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Cornell University Library 
 
 RC 60.V91 
 Clinical lectures on subjects connected 
 
 3 1924 012 513 093 
 
*3> 
 
THE NEW SYDENHAM SOCIETY, 
 
 Instituted MDOCCLVIII. 
 
 VOLUME CXLVII1. 
 
The original of this book is in 
 the Cornell University Library. 
 
 There are no known copyright restrictions in 
 the United States on the use of the text. 
 
 http://archive.org/details/cu31924012513093 
 
CLINICAL LECTURES 
 
 SUBJECTS CONNECTED WITH 
 
 MEDICINE AND SURGERY. 
 
 BY'VABIOUS 
 
 GERMAN AUTHORS. 
 
 THIRD SERIES. 
 
 THE NEW SYDENHAM SOCIETY, 
 LONDON. 
 
 MDCCCXCIV. 
 
A. 7 iU3 
 
 iLoimou : 
 
 Printed by Jas. Tbuscott & Sox, 
 
 Suffolk Lane, E.C. 
 
 ®tK| 
 
TABLE OF CONTENTS. 
 
 PAGK 
 
 On the Mutual Action of Living Vegetable And Animal 
 
 Cells. By Prof. Th. Billroth 1 
 
 Neurasthenia and its Treatment. By Prof. H. von Ziemssen ... 53 
 
 The Causes of Tuberculosis. By Prof. H. von Ziemssen 87 
 
 On the Healing-in of Foreign Bodies. By Dr. Fritz A. Salzer ... 107 
 
 Diabetes Mellitus. By Dr. B. Hoffmeister 151 
 
 Syphilis of the Nervous System. By Prof. H. von Ziemssen ... 203 
 
 Progressive Muscular Dystrophy. By Prof. Wilhelm Erb ... 231 
 
 Asthma and Diseases of the Generative Organs. By Dr. 
 
 Alexander Peyer 269 
 
 Traumatic Neuroses. By Prof. Adolf. Strumpell 
 
 301 
 
 The Causes and Treatment of Severe and Obstinate Cases 
 
 of Enuresis Nocturna in Males. By Alexander Peyer ... 327 
 
 Recent Advances in the Treatment of Chronic Disease of 
 
 the Spinal Cord. By Dr. L. Lb'wenfeld 345 
 
ON THE MUTUAL ACTION 
 
 OF 
 
 LIVING VEGETABLE AND ANIMAL 
 CELLS, 
 
 A BIOLOGICAL STUDY. 
 
 BY 
 
 PROFESSOR TH. BILLROTH. 
 
 Translated Tnj 
 P. A. JUNKER VON LANG-EGG, M.D., M.R.C.S., Eng. 
 
CONTENTS, 
 
 PAGE 
 
 Change of views on the etiology of the inflammatory processes by the 
 
 miorobiotic doctrine 5 
 
 Homogeneous grouping of inflammation and wound fever with accidental 
 
 diseases of traumatic origin 6 
 
 Septic coccobacteria and the hypothesis concerning them 8 
 
 The first inoculations into the living cornea and their consequences. 
 Conclusive demonstration of the action of primary pathogenic mi- 
 crobes on the healthy living tissue 9 
 
 Microbes as a formative stimulus in general 11 
 
 The microbes as exciters of specific inflammations 14 
 
 Causes of the termination of the inflammatory processes 15 
 
 The formative stimulus and its effects 17 
 
 Conjugation and copulation as formative stimuli 19 
 
 Solution of continuity as cause of formative stimuli 23 
 
 Foreign bodies and pressure as causes of formative stimuli 25 
 
 Medicinal substances as 1 formative stimuli 30 
 
 Extravasation and engorgement of nutritive fluid and increase of function 
 
 are not of themselves a cause of formative stimulus 31 
 
 Bacilli as formative stimuli— 
 
 Lepra, Rhinoscleroma 32 
 
 Tubercle „ 33 
 
 Glanders 38 
 
 Syphilis 38 
 
 Gonorrhoea 39 
 
 Streptococcus urinaa , 40 
 
 Effects of living animal cells upon vegetable cells and vegetable tissue ... 41 
 
 Formative irritability of vegetable cells , 41 
 
 The gall formation — 
 
 Galls on buds, petioles and roots mycocecidia 42 
 
 Zoocecidia 43 
 
 Plant lice galls produced by aphidse 43 
 
 Fly and wasp galls 43 
 
 Origin of galls. Mode of action of animals on the vegetable tissue ... 44 
 Specific influence of the products of growth of animal cells on vege- 
 table cells 47 
 
 Synopsis of the gall formation 49 
 
 The effects of the formative stimuli by microbes upon animal epithelial 
 
 cells 50 
 
 Is the existence of a carcinoma bacillus probable ? 50 
 
ON THE MUTUAL ACTION OF LIVING 
 
 VEGETABLE AND ANIMAL CELLS. 
 
 A BIOLOGICAL STUDY. 
 
 By TH. Billroth. 
 
 Those who have followed with earnest interest the great develop- 
 ment of the medical and surgical sciences during recent times 
 certainly will hail with genuine satisfaction the elucidation of so 
 many hazy speculative opinions which, especially on the causes 
 of disease, have been handed down to us by our predecessors. 
 It is scarcely twenty years since what was called " the genius 
 epidemicus and endemicus " of disease, the different character of 
 the healing tendency of wounds during this or that state of the 
 weather, the causation of pyaemia by the emanations of patients 
 affected with suppuration, and of pneumonia by chills, the indi- 
 vidual predisposition to this or that disease, had been maintained 
 as undoubted facts. And now, that all this should no longer be 
 true ! Now the general shibboleth is : " Microbes ! " The cause 
 of suppuration in general : "Microbes ! " The cause of pyaemia : 
 " Microbes ! " The cause of pneumonia : " Microbes ! " The cause 
 of the formation of tubercles : " Microbes ! " 
 
 Indeed, the modern pathological anatomy of the present day 
 propounds the theorem, "Acute and chronic inflammations are 
 almost in every case produced by Microbes." Only a few poisons 
 when repeatedly and for a longer period introduced into the 
 body may cause chronic inflammatory processes — e.g., alcohol 
 (cirrhosis of the liver, chronic gastritis), phosphorus (maxillary 
 osteitis). Several substances — viz., cantharides, mustard-oil, 
 petroleum, the oils of turpentine and of croton, and ammonia — 
 call forth to the extent to which they come into contact with 
 tissues acute suppurative inflammations, but without ever pro- 
 ducing progressive phlegmonous processes. Cases of accidental 
 application of the last-mentioned substances are so extremely 
 rare that on the whole they may be entirely omitted from the 
 
6 BILLROTH ON THE MUTUAL ACTION OF 
 
 etiology of inflammatory processes. The inflammations and sup- 
 purations, including the common suppuration of wounds, which we 
 meet in medical and surgical practice, are the effects of Microbes. 
 
 It is a hard strain on men of the older and middle-aged 
 generations now to throw overboard all their former convictions, 
 and with these at the same time the enormous lumber of thera- 
 peutics suggested by these now discarded views. They must 
 have some misgivings that their medical craft will prove too light, 
 and will drift without helm and compass, as the shipping of the 
 new freight can neither be easily nor speedily enough effected. 
 
 I still vividly bear in mind how I myself, though I was in the 
 midst of the movement, and perhaps .in some degree its origi- 
 nator, frequently apprehended that it might prove too rapid and 
 one-sided. Certainly surgery has, as regards the therapeutics, 
 earned off the lion's share. I also have very cautiously followed 
 the movement, testing every step and weighing every detail, 
 until I felt fully convinced and became a zealous advocate of 
 the new doctrine, and enthusiastically pursued the new direction. 
 What in the beginning I sadly missed, principles strictly based 
 upon natural science for the methods of the antiseptic operations 
 and treatment, and what I in vain aimed at in my finally aban- 
 doned researches on the coccobacteria septica, had afterwards 
 been advised by others in such a successful manner that the 
 anatomico-physiological details of these investigations, as well as 
 the enormous painstaking work enhanced by these researches 
 and its ingenious execution, have evoked in me wondering 
 admiration. 
 
 I have already demonstrated in earlier papers on traumatic 
 fever and accidental traumatic affections — at a time when trau- 
 matic and inflammatory fevers were still considered as so-called 
 irritative fevers due to nervous action, and when pyaemia was 
 believed to be a miasmatic disease entirely independent of those 
 with which the injured patient may suddenly be seized in a 
 similar manner as with acute traumatic fever — that inflammation, 
 suppuration, and gangrene are intimately connected with trau- 
 matic fever, inflammatory fever, pyaemia, and septicaemia, and 
 that they represent analogous processes in a progressive ratio of 
 danger. 
 
 This homogeneous arrangement of the traumatic and inflam- 
 matory fevers was much more in accordance with the actual 
 
LIVING VEGETABLE AND ANIMAL CELLS. 7 
 
 conditions than the former views, and soon found general accept- 
 ance. What was more natural than to search for a uniform 
 cause which obviously manifested itself in the disintegration of 
 the tissue fluids in the injured and inflamed tissues ? In this 
 instance the term " disintegration " (" Umsetzung ") was accepted 
 in its widest sense. I considered it as a series of changes, the 
 starting-point of which was a most minute disturbance of nutri- 
 tion called forth by a slight solution of continuity, passing on 
 to suppurative solution of the tissue, and terminating in gan- 
 grene and putrefaction. Not only quantitative but also qualita- 
 tive differences were presupposed in this process. The absorption 
 of the products of disintegration caused general disturbances in 
 the organism, mostly fever, occasionally also dangerous condi- 
 tions of poisoning without concomitant fever. Thus originated 
 such terms as aseptic fever without reaction during the healing 
 process, simple traumatic fever, suppurative fever, septic fever, 
 sepsis with collapse, &c. 
 
 Then also a uniform poison, by the absorption of which these 
 conditions were called forth, was searched after, and was pre- 
 sumed to originate in purulent matters (Panum's and Bergmann's 
 "sepsin"). 
 
 But when the conviction became more and more generally 
 accepted that putrefaction, like fermentation, is brought on by 
 very minute living organisms, and when Pasteur, by his important 
 investigations in this direction, by new methods opened new 
 roads, contrary to those of IAebig, whose authority as a chemist 
 had hitherto seemed to me of greater weight and more acceptable 
 than that of Pasteur, I could not, and even now cannot, discard 
 the opinion that every organic tissue, as soon as life is ex- 
 tinguished, or is materially interfered with, must in accordance 
 with its. surroundings enter upon a new mode of change of 
 matter, as it is certainly unable to maintain itself unaltered 
 under these totally different conditions ; there cannot, therefore, 
 in my opinion, exist also a transformation of decaying and 
 decayed tissue without the influence of microbes. The absorp- 
 tion of such kinds of products of decomposition of diseased, i.e., 
 decayed tissues, was, according to my former views, the sole 
 cause of primary traumatic and inflammatory fever. If this, 
 moreover, led to the death of tissue — to gangrene — then the 
 microbes, which in wounds and other focuses of inflammation 
 
8 BILLROTH ON THE MUTUAL ACTION OF 
 
 I considered as saprophytes, appeared and produced that condi- 
 tion generally known as fetid putrescence. By the transmission 
 of these microbes into suppurating wounds, into the urine and 
 the saliva, after they had been accustomed to a certain change 
 of matter in putrid tissue fluids, they likewise could, when taken 
 up in suppurating wounds, in the urine and the saliva, call forth 
 processes of fermentation and putrescence, and thus become 
 secondary causes of disease. 
 
 Influenced, I willingly admit, by the authority of my friend 
 Ghiesinger, I regard the microbes as the undoubted vehicles of 
 contagia, but I had not yet conceived the now generally current 
 idea of "pathogenic bacteria." Though the anthrax bacilli were 
 already known, there was still much divergence of opinions on 
 their significance. 
 
 How then are these microbes constituted ? In what manner 
 do they act ? How do they behave in fermentation ? How in 
 putrescence ? There was then a chaos of the most minute living 
 organisms known by the name of "Infusoria" ; from these we 
 had to start in our investigations. The " Vibriones " were still 
 considered by the majority of physicists to be animalculi ; the 
 notion of the " Sivarm-spores " (" Schwarm-Sporen ") of plants 
 had scarcely yet found its way into medical circles. Now-a- 
 days, when everything has been so well arranged and classified, 
 no one can form an idea of the amount of pains and difficulties 
 it caused to me gradually to separate the individual forms of 
 Cocci and Bacteria, to construe the terms Coccus, Diplococcus, 
 Streptococcus, Streptobacteria, Gliacoccus, Petalococcus, and 
 Ascococcus, to recognise that they are composed of a plasma and 
 a wall, to trace their conditions of growth, and finally clearly to 
 understand that they belong to the Alga, that Zygospores or 
 Besting-spores (" Dauer-Sporen ") and Vacuoli form in them, 
 that they are liable to vesicular degenerations, and that their 
 membranes sometimes develop into thick mucous investments, 
 and in what manner this can to a certain degree be brought 
 about by the nutritive medium (" Nahrboden "), &c Each 
 newly appearing form led again in a roundabout way to new 
 investigations on the Algaa and Fungi, in order to gain some- 
 how a morphologic support. The whole task was carried out on 
 too broad a basis, it was far beyond my botanical and chemical 
 knowledge. No one could more keenly feel the shortcomings 
 
LIVING VEGETABLE AND ANIMAL CELLS. » 
 
 of his work than L They may only be compared with the ex- 
 plorations of an insufficiently instructed traveller in a country 
 still very little known. I therefore was obliged, in order not to 
 lose the little I had achieved, to stop short, and I constructed a 
 typical form, " the Coccobacteria septica," from which I imagined 
 the majority of the other forms which came within the range 
 of my investigations were derived. I was supported in my 
 speculations by the dawning Darwinism, and the authority of 
 Naegeli. I wound up, as regards etiology, with the hypothesis, 
 " the products of inflammation " (the first origin of which in most 
 cases still remained to me as obscure as before), specially the 
 ferment which I conjectured to exist in them, "the Zymoide" — 
 are a particularly favourable nutritive medium for the whole 
 progeny of the Coccobacteria group which gain entrance partly 
 from outside, partly from the blood. Here they luxuriate and 
 by their intrinsic vital activity increase the inflammatory process 
 and materially contribute to its progress. They undergo in each 
 focus of inflammation a certain change of matter and transfer it, 
 when entering another living tissue, into the latter. 
 
 The normal uninjured surface of the body is protected against 
 the invasion of these elements. The dried microbes only act 
 when converted into resting-spores, and when, after their ingress 
 into the animal body, they find sufficient water to enable them 
 to swell out and germinate. 
 
 What next strongly impressed me on this subject was the 
 inoculation of putrescent fluids containing microbes into the 
 living cornea. What had hitherto seemed to me a hypothesis, 
 viz., that cocci may be capable of finding their way also into 
 healthy tissues and thus to overpower and destroy the vital 
 energy of the tissue-cells, has in this instance become a proved 
 fact. At the same time another phenomenon became evident : 
 that the effect on the cornea of dogs was very slight, but on the 
 cornea of rabbits in many cases totally destructive. But as the 
 same star-shaped figures, as shown by the investigations of A. von 
 Frisch, likewise appeared on the dead cornea, these inoculated 
 cocci might also be genuine sapr.ophytes, which, owing to a 
 peculiar vegetative energy in the living cornea, only gained 
 more permanent hold, and this view is supported by the con- 
 siderable differences of reactive processes observed in the living 
 cornea of rabbits. These investigations were followed by the 
 
10 BILLROTH ON THE MUTUAL ACTION OF 
 
 more and more interesting results of inoculation with Anthrax 
 bacteria, and finally by Koch's new methods of cultivating microbes 
 on solid nutritive mediums, which, for the time, explains the 
 preceding observations, and thus within a short time the idea of 
 "specific pathogenic bacteria" became fully established, almost 
 like Minerva sprung from Jupiter's brains. Even then I still 
 hesitated ; we only become partially acquainted by these experi- 
 ments with the amphibious nature of these Algas ; their behaviour 
 against pigments offers only an external evidence. Chemists 
 always mistrust a chemical substance which is only known by its 
 reactions, they demand an elementary analysis. We in like 
 manner ought to survey the development of microbes in all their 
 stages before we are justified in saying that we thoroughly 
 know them. What we at present individualise by colouration 
 as specific pathogenic forms, may be very deceptive characteristics 
 of generic differences. Algae are by their nature genuine 
 aquatic plants ; may not many of those which at present we 
 distinguish as separate genera prove themselves to be merely 
 different stages of a still unknown series of successive develop- 
 ments? Need I remind you of the formerly unsuspected 
 connection between Tape-worm, Cysticercus and Echinococcus ; 
 of the history of the Pencillium ; of so many Pleomorphisms ; of 
 the Parthogenesis through numerous generations ; of the manifold 
 larval conditions of insects ; of the sea-stars, &c. ? We still are 
 uncertain whether we have to consider the different forms of the 
 yeast plant as occasional vegetative forms of Fungus spores in 
 fluids, or as a special genus of plant. 
 
 All these considerations, however, become of but minor import- 
 ance in view of the immense progress achieved, especially in 
 etiologico-pathological respect, by the methods of Koch and his 
 followers. The number of observations systematically pursued 
 is overwhelming. A summary collection of these by Baumgarten 
 in his classical work (" Manual of pathological Mycology" *) raises 
 our imagination into the loftiest regions of a reliable etiology of 
 the future, especially as regards the inflammatory processes and 
 the zymotic diseases. It is a charm equal to the highest artistic 
 enjoyment, to give oneself to the study of such a book with the 
 warmest enthusiasm, as it contains the summary of the best 
 scientific minds of our time. Where a vigorous movement 
 
 * " Lehrbuch der pathologischen Mykologie." Braunschweig, 1890. 
 
LIVING VEGETABLE AND ANIMAL CELLS. 11 
 
 towards progress commences it is perceived by minds which, 
 irresistibly attracted by this movement, are at first carried away 
 by it and soon themselves turn the wheels by the force of their 
 own labour. This we have witnessed in Histology, in the history 
 of evolution, in Pathological Anatomy and Histology, in Physi- 
 ology and in Surgery. 
 
 We shall now consider the views which have been formed on 
 the relation of " Pathogenic Microbes " to the tissues of the animal 
 body.* 
 
 We must, above all, clearly understand that only a growing 
 and multiplying organism can become dangerous to the healthy 
 animal living tissue, and that only in the case when its assimi- 
 lative energy is more intense than that of the tissue-cells. The 
 cocci and bacteria, after their ingress into the respective tissue 
 fluids, must not only be able to live, to continue their existence, 
 but they must also be stimulated by their reception to an energetic 
 activity of growth, to vigorous reproduction. One might here 
 already say, the products of change of matter of the animal tissue 
 cells furnish the formative stimulus for the vegetable cells (the 
 microbes) in a manner the reverse of what takes place in the 
 formation of galls, of which anon. 
 
 It will scarcely be of any importance what the microbes add 
 by their probable inherent poisons. The eifects of their growth can 
 at first merely be purely mechanical. I shall not underrate the 
 effect on tissues like the cornea ; the sundering of the lamellae 
 certainly will cause a very material disturbance of nutrition. 
 But this effect is strictly local, and in other kinds of tissues does 
 not come into consideration. The chemical effects, however, are 
 of much higher importance. We believe they are as follows : — 
 
 1. Microbes deprive the tissues of a great portion of their 
 special nutritive fluids. The tissues are starved, they atrophy — 
 genuine parasitism— certainly an extremely rare occurrence in 
 animal tissues, because the growth of microbes can barely be 
 imagined without an influence on the tissues of their change of 
 matter, which must never be lost sight of. 
 
 2. Microbes deprive the tissue fluids of certain indispensable 
 
 *I should'like to propose a more general use of the word "Microbes'' as a 
 collective term. I fail to understand that the collective term " Bacteria" should 
 also include the " Cocci." It seems to me altogether contrary to the sense to 
 designate a globe by the Greek name of a ro<Z,"BaicTi;pia ) " and to employ the 
 Latin translation "Bacillus " for a subdivision of "Bacteria." 
 
12 BILLROTH ON THE MUTUAL ACTION OF 
 
 constituents ; what is left to the tissues is either absolutely in- 
 sufficient for their existence, or produces in them abnormal 
 conditions, e.g.., softening or coagulation. 
 
 3. Microbes produce secretory matters which call forth an 
 abnormal condition in the tissues, and eventually directly 
 destroy them. 
 
 4. The products of change (Ptomaines, Brieger) enter into the 
 Wood and act as poisons, e.g., on the nervous system ; or they 
 directly cause decomposition of the blood, which only slowly or 
 not at all is neutralised. These effects on the blood also cease 
 with the action of the microbes on the diseased part. 
 
 5. Microbes find their way into the blood, fix themselves in 
 the capillaries at odd places, produce here new focuses of disease, 
 from which result the same effects on the blood as from the 
 primary focus, i.e., they set up metastasis. 
 
 6. The microbes enter into the blood, live and multiply in the 
 circulating blood, and starve, or poison, or decompose it. 
 
 • I do not assert that herewith all the possible effects of the 
 action of the microbes, which, until lately, we always considered 
 merely as destructive, are exhausted, but the principal points of 
 our idea may hereby be indicated, as they of course can enter 
 into manifold combinations with each other. 
 
 These conclusions were followed by communications on the 
 Lepra-bacilli (Klebs), on the Scleroma-bacilli (A. von Frisch), as 
 excitants of proliferation of connective tissue, which at once 
 upset the notions which we hitherto had entertained on the 
 purely destructive effects of the microbes. We suddenly found 
 ourselves face to face with the fact that vegetable cells can act as 
 a fwrely formative stimulus on the animal tissue cells. Now 
 followed the most recent observations on the formation of 
 tubercles, and of the nodules of Charbon by the action of bacilli, 
 which at first act as a formative stimulus on the fixed corpuscles 
 of the connective tissue, then produce increased vascularity, 
 eventually suppuration in the circumference, and finally cause 
 necrosis of the primary new formation. Likewise a combination 
 of hyperplasia with inflammation and necrosis. This kind of 
 action of growing vegetable cells on animal cells presents a most 
 remarkable phenomenon, which, in the following, I shall endeavour 
 to treat of more explicitly. 
 
 But before we continue, may I be permitted to speak of some 
 
LIVING VEGETABLE AND ANIMAL CELLS. 13 
 
 phenomena which had been brought to our knowledge by the 
 latest investigations as regards the etiology of inflammation ? 
 The alterations which tissues undergo in acute inflammation are 
 fairly known. We are acquainted with the inflammations of 
 surfaces, as acute catarrhs, as blennorrhoeas, in which the white 
 blood corpuscles emigrate in masses from the blood-vessels, the 
 epithelium more rapidly exfoliates, the vessels become larger, 
 and the glands more copiously secrete. We know the croupous 
 inflammations, in which fibrine forms on the surface of membranes. 
 We know the diphtheritic inflammations, in which the formation 
 of superficial fibrinous membranes is associated with coagulation 
 of the tissue fluids ; this coagulation again partially resolves, but 
 may also lead to necrosis of the whole affected tissue. We like- 
 wise know the phlegmonous process, which rarely resolves without 
 suppuration, frequently terminates in coagulation of the tissue 
 fluids, in partial necrosis of the connective tissue with formation 
 of abscesses, sometimes also in gangrene of the skin, in which 
 after the arrest a process of regeneration follows, which finally 
 ends in cicatrisation. 
 
 Formerly the causes of these processes had barely been ex- 
 plained. Now we know that they always are called forth by 
 microbes, and almost exclusively by cocci, which either immigrate 
 from the outside (the diphtheria cocci also through the hair-bulbs 
 in the uninjured skin) or from the blood (where they may be 
 present in infinitesimal numbers), and sometimes enter into the 
 previously injured or diseased tissues, but may also enter into 
 perfectly healthy tissues (spontaneous osteo-myelitis). 
 
 But what seems to me most remarkable is the fact that these 
 conditions,which we hitherto have generally considered as different 
 degrees of one and the same process, are caused by entirely different 
 hinds, although morphologically related genera, of cocci. Thus we 
 have the Slennorrhosal (gonorrhoea) coccus, which merely produces 
 the egress of leucocytes accompanied by slight hypersemia, but 
 never leads to parenchymatous processes. Further, we have the 
 coccus of pneumonia and diphtheria, which sets up inflammation 
 with formation of fibrine. We have the very frequent Staphylo- 
 coccus pyogenes aureus, which engenders the majority of phlegmons 
 and abscesses and endocarditis. We have the Staphylococcus 
 pyogenes albus, which, forming a milky-white pulp, corrodes the 
 tissues ; the Streptococcus pyogenes, which more frequently is met 
 
14 BILLROTH ON THE MUTUAL ACTION OF 
 
 with in suppurating cavities, and very probably is identical with 
 the Erysipelas coccus, &c. In short, there is a special form of coccus 
 for every kind of inflammation, which again may become more or 
 less dangerous in proportion to its vegetative energy. The 
 whole of our antiseptic art consists in the successful exclusion 
 from wounds of these ubiquitous microbes, which not only vege- 
 tate within, but also outside the animal organisms (and are at 
 the same time both saprophytic and pathogenic). If we succeed 
 in that, there will be no suppuration even in the most extensive 
 losses of substance ; there will only be regenerative processes, 
 which are entirely independent of microbes. And here we meet 
 with the most remarkable phenomenon of immunity or resistance 
 of certain kinds of animals against these microbes. The pus-cocci 
 vegetate in no animal so well as in man ; in the dog, e.g., only 
 with extreme difficulty. Indeed, every new experience in this 
 field raises new problems. At any rate, these experiences on 
 the most eclectic peculiarity of the action of vegetable cells on 
 the tissues of different kinds of animals is in the highest degree 
 remarkable and interesting, and continually recalls to us new 
 mysteries of the cell life in the face of which our chemical know- 
 ledge fails. 
 
 It seems in some cases as if animal cells would directly be 
 poisoned by the secretion accompanying the growth of the 
 vegetable cells. In other cases, e.g., in the blennorrhceic process, 
 the connection of the capillary walls appears to become loosened 
 so that the leucocytes more easily find egress. Or are these 
 perhaps even attracted by the Blennorrhoeal coccus through the 
 capillary walls? Other kinds of coccus again loosen the capillary 
 walls in such a manner that they permit the more easy escape 
 especially of the red blood corpuscles, that perhaps they more 
 readily tear, in short that they invest the morbid processes with 
 a hsemorrhagic character. Other kinds of Microbe cause 
 coagulation of the fluids on the surface of the tissues, others 
 within the interstices of the tissues, others again render the 
 coagulated blood of the thromboses in the vessels mucoid, or 
 soften it into puriform pulp, whilst others again convert the 
 connective tissue into a soft gelatinous state (a kind of pep- 
 tonisation), which may take its course with or without profuse 
 extravasation of leucocytes. There consequently exist specific 
 forms of cocci, or at least different degrees of their vegetative 
 
LIVING VEGETABLE AND ANIMAL CELLS. 15 
 
 energy, for every form, almost for every stage, of inflammation, 
 suppuration, and necrosis. 
 
 And now. in what manner, and for what reason, do such pro- 
 cesses of microbic proliferation terminate ? Various suggestions 
 have been offered on this subject. We have long been acquainted 
 with the manner and the mode in which the amcebas encompass 
 with their plasma minute bodies and their immediate surround- 
 ings, how they take them up, sometimes digest and also again 
 eject them. We know that the leucocytes behave exactly in the 
 same manner as the amcebas, also when after their emigration 
 they had been converted into pus-corpuscles by the trifoliated 
 fission (" Kleeblattfurchung ") of their nucleoli. Moreover, they 
 frequently have been fed without impairment of their vitality 
 with the most subtile carmine or cinnabar granules for the pur- 
 pose of special examination. In like manner it has been 
 observed that leucocytes receive within themselves, amongst 
 others, also vegetable microbes, cocci and bacteria, and that 
 either they are poisoned by, or kill and digest them. Metsch- 
 nihoff most accurately investigated these processes, and called 
 those cells which devour the microbes by the name of 
 " Phagocytes." It, however, seems very doubtful, and is most 
 emphatically contradicted, particularly by Baumgarten, that this 
 manner of death of the microbes, which moreover seems not to 
 be all too common, constitutes a very essential cause for the 
 cessation of the processeswhich are set up by microbic vegetations. 
 Another cause may prove of greater importance. It is an 
 universal law for organised beings that they cannot live in the 
 final products of their change of matter. The ferment cell 
 perishes in the alcohol which it has produced from the sugar ; 
 the bacteria of putrescence die in the putrid products of decom- 
 position into which they have split up the albuminous substances. 
 Man dies in the carbonic acid which he expires if the further 
 supply of fresh oxygen is cut off. 
 
 The fermentation fungi in the products of this change of 
 matter gradually become less and less vigorous in their chemical 
 action ; they sink to the bottom, and their vegetation ceases long 
 before all the sugar has been converted into alcohol and carbonic 
 acid, and long before the nitrogen, which is necessary for their 
 existence, has been used up. In consequence of this vegetative 
 exhaustion, other kinds of fungi settle in the alcoholic solution, 
 
16 BILLROTH ON THE MUTUAL ACTION OF 
 
 and convert the alcohol into acetic acid. In most cases during 
 rapid fermentation the acid fermentation soon commences along- 
 side the alcoholic fermentation. The same thing takes place in 
 the transition of lactic into butyric acid fermentation, &c. If 
 we apply the same notion, e.g., to a phlegmonous process set up 
 by the Staphylococcus aureus, we may presume that the coccus 
 vegetation which in healthy tissue fluids energetically thrives 
 and rapidly spreads into the interstices of the tissue, will sooner 
 or later partly be destroyed by the products of change of matter, 
 partly be impaired in its vegetative energy, and consequently 
 more and more slowly extend into the healthy tissue. At the 
 commencement the victory is entirely with the microbes, gradu- 
 ally, however, their vigour grows weaker, and now the tissue 
 cells and leucocytes can again successfully take up the battle 
 for the nutritive material, which the microbes in their state of 
 exhaustion can no longer materially alter. I made the following 
 observation in the fluid contents of metastatically inflamed 
 articulations which I repeatedly punctured: the first, as yet 
 moderately clear, fluid obtained by puncture contained a large 
 quantity of streptococci, but only few pus cells. A few days 
 later the fluid was already changed into thin pus with few strep- 
 tococci but a prevailing quantity of pus cells. Again, somewhat 
 later there were scarcely any more streptococci to be found in 
 the pure and already somewhat thickened pus. The pus cells, 
 therefore, had finally conquered the whole field ; the streptococci 
 had perished in the chemical and morphological products of its 
 own vegetative activity. 
 
 Experiments in artificial cultivation yielded another important 
 result; they showed that microbes on the identical nutritive 
 medium, in which in the beginning they most luxuriantly throve, 
 gradually perished, even when the new generations had again 
 and again been transplanted into new nutritive media of exactly 
 the same kind. Before the complete cessation of their vegetation, 
 the growth gradually became weaker and weaker, and more 
 slow; the forms no longer attained their perfect development, 
 and their elements in experimentative inoculations were ever 
 decreasing until their virulence was entirely exhausted. It 
 would therefore seem that these minute and most simple plants 
 are as little capable as larger plants of more complicated structure, 
 of growing continually with uniform vigour, but that they 
 
LIVING VEGETABLE AND ANIMAL CELLS. 17 
 
 require rest from time to time, which is offered them in nature 
 by the variations of temperature and of the amount of moisture 
 in the air and the soil ; they perhaps moreover require a frequent 
 change of nutritive medium in order not to degenerate. Of the 
 Spirochietes, the cause of recurrent fever, it must be concluded 
 from all the symptoms that their vegetative life in the human 
 blood is only of but a few days' duration, after which a state of 
 rest sets in, which again after the lapse of a few days is followed 
 by a new period of growth. Similar conditions may be the 
 cause also of many other strictly typical zymotic diseases. 
 Gardeners assert that old seed grains germinate much later than 
 young ones under perfectly identical conditions. The like may 
 also be the case with the resting-spores (" Zygospores ") of 
 microbes. In short, the conditions of vegetable life, of its 
 vigorous or feeble growth (with which the virulence is essentially 
 related), its degeneration and its decay, are so manifold and 
 dependent on so many circumstances, that we shall still for a 
 long time necessarily be engaged in their study. Immense as 
 has been the progress of our knowledge of the microbes in regard 
 to their pathogenic properties, we shall not possess an exhaus- 
 tive comprehension of their nature before we have acquired 
 further information in botanical, anatomical, and physiological 
 directions. Then only many an obscure fact may be cleared up, 
 which at present remains unexplained, as to the absolute and 
 relative immunity of single genera of animals, of single varieties 
 and single individuals. 
 
 We have now well-nigh accustomed ourselves to consider the 
 microbes as destructive enemies of the animal cells and their deriva- 
 tives, the tissues, and to recognise their peculiar different patho- 
 genic effects in this direction. But, as already mentioned, a 
 perfectly new fact has recently come to our knowledge, viz., that 
 the microbes may act upon the animal cells not only as destructive, 
 but also as formative stimuli. 
 
 Formative stimulus and formative irritability ! These notions 
 had first been developed by Virchow in his ingenious paper, 
 " Irritation and irritability " (" Beizung und Beizbarkeit," Arch. 
 fiir pathol. Anat., vol. xiv.). Our present generation cannot 
 realise the impression which this and many similar compre- 
 hensive critical treatises of Virchow made at the time upon the 
 younger generation whom he associated with his researches and 
 
 C 
 
18 BILLROTH ON THE MUTUAL ACTION OF 
 
 who followed his lead. Now-a-days everything is over-hastened 
 our time suffers from an unappeasable hankering after continual 
 new, or apparently new, facts, with the hope of a possible sensa- 
 tional success. No time will now-a-days be allowed to take 
 occasional rest for reflection and reconsideration on the on- 
 ward road of scientific pursuits. Where have we arrived at ? 
 What have we left behind— what lies ahead ? Is it worth the 
 while to proceed in this or that direction ? Did we gain by our 
 detailed work profitable knowledge of, and insight into, the 
 whole? For all this one does not find time now.- "Irritation 
 and irritability," once the watchword, the Alpha and the Omega 
 of a whole medical, school! We cannot dispense with these 
 notions in our investigations of organic nature. Therefore also 
 Virchoiv's interpretation in this direction can never become 
 obsolete ; on the contrary, it still remains to the present day the 
 basis of whatever we can or wish to designate by these terms, 
 strange as it may seem to us to find the great reformer battling 
 against views which for the. present generation can only appear 
 intelligible by the aid of detailed historical studies. In that, 
 however, we best recognise the fundamental influence which 
 Virchow has exerted from the standpoint of pathological anatomy 
 over the whole conception of the processes of living organisms. 
 Virchow was the first who lucidly demonstrated that not only the 
 nerves and muscles are invested with irritability, but that irrita L 
 bility is likewise a property of the substance of each individual 
 cell, and that this irritability can manifest itself by alterations of 
 function, nutrition, and formation ; the action of the stimuli can 
 only be explained on the supposition that they transiently call 
 forth, or permanently produce, specific chemical and physical 
 alterations in the change of matter of living organisms. Although 
 the limits of functional, nutritive, and formative irritability can as 
 little be separated with precision as those of the functional, 
 nutritive, and formative stimuli, nevertheless there is in this 
 distinction a rich source of understanding of, and interest in, 
 processes taking place in tissues which in their continual evo- 
 lution lead to the most remarkable normal and pathological 
 products. Virchow, in his afore-mentioned treatise, principally 
 occupied himself with the formative irritability. We shall in the 
 following briefly review those influences on the living organisms 
 which have to be considered as formative stimtdi on living tissues. 
 
LIVING VEGETABLE AND ANIMAL CELLS. 19 
 
 It is self-evident that formative stimuli only can take effect if 
 the nutritive processes be at the same time increased. Increased 
 nutrition, however, does not always result in a new formation, 
 i.e., an increase of tissue elements, and as little also increase of 
 function. A certain specific properly must therefore be attributed 
 to the formative stimulus. 
 
 This will not likely be disputed as regards the alterations 
 which take place in fully developed organisms. In growing 
 organisms, however, nutrition and formation are so intimately 
 blended that they cannot be thought of separated even for the 
 shortest moment. The action of the spermatoid on the ovum 
 appears to me as the highest exercise of power of a specific 
 formative stimulus and of a specific formative irritability. Let 
 us submit the processes herein involved to a summary examina- 
 tion. A series of Algae of the lowest order, to which also belong 
 the so-called " Schizo-" and " Phyco-mycetes," which are of special 
 interest (Bacteria, Cocci, and yeast-plants), only multiply by 
 continuous division of cells ; favourable (fluid or soft) conditions 
 of the soil suffice to keep up their intrinsic formative irritability 
 for a considerable time, but will finally prove capable of ex- 
 haustion for vegetations produced by a certain generation in the 
 same nutritive medium. There nutrition and formation go entirely 
 hand in hand ; the essential in the life of these organisms is just 
 their multiplication ; we may say of these organisms that we 
 only can recognise their life in, and by, their multiplication. 
 
 The first phenomenon which we can bring into relation with 
 conjugation is the appearance of Zygospores (resting-spores), which 
 are even found in so low an order of Algae as the bacteria (resting- 
 spores have not yet been observed in cocci). In these the con- 
 tents of the cell, in which up to this moment a continuous division 
 had taken place, contract to a solid globule, which henceforth 
 remains for some time at rest, may become completely desiccated 
 like a seed-grain, but afterwards germinates when brought under 
 favourable conditions of moisture and temperature, and growing 
 more or less luxuriantly according as it subsequently finds 
 assimilable nutritive matter (of which anon), produces a new Alga 
 identical with that from which the spore first sprang. 
 
 A somewhat different process takes place in the Mucorini (to 
 which order the moulds belong). In these a firm conjugation 
 takes place between the terminal points of two filaments of the 
 
20 BILLROTH ON THE MUTUAL ACTION OF 
 
 same plant, the septum between the conjugated terminal cells 
 disappears, the contents of both cells commingle and contract to one 
 solid capsulated globule. This represents the resting-spore or 
 Zygospore of these fungi, which possess the same properties as the 
 afore-mentioned Zygospores which had been produced by the 
 contents of a single cell. 
 
 The "same is the case with the conjugation of Swarm-spores as 
 it takes place in the genera of Algae of the Pandorinae, the Hydro- 
 dictyons, and the Ulothrichse in the most varied modes, in which 
 also three or four cells may combine into the formation of a 
 zygospore. Whether the fusion into plasmodia of the Myco- 
 mycetes, to which also the Amoeba belong, which so closely 
 resemble the leucocytes and the pus cells, may be considered as 
 a true conjugation, still remains doubtful. 
 
 We see that in these plants no separation of sexes yet exists, or 
 at least is not perceptible, in order to produce a cell which already 
 potentially includes a new plant. We, therefore, cannot say in 
 this case that one of the cells which participate in the conjuga- 
 tion exerts on the other cell a formative, though for the time 
 being merely a local formative stimulus. 
 
 Such a formative stimulus first distinctly manifests itself in 
 the Oogonia and Antheridia (Sea- Algae, fucus) by the formation 
 of differently shaped elements, of which the movable, ciliated, 
 mostly very minute cells are distinguished as male cells (Sperma- 
 tozoids), and the resting, larger ones, as female cells (ovule cells). 
 Hereby we suppose that the spermatozoids act as a specific 
 formative stimulus on the specific formative irritability of the 
 ovule by the conflux of its plasma with that of the ovule cell. 
 I purposely use the term "specific formative stimulus," because 
 the fully developed unfertilised ovule cells most probably are 
 susceptible of purely nutritive, and also of other kinds of stimuli. 
 It is of course a mere hypothesis if we surmise that the ovule 
 cells as well as the epithelial cells of the seminal ducts of the 
 testis participate in the formation of tumours, especially of tera- 
 tomas, in which we as little know the formative stimulative im- 
 pulse as the process itself. The supposition of such a process, 
 however, does not contradict our other views on the processes in 
 the cellular elements as far as I am able to survey them. 
 
 A striking difference between the most highly organised plants 
 the giant trees of the virgin forest, and the most highlv deve- 
 
LIVING VEGETABLE AND ANIMAL CELLS. 21 
 
 loped animals, is found in the circumstance that the impulse to 
 formative development in the former seems to act almost without 
 limit, and that the formative irritability in their growing parts 
 persists, as from every young twig a young tree may be raised, 
 whilst the growth in the most highly organised animals stops at 
 a certain limit, and no multiplication from single parts (with the 
 exception of the fertilised ovum), no genuine vegetative multipli- 
 cation is known. If a tree always remains under the same 
 conditions of nutrition, moisture, and climate, if it neither be- 
 comes diseased nor is in any other way injured, we might imagine 
 that it would eternally continue to live and grow. Even if we 
 were to saw it off above its main root, new buds would spring 
 up between the wood and the bark, or from the roots, which 
 again would grow into branches ; branches would strike new 
 roots, and whilst the stem and the majority of the roots of the 
 former giant tree had barely decayed, several young saplings 
 would have already sprung up, of which the most vigorous, the 
 most rapidly growing, would overwhelm the others, secure for 
 itself light and air, and after a thousand years a new giant tree 
 would replace the old one. Thus this plant, provided that it has 
 not been exterminated by root and branch, cannot be annihilated ; 
 it does not require organs of fructification to produce never so 
 many generations ; it persists through countless ages by its own 
 inherent formative force. Nutrition and formation are here one 
 and the same ; the nutritive sap, the temperature, the conditions 
 of moisture, are at the same time both nutritive and formative 
 stimulus. The tree is. (with the exception of the wood) continu- 
 ally growing in all its parts, ever young, ever able to reproduce 
 from itself, without the act of fertilisation, new individuals. 
 
 If we fully take in the conception of this immense formative 
 vegetative energy and persistency, and then compare with it the 
 very limited measure of vegetative life, and the necessity of the 
 connection of two sexes for the reproduction of new individuals, 
 which is always more or less liable to the casualties of contact ; 
 and if we consider the rapidity with which the growth may be 
 arrested in the most highly organised animals, then the forma- 
 tion of animals will no longer appear as the result of the highest, 
 but rather of an already diminished generative force. 
 
 After having recognised persistent growth, unimpeded forma- 
 tion, as the most important manifestation of life, as the essential 
 
22 BILLROTH ON THE MUTUAL ACTION OF 
 
 condition of life in the most highly organised plants, the question 
 will arise. What causes; e.g., man's growth to stop at a certain 
 limit ? Why.has only one period of growth been allotted to him ? 
 We had to become familiar with the mystery of growth ; we like- 
 wise have to accept the mystery of arrest of growth. These 
 phenomena, just because they are mysteries to us, still lie 
 beyond the compass of the natural sciences. Their nature is 
 so inscrutable for our as yet insufficient methods of investigation 
 that they fail to extend our knowledge.* 
 
 * The experiments hitherto made with a view to explain or to understand the 
 cessation of growth caused by mechanical conditions have but very little 
 satisfied me. Professor Thiersch was the first who, in the province of histology, 
 pointed out, albeit in a most guarded and modest manner, that the connective 
 tissue atrophies in advanced age (his examinations started from the facial inte- 
 gument of old men) , and becomes flaccid from this cause, and that, in consequence, 
 its epithelial elements, especially also the glands and hair follicles, released from 
 the pressure of the tense connective tissue, may readily lend themselves to 
 extravagant new formations. This logically leads to the idea that at the termi- 
 nation of growth epithelial and connective tissue elements are brought into that 
 opposite state of pressure which is necessary for the persistent normal function 
 of these tissues. Eeality, however, does not confirm this hypothesis, e.g., the 
 observation of those distressing cases in which the most terrible epithelial carci- 
 nomas develop in the rectum of still young, strong men. If the impulse of 
 growth, by which nucleus diverges from nucleus and cell from cell, actually be 
 latent in the developed tissue, viz., in some manner be converted into expansive 
 force, this is not likely to be dependent on the mutual pressure of the tissues, as 
 even under the pressure of so dense a [membrane as, for instance, the tunica 
 albuginea of the testicle, occasionally from quite unknown causes, and not rarely 
 after a contusion, an immense luxuriant mass of' sarcoma may develop. The 
 pressure of such tissues on each other is not able to arrest either the growth or 
 the pressure from secretions, e.g., of a cyst; how could otherwise so many thick- 
 walled continuous ovarian cysts form ? The other hypothesis, that in each cell 
 and in each congeries of cells the continuance of the change of matter occurs 
 only for a certain period, and thereby the capability of multiplicating is limited, 
 or in other words, also that the formative functions of the cells are exhaustible, 
 is merely a periphrase, but not an explanation, of observed facts, as has already 
 previously been mentioned concerning the microbes. It is as if we were to say 
 that a " Fate ' ' also rules over these phenomena ; it is the standpoint of resignation 
 on which we may, perhaps, for the present rest, without letting ourselves be 
 deterred from further investigations and combinations of our sensory observa- 
 tions by Dubois' anathema, " IgnoroMmus ! " It may perhaps be a comfort to 
 some that even this fate, which dominates the duration and termination of our 
 growth, may occasionally be outwitted, by what power we, of course, do not 
 know ; but if we have set up a good Ormuzd, a wicked Ahriman will not fail to 
 turn up too. There is in the anatomico-pathological museum at Vienna a well- 
 formed skeleton in which all the epiphysial cartilages are persistent, and which, 
 from the size and slenderness of the bones, might be supposed to be that of an 
 individual of about twelve years of age. But it actually belonged to a dwarf 
 who earned his living as a pedlar in Vienna, and who died in his thirty-ninth 
 year. Nothing is known about the size of his parents. "We meet in this case 
 with the continuance of the juvenile stage. We shall not be able to understand 
 
LIVING VEGETABLE AND ANIMAL CELLS. 28 
 
 We now arrive at the phenomena, which, in the fully developed 
 organism, we may accept as the results of the action of formative 
 stimuli. 
 
 One of the most powerful stimuli we know of, and the most 
 certain in its action, besides fecundation, is the solution of 
 continuity of tissues (from which we except' the fluid tissues, as 
 blood, lymph, and pus, in which solution of continuity, strictly 
 speaking, cannot take place.) 
 
 Whether the tissues be separated from the outside at the 
 same time with the skin, or whether their continuity be anyhow 
 subcutaneously interfered with, the remarkable process will 
 always take place, that at the edges of the point of separation 
 they will, by the division of the nuclei and the cells of their 
 specific tissue elements, enter in some measure into a foetal 
 condition in a certain, though mostly only limited extent, and 
 that a new period of growth will set in, which as a rule is limited 
 to only a few days.* 
 
 or to explain, either by mechanical or other kinds of processes, why in this in- 
 stance the growth had been suddenly arrested, and why the epiphysial cartilages 
 did not become ossified as pre-ordained by fate. 
 
 No more significance than the calling up of " Pate " is the familiar comparison 
 of the building up of the organism by cells with the building up of a house ; the 
 latter pre-supposes a builder who carries out a certain plan. But as we know 
 absolutely nothing of such a builder and a plan in the construction of an organism 
 which, according to the comparison, ought also some time to reach a certain 
 finish; and as modern physiology, on the contrary, maintains that every in- 
 dividual particle of protoplasm constitutes at the same time both builder and 
 building material, so this comparison likewise proves lame, and fails to advance 
 lis any further. 
 
 Finding the greatest enjoyment in the intellectual play with ideas which we 
 derive from our observations of nature, I could not refrain from writing and 
 publishing this little essay in order to relieve my mind at last of these thoughts. 
 In doing so, I, of course, have the feeling that such kind of reflections offer to 
 ourselves, and perhaps also to others, more subjective artistic pleasure than 
 that they objectively advance us in science, and that our imagination is more 
 engaged in it than our intelligence. But where lies the boundary line ? Often 
 already have I put to myself the question, without, however, ever having suc- 
 ceeded in solving it, whether in the composition of the ninth Symphony 
 Beethoven's imagination, sentiment, or intellect, had been the most active. I 
 believe that these our reflections likewise spring from a source which had already 
 existed as a unity before the division of our Psyche into the germinal layers of 
 the intelligence, the sentiment, and the imagination. 
 
 *Rabi, in a discussion on his paper " On the principles of histology " (" Ueler die. 
 Principien der Histologic" Verhandlungen der anatomischen Gesellschaft, 1889, p. 
 62), protests against the use of the term "fatal" and its interpretation. He says, 
 " Cells are elementary organisms, and being such, they are subjected to the same 
 laws as organisms of a higher order, persons, and their parts. Just as little as a 
 higher organism may become degenerated ever so much, and again return to its 
 
24 BILLROTH ON THE MUTUAL ACTION OF 
 
 If we succeed in excluding every other kind of stimulus, espe- 
 cially all kinds of microbes, this growth in contiguous wound- 
 surfaces will continue for about six to eight days, by which time 
 the softened edges of the wound will in some measure have be- 
 come blended ; the foetal growth with its rich formation of cells 
 now ceases, the foetal connective tissue becomes converted into 
 cicatricial connective tissue, and the luxuriation of muscular 
 cells and nerve and vascular cells altogether stops. If the 
 different tissues are placed into accurate juxtaposition, the 
 muscles will unite with muscular tissue, nerves with nerve 
 tissue, and vessels with their orifices, and after the lapse of some 
 time it will be scarcely possible to discover the cicatrice. 
 
 As in the foetus, so also here, everything is in the beginning 
 formed in excess, especially in the primitive vascularisation. In 
 like manner, as the whole foetal capillary network of the vitreous 
 body disappears, so also in the cicatrix the numerous vessels, 
 which will no longer be necessary for the subsequent nutrition 
 of the tissue with its regular circulation of fluids, will disappear; 
 the cicatrix, which in the beginning had been thick and red, 
 
 embryonic condition, so likewise an already developed tissue can never again 
 recover its former embryonic state." This seems to me a battle with the wind- 
 mills. Surely nobody would ever have thought of understanding the term 
 " embryonic " employed in pathologic histology in such a sense that the cells, 
 which for the purpose of regeneration of tissues are produced from elements of 
 the latter, are equivalent, let us say, to the segmentation spheres of the ovum. 
 The terms " embryonic " or "fcetal " are here only intended to express, that a tissue 
 which had already arrived at its termination of growth, may again return to a 
 growing, i.e., juvenile state. We use here the term " return " (*' zuriickkehren " ) 
 because we suppose in most of the animal tissues, at the same time with the 
 termination of growth, a finished boundary state beyond which there is no 
 further advance ; Rail himself also speaks of "fully developed tissues" (" ausgebil- 
 deten Geweben "). Our interpretation of these processes of tissue regeneration in 
 man (entirely leaving out of the question the inflammatory process) is shortly as 
 follows : man is composed of a number of tissues which entirely consist of cells 
 and of fluid, as the epithelia, the blood, and the lymph. Epithelial strata com- 
 posed of several layers not even in old people attain in the deepest layers a 
 fully developed state, they continue to form and grow as long as the organism 
 lives. Of the process of multiplication and regeneration of the red blood 
 corpuscles in fully developed organisms we know almost nothing. Of the 
 lymph cells we merely suppose that they may be produced by division or budding 
 from the elements of the lymphatic glands, the spleen and the medulla of the 
 bones. We know of the corneal epithelium, that defects aro not replaced from 
 the depth, not from the corneal elements, but by lateral sprouting of the 
 epithelial cells which surround the defect ; I must however waive the question 
 whether an alteration takes place in the cellular substance itself, or whether the 
 corneal epithelium never is "fully developed," but perhaps is equivalent to the 
 cells of the Bete Malpighii. As regards the simple fibrous tissue, with which I 
 
LIVING VEGETABLE AND ANIMAL CELLS. 25 
 
 becomes thin and pale. The whole process has definitely 
 terminated, it has attained its permanent state. Why so ? 
 That we know as little as we know why, in general, growth 
 ceases or commences. We must here again fall back upon the 
 idea of " hereditary tendency," which means about as much and 
 as little as " Kismet." 
 
 We know several causes which are able to increase the forma- 
 tive irritability after injury. 
 
 In the first place, foreign bodies, e.g., coagulated blood, between 
 the edges of the wound or between the separated tissues in 
 general. The serum which during coagulation had been pressed 
 out, is absorbed, and the clots only temporarily remain. We 
 already have discarded as erroneous the former view that coagu- 
 lated blood may be converted into living tissue. On the contrary, 
 it acts as a formative stimulus, the surrounding tissues having 
 reverted to a foetal condition, grow into the coagulum, act upon 
 it, liquefy it and take its place, whilst behind it permanent tissue 
 
 class the connective tissue, the muscles, and the nerves, we in general suppose 
 that they, provided there be no special formative stimuli in action, are "fully 
 developed " as soon as the growth of the whole organism ceases. At this moment 
 all the granular protoplasm around the nuclei, barring some most minute remains, 
 will have been converted into fibrous tissue. This we consider to be the final 
 state decreed by Fate in the individual animal body in which it henceforth will 
 persist for a longer or shorter term. If we now observe, e.g., in divided muscular 
 fibre, that Karyolmeds* commences in the stump, that at the same time granular 
 protoplasm forms round the new nuclei, and that this process continues for 
 several days, so that the end of the stump of muscular fibres now entirely 
 consists of nuclei and granular protoplasm, if we moreover observe how this 
 protoplasm separates and attaches itself to the individual nuclei and is con-, 
 verted into striped muscular fibrillse, and how the muscular fibres now somehow 
 grow out of the sarcolemma of the old one, then we call this process "rejuvenes- 
 cence" (-" Junffwerden") of the muscular tissue, the amputated fibres and fibrillsB 
 of which could not at once grow out, but at, and between those, new granular 
 protoplasm had first to be formed, so that the new muscular fibres were produced 
 in the same manner as we had observed in their development in the embryo. It is 
 not my intention to enter here more fully into processes of regeneration which 
 take place in a gradually more complicated manner in other kinds of tissue, in 
 which, in essentials, the same processes are observed. Let us therefore retain 
 the term and the interpretation of " Return to the embryonic state " (" Embry- 
 onalwerden") of tissues in the regenerative processes, until these observations 
 have been proved erroneous or the interpretation of these observations as absurd. 
 
 *Nole by the Translator. — Karyohinesis (napuov "walnut," also nucleus, «"""» 
 "I move") is the process of division of cells (in the tissue cell) as far as it 
 passes through a series of certain successive alterations strictly according to the 
 law, in the interior of the nucleus, whereby the latter find expression in the 
 different arrangements of the formed constituents of the nucleus (nucleus 
 corpuscles) and retiform framework of the nucleus. 
 
26 BILLROTH ON THE MUTUAL ACTION OF 
 
 is already forming. Muscles and nerves probably are soon 
 arrested in their growth, but the young connective tissue with 
 its vessels (granulation tissue) sprouts into the blood coagulum, 
 and only stops after it has grown from both sides into one another. 
 
 In the meanwhile all the coagulum will have become liquefied 
 and, with the exception of a few remains of pigment, will have 
 become absorbed. The young (inflammatory) new formation, 
 the granulation tissue, will now at last also come to rest, and 
 pass into the permanent state of a cicatrix. In this manner, 
 in a roundabout way, and of course with loss of time, the same 
 result has been attained as if no foreign body had ever been 
 interposed between the surfaces of the wound. This process, 
 however, may be frustrated by the amount of the extravasation, 
 or by the defective formative activity of the insinuating young 
 tissue. The vegetative energy of the granulation tissue may 
 sooner or later become exhausted, long before it has grown into 
 the blood coagulum. The granulation tissue is arrested in its 
 formation, it is converted into very vascular cicatricial tissue, and 
 now yields also a small quantity of transudation, by which the 
 coagulum is again rendered richer in fluids (if perhaps complete 
 coagulation had not already taken place from the beginning). In 
 this manner is achieved the inca/psulcdion of the extravasated 
 blood, which, like other kinds of longer standing exudations and 
 secretions, becomes more and more rich in albumen or mucin, to 
 such a degree that altogether it can no longer, or only very 
 slowly, be absorbed. Thus we now have a " Hcematoma," an 
 " inaa/psulated blood cyst," before us. 
 
 If a non-absorbable foreign body (glass, porcelain, iron, lead, 
 wood, &c.) is embedded in the tissue, it acts in the first line by 
 solution of continuity as a formative stimulus. Let us suppose 
 the most favourable case, viz., that the foreign body is perfectly 
 free from pus cocci, moreover, that it has not carried with itself 
 into the tissue such cocci during its entrance, then its formative 
 stimulus will be but very slight, and will in most cases soon 
 entirely cease. The foetal connective and vascular tissues which 
 have developed around it very soon will be arrested in their 
 growth, and will be converted into cicatricial tissue. The foreign 
 body will be incapsulated. According to Professor F. A. Salzer's 
 investigations, the following modifications will now take place. 
 The foreign body by its own weight presses upon the tissue, it 
 
LIVING VEGETABLE AND ANIMAL CELLS. 27 
 
 gravitates (iron, lead), and thereby continually, but very slowly, 
 causes new slight solutions of continuity, which again will call 
 forth new slight formative stimuli ; behind it the tissue closes 
 with the most minute formation of cicatrix, whilst before it new 
 young tissue, though in the most minute quantity, continues to 
 form. The mechanical irritation also by sharp-pointed edges 
 (glass) comes into consideration ; by these longer and more inten- 
 sive formative stimuli are kept up ; the capsules which form 
 around such bodies become thick and callous, their inner surface 
 becomes permanently organised and commences to exude serum 
 into the interior ; thus a cyst forms around the foreign body. 
 The formation of new bursas mucosas under callosities, which 
 have been considered as effects of pressure, may likewise be ex- 
 plained as the effect of frequently repeated minute interruptions 
 of continuity of tissue, as the single effects of pressure may be 
 imagined to be divided. Or we might likewise regard as forma- 
 tive stimuli the continuous effects of pressure which do not 
 materially disturb the tissue and the circulation. That would 
 also represent a new cause of formative stimulus, against which 
 no objection could well be raised. 
 
 We cannot dismiss the problem of the formative stimulus 
 produced by the presence of foreign bodies without mentioning 
 a phenomenon in which this stimulus probably acts with its 
 highest power, namely, the effect of a large sequestrum enclosed 
 within an osseous capsule on the continuously increasing, though 
 not unlimited, thickening of this osseous capsule, as long as the 
 sequestrum remains in it. Circumscribed accumulations of pus 
 in the medulla, and large yellow tubercles, may likewise call 
 forth a formative stimulus on the cambium layer at the surface 
 of the bone. Such a stimulus may occasionally also produce 
 extensive stalactite-like formations of osteophytes in tuberculous 
 articular epiphyses. But such new formations of bone will not 
 under any other circumstances take place with the same regu- 
 larity as around the sequestrum. That this really is pre- 
 eminently a mechanical stimulus — the chemical stimulus in this 
 case is probably of minor importance — that it is brought on by 
 the dead bone is evident from the fact that after the removal of 
 the sequestrum all further thickening of the bony shell ceases, and 
 that after the extraction of the sequestrum the filling up of the 
 remaining empty cavity as a rule takes place very slowly, and 
 
28 BILLROTH ON THE MUTUAL ACTION OF 
 
 that very soon after sequestrotomy a partial absorption of the 
 newly formed bony masses at the same time with sclerosis of the 
 remaining parts generally follows. I observed a necrosis caused 
 by acute osteomyelitis of the whole tibial diaphysis accompanied 
 by purulent softening of both epiphysial cartilages. The seques- 
 trum naturally very soon being loosened, I extracted it in order 
 to diminish the suppuration. In this case only the somewhat 
 thickened periosteum was but slightly ossified, and this very 
 inconsiderable formation of bone also disappeared after the 
 removal of the sequestrum, and there remained an incurable 
 pseudo-arthrosis, owing to the small amount of bone formed from 
 the remaining articular end where no ossification whatever took 
 place at the greater portion of the diaphysis. 
 
 I now have to treat of the conditions under which a formative 
 stimulus manifests itself at a defective cutaneous surface. The 
 results from the loss of skin by lacerations, charring, freezing, 
 excision, &c, are that the granulation tissue is exposed on the 
 surface without any chance of ever uniting with the opposite 
 tissue. In what manner is this loss of substance to be replaced, 
 and permanent cicatricial tissue formed ? What becomes of the 
 tissue after the formative stimulus of the solution of continuity 
 has ceased to act? Every surgeon knows that this process is 
 terminated by the formation of an investment of epidermis which, 
 commencing at the periphery of the loss of substance, gradually 
 continues over the granulating surface. Already the earlier 
 observations on the healing process of superficial wounds under 
 a scab have shown that the formation of granulations under the 
 scab is very restricted ; that under particular circumstances the 
 formation of epidermis continues also under the scab, and that 
 after the casting oif of the latter a complete cicatrix appears. 
 Similar processes have in recent times likewise been observed in 
 extensive losses of substance, and have been obtained by the 
 exclusion of vegetations of pus-cocci, i.e., by a perfectly suc- 
 cessful antiseptic treatment. 
 
 If we, however, combine the older and the more recent 
 observations, we still find that under certain circumstances the 
 granulation tissue will develop with peculiar luxuriance- in 
 other words, that the formative stimulus of the solution of con- 
 tinuity sometimes persists. We know that the conversion of 
 granulations into cicatricial connective tissue only takes place in 
 
LIVING VEGETABLE AND ANIMAL CELLS. 29 
 
 a regular manner if the granulating surface is established upon 
 moveable and contractile tissues. The condensation of granula- 
 tion tissue, which to a certain extent also brings on contraction 
 and eventually obliteration of the immoderately developed vessels, 
 favours the development of epidermis upon the granulating sur- 
 faces. We may therefore say that the incapability of contraction 
 of the granulating base (bone and fascia) acts in some manner 
 as a passive formative stimulus influencing the luxuriance of the 
 development of the granulations by preventing them from under- 
 going their natural fate of transformation into cicatricial tissue. 
 Practical surgery has long ago recognised this fact, and has 
 devised a series of methods in order to further under these 
 circumstances the condensation of the granulations. 
 
 The profuse secretion of pus (though frequently merely a kind 
 of mucous discharge) in these granulations when becoming 
 fungous, being certainly dependent on the settling of pus or 
 blennorrhoeal cocci in these granulations, we might perhaps 
 attribute to them, as promoters of the pus secretion, a certain 
 degree of formative irritation. I merely mention this in relation 
 to later experiences according to which some kinds of bacteria 
 (tubercle bacilli) bring about at the same time formative irrita- 
 tion of the fixed tissue-elements, emigration of leucocytes, 
 vascularisation, and formation of granulation tissue.* 
 
 Finally, we should not omit to mention that we are acquainted 
 with certain medicinal substances which must undoubtedly be 
 
 * We cannot deny that from the present standpoint of our knowledge, a precise 
 distinction between purely phlogogenic, pyogenic, and formative stimuli, and 
 consequently also an absolute distinction between inflammation, suppuration, 
 and regeneration, is barely feasible without straining the observed facts. All 
 these three processes may certainly almost exist entirely each by itself, but their 
 combination is by far the more frequent occurrence, although with a prominence 
 of one or the other. On this subject I have come to the following conclusions : 
 (1) We must regard the softening of tissues (especially of the walls of the blood- 
 vessels) in inflammation as a kind of peptonisation, as the immediate effect of the 
 growth of phlogogenic microbes. This effect may be very slight and transient, 
 so that the tissue elements, without having undergone a formative alteration, 
 very soon return to their normal physiological condition ; the walls of the vessels 
 permit the emigration of a number of leucocytes which re-immigrate into the 
 vessels and return to their normal state. (2) The stimulus acts longer and more 
 slowly; it also involves the fixed tissue elements, especially the cells of the 
 connective tissue and the vessels, it acts formatively upon these ; at the same 
 time emigration of leucocytes in moderate number takes place, perhaps here 
 and there also a fibrinous exudation forms. These processes may occur in sub- 
 acute and chronic inflammations, and they may terminate in hypertrophic 
 thickening, which again may completely disappear. (3) The phlogogenic 
 
80 BILLROTH ON THE MUTUAL ACTION OF 
 
 considered as formative stimuli. While it is generally ad- 
 mitted ■ that the leucocytes, much as they have been experi- 
 mented with and discussed, are not able to produce granulation 
 and connective tissue, we must suppose that' the granulation 
 tissue with its vessels can only be the product of fixed tissue 
 elements, though direct observations in this respect have not 
 come to my knowledge. Granulation tissue surely is always 
 the result of formative stimulus, and genuine tissue formations 
 always proceed only from fixed tissue elements. I am inelined 
 to maintain, a priori, that the principal elements of granulation 
 tissue are the product of the .cells of the vascular walls. The 
 older surgeons employed a number of remedies in order to further 
 the formation of granulations. Warmth and moisture in the 
 form of poultices and continuous warm local baths, turpentine 
 ointment, tartar emetic ointment, nitrate of silver ointment, 
 savin ointment,' &c, enjoyed a well-founded reputation as stimu- 
 lants for the formation of granulations. We know of jodoform, 
 that its continuous application calls forth a particular vascular 
 granulation, even in excess. Glycerine behaves in' a similar 
 manner, and especially increases to the utmost the dilatation of 
 the vessels. Solutions of carbolic acid act as a lasting formative 
 stimulus, producing thick vascular cheloid cicatrices. Similar 
 effects are known in the cases of cicatrices from cauterisation with 
 sulphuric or nitric acid, of the cicatrices of burns by flame, &c. 
 
 It has been proved; by similar observations,' that the formative 
 irritation .therefore can likewise be increased by chemicals, as has 
 already been shown by former observations, that it can be called 
 forth by mechanical means. 
 
 ptomaine sooner or later kills the tissue with or without coagulation. Thereby 
 loss of substance is brought about, a solution of continuity which by itself acts 
 as a formative stimulus and leads to cicatrisation — to regeneration. 
 
 It seems to me, however, barely theoretically feasible to regard this latter case 
 as the only possible one, and to deny every kind of formative stimulant effect to 
 the chemical products of growth from the staphylo- and strepto-coccus, &c, par- 
 ticularly in consideration of the fact, that also in the majority of blennorrhceas 
 the vessels are not only mechanically enlarged, but also become in many ways 
 tortuous and twisted, the latter always being the consequence of a longitudinal 
 growth of the vessels ; and real growth cannot altogether be imagined without a 
 numerical increase of tissue element, because the mere enlargement alone of the 
 elements could not cause the formation of so many windings and meanderings of 
 the vessels in the inflamed tissue. I can only fully agree with Baumgarten, 
 when he states : " We shall now be obliged to admit an inflammatory proliferation, 
 of the fixed tissue cells, beside the regenerative and purely hyperplastic (tumour- 
 forming) one." 
 
LIVING VEGETABLE AND ANIMAL CELLS. 31 
 
 Some of my readers may perhaps have been surprised that 1 I 
 had not long before alluded to the accumulation and engorgement 
 of nutritive fluid in certain regions of the body as formative stimuli. 
 I believe that this cause has been much overrated. There is a 
 general current and hackneyed opinion that the- development 
 of varicosities produces not only purely hypertrophic but also 
 hyperplastic processes in the skin, the subcutaneous cellular 
 tissue, and even in- and on the bone. But even should the 
 problem be solved why varices only occasionally call forth these 
 conditions, and why sometimes not at all, I should still hesitate 
 to attribute it to the engorgement of venous blood and of lymph 
 alone without further inquiries for the cases of hyperplastic 
 elephantiasis. Sporadic cases of elephantiasis of the leg- as they 
 occur in man are frequently accompanied -by far slighter vari- 
 cosities than in the' female > with the most delicate normal skin. 
 I suppose that the aforementioned hyperplasias have -the same 
 causes as other kinds of inflammation, namely, that they are 
 brought about by feebly formative irritant microbes, and that they 
 therefore always represent a merely accidental ■ combination with 
 varicosities. We must not forget that the formation of vari- 
 cosities is essentially due to an enormous untimely longitudinal 
 growth of certain veins which surely cannot possibly take place 
 without hyperplasia of the cells of the vascular walls. If increase 
 of intervascular pressure (to which the main cause is mostly 
 attributed in the etiology of varicosities) really participate in this 
 process, the effect could only very slowly be brought about; 
 experiments may perhaps elucidate this question. Again, heredity 
 or " Fate " is here, according to my experience, the principal 
 cause ; the predisposition to hyperplasia of the venous walls is 
 transmitted by the act of impregnation 5 it also takes place without 
 any accidental causes. Not long ago I saw in consultation a 
 strong young man of about twenty years of age, whose leg was 
 completely covered with thick varicosities but without thickening 
 of the skin. All my inquiries after accidental causes failed. 
 His mother, when still quite a young woman, had already become 
 affected with varicosities. - 
 
 It has not yet been ascertained whether increased, function 
 may also be considered as one of the formative stimuli. The 
 majority of those who have investigated this subject, especially 
 Nbthndgel in his instructive treatise, " On adaptations and com- 
 
32 BILLROTH ON THE MUTUAL ACTION OF 
 
 pensations in pathological processes " (" Ueber Anpassungen unci 
 Ausgleichungen bei pathologischen Zustdndsn "), favour the supposi- 
 tion that increased function principally acts as a "nutritive" 
 stimulus, i.e., that the increase in mass, with the increased action 
 of muscles and glands, is principally brought about by enlarge- 
 ment of the functional tissue elements (hypertrophy), but scarcely 
 traceable to multiplication of these (hyperplasia). To this the 
 arteries of medium size apparently are an exception, which 
 immensely thicken and elongate for the establishment of the 
 collateral circulation, This interstitial hyperplasia of the walls 
 of the vessels, however, is not the immediate consequence of the 
 increased muscular action above the ligature, it does not occur 
 even in the ligatured arteries above the ligature, and therefore 
 could not be compared with the hypertrophy of the left ventricle 
 in consequence of stenosis of the aorta. On the contrary, it 
 occurs in those arteries which, branching off above the ligature, 
 establish the collateral circulation. I am unable to decide 
 whether Nothnugel's hypothesis be correct, that the increased 
 velocity of the blood current in these small arteries, which are 
 devoid of vasa vasorum, causes the nutrition, and thereby the 
 hypertrophy and hyperplasia, of the elements of' the vascular 
 walls. At any rate, it does not conform with this view if we 
 consider the lessened velocity of the current and the increased 
 pressure in the veins as formative stimulus as the cause of the 
 development of varicosities, a view which, as I have already 
 stated, I do not share, though I am unable to substitute for it a 
 more feasible explanation.* 
 
 I shall now treat of the formative stimuli which are called forth 
 by a groiving vegetable cell upon the cells of the animal organism. 
 I have no personal experience on Lepra, but MicJculicz's re- 
 searches on Rhinoscleroma had been carried out under my eyes at 
 a time when the bacterial etiology which had been propounded by 
 von Frisch at a much later period had not even been thought of. 
 
 A kind of firm granulation tissue is produced, of which we at 
 present know that it must have emanated from the fixed elements 
 of the connective tissue by formation of cells of epithelial (or 
 
 * The latest experiments of Ponfck on the immense capability of regeneration 
 of the liver after excision of even very large portions of it are of particular great 
 interest. This process is so powerful that it probably can only be brought about 
 by a genuine " hyperplasia." It is the most considerable instance of regeneration 
 hitherto known of in warm-blooded animals. 
 
LIVING VEGETABLE AND ANIMAL CELLS. 33 
 
 more accurately, perhaps, of endothelial) character. The new 
 connective tissue which is enclosed within the old, is, in contrast 
 to the genuine granulation tissue, but very scantily vascularised ; 
 it soon changes into firm cicatricial cheloid tissue, which becomes 
 more and more dense, and finally may even ossify. Suppuration 
 is only brought about in it by accidental causes acting from with- 
 out. Knowing at present that the whole process has been called 
 forth by bacilli, we must say that the bacilli act in the first line 
 as a formative stimulus on the fixed cells of the connective tissue, 
 probably also of the muscles and nerves ; but their effect as 
 formative stimulants is but of very short duration. It scarcely 
 comes to a disturbing emigration of leucocytes and excessive 
 vascularisation ; but the effect of the bacilli is merely formative 
 and is soon extinguished; the transformation of a new tissue 
 into a cicatrix takes place with relative rapidity without any 
 kind of disturbance whatever. The process much resembles the 
 formation of the fibrous tubercle, of which anon. 
 
 The action of the tubercle bacilli upon the cellular elements of 
 the animal body is much more complicated. The effect of these 
 bacilli, which grow with but moderate vegetative energy, manifests 
 itself, according to Baumgarten, in this, that a more or less rapid 
 division of the nuclei after the various types of the so-called 
 " Kcuryokinesis " takes place in the fixed elements of the con- 
 nective tissue, by which large flat cells with oval nuclei are pro- 
 duced, which are converted into a firm tissue granule, the primary 
 tubercle proper. Thereby under certain conditions also the 
 formation of multinucleated cells more or less frequently comes 
 about — of the so-called " tubercle giant cells" with nuclei attached 
 to the wall and central disintegration. 
 
 I shall here omit to speak of the " giant cells," which recently 
 have been the subject of so much discussion, and of the manifold 
 hypotheses regarding their origin, as they are not of material im- 
 portance for the fundamental biological processes which now 
 follow. 
 
 The common fate of tubercles is, as is well known, their disin- 
 tegration into a dry cheesy mass. But before this process is so 
 far advanced, dilatation of the vessels with emigration of leuco- 
 cytes, and after that the formation of an envelope of lymphoid or 
 granular tissue, takes place in their immediate neighbourhood. 
 Herewith the central growth of the tubercle generally ceases ; 
 
34 BILLROTH ON THE MUTUAL ACTION OF 
 
 its disintegration will be complete ; it will be incapsulated like a 
 foreign body by the conversion of the granulation tissue into 
 cicatricial tissue (provided that no pus cocci intervene and change 
 the tubercle into a tuberculous abscess or into a tuberculous 
 ulcer). 
 
 To this I have still to add that the disintegration of the 
 tubercle by no means always takes place. There are (though 
 very rare) cases in which the endothelial cells — probably when 
 the irritation set up by only a few bacilli with but feeble vege- 
 tative energy — are directly converted into firm connective tissue 
 without previous disintegration. The "fibrous tubercle " formed 
 in this manner, which especially is occasionally observed in the 
 cervical and axillary glands, contains, as 1 have only recently 
 had an opportunity of convincing myself, no detritus, and does 
 not represent anything like a firm capsule around the disinte- 
 grated tubercles, but is throughout purely fibrous. I now feel 
 convinced that those forms of fibrous malignant lymphoma which 
 had been investigated in my clinic and described by von Wini- 
 warter, and which are so very differently constructed from the 
 soft malignant lymphoma which partially disappears under 
 arsenical treatment, are a bacillary, genuine tubercle disease. 
 These investigations ought to be repeated from this new point of 
 view. 
 
 The question now arises, as regards the common form of the 
 centrally disintegrated tubercle, By what hind of stimulus is the 
 granulation tissue produced which luxuriates around it ? We might 
 here, in the first place, suppose, that the disturbance of continuity 
 and the gradually increasing pressure of the growing tubercle 
 act as formative stimulants. We know that a gradual new 
 formation of tolerably dense membrane of connective tissue 
 takes place around a slowly growing cysticercus, around trichini, 
 and around ecchinococcus cysts. We know that some cyst walls 
 ■consist of entirely new formed membrane. We further know 
 that the tunica vaginalis around the fluid of hydrocele frequently 
 becomes extremely thickened by new formation of connective 
 tissue, that moderately dense membrane develops around the fat 
 enclosed in sebaceous glands (atheroma), and also in the forma- 
 tion of ranula a similar membrane forms around the retained 
 mucus-like saliva. In all these cases both pressure and dis- 
 turbance of continuity are undoubtedly, although slowly and 
 
LIVING VEGETABLE AND ANIMAL CELLS. 35 
 
 feebly, active as formative stimulants, without, however, any 
 particular concomitant chemical effects whatever on the enclosed 
 fluid or pulpy contents of these cysts. The expansion of a 
 tubercle, however, is so slight, and in comparison with the 
 above-mentioned cases relatively of so short a duration, that 
 other and more important features must certainly here come into 
 play. What causes, then, the formation of granulations around 
 the tubercle ? Is it the continued direct effect of the tubercle 
 bacilli, or is it due to the action of endothelial cells which had 
 been primarily produced by the bacilli, and consequently an 
 indirect bacillary effect, somehow in the second generation? 
 Baumgarten's observation, that in rapidly forming miliary 
 tubercles the number of bacilli is very great, the disintegration 
 of the endothelial new formation is very rapid, the development 
 of the covering lymphoid tissue is so very rapid, that the forma- 
 tion of an epithelial nodule may be easily, almost entirely, over- 
 looked, support the view that the bacilli themselves constitute 
 the formative stimulus also in the formation of lymphoid (granu- 
 lation) tissue. They consequently would be able to produce one 
 after the other two kinds of tissue — viz., the endothelial nodule 
 and the granulation tissue. That the latter, according to our 
 present views, can only be brought about by leucocytes, I already 
 repeatedly pointed out. The apparent peculiarity of this pheno- 
 menon might perhaps be explained in that bacilli act as a 
 formative stimulus also on the capillary cells. Some closer 
 attention ought perhaps to be directed to the possibility of 
 Karyokinetic forms in the nuclei of the capillaries. If such are 
 discovered — which seems not to be improbable after the observa- 
 tions of giant cells, which are found in intimate connection with 
 the walls of the vessels in Paechioni's granulations (Kolliker's 
 Osteoblasts') — we may suppose that the capillaries, with their 
 adventitious cells, and especially the cells on the walls of the so- 
 called " transition vessels," lead not only to the new formation 
 of vessels, but in general to the development of granulation 
 tissue, the origin of which, from leucocytes, is now no longer 
 tenable. 
 
 The formative stimulating action of the tubercle cells accord- 
 ing to their quantity and their vegetative energy is at any rate 
 extremely various (we here leave entirely out of consideration 
 the relative immunity of individual warm-blooded animals, as 
 
36 BILLROTH ON THE MUTUAL ACTION OF 
 
 well as the question of the existence of individual immunity and 
 predisposition). We may well regard the acute miliary tubercle 
 with its rapid lymphoid transformation as the one end, and the 
 fibrous tubercle in which scarcely an appreciable formation of 
 lymphoid tissue takes place, as the other end of the series. 
 
 The formative stimulus of the tubercle detritus, of the yellow 
 tubercle, is at any rate but very slight. We may observe, e.g., 
 that in bone an eburnified shell is formed around the tubercle, 
 which, however, does not give rise to extensive sclerosis or ex- 
 tensive osteophytes over a large area except in the case of the. 
 formation of a sequestrum and the immigration of pus cocci, 
 which then again calls forth a new formation of granulations 
 around, and purulent softening of the tubercle, an accident 
 which also seems again to support the view that a certain degree 
 of formative stimulus may likewise be attributed to the pus cocci. 
 That the tubercle bacilli themselves are able directly to stimulate 
 the suppurative process in a material degree is very improbable, 
 according to the observations which we have gathered up to this 
 date, although the opportunity for the emigration of leucocytes 
 must be facilitated by the formative stimulus on the vascular 
 walls, and the transformation of the latter into soft protoplasm. 
 
 One point more ought here to be mentioned. A copious rapid 
 development of a crop of tubercles leads in the majority of 
 cases to the formation of fluid sero-fibrinous exudations. These 
 are genuine exudations, not merely transudations, like those in 
 the pleural and peritoneal cavities during the development of 
 tumours, especially of carcinomas and sarcomas. Acute tuber- 
 culosis of the synovial membrane, of the pleura and the meninges, 
 is almost always followed by exudations which cannot be dis- 
 tinguished from others in acute inflammations. Consequently, 
 tubercle bacilli, when acting with exceptional vegetative energy, 
 may call forth nutritive disturbances which seem entirely iden- 
 tical with inflammations acutely produced by staphylo- and 
 strepto-cocci. At the same time also pyrogenic matters are 
 formed, the absorption of which gives rise to fever and even 
 general septic typhoid disease. 
 
 Though we must admit that tubercle bacilli alone will not 
 produce all the acute phlegmonous processes, blennorrhoeas, and 
 purulent exudations, at least not primarily, still, according to the 
 already stated facts, we know of no other kind of bacilli or cocci 
 
LIVING VEGETABLE AND ANIMAL CELLS. 37 
 
 whose effect on the animal tissue, in one and the same species, 
 are so multiform. The disproportion between the size of the 
 primary tubercle and the luxuriance of granulations and the 
 exudation produced around it, presents itself to the surgeon 
 particularly in the so-called "cold abscesses" by tubercle of the 
 bone ; these originally always contain only a thin and clear, later 
 on a turbid, sometimes slightly blood-tinged, or may be a mucus- 
 like serum, and here and there mingled with clots; their 
 capsule is lined by mucous granulations, in which only very 
 rarely tubercle-granules with tubercle-bacilli are found. The 
 latter completely disappear if the abscess burst and pus cocci 
 immigrate, or if they, in very rare instances, find admission from 
 the interior of the body into the wall of the abscess. This will 
 manifest itself by increase of pain and fever. A cold abscess con- 
 taining one litre (two pints) or more may result from a tubercle in 
 bone of the size of a pea. We find, on the other hand, in dry caries, 
 neither excessive luxuriance of granulatious, nor suppuration, nor 
 exudation, but either firmer granulations (sometimes almost of 
 the consistency of cartilage) which are imbedded in the lacunas 
 of the eroded bone, and frequently contain many giant cells, and 
 only a few or no bacilli at all (analogous to the fibrous tubercle 
 of the soft parts), or we find the carious focus only filled with, 
 and surrounded by, yellow tubercle pulp without a trace of forma- 
 tion of granulations and suppuration in the neighbourhood, this 
 pulp being merely enclosed by a moderately thick capsule. It 
 is only by the frequent opening of abscesses and the energetic 
 operative treatment of these cases that we acquire a larger 
 experience of the manifoldness of these processes of which the 
 pathological anatomist sees only the final stages. 
 
 In these observations we now have to face the question, Are 
 these differences of effect really caused by differences of the 
 vegetative energy, and by the number of the bacilli accidentally 
 retained in the tissue, or, are there different varieties of tubercle 
 bacilli which we are not yet able to distinguish from each other ? 
 Or are there vegetative forms and stages of development of these 
 bacilli which we have not yet succeeded in demonstrating by our 
 present method? We know how unsettled still are the views, 
 whether the delicately granulated varieties occurring under certain 
 conditions in the plasma of the tubercle bacilli have to be inter- 
 preted in this or that manner. Are they spores or are they 
 
38 BILLROTH ON THE MUTUAL ACTION OF 
 
 vacuoles ? And if they be spores, where do they remain ? They 
 disappear and we are no longer able to trace them ; nobody has 
 ever seen them germinating. Could they not continue to 
 vegetate in some form of cocci, and as such call forth different 
 kinds of stimulus on the tissue from that of the fully developed 
 bacilli ? " Chi lo sa ? " (" Who knows ? "). 
 
 Whilst the tubercle bacilli only conditionally produce the 
 phenomena of acute inflammations, and as such never copious 
 suppuration, the Glanders bacilli act at the same time as for- 
 mative stimuli and also pyogenic, upon the fixed tissue elements. 
 
 The formation of small foci of endothelial cells is speedily 
 followed by the emigration of leucocytes in masses, and sub- 
 sequently also by destruction by purulent softening of the tissue. • 
 The glanders bacilli therefore occupy, as regards their pathogenic 
 effects, in some measure the mean between tubercle bacilli and 
 pus cocci. Thereby they rapidly lead to purulent ulcerative 
 processes, and, when rapidly developing and energetically 
 vegetating, to general septo-pyasmic poisoning ; again, a quite 
 peculiar action of vegetable cells upon animal cells. 
 
 The existence of the Syphilis bacillus has not yet been proved 
 beyond dispute.* There is some probability that it might be 
 related to the tubercle and the glanders bacillus. The soft 
 
 * Note by the Translator. — Passing over those agents of the syphilitic virus which 
 had formerly teen regarded as syphilis microbes, which, however, did not comply 
 with the requirements of the present standpoint of Bacteriology, we have first 
 to mention the bacillus discovered in 1885 by Lustgarten in syphilitic products, 
 which much resembles, both in its form and in its size, the tubercle bacillus, and is 
 characterised by specific methods of staining. Lustgarten dyed his sections in 
 Ehrlich Weigert's solution gentian violet at the temperature of the room for 
 twelve to twenty-four hours, and after this at a temperature of 40° C. (104°F.) in 
 an incubator for two hours, washed them for a few minutes in absolute alcohol, 
 and placed them for the purpose of discolouration for ten seconds in an aqueous 
 solution of one and a half per cent, of hypermanganate of potassium, and then 
 for about the same length of time in sulphurous acid. After washing the sections - 
 in water they are again placed for about three to four seconds into the above- 
 mentioned discolouring fluid, and after three to four times repeating the process the 
 ground of the preparation will be discoloured and only the bacilli will appear as 
 violet, slightly undulated, or S-shaped curved rods. Dry cover glass preparations 
 of syphilitic sections or tissue fluid are stained in the same manner, only that 
 the preparations are left for a shorter time in the colouring solutions, and after 
 staining them in the gentian violet they are not washed in alcohol, but in water. 
 
 A more simple method is that of Be Giacomi, who stains his dry cover glass 
 preparations for a few minutes in a hot solution of fuchsine and then in water 
 with the addition of a few minims of a solution of perchloride of iron, and after 
 washing them in water, discolours them in a" concentrated solution of perchloride 
 
LIVING VEGETABLE AND ANIMAL CELLS. 39 
 
 chancre shows a certain analogy with glanders, the hard chancre 
 partly with the slowly vegetating tubercle prone to disintegration, 
 and in its later stages to the fibrous tubercle. The luxuriation 
 in and around the syphilomas is very variable ; in bones there is 
 a disposition to necrotic caries both in syphiloma and in tubercle. 
 Every experienced surgeon knows how difficult it sometimes is 
 to distinguish between Tuberculosis, Syphilis, Ehinoscleroma, 
 and Lepra (Carcinomatosis) in their products. 
 
 It is generally agreed that the gonorrhoea-cocci exert no 
 formative stimulus and produce no phlegmonous process. The 
 
 of iron. This preparation, which shows the bacilli in red colour, may be stained 
 a second time with any optional contrast colour. 
 
 For sections preparations Gottstein's modification of Giacomi's method will be 
 found particularly suitable ; the sections stained with fnchsine for twenty-four 
 hours, after having washed with water and placed for a few seconds in a diluted 
 solution of perchloride of iron, are again washed with alcohol, rendered trans- 
 parent by oil of cloves or xylol, and preserved in Canada balsam. Doutrelepont 
 has demonstrated the same bacilli in syphilitic tissues independently of Lustgarten 
 by a different method of staining ; treatment for twenty -four to forty-eight hours 
 with an aqueous solution of gentian violet, discolouration during a few seconds 
 in a mixture of one part of nitric acid and fifteen parts of water, and after that 
 for five to ten minutes in sixty per cent, alcohol ; second staining in an aqueous 
 solution of- saffron, washing again with sixty per cent, alcohol, discolouration in 
 absolute alcohol, rendering transparent in oil of cedar and preservation in Canada 
 balsam. 
 
 Controlling examinations by a number of other investigators (Matterstock, 
 Klemperer, Goitstein, Marcuse, Lewy, #c.) proved the constant presence of these 
 bacilli in all syphilitic secretions and in every tissue affected by syphilis, so that, 
 supported by these confirming evidences, Lustgarten, Weigert, and Doutrelepont 
 regard these bacilli as the agent of the syphilitic poison ; cultures of, and inocu- 
 lations with, them have however not yet succeeded. Soon afterwards nevertheless 
 Alvarez and Tavel oonjointedly, and Matter stock working independently, discovered 
 a bacillus so much like the syphilis bacillus, in the preputial smegma, in the 
 secretions of the mucous membrane of the female genitals and also at the anus 
 of healthy people, that many investigators consider these as identical with the 
 smegma bacillus. The syphilis bacilli, however, acording to Lewy, lie mostly 
 on the epithelium, and only occur singly and exposed on the surface ; they are but 
 rarely observed in larger groups. The smegma bacilli, on the contrary, are 
 found upon, or in close connection with, the epithelium. They frequently occur in 
 larger groups, but are also found in great number outside the epithelium. The 
 syphilis bacilli present mostly slender, straight, or curved rods ; the smegma 
 bacilli are smaller, plumper rods, and in general show a muoh greater variety of 
 form. Whilst the syphilis bacilli resist the alcohol tolerably long, the smegma 
 bacilli are soon discoloured by it. Acids discolour the syphilis bacilli within 
 thirty to forty-five seconds ; the smegma bacilli frequently withstand acids for 
 two minutes and longer. The syphilis bacilli are almost immediately discoloured 
 by glacial acetic acid, and the smegma bacilli withstand glacial acetic acid up to 
 twenty-five seconds. The syphilis bacilli are the more numerous the younger 
 the infiltration, the smegma bacilli, on the contrary, are the more numerous the 
 longer the secretion had been accumulating. 
 
40 BILLROTH ON THE MUTUAL ACTION OF 
 
 fact that frequently after gonorrhoea of long standing no stricture 
 forms, and after gonorrhoea of but short existence it does so 
 occasionally, and in that case also suppuration around the urethra 
 and the prostate (perineal abscesses), seems to indicate that 
 these processes are merely accidental and caused by casual immi- 
 gration of pus-cocci. But what happens in the case of acuminate 
 condylomas ? Their appearance in gonorrhoea is so variable that 
 in this instance they may be regarded as accidental. Here comes 
 a new circumstance which hitherto has not been taken into 
 account, namely, the formative irritability of the genuine epi- 
 thelia and the causes which call forth their activity. As this is 
 immediately connected with the question, whether perhaps the 
 formation of carcinoma may likewise be thought of as dependent 
 on microbes, a question which I intend to enter into at the 
 conclusion of these observations, I shall not discuss this subject 
 here. 
 
 There is one more point which I ought not to pass over, 
 namely, the formation of the so-called soft flat condylomas on the 
 skin continually irrigated by urine. We observe this as well in 
 vesico-vaginal fistula as in extroversion of the bladder. The 
 continuous bathing of the perineal and femoral skin in fluids 
 alone cannot account for it. We know from the time when 
 wounds were treated by continuous irrigation or permanent 
 baths that the cutis swelled to an enormous degree, but uni- 
 formly, yet no formation of condylomas took place. There is 
 little probability that in the circumscribed form of these condy- 
 lomas the salts of the urine, or the ammonia of the decomposed 
 urine alone, produce these formations, although also the ammonia 
 contained in the alkaline urine may soften the epidermis, and 
 even the superficial capillaries of the cutis. The afore-mentioned 
 urinary condylomas respond rather to the settling of colonies of 
 streptococcus urinse, which, retained in the slight unevennesses of 
 the softened epidermis, establish themselves here and there, and 
 bring about a moderate papillary hyperplasia with increased 
 formation of epidermis. We therefore must consider also the 
 streptococcus urinas as a formative, though only slightly intensive 
 cause of stimulation. 
 
 After having passed in review all the effects of formative 
 irritation known to us of the different vegetable cells upon the 
 
LIVING VEGETABLE AND ANIMAL CELLS. 41 
 
 animal tissues, I now shall consider whether animal cells are able 
 to act in a similar manner upon the vegetable tissue. 
 
 It is known that there' are not only saprophyti, but also 
 specific pathogenic fungi, which attack and eventually destroy 
 plants of complicated structure, that the moulds or mildew fungi 
 and the more highly organised algce may be again, destroyed by 
 microbes which on their part are to be classified with the sapro- 
 phytic and pathogenic series. It must be left an open question 
 whether there are processes in plants which according to their 
 nature can be compared with the inflammatory processes in 
 animal tissues. The condition which is called by phytopatho- 
 logists ''■Frost-gangrene'' ("Frost-brand") and "canker of the 
 trees" (apple-trees and beeches) may also partly belong to this 
 class. There is much probability in favour of the view that these 
 processes are brought about partly by a fungus, a Pyromycetes 
 (JSfectaria ditissima), partly by the apple aphis or American 
 blight (" Blutlaus," Schizoneura lanigera Hausm.). 
 
 "We shall now only occupy ourselves with observations on the 
 formative irritability of vegetable cells. My-previous remarks on 
 copulation and fertilisation as formative stimuli, having already 
 referred to vegetable cells, need therefore no repetition. 
 
 In the plants also separation of continuity acts as a powerful 
 formative stimulus. It is followed by new formation of, tissue, 
 cicatrization, formation of callus ("Uberwallung") with or with- 
 out necrosis, and eventually leads to the union of two opposite 
 wound-surfaces. The improvement in the quality of fruit-trees, 
 of roses, &c, by budding or grafting is brought about by this 
 process. The tissue of the so-called "callus" ("Uberwallung") 
 as it forms, e.g., after the lopping of the branches, is the so-called 
 "corky layer" (" Periderma") which proceeds from the paren- 
 chyma of the bark, of the cambium, and of the pith, and might be 
 compared with the granulation tissue in animals. 
 
 The formative stimulus of the separation of continuity in 
 plants, is, under certain circumstances, particularly increased. 
 New plant individuals can be raised from parts of plants ; multi- 
 plication by layering, cuttings, or slips. When a boy, I watched 
 with the keenest interest a cutting of a damask rose placed in 
 a phial of water in which the lower border of the section gradu- 
 ally thickened and finally put forth delicate white adventitious 
 roots (radicles). Moreover, in many plants a new plant may be 
 
42 BILLROTH ON THE MUTUAL ACTION OF 
 
 produced from each portion of a branch, and at the superior 
 portion of the branch sometimes even new, so-called " adventitious 
 bud-spores " are formed. The leaves of many Gesneriacece produce, 
 at the place where the petiole has been fractured or notched, new 
 buds, which may become starting points of new leaves and 
 branches. Therefore a pathological stimulus is followed by the 
 formation of new physiological organs. (This reminds one of 
 the "post-regeneration" in injured frog eggs, described by W. 
 Boux.) We shall not, probably, for a long time succeed in 
 tracing the causes of these p-ocesses, even if we were able to 
 analyse the morphological process itself much more accurately 
 with improved microscopes than we have already been able to do. 
 
 In general we may suppose that the effects of formative irri- 
 tation also in more highly organised plants are much more 
 effective in every direction than in animals. 
 
 As, according to the observations at our disposal, divided vege- 
 table cells always perish, and only the next following uninjured 
 cells come into formative activity, we might surmise that the 
 products of decomposition forming during the decay of the 
 injured cells act as chemical irritants upon the nearest cells. 
 All these, however, are but infinitesimal agents in processes of 
 such magnitude in their essence and effects. 
 
 What is of particular interest to us is the observation that a 
 large series of excessive tissue formation in plants or buds, leaves, 
 stalks, and roots, the so-called " galls " or " cecidia " are called 
 forth by stimuli which undoubtedly are caused by animal cells.* 
 
 I shall only briefly mention the existence of the mycocecidia, 
 i.e., galls, which are exclusively produced by the luxuriant growth 
 of fungi. To these belong the " Wood-knot " (" Holzkropf") of the 
 trembling poplar or aspen (" Populus tremula ") on the stem and 
 branches of which knobs of the size of a filbert to that of a 
 pigeon's egg are formed by the luxuriant growth of certain 
 fungi (" Pyrenomycetes "), the turgescences of the roots of Papi- 
 lionaceai and of the alder by a fungus as yet little known 
 (" Schinzoa leguminoswmm"), &c. Of great morphological 
 interest are likewise the microscopical galls which are produced 
 on some algas by Chytridiacece, especially of the genus Synchi- 
 
 * I am principally indebted for my information on these most remarkable 
 formations to the excellent work of A. B. Frank, "Diseases of Plants" ("Die 
 Krankheiten der Pflanzen." Breslau, 1880.) 
 
LIVING VEGETABLE AND ANIMAL CELLS. 43 
 
 trium. The swarm spores of these fungi bore into the epidermis 
 of the algas, and after the development from them of a sorus, i.e., 
 a small round cluster of cells with the character of Sporangia, 
 the latter is incapsulated by a luxuriant growth of epidermis 
 cells. (A quite identical process is brought about in algas of the 
 genus Vaucheria by Rotatoria and their brood.) The number of 
 these genera of the Mycocecidia is, on the whole, however, very 
 small in comparison with the extremely rich variety of forms of 
 galls produced by animals. 
 
 The most manifold and peculiar forms of galls are caused by 
 Mites, Phyioptus (Acaro- or Phytopto-cecidia). They produce the 
 pathological formation of hair on the surface of leaves (" Phineum 
 formation " on walnut, vine, lime, oak, beech, apple, birch, and 
 poplar leaves, &c, and on many herbs), the pocket or bladder galls 
 (on linden, plum, maple, elm, willow, and beech leaves, &c), the 
 peculiar leaf rolls and folding and crimping of leaves with thicken- 
 ing of the leaf itself (of the linden, beech, willow, rose, virgin's 
 bower, or clematis, &c), the swelling of buds and deformation oj 
 the apices of the buds, the spangle galls (" Pockenkrankheit ") 
 of the leaves (of the pear, apple, walnut, and elm), and on the 
 back of the oak leaves.* 
 
 Many kinds of Hemiptera produce galls, of which those caused 
 by theplant lice or Aphidos (Aphidiocecidia) are the most numerous. 
 Their forms are similar to those of the former class, and are again 
 distinguished as leaf rolls, pocket galls, deformations of the apices 
 of the buds (pineapple or spruee galls'). There are, moreover, 
 root galls, as those produced, e.g., on the vine roots by Phylloxera 
 vastatrix (kind of aphis). 
 
 A large series of most curious forms of galls are produced by 
 the larvae, of flies and wasps, but only in rare cases also by those 
 of butterflies, moths, and beetles. Also in this series all the "afore- 
 named types are represented, some of particularly'luxuriant and 
 interesting form, among which we class also the turgescences of 
 the stalk, the stalk galls (" Stengelgallen "), e.g., the Cecidomyca 
 salicis on the goat willow (Salix caprd) and the Lascoptera rubi 
 on the bramble. 
 
 The best known are the galls on the oak leaves, the so-called 
 " Oak apples " (again of the most manifold form, e.g., the Arti- 
 
 * Note by the Translator. — The latter kind of spangle galls are also caused by 
 the Neuroterus lenticularis, a kind of gall wasp (Oynips) . 
 
44 BILLROTH ON THE MUTUAL ACTION OF 
 
 choke galls on the Quercus pedunculated, a variety of the English 
 oak, Quercus robus), and the Mossy galls; also called " Rose Bede- 
 guwrs " or " Robin Redbreast's pincushion," the first of which (the 
 oak galls) are produced by several kinds of wasp (mostly by 
 some species of Gynips), the latter (the mossy gallsj resembling 
 bundles of moss, frequently of most luxuriant and showy forma- 
 tion, are caused by the Rhodites rosarum which infests the Rosa 
 spinosissima and Eglanteria. 
 
 There is a particular charm to be found in the study of the 
 manifoldness of these formations and of the process of their de- 
 velopment. They offer so interesting a parallel with the formation 
 of genuine tumours in animals, that we might well be induced to 
 arrange them into similar groups as tumours according to their 
 form. There would be no difficulty in arranging groups, as for 
 example, Papilloma, Polypus, Fibroma, Sarcoma, Osteoma, &c. 
 I have already mentioned that carcinomatous ulcerations and 
 luxuriations in plants are also spoken of. 
 
 We are here only interested in learning whether particulars 
 are known of the mode of development of these gall formations, 
 as there is no longer any doubt about their cause and their 
 growth in general. 
 
 The one fact we can accept as certain, is that the slight 
 mechanical injury caused by the insects in the deposition of their 
 eggs into, or upon, the surface of a plant, can never be alone the 
 cause of gall formation, however high we may value the separa- 
 tion of continuity as a formative stimulus in plants. Even the 
 hypertrophical cicatricial callus (" Narbeniiberwallung "), as it 
 especially occurs after lesions of the bark, have neither in struc- 
 ture nor in form any resemblance to galls. They are always in 
 proportion in shape and depth to the injury, as we know from 
 letters cut in the stems of young trees in which the deeply incised 
 parts are replaced by wheals formed of minute warts. Here the 
 forces of regeneration and growth combine in order to produce a 
 new formation pathological both in form and structure. The 
 comparison with cheloid cicatrices readily suggests itself, though 
 also in the latter the fatalistic formation of growths does not enter 
 into the question. 
 
 Already the fact that only certain kinds of animals produce 
 galls of specific forms on certain kinds of plants is an indication 
 that here quite particular conditions come into action. It may 
 
LIVING VEGETABLE AND ANIMAL CELLS. 45 
 
 perhