifica- 
tions of influence of, 245 ; nature of, 
224; nature of action of, 227 ; object 
of, 224; principles of administration 
of, 243 ; rational therapeutics of, 230, 
231; "standardisation" of, 226; tol- 
eration of, 245 ; vaso-dilators, 234 
Dry cupping, 307 
Dysentery, dietary in, 394 
Dyspepsia, climate in, 294; dietary in, 
402, 404 ; hydrotherapeutics of, 345 
Eczema, diet in, 411 
Effusions, haemorrhagic, massage in, 
378 ; inflammatory, massage in, 377 
Electric bath, 363 
Electric osmosis, 351, 364 
Electrical reactions, 356 
Electrical testing, of sensibility, 362 ; of 
tinnitus aurium, 371 ; practical, 360 
Electricity, medical, apparatus, 351; 
applications of, 349, 362; bibliogra- 
phy, 373; definition, 350; physio- 
logical action of, 350; units of meas- 
urement in, 353 
Electrification, general, 363; localised, 
364 
Electrolysis, 351, 364 
Electrostatic combined battery, 353; ma- 
chine, Wimshurst, 352 ; treatment, 352 
Electrotonus, 350 
Embolism, food in, 395,401; in pyaemia, 
591, 603 
Emphysema, climates for, 293; com- 
pressed air bath in, 315 ; food in, 398 ; 
with reference to life assurance, 484 
Endocarditis in children, treatment of, 
420 
Endocarditis, infective, aetiology and his- 
tory of, 627 ; age in, 632 ; bacteriology, 
630 ; bibliography, 634 ; causes of, gen- 
eral, 631 ; chemical pathology, 634 ; in 
connection with pyaemia, 591 ; paths of 
infection of, 632; types of various, 630 
Endospores, 508 
Endothelial cells, enlargement of, in 
inflammation, 116 
Endothelium, vascular, in inflammation, 
100; action of diffusible irritants on, 
106 
Enemata, nutrient, 437 ; purgative, 436 
Enteric fever, 791; aetiology of, 793; 
bibliography, 863; definition, 791 ; 
diagnosis, 834 ; diet in, 391, 845 ; ery- 
sipelas in, 815 ; geographical distribu- 
tion of, 793 ; history of, 791; infection, 
immunity from, 807 ; remoter causes 
of, 806 ; spread of, 802 ; mixed infec- 
tion in, 832 ; mortality from, 844 ; nu- 
trition of body in, 831 ; pathology, 837- 
842 ; prognosis, 843 ; prophylaxis, 858 ; 
relapse in, 831 ; sequelae, 828 ; stools, 
examination of, 798 ; sudden death in, 
844; symptoms, 816-842; tables of 972 
SYSTEM OF MEDICINE 
mortality, 860 ; temperature in, 812 ; 
temperature in post-typhoid, 814; 
treatment, 347, 846-857 ; treatment of 
special symptoms, 854; varieties of, 832 
Enteritis, diet in, 403, 404 
Enzymes, 519 
Eosinophile cells, 78; excretory func- 
tions of,' 91 
Epilepsy, dietary in, 396 
Eruptions in enteric fever, 814 
Erysipelas, aetiology of, 614 ; bibliogra- 
phy, 626 ; curative, 616 ; bacteriology, 
616 ; complications in, 620 ; diet in, 
394 ; definition, 613 ; diagnosis, 621 ; 
history, 613; minute anatomy, 615; 
pathology, 617; prognosis, 621 ; result- 
ing from wounds, 615 ; sequelae, 620 ; 
symptoms, 618 ; treatment, 622 
Erysipelas in enteric fever, 815 
Erythemata, diet in, 411 
Erythro-proteid reaction, 177 
Exanthemata, diet in, 393 
Family diseases, 43 
Famine fever, see Relapsing fever, 940 
Feeding-bottles, 457 
Feeding-cup, 387 
Fermentation, 519 
Ferments in inflammatory exudate, 99 
Fever, abnormal action of the skin in, 
152 ; aetiology, 156 ; changes of volume 
of the skin in, 152; disorder of nutri- 
tion in, 144 ; phthisis and climate, 287, 
291; surface temperature in, 153; 
thermotaxis in, 150 
Fever, the doctrine of, 139 ; Cohnheim's 
theory, 143; Lehmann and Zuntz on, 
144; Leyden's theory, 142 ; Lieber- 
meister's theory, 140, 151; Pfliiger's 
experiments, 143; Senator's theory, 
142 ; Traube's theory, 140, 151 ; Vir- 
chow's researches, 140 
Fibrin in the inflammatory exudate, 97 
Fibroblasts in inflammation, 117 
Fibrosis, 178 
Fibrous substitution, 121 
Fistula in life assurance, 485 
Flagella, 509 
Fraenkel's pneumatic apparatus, 308 
Friction in diseases of children, 420 
Furuncle, 651 ; aetiology of, 652 ; bac- 
teriology of, 652; situation of, 652; suc- 
cessive crops of, 652 ; treatment of, 653 
Gall-stones, diet in, 404 
Gangrene, acute spreading, 176 
Gangrene, dry, 175 
Gangrene, moist, 176 
Gangrene, secondary, 174 
Gastritis, dietary in, 401 
Geigel and Mayer's pneumatic apparatus, 
309 
Geography, medical, of Great Britain, 46 
Giant cells, nature of, 81 
Gluge's corpuscles, as result of inflam- 
mation, 81 
Glycogen in the liver, storage function 
of, 163 
Glycosuria, balneo-therapeutic treatment 
of, 335 ; dietary in, 407 ; in life assur- 
ance, 486 
Goitre, exophthalmic, electric treatment 
of, 371 
Gonorrhoea in life assurance, 486 
Gout and rheumatism, climates for, 293 
Gout, balneo-therapeutic treatment of, 
335 ; dietary in, 409 ; distribution of, 
23; hydrotherapeutics of, 345; and 
life assurance, 485 
Granulation of cells, table, 78 
Gravel and stone, balneo-therapeutics 
of, 335 
Gutta rosacea, diet in, 411 
Gynaecology, massage in, 383 
H.ematoidin, 196 
Haemophilia, dieting in, 405; and in- 
herited gout, 45 
Haemoptysis, treatment of, by climate, 
286 ; and life assurance, 483 
Haemorrhage, cerebral, feeding in, 395 
Haemorrhage in enteric fever, 822, 855 
Haemorrhages in diphtheria, 737 
Haemosiderin, 196 
Hahnemann's theory of disease, 221 
Handball sprays, 305 
Harelip, inheritance of, 46 
Head, retraction of, in epidemic c.-sp. 
meningitis, 665 
Headache in epidemic c.-sp. meningitis, 
665 ; in influenza, 684 
Health resorts, mountain, 274; principal, 
256 ; summer, 270, 292 ; winter, 270, 
292 
Heart disease, climates for, 293; in 
phthisis, climatic treatment of, 287 ; 
and life assurance, 484 
Heart, diseases of, balneo-therapeutics 
of, 334 ; diet in, 399, 400 
Heat, effects of great, 491; sedative 
action of, 344 
Heat-stroke, see Insolation, 491 
Helpless persons, feeding of, 387; nurs- 
ing of, 430 
Hemiplegia, electric treatment of, 364 
Heredity and life assurance, 483 
Hernia and life assurance, 485 
Herpes in epidemic c.-sp. meningitis, 667 
Heterology, 202 
Hodgkin's disease, diet in, 406 
Humoral theory, the, 88 
Hyaline cells, as phagocytes, 91; and 
leucocytes, 79 ; and fibroblasts, 118 
Hyaloplasm, 165 INDEX 
973 
Hydrocephalus, Chronic, after epidemic 
c.-sp. meningitis, 668 
Hydrophobia, feeding in, 395 
Hydrotherapeutics, action and physio- 
logical effects of, 341 ; bibliography, 
348; cases suitable for, 345; contra- 
indications to, 348 ; definition, 339 ; 
history, 339 ; modes of application, 340 
" Hydrotherapeutic reaction" to cold, 
341 ; to heat, 343 
Hyperplasia, 200 
Hyperplasia, fibrous, forms of, 124 ; and 
inflammation, 119; non-inflammatory, 
124 
Hyperpyrexia, 154; hydrotherapeutics, 
of, 348 
Hypertrophy, 197 ; causes of, 199; com- 
pensatory, 198 
Hyphomycetes, 504 
Hypochondriasis, climates for, 294 ; elec- 
tric treatment of, 370 
Hypoplasia, 178 
Hysteria, hydrotherapeutics of, 346 ; diet 
in, 396; electric treatment of, 369; 
massage in, 383 
Ichthyosis, 44 
Idiosyncrasy, 44 
Immunity, 558 ; definition of, 563 ; ac- 
quired, 558 ; acquired, Bouchard's 
hypothesis of, 563; acquired, factors 
in production of, 573; acquired by 
feeding with living organisms or prod- 
ucts, 565 ; acquired by injections of 
bacterial products, 560 ; acquired by 
inoculation with attenuated virus, 559 ; 
acquired by small doses of virulent 
virus, 559; acquired, hypothesis of 
retention, 568 ; acquired, natural, after 
infection, 559; acquired, Pasteur's 
hypothesis of exhaustion, 566 ; ac- 
quired, theories of, 566 
Immunity, active, 565, 572 ; individual, 
575; hereditary, 578; natural, 575; 
natural and acquired compared, 577 ; 
natural, theories of, 576 ; passive, 565, 
572 ; racial, 575 
Inanition, discharge of nitrogen in, 147 ; 
from disease, 170 
Infants, diet of, 416 
" Infants' foods," 415 
Infection, 537 ; and contagion, 540 ; and 
intoxication, 538 ; bibliography, 585 ; 
general pathology, 503 ; latent, 555 
Infection, congenital, 556; germinal, 
557 ; placental, 557 ; septic, 587 
Infection, disposition to, congenital, 554; 
individual, 550; racial, 550 
Infective diseases, definition of, 538 ; in- 
cubation of, 539 ; propagation of, 542 
Infiltration, albuminous, see Cloudy 
Swelling, 192 
Infiltrations, 177 
Inflamed areas, increased temperature 
of, 124 
Inflammation, classification of forms of, 
126; comparative pathology, 56; defini- 
tion, 54, 134 ; experimental production 
of, 62, 66; systemic changes conse- 
quent on, 131; the leucocytosis of, 77 
Inflammation of the cornea, 63 
Inflammation, suppurative, experimental 
production of, 70; processes of, 72 ; 
septicsemic extension of, 73 
Inflammatory exudation, 94 ; dilution of 
irritant by, 96; and ordinary lymph, 
96 ; " flushing out" action of, 95 
Inflammatory fever, 74 
Inflammatory process, factors in, 77 ; 
phenomena of, 75 
Influenza, 679 ; aetiology of, 692 ; bacteri- 
ology of, 694 ; bibliography of, 701 ; 
description of, 679 ; diagnosis of, 698 ; 
diagnosis of, from Dengue, 692 ; diag- 
nosis of, from pertussis, 693; dietary in, 
394; history, 690; incubation, 693; mor- 
bid anatomy, 695; nervous phenomena, 
683 ; prophylaxis, 700 ; sequelae, 687 ; 
symptoms, 684 ; types of, 680 
Influenza, typhoidal, 698 
Inhalation, methods of, 301 ; of carbonic 
acid, 302 ; of chlorine, 303 ; of iodine, 
303 ; of mercury, 304 ; of nitrous oxide, 
302 ; of oxygen, 301 ; of steam, 304 ; 
of sulphur, 304 ; of turpentine, 306 
Inheritance in disease, laws of, 39 
Insanity, massage in, 383 
Insolation, 491 ; bibliography of, 502 ; 
cases of, 500 ; forms of, 495; hyper- 
pyrexia in, 500; morbid anatomy, 
497 ; prognosis, 496 ; prophylaxis, 497 ; 
sequelae, 500; statistics of (India), 
493, 494 ; symptomatology and pathol- 
ogy, 494 ; treatment, 498 
Insomnia, electric treatment of, 370; 
massage in, 379 
"Insurance heart," 484 
Intemperance and life assurance, 485 
Intestinal obstruction, feeding in, 404 
Intoxication, septic, 586 
Jaundice, diet in, 404; in relapsing 
fever, 943 
Junod boot, the, 307 
Kaposi's disease, inheritance of, 44 
Keratinisation, 196 
Ketchum's pneumatic cabinet, 309 
Kidneys, diseases of, climates for, 294 
Kidneys, lardaceous disease of, diet in, 407 
Koch's comma bacillus, 879 ; chemistry 
of, 892; pathogenetic properties of, 
889 ; vitality of, 894 
Kopf tetanus, 780 974 
SYSTEM OF MEDICINE 
Laryngeal affections in enteric fever, 
818 
Laryngitis, feeding in, 397 
Lead poisoning, diet in, 409; electric 
treatment of, 368 
Lecithin, importance of, in nutrition, 
165 ; in fatty degeneration of nervous 
system, 188 
Leprosy, transmission of, 42 
Leuchaemia, diet in, 405 
Leucocytes, action of diffusible irritants 
on, 106 ; classification of, 79; diape- 
desis of, in inflammation, 104; mass- 
ing of, 68 
Leucocytopenia, 132 
Leucocytosis in diphtheria, 729 
Life assurance, 476 ; contingent risks in, 
477 ; claims in, 486; endowment as- 
surances, 477 ; forms of application 
for, 479, 480; issue risks in, 477 ; 
medical examination of applicants, 
478, 481; medical officials, duties of, 
478 ; rating in, 481, 482 
Light, effects of, on bacteria, 254 ; effects 
of, on oxidation of animal cells, 253 
Lithaemia, dietary in, 404 
Liver, influence of, on nutrition, 166 
Locomotor ataxia, massage in, 382 
Longevity, inherited, 169 
Lumbago, electric treatment of, 369 
Lymphadenitis in diphtheritic sore 
throat, 734 
Lymphatic glands in plague, 929 
Lymphocytes, 79 
Malaria, climatic treatment of, 294 
Map of cancer, 51; comparison of cancer 
and phthisis, 53; heart disease, 49 ; 
phthisis among females, 52 
Maps of diseases of Great Britain, 48 
Massage, 373 ; abdominal, 376 ; bibliog- 
raphy of, 385; contra-indications to, 
384; general, 376; immediate effect 
of, 377 ; physiology, 377 ; technique, 
374 
Measles, distribution of, 26 
Medical statistics, 3 
Medication by mouth, 243 ; by rectum, 
243 ; by skin, 243 
Melancholia, massage in, 383 
Melanin, 197 
Mellin's food for infants, 415 
Meningitis, epidemic cerebro-spinal, 659 ; 
aetiology, 672 ; complications and se- 
quelae, 668 ; bacteriology, 673 ; bibliog- 
raphy, 678 ; diagnosis, 671; features, 
cutaneous, 667 ; general features of, 
664 ; history, 660 ; morbid anatomy, 
661; outbreaks of, in United Kingdom, 
676 ; prognosis, 670 ; symptoms and 
course, 663; treatment, 669; types, 
various, 664 
Mental alienation, distribution of, 33 
Mental diseases in enteric fever, 829 
Metamorphoses, 177 
Metamorphosis, fatty, 185 
Metaplasia, 202 
Micrococci, 506 
Micro-organisms, aerobic, 513; anae- 
robic, 513; atmospheric pressure on, 
515 ; chromogenetic, 518 ; classifica- 
tion, 516; cultivation, 512, 515; in 
infectious diseases, 538; interaction, 
534, 552 ; latency, 555; mechanical 
effects, 539 ; pathogenetic, 535; sun- 
light and, 514 ; variability of virulence, 
530, 537, 543 
Micro-organisms, involution forms, 510 ; 
morphology, 504 ; pleomorphism, 510 
Migraine, dietary in, 396 ; massage in, 
380 
Milk, of cow and human, 413 ; sterilised 
for infants, 414; sterilised or boiled, 
393 
Mitosis in acute inflammation, 101, 116 
Morphiomania, massage in, 384 
Motor points, diagrams of, 357 
Moulds, 504 
Mucin in inflammatory exudate, 97 
Murray's pneumatic instrument, 307 
Muscle, atrophic changes of, 184 
" Muscular rheumatism," hydrothera- 
peutics of, 345 
Myco-proteins, 527 
Myopia and dolichokephaly, 33 
Myxoedema, diet in, 406 
Nasal feeding apparatus and method, 387 
Necrosis of tissue, by disturbance of 
circulation, 172; causesand pathogeny, 
171, 172 ; morbid anatomy and pathol- 
ogy, 174. 
Necrosis coagulation, 174; colliquative, 
174; fat, 175; septic, see Gangrene, 
175 
Neoplasms and inflammation, 113 
Nephritis, dietary in, 406, 407 
Nerves, injuries of, electric treatment of, 
366 
Nervous system, affections of, climates 
for, 294 ; balneo-therapeutic treatment 
of, 336 
Nervous system and nutrition, 168 ; and 
inflammation, 108 
Neuralgia, climatic treatment of, 295; 
electric treatment of, 369 ; hydrother- 
apeutic treatment of, 345; massage 
in, 380 
Neurasthenia, climates for, 294 ; electric 
treatment of, 370; massage in, 383 
Neuritis, diet in, 395 ; electric treatment 
of, 368 ; massage in, 380 
Neutrophile cells, as phagocytes, 91; 
classification, 79 INDEX 
975 
New growths, attempts to cultivate mi- 
crobe of, 214 ; bibliography, 217 ; en- 
demic location of, 209 ; general pathol- 
ogy, 201 ; metastasis, 203; parasitic 
theory, 206, 210; pathogenesis, 204- 
206; structure, 201 ; treatment, 213- 
216 
Nitrification, 529 
Nuclein, composition of, 165 
Nurses, age for training of, 423 ; duties of, 
as to gynaecological work, 439; duties 
of, as to hospital ward work, 424 
Nursing, 423; district, 446; medical, 
428 ; of children, 442 ; of children in 
tracheotomy, 443; of helpless patients, 
430; private, 444 ; puerperal, 450; 
surgical, 424 
Nystagmus in epidemic c.-sp. meningitis, 
666 
Obesity, massage in, 384 
Occupation neuroses, massage in, 381 
Oertel's steam nebuliser, 305 
Optic neuritis in epidemic c.-sp. menin- 
gitis, 666 
Osteomyelitis, acute suppurative, in 
pyaemia, 605 
Oxyphile cells, classification, 79 
Pancreas and nutrition, 167 
Paralysis in epidemic c.-sp. meningitis, 
666 ; acute atrophic, massage in, 382 ; 
bulbar, feeding in, 395 ; facial, electric 
treatment of, 367 ; in diphtheria, 739; 
infantile, electric bath for, 363; electric 
treatment of, 365; pseudo-hypertro- 
phic, massage in, 382 
Parasitic skin diseases, diet in, 410 
Parotitis in enteric fever, 820 
Peptones in inflammatory exudate, 97 
Peptonised foods, 393 
Perforation in enteric fever, 823 
Pericarditis in Bright's disease, diet in, 
400; in children, treatment of, 420 
Perichondritis in phthisis, effect of Alps 
on,287 
Periostitis in pyaemia, 605 
Peripheral) neuritis in enteric fever, 829 
Peritonitis, diet in, 404, 405 
Pestis major, 928 
Pestis minor, 928 
Phagocytosis, 81, 567 ; theory of, 86 
Pharmaceutike rationales (1574), 218 
Pharmacopoeia (London, of 1618), 217 ; 
(of 1632), 217; (of 1677), 219; (of 
1788), 220 
Pharyngo-typhoid, 821 
Phosphorescence, 531 
Phthisis, climatic treatment of, 273, 276, 
286 ; compressed air bath in, 316 ; dis- 
tribution of, 24 ; heredity of, 556 ; rarity 
of, in Alps, 273 ; and life assurance, 483 
Phthisis pulmonalis, dietary in, 398 
Pigmentation, 195 ; extrinsic, 197 ;haema- 
togenous, 196 
Pituitary body, in nutrition, 168 
Plague as a communicable disease, 926 ; 
bacteriology, 921; bibliography, 938 ; 
conditions favourable to, 925; defini- 
tion, 917 ; diagnosis, 934 ; general 
pathology, 920 ; history, 917 ; morbid 
anatomy, 934 ; mortality from, 933 ; 
prognosis, 934; prophylaxis and pre- 
vention, 936 ; stages, 928 ; symptoms, 
932 ; treatment, 935 
Plague, endemic, 922 ; as a soil disease, 
923 
Plasters, mustard, 435 
Pleurisy and life assurance, 484 
Poisoning, chronic metallic, hydrothera- 
peutic treatment of, 346 
" Poisson's formula," 4 
Polio-myelitis, anterior, faradism in, 383 ; 
massage in, 383 
Polio-myelitis in enteric fever, 829 
Polyuria, climatic treatment of, 295 
Pneumonia, epidemic, 655; aetiology, 
657 ; bacteriology, 658 ; occasional 
phenomena of, 656; relation of, to 
age, table, 657 ; symptoms, 656 ; trans- 
mission, 659 
Pneumonia, diet in, 398; in connection 
with malignant endocarditis, 633; in 
enteric fever, 819 
Predisposition, acquired, 548 ; and im- 
munity, 558; hereditary, 554; personal, 
547 
Pregnancy and life assurance, 486 
Proliferation of connective tissue in in- 
flammation, 116 ; of fixed cells in tuber- 
culosis, 117 
Protective power of blood serum, 570 
Proteids in inflammatory exudate, 97 
Psoriasis, diet in, 411; hydrotherapeutic 
treatment of, 346; inheritance of, 
44 
Ptomaine poisoning in children, treat- 
ment of, 419 
Ptomaines, 519 
Puerperal fever, charts of, 642 ; in con- 
nection with sapraemia, 591 
Puerperal septic disease, aetiology of, 637 ; 
bacteriology of, 638 ; bibliography of, 
651; history of, 635 ; mortality from, 
in lying-in hospitals, 636; pathology 
of, 640 ; paths of infection in, 639 ; 
symptoms of, 641 ; theory of auto-in- 
fection in, 638 ; treatment, preventive, 
646 ; remedial, 648 
Purpura, diet in, 405 ; in epidemic c.-sp. 
meningitis, 667 
Putrefaction, 529 
Pyaemia, age in, 605; diagnosis, 611; 
definition, 587 ; experimental, com- 976 
SYSTEM OF MEDICINE 
pared with human, 590 ; history, 601; 
joint lesions in, 604, 608 ; morbid anat- 
omy, 609 ; pathology, 602 ; prognosis, 
612; symptoms, 606; tissue changes 
in, 605 ; treatment, 612 
Pyaemia, chronic, see Abscesses, multi- 
ple, 587 ; idiopathic, 591; portal, see 
Pylephlebitis, suppurative, 610 ; puer- 
peral, 645 
Pyle-phlebitis, suppurative, 591, 602, 610 
Pyloric stenosis, dietary in, 403 
Pyrexia, see Fever, 139 
Pyrogen, 157 
Quarantine for cholera Asiatica, 867 ; 
for plague, 937 
Rainfall in different regions, 252 
Ranvier's cells as result of inflammation, 
81 
Rash in relapsing fever, 943 
Rashes, antitoxin, 584 
Raynaud's disease, electric treatment of, 
371 
Reaction of degeneration, 359 
Recruiting statistics, American, 27 ; Bel- 
gium, 31; French, 29 ; French table, 32 
Relapse in relapsing fever, 944; period 
of, 945 
Relapsing fever, 940; aetiology, 948 ; 
bibliography, 958; contagion in, 949; 
diagnosis, 955; duration, 941; inter- 
mission in, 945 ; micro-organism, 950 ; 
morbid anatomy, 956; prognosis in, 
956 ; relation of, to typhoid fever, 953 ; 
sequelae, 956 ; symptoms, 942; syn- 
onyms for, 940 ; treatment, 958 
Respirators, 305 
Respiratory gymnastics, 316 
Respiratory organs, diseases of, balneo- 
therapeutic treatment of, 333 
Response to injury among annelids, 60 ; 
metazoa, 58 ; protozoa, 56 ; vertebrata, 
62 
Retinitis pigmentosa, inheritance of, 44 
Rheumatic fever, dietary in, 409 
Rheumatism, chronic, balneo-therapeu- 
tic treatment of, 335 
Rheumatism, hydrotherapeutics of, 345 
Rickets, dietary in, 410 ; hydrotherapeu- 
tics of, 346 
Rigors in influenza, 686 
Salivary glands in diphtheria, 735 
Sapraemia, aetiology, 592 ; definition, 586 ; 
diagnosis, 595 ; experimental, 588; 
morbid anatomy, 594 ; pathology, 590 ; 
prognosis, 595 ; symptoms, 593 ; treat- 
ment, 595 
Sapraemia in puerperal disease, 638 
Sarcinae, 507 
Sarcoma, definition of, 203 
Scarlatina, distribution of, 26 
Schizomycetes, 506 
Sciatica, electric treatment of, 369 ; hy- 
drotherapeutic treatment of, 345; mas- 
sage in, 380 
Scorbutus, dietary in, 405 
Scrofula, climates for, 293 ; inheritance 
of, 42 
Scurvy, infantile, diet in, 410 
Sea voyages, 257, 291 
Senile decay, climatic treatment of, 
296 
Septicaemia, contagiousness, 598 ; defini- 
tion, 587 ; diagnosis, 600; experi- 
mental, 589 ; morbid anatomy, 599 ; 
pathology, 532, 596; phlebitis, 591, 
602 ; prognosis, 600 ; symptoms, 599 ; 
treatment, 601 
Septicaemia, puerperal, 639 
Serum, antitoxic, treatment, 579 ; pro- 
tective value of, 581, 585; summary 
of results of, 583 
Serum, curative, administration of, 584; 
dosage of, 583; rashes due to, 584; 
specificity of, 569, 582 
Serum therapeutics, 579; bibliography, 
585 ; limits, 580 ; methods, 581 
Serum treatment in diphtheria, 754; in 
plague, 936; in tetanus, 771 
Serum-albumin in inflammatory exu- 
date, 97 
Serum-globulin in inflammatory exu- 
date, 97 
Sex in dosage of drugs, 244 
Sexual organs, affections of the female, 
balneo-therapeutic treatment of, 336 
Shivering, reflex action of, 159 
Sickness in various armies, table, 7; 
countries, tables, 8-11 
Skin, chronic affections of, hydrothera- 
peutic treatment of, 346 
Small-pox, distribution of, 26 
Snow, influence of, on atmosphere, 252 
Soldiers, liability of, to cerebro-spinal 
meningitis, 672 
" Soothing syrups " for children, 422 
Specificity of disease, 535; limitations 
of, 536 
"Spinal irritation," massage in, 379 
Spirilla, 507 
Spleen, influence of, on nutrition, 168 ; 
in relapsing fever, 952 
Spongioplasm, 165 
Spores, 508 
Staphylococci, 507 
Stature in connection with disease, 29 
Stigmata, 106 
Stomatitis, dietary in, 401 
Streptococci, 506 
Sunstroke, see Insolation, 491 
Suppuration from bacteria, 129 ; from 
chemical substances, 129 INDEX 
977 
Suprarenal capsules, influence of, on 
nutrition, 168 
Syncope in boys, 472 ; in insolation, 494 
Synovitis, massage in, 379 
Synovitis, gonorrhoeal, diet in, 410 
Syphilis, balneo-therapeutic treatment 
in, 336; diet in, 395; inheritance of, 
40 ; and life assurance, 486 
Syrups, medicated, 422 
Teeth, racial characters of, 34 
Temperament, 36 ; suggestions for new 
system of, 38 ; types of, 39 
Temperature, atmospheric, influence of, 
on plague, 925 
Temperature of soil, influence of drain- 
age on, 255 ; vegetation on, 255 
Tendon reflexes in epidemic c. -sp. men- 
ingitis, 666 
Tetanus, 758 ; accidental traumatic, 766 ; 
artificial immunity from, 770; bac- 
teriological diagnosis, 767 ; bibliog- 
raphy, 790 ; diagnosis, 780 ; experi- 
mental, 764; "idiopathic," 764, 778; 
incubation, reference to severity, 773 ; 
morbid anatomy, 788 ; pathology, 759 ; 
statistics, in American war, 789 ; 
symptoms, 776 ; treatment, 783 
Tetanus antitoxin, 772 
Tetanus bacillus, the, 760 ; culture of, 
762 ; inoculation of, 763 
Tetanus, feeding in, 395 
Tetanus, infantile, 789 
Tetanus neonatorum, 789 
Tetanus poison, the, 766 
Tetanus, serum treatment in, 771 ; re- 
sults of, compared with diphtheria, 775 
Tetany, 782 
Tetracocci, 507 
Thermogenesis, 148, 159 
Thermolysis, 159 
Thermotactic centre, the, 151 
Thermo taxis, 159 
Thrombo-phlebitis in carbuncles, 655 
Thrombosis, food in, 395, 401 ; in enteric 
fever, 817 ; in influenza, 683; in pyae- 
mia, 591, 603 
Thyroid body, influence of, on nutrition, 
167 
Tinnitus aurium, electric treatment of, 
370 
Tissue, calcification of, 193 ; associated 
with fatty degeneration, 195 
Tissue cells, degeneration of, in inflam- 
mation, 113; "reversionary" degen- 
eration of, in inflammation, 114 ; re- 
generation of, 115 ; in inflammation, 
113 
Tissues, interdependence of, 166 
Tonics in diseases of children, 421 
Tonsillitis, diet in, 401 
Torticollis, massage in, 382 
Toxalbumins, 519 
Toxic proteins, 523 
Toxins, 517 ; intravascular and extra- 
vascular, effect of, on diapedesis, 106 
Tracheotomy in diphtheritic croup, 751 
"Transmutation in transmission," 46 
Trophotropism, 58 
Trousseau's cigarettes, 304 
Tuberculosis, inheritance of, 41 
Tuberculosis of lymph glands, diet in, 
406 
Tufnell's diet, 400 
Tumours, innocent, 202; growth of, by 
inflammation, 203 ; malignant, 202 ; 
multiplicity of, 302 
Tympanites in enteric fever, 823, 855 
Typhilitis, diet in, 403 
Typhoid bacillus, character and biology 
of, 793; diagnosis of, from B. coli 
commune, 796; inoculation on ani- 
mals of, 801; pathogenetic nature of, 
799; portals of entrance into human 
body, 808 
Typhoid spine, 829 
Typhus, relapsing, and other fevers, 
dietary in, 392 
Tyrosis, 175 
Ulcer, gastric, dietary in, 402 
Uraemia, feeding in, 407 
Urinary organs, diseases of, dietary in, 
406 
Urine, incontinence of, electric treatment 
of, 372 
Urticaria, diet in, 411 
Uterine fibroma, electric treatment of, 
372 
Vaso-motor paralysis and inflammation, 
111 
Venosity, abdominal, balneo-therapeutic 
treatment in, 333 
Ventilation of medical wards, 428; of 
surgical wards, 424 
Virchow's theory of inflammation, 114 
Vomiting, hysterical, diet in, 396 
Vomiting, in diphtheria, 738; in epidemic 
c.-sp. meningitis, 666 
Waldenburg's pneumatic apparatus, 
307 
Wasting in children, treatment of, 422 
Water-beds, 431 
Water boiled, use of, in dietetics, 393 
Water, internal use of, 344 ; cold, local 
application of, 343; cold treatment, 
341 ; hot, local application of, 344; 
warm, treatment, 343 
Waters, alkaline, 323 ; action of, 324; 
enumeration of spas, 324; uses of, 
325; varieties of, 324 
Waters, arsenic, 327 
VOL. I 
3 B 978 
SYSTEM OF MEDICINE 
Waters, common salt, or muriated sa- 
line, 321; action of, 322 ; enumeration 
of, 321 ; uses of, 323 
Waters, earthy or calcareous, 329; action 
of, 330 ; enumeration of, 329 ; uses of, 
330 
Waters, iron or chalybeate, 326 ; action 
of, 327 ; enumeration of, 326 ; uses of, 
327 
Waters, mineral, carbonic acid in, 323 ; 
choice of, in individual case, 332 ; 
classification of, 319; description of, 
318 ; therapeutic employment of, 330 
Waters, simple thermal, 319 ; action of, 
320 ; enumeration of, 320; uses of, 321 
Waters, sulphated or bitter, 325 ; action 
of, 325 ; enumeration of, 325 ; uses of, 
325 
Waters, sulphur, 328 ; action of, 329 ; 
enumeration of, 328 ; uses of, 329 
Weir Mitchell's rest treatment, 382; 
treatment of hysteria, 397 
Work-hypertrophy, 198 
Writer's cramp, massage in, 381 
Xanthochroi, 36 
Xeroderma, inheritance of, 44 
Xeroderma pigmentosum, 44 
Yaws, 27 
Yellow fever, distribution of, 25 
Youth, the hygiene of, 457 
END OF VOL. I Works on Medical Science and 
Cognate Subjects. 
PUBLISHED BY 
MACMILLAN & CO. 
ANDERSON (J. W.).-Lectures on Medical Nursing. i6mo. 75 cents. 
Essentials of Physical Diagnosis of the Chest and Abdomen. 75 cents. 
" Dr. Anderson has written in a style as compact as possible, with a view to the economy of time, 
yet has satisfactorily covered his subject."-W. Y. Tinies. 
BALFOUR. - The Senile Heart. Its Symptoms, Sequelae, and Treatment. By 
George William Balfour, M.D. i2mo. Cloth. $1.50. 
" Cleverly written in a thoroughly interesting and practical style." - American Medico-Surgi- 
cal Bulletin. 
" A very clearly expressed and readable treatise upon a subject of great interest and importance. 
We can heartily commend this work as a valuable contribution to the literature of old age." - Medi- 
cal Record. 
BALLANCE (C. A.) and EDMUNDS (W.). - A Treatise on the Ligation 
of the Great Arteries in Continuity. With Illustrations. Royal 8vo. 
$4.00. 
" This book will become a classic. It is on a timely and important subject, and is the fruit of 
deep and thorough research." - Medical and Surgical Journal. 
BARWELL (R.). - Lateral Curvature of the Spine. $1.75. 
BICKERTON (T. H.). - On Colour-blindness. Illustrated. Nature Series. 
(In the pressl) 
BLYTH (A. W.).- A Manual of Public Health. 8vo. $5.25. 
Lectures on Sanitary Law. 8vo. $2.50. 
BRODIE. - Dissections Illustrated. A Graphic Handbook for Students of 
Human Anatomy. By C. Gordon Brodie, F.R.C.S., Senior Demonstrator 
of Anatomy, Middlesex Hospital Medical School; Assistant Surgeon, North- 
west London Hospital. With plates drawn and lithographed by Percy 
Highley. Complete in one volume. $9.00. 
1 2 
WO 7? IIS ON THE MEDICAL SCIENCES 
Part I. The Upper Limb. With seventeen Coloured Plates, two-thirds 
natural size, and ten Diagrams. $2.00. 
" The plates are exceedingly well drawn and placed on the stone. . . . The explanatory letter- 
press is clear and concise." - The Lancet. 
" Of such high merit are the plates of this, the first volume, that the publication of the three 
remaining numbers of the series will be awaited with impatience by all students of anatomy." - The 
Hospital. 
" The scheme is admirably carried out and the plates most reliable. . . . We can confidently 
recommend the work."-Guy's Hospital Gazette. 
Part II. The Lower Limb. With twenty Coloured Plates and six Dia- 
grams. $2.50. 
Part III. Head, Neck, and Thorax. With 20 Plates. $2.50. 
Part IV. Abdomen. With 16 Plates, 13 Diagrams. $2.50. 
BRUNTON. -Works by T. Lauder Brunton, M.D., F.R.S. 
On Disorders of Digestion: their Consequences and Treatment. 8vo. $2.50. 
Pharmacology and Therapeutics; or, Medicine Past and Present. $1.50. 
An Introduction to Modern Therapeutics. 8vo. $1.50. 
BURDON-SANDERSON (J.). - Memoirs on the Physiology of Nerve, 
of Muscle, and of the Electrical Organ. Edited by J. Burdon- 
Sanderson, M.D., F.R.SS.L. & E. 8vo. $5.25. 
CARRINGTON (R. E.). - A Manual of Dissections of the Human 
Body. Second Edition, revised and enlarged. $2.50. 
CARTER (R. B.). - Eyesight: Good and Bad. Second Edition, enlarged. 
With Illustrations. 8vo. $1.00. 
CREIGHTON.-A History of Epidemics in Great Britain. By Charles 
Creighton, M.A., M.D., formerly Demonstrator of Anatomy in the Uni- 
versity of Cambridge. 8vo. 
Vol. I. From A.D. 664 to the Extinction of the Plague. $4.50. 
Vol. II. From the Extinction of the Plague to the Present Time. 
8vo. $5.00. 
CROCKER.-Atlas of the Diseases of the Skin. In a Series of Illustra- 
tions (coloured) from Original Drawings, with Descriptive Letterpress. By H. 
Radcliffe Crocker, M.D., F.R.C.P., Physician, Skin Department, University 
College Hospital, London ; formerly Physician to the East London Hospital 
for Children ; Examiner in Medicine, Apothecaries' Hall, London. Superbly 
illustrated in colours. The plates (96 in number) represent fully 200 life-size 
figures, and are reproduced by chromo-lithography from the original water- 
colour drawings. Each fasciculus consists of six full-page plates, with descrip- 
tive letterpress. The letterpress not only describes the cases from which the 
drawings are taken, but also gives a general account of each disease, its 
differential diagnosis, and treatment. To be issued in 16 folio bi-monthly 
parts. Each part, $6.00. Sold only on subscription to the entire set. 
DOLAN (T. M.). - Pasteur and Rabies. By Thomas M. Dolan, M.D., 
F.R.C.S. i6mo. 50 cents. 
DOWNIE. - Clinical Manual for the Study of Diseases of the Throat. 
By James Walker Downie, M.B. $2.50. AND CONNECTED SUBJECTS. 
3 
ECCLES. - Sciatica. A Record of Clinical Observations on the Causes, Nature, 
and Treatment of Sixty-eight Cases. By A. Symons Eccles. $i.oo. 
" The generally accepted views touching the origin, symptoms, and treatment of sciatica, are 
lucidly presented in this brief record of personal observations. The author does not aim to furnish an 
elaborate monograph on the subject. As a clinical contribution to sciatica the little book will be read 
with interest." - Medical Record. 
The Practice of Massage: Its Physiological Effects and Therapeutic 
Uses. By A. Symons Eccles, M.B. Aberd., Member Royal College Sur- 
geons, England; Fellow Royal Medical and Chirurgical Society, London; 
Member Neurological Society, London; etc. 8vo. $2.50. 
FAYRER - On the Preservation of Health in India. By Sir J. Fayrer, 
K.C.S.I., M.D., F.R.S. i8mo. 35 cents. 
FEARNLEY (W.). - A Course of Elementary Practical Histology. $2.00. 
FITZGERALD (C. E.). - Lectures on Physiology. Hygiene, etc. With 
Illustrations and Diagrams. 75 cents. 
FLUCKIGER (F. A.) and HANBURY (D.).- Pharmacographia. Second 
Edition, revised. 8vo. $5.00. 
FOSTER. - A Text-Book of Physiology. By Michael Foster, M.A., M.D., 
LL.D., F.R.S., Professor of Physiology in the University of Cambridge, and 
Fellow of Trinity College, Cambridge. 8vo. With Illustrations. Sixth Edi- 
tion, largely revised. 
Part I. Blood; the Tissues of Movement; the Vascular Mechan- 
ism. $2.60. 
Part II. The Tissues of Chemical Action; Nutrition. $2.60. (Z« 
the press?) 
Part III. The Central Nervous System. $1.75. 
Part IV. The Central Nervous System (concluded} ; The Tissues 
and Mechanisms of Reproduction. $2.00. 
Part V. (Appendix) The Chemical Basis of the Animal Body. By 
A. Sheridan Lea, M.A., Sc.D., F.R.S. $1.75. 
" The present edition is more than largely revised. Much of it is re-written, and it is brought 
quite abreast with the latest wave of progress of physiological science. A chief merit of this work is 
its judicial temper, a strict sifting of fact from fiction, the discouragement of conclusions based on 
inadequate data, and small liking shown toward fanciful though fascinating hypotheses, and the 
avowal that to many questions, and some of foremost interest and moment, no satisfying answers can 
yet be given." - New England Medical Journal. 
" It is in all respects an ideal text-book. It is only the physiologist, who has devoted time to the 
study of some branch of the great science, who can read between the lines of this wonderfully general- 
ized account, and can see upon what an intimate and extensive knowledge these generalizations are 
founded. It is only the teacher who can appreciate the judicial balancing of evidence and the power 
of presenting the conclusions in such clear and lucid forms. But by every one the rare modesty of the 
author in keeping the element of self so entirely in the background must be appreciated. Reviewing 
this volume as a whole, we are justified in saying that it is the only thoroughly good text-book of 
physiology in the English language, and that it is probably the best text-book in any language." - 
Edinburgh Medical Journal. 
" From its first issue as a single octavo volume of moderate size, in 1876, it has so grown that 
each of the five Parts is, in this sixth edition, nearly as large as the entire original work. From the 
beginning it was regarded as a masterpiece, and at once took a prominent place among text-books of 
physiology. ... If one seeks for the reason of the high estimate in which this work is held on both 
sides of the Atlantic, by the most advanced students as well as by general readers, it may be found in 
the beauty and simplicity of the style, in the lack of personal prejudice on the part of the author, in • 4 
WORKS ON THE MEDICAL SCIENCES 
his thorough familiarity with the progress of physiological knowledge, and in the rare judgment with 
which purely hypothetical ideas and those founded on sufficient evidence are discriminated. The 
work is therefore a most admirable guide to physiological progress as well as general physiological 
knowledge." -The Nation. 
FOSTER. - Text-Book of Physiology. In one volume. By Michael 
Foster, M.A., M.D., etc., etc. Abridged and revised from the Sixth Edition 
of the Author's larger Work published in five octavo volumes. 8vo. Cloth, 
$5.00 ; Sheep, $5.50. 
This new Edition will contain all the Illustrations included in the larger work, and will be pub- 
lished in one octavo volume of about 1000 pages. It will contain all of the author's more important 
additions to the complete work, and be like the sixth edition of that copyrighted in this country. 
FOSTER (M.) and BALFOUR (F. M.). - Practical Embryology. With 
Illustrations. $2.60. 
" A book especially adapted to the needs of medical students, who will find in it all that is most 
essential for them to know in the elements of vertebrate embryology." - Academy. 
FOSTER (M.) and LANGLEY (J. N.). -A Course of Elementary Prac- 
tical Physiology. Fifth Edition, enlarged. $2.00. 
" This work will prove of great value to the teacher of physiology, as an aid to the preparation 
of an eminently practical course of lectures and demonstrations of elementary experimental physi- 
ology. Its chief utility, however, will be to the intelligent student, who, armed with a dissecting case, 
a microscope, and the book, will be enabled to pass his summer vacation in a manner at once interest- 
ing and profitable." - Medical Record. 
FOSTER (M.) and SHORE (L. E). - Physiology for Beginners. i6mo. 
Illustrated. 75 cents. 
" It is a veritable multum in parvo, and will be fully appreciated by those for whom it is 
intended." - American Medico-Surgical Bulletin. 
" Nothing at once so scientific and so simple has appeared on the subject. It is unreservedly 
commended as a text-book for secondary schools."- The Educational Review. 
GALTON. - Healthy Hospitals. Observations on some points connected with 
Hospital Construction. With Illustrations. By Sir Douglas Galton, K.C.B., 
F.R.S. $2.75. 
" This is a valuable contribution to the literature of a most important subject. The eminence in 
engineering circles of Sir Douglas Galton would alone determine its merit. After a brief introduction 
into the origin of hospitals, he defines them as places ' not only for the reception and cure of the sick 
poor . . . but also as technical schools in which the medical student must learn his profession, and as 
experimental workshops in which the matured physician or surgeon carries on scientific research.' . . . 
While the subject-matter is largely technical, it is presented in a clear style, and its meaning is clear 
to any intelligent person. We commend Sir Douglas Galton's book to all builders of hospitals." - 
Medical Record. 
GAMGEE. - A Text-book of the Physiological Chemistry of the Ani- 
mal Body. Including an Account of the Chemical Changes occurring in 
Disease. By Arthur Gamgee, M.D., F.R.S. 8vo. 
Vol. I. The Proteids. $4.50. 
Vol. II. The Physiological Chemistry of Digestion. With two chromo- 
lithographic Charts by Spillon and Wilkinson. $4.50. 
GILLIES.-The Theory and Practice of Counter-irritation. By H. 
Cameron Gillies, M.D. 8vo. $2.50. 
GOODFELLOW (J.). - The Dietetic Value of Bread. $1.50. 
GRESWELL (D. A.). - A Contribution to the Natural History of Scar- 
latina. 8vo. $2.50. .TAT) CONNECTED SUBJECTS. 
5 
GRIFFITHS (W. H.).- Lessons on Prescriptions. i8mo. $1.00. 
HAMILTON (D. J.). - A Systematic and Practical Text-book of 
Pathology. 
Vol. I. Technical. General Pathological Processes. Diseases of 
Special Organs. 8vo. $6.25. 
Vol. II. Diseases of Special Organs ^continued^. Bacteriology, etc. 
2 Parts. 8vo. Each $5.00. 
" This is beyond question the most complete work on Pathology in the English language to-day. 
The author has accomplished his laborious task most successfully. We cannot better criticise it than 
by saying it is beyond criticism."- Canada Medical Record. 
HAVILAND. - The Geographical Distribution of Disease in Great 
Britain. By Alfred Haviland. Second Edition. 8vo. $4.50. 
HAWKINS (H. P.). - On Diseases of the Vermiform Appendix. With 
a consideration of the symptoms and treatment of the resulting forms of 
Peritonitis. By Herbert P. Hawkins, M.A., M.D., F.R.C.P. 8vo. Cloth, 
pp. 139. $2.25, net. 
HILTON (J.). - Rest and Pain. Edited by W. H. A. Jacobson. $2.00. 
HOBLYN. - Dictionary of Medical Terms. Tw.elfth Edition. $2.25. 
HULL AH (J.). - The Cultivation of the Speaking Voice. Clarendon 
Press Series. Second Edition. i6mo. 60 cents. 
HUXLEY (T. H.). - Lessons in Elementary Physiology. With numerous 
Illustrations. Revised by Dr. Foster. i6mo. $1.10. 
" Unquestionably the clearest and most complete elementary treatise on this subject that we 
possess in any language. In this admirable little work, the outlines of the physiology of the human 
body are set forth in the plainest English, with a simplicity and earnestness of purpose which com- 
mand our highest admiration." - Westminster Review. 
JENNER (Sir William). - Lectures and Essays on Fevers and Diphtheria, 
1849-1879. 8vo. $4.00. 
" This volume is a fitting exemplar of the careful and scientific work that has placed the author 
in the foremost rank of his profession. It cannot fail to prove interesting to physicians." - New 
York Medical Journal. 
Clinical Lectures and Essays on Rickets, Tuberculosis, Abdominal 
Tumours, and Other Subjects. 8vo. $4.00. 
JEX-BLAKE (Sophia). - The Care of Infants. i8mo. 40 cents. 
KANTHACK (A. A.). - A Course of Elementary Practical Bacteriology, 
including Bacteriological Analysis and Chemistry. By A. A. Kan- 
thack, Lecturer on Pathology and Bacteriology, St. Bartholomew's Hospital, 
and J. H. Drysdale, umo. Cloth. $1.10. 
KIMBER. - Text-book of Anatomy and Physiology for Nurses. Com- 
piled by Diana Clifford Kimber, graduate of Bellevue Training School; 
Assistant Superintendent New York City Training School, Blackwell's Island, 
N. Y.; formerly Assistant Superintendent Illinois Training School, Chicago, Ill. 
Fully Illustrated. 8vo. $2.50. 
" A well written and unusually thorough work for its purpose. Although intended for nurses, it 
would make an admirable text-book in our schools and academies."-American Medico-Surgical 
Bulletin. 6 
IVORIIS ON THE MEDICAL SCIENCES. 
KLEIN (E.).- Micro-organisms and Disease. Revised, with 120 Engrav- 
ings. $1.00. 
The Bacteria in Asiatic Cholera. $1.25. 
KOCHER.-Text-Book of Operative Surgery. By Dr. Theodor Kocher, 
Professor of Surgery and Director of the Surgical Clinic in the University of 
Bern. Translated with the Special Authority of the Author from the Second 
Revised and Enlarged German Edition by Harold J. Stiles, M.B., F.R.C.S., 
Edin., Senior Demonstrator of Surgery and formerly Demonstrator of Anatomy 
in the University of Edinburgh, etc. With 185 Illustrations. 8vo. $3.50. 
MACALISTER. - A Text-Book of Physical Anthropology. In press. 
MACDONALD (Greville). - A Treatise on Diseases of the Nose and 
its Accessory Cavities. Second Edition. 8vo. $2.50. 
MACEWEN. - Pyogenic Infective Diseases of the Brain and Spinal 
Cord, Meningitis, Abscess of Brain, Infective Sinus Thrombosis. 
By William Macewen, M.D., Glasgow. 8vo. Buckram. $6.00. 
Atlas of Head Sections. 53 Engraved Copperplates of Frozen Sections of 
the Head, and 53 Key Plates with Descriptive Tests. Folio. Bound in 
buckram. $21.00. 
" The ' Atlas ' should certainly be in the hands of every surgeon who aspires to enter the field of 
brain surgery, as a careful inspection of these plates will teach more than many volumes written upon 
the subject. . . . The plates themselves have been executed with the greatest care, the illustrations 
being very fine photogravures from photographic plates, about two-thirds of the actual size of the 
head. The appearance of the book is a credit both to the author and to the publisher." - Medical 
Record. 
M'KENDRICK (J. G.).- A Text-book of Physiology. In 2 volumes. 
Vol. I. General Physiology. 8vo. $4.00. 
Vol. II. Special Physiology. 8vo. $6.00. 
Life in Motion ; or, Muscle and Nerve. Illustrated. $1.50. 
MACLAGAN (T.). -The Germ Theory. 8vo. $3.00. 
MACLAREN (Archibald). - A System of Physical Education. With 
Illustrations. Clarendon Press Series. i6mo. $1.75. 
MACLEAN (W. C.). - Diseases of Tropical Climates. $3.00. 
MARSHALL. - Pain, Pleasure, and Esthetics. By Henry Rutgers Mar- 
shall. 8 vo. $3.00. 
" The book must necessarily have a deep interest for physicians, and especially neurologists, for 
it is concerned largely with the explanation of a phenomenon - pain, the prevention and relief of 
which form such a good portion of their duty. We can heartily recommend it to their perusal and 
study."- Journal of Nervous and Mental Disease. 
MAUDSLEY. - The Pathology of Mind : A Study of its Distempers. 
Deformities, and Disorders. Second Edition. By Henry Maudsley, 
M.D. 8vo. Cloth, pp. 571. $5.00, net. 
MERCIER (C.). - The Nervous System and the Mind. 8vo. $4.00. 
MIERS (H. A.) and CROOSKEY (R.). -The Soil in Relation to Health. 
By Henry A. Miers and Roger Crooskey. $1.10. 
MIGULA (W.). - An Introduction to Practical Bacteriology. Translated 
by M. Campbell, and edited by H. J. Campbell, M.D. Illustrated. $1.60. 
" Its practical character fits it for a guide for students desiring a knowledge of the elementary 
principles of this interesting and important topic." - Popular Science Monthly. AND CONNECTED SUBJECTS. 
7 
MIVART (St. George). - Lessons in Elementary Anatomy. With 400 
Illustrations. i6mo. $1.75. 
PALMBERG (A.). - A Treatise on Public Health, and its Application in 
Different European Countries (England, France, Belgium, Germany, 
Austria, Sweden, and Finland). Edited by Arthur Newsholme. 8vo. 
$5.00. 
" The book is rich in descriptions and illustrations of sanitary appliances, modern and practical." 
- Popular Science Monthly. 
PIFFARD (H. G.).- An Elementary Treatise on Diseases of the Skin. 
With Illustrations. 8vo. $4.00. 
PRACTITIONER (The). - A Monthly Journal of Therapeutics and 
Public Health. Edited by T. Lauder Brunton, M.D., F.R.S., and Don- 
ald Macallister, M.A., M.D. Price, 35 cents, monthly. Annual Sub- 
scription, $3.50. 
Vols. I.-XLII. Half-yearly vols. $2.50. 
Cloth covers for binding volumes, 40 cents. 
REYNOLDS. - A Primer of Hygiene. By Ernest S. Reynolds, M.D. 
(Lond.), Senior Physician to the Ancoats Hospital, Manchester, etc., etc. 
With 50 Illustrations. i8mo. 35 cents. 
" This is a rare bit of text-book making. The pedagogical features are eminently creditable ; the 
literary work, from the text-book standpoint, is admirable. The illustrations are simple, but ideal in 
their clearness and illustrative qualities."-Journal of Education. 
RICHARDSON. - Works by B. W. Richardson, M.D. 
On Alcohol. Paper, 30 cents. 
Diseases of Modern Life. New Edition. (In the Press.) 
ROLLESTON and KANTHACK.-Manual of Practical Morbid Anat- 
omy. Being a Hand-book for the Post-mortem Room. Cambridge Natural 
Science Manuals : Biological Series. I2mo. 81.60. 
" To those interested in post-mortem work, this book can be heartily recommended as a most 
valuable, complete, and efficient guide."- American Medico-Surgical Bulletin. 
STEVEN (J. L.).-Practical Pathology. $1.75. 
STRAHAN. - Suicide and Insanity. A Physiological and Sociological Study. 
By S.A. K. Strahan, M.D., Author of "Marriage and Disease," "Instinctive 
Criminality," etc. I2mo, cloth. $1.75. 
" The subject treated of in Dr. Strahan's excellent little work has always possessed, and, in the 
nature of things, must in future possess keen interest, not only for physicians and jurists, moralists, 
and sociologists, but for all thinking persons. That such a fundamental instinct as the desire to live 
should ever so far yield, either to reason or imperative craving, as to culminate in self-destruction, is 
a phenomenon so opposed to the principles of animal existence as to affect even the most unimagina- 
tive very much as would the sudden reversal of the law of gravitation." - Medical Record. 
" The book is a most interesting contribution to the literature of a subject that is of increasing 
interest to the alienist and psychologist." -N. Y. Medical Journal. 
" The author has presented a very interesting and unbiased study of a topic that is engaging more 
and more attention, for it is not one of the least of the charges against modern society that its organi- 
zation is such that men and women are unwilling to continue as associates thereof."-Popular 
Science Monthly. 
THORNE. - Diphtheria. Its Natural History and Prevention. By R. Thorne. 
$2.00. 8 
ICCRNS ON THE MEDICAL SCIENCES. 
VON KAHLDEN. - Methods of Pathological Histology. By C. von 
Kahlden, Assistant Professor of Pathology in the University of Freiburg. 
Translated and Edited by H. Morley Fletcher, M.D., Casualty Physician to 
St. Bartholomew's Hospital, and Assistant Demonstrator of Physiology in the 
Medical School. With introduction by G. Sims Woodhead, M.D., Director of 
the Laboratories of the Royal Colleges of Physicians and Surgeons, etc. $1.40. 
" This manual of methods recommends itself to every student of histological research. In the 
form of footnotes are presented additions and modifications of great practical value, which bring the 
book up to date. There are chapters on the microscope and apparatus requisite for histological work, 
examination of fresh tissues, methods of hardening, decalcification of tissues, methods of embedding, 
infection of tissues, preparing and mounting sections, staining processes, bacteria, moulds, fungi, 
animal parasites, and microscopical examinations for medico-legal purposes." - Medical Summary. 
WHITE (W. Hale, M.D.). - A Text-book of General Therapeutics. $2.50. 
" In no other text-book of Therapeutics can the same interesting, varied, and necessary material 
be found so usefully, successfully, and agreeably presented." - N. E. Medical Monthly. 
WILLIAMS. - Aero-Therapeutics. The Treatment of Lung Diseases by 
Climate. Being the Lumleian Lectures for 1893 delivered before the Royal 
College of Physicians. With an address on the high altitudes of Colorado. 
By Charles Theodore Williams, M.D., Senior Physician to the Hospital 
for Consumption and Diseases of the Chest, Brompton, and late President of 
the Royal Meteorological Society. 8vo, cloth. $2.00. 
"It is not an exhaustive work, it is true, but it is sufficiently full for the practitioner's needs, 
accurate, practical, and charmingly written. For those who wish a small work on the climatic treat- 
ment of pulmonary diseases, written by a recognized authority on the subject, and presenting practi- 
cally and usefully most reliable information on a very important subject, we must heartily recommend 
Dr. Williams's work."--N. Y. Medical Journal. 
WILLOUGHBY (E. F.).-Handbook of Public Health and Demography. 
i6mo. $1.50. 
" An admirably concise and lucid treatment of preventive medicine, alike commendable to general 
readers, teachers, students, physicians, and sanitary inspectors." - The Sanitarian. 
ZIEGLER. - A Text-book of Pathological Anatomy and Pathogenesis. 
With Illustrations. 8vo. 
Part I. General Pathological Anatomy. $3.50. 
Part II. Special Pathological Anatomy. Sections I.-VII. $3.50. 
Part II. Special Pathological Anatomy. Sections IX.-XII. $3.50. 
ZIEHEN (Theodore). - Introduction to Physiological Psychology. 
Translated by C. C. Van Liew and Dr. Otto Beyer. With 21 Illustrations. 
$1.50. 
" The book can be highly recommended to all who wish a short and clear outline of the science " - 
Educational Review. 
" The general reading of this book would, we think, do more for the schools of America than the 
investment of the same amount of time and money in anything else." - Journal of Education. 
MACMILLAN & CO., 
NEW YORK: 66 FIFTH AVENUE. 
CHICAGO: ROOM 23, AUDITORIUM.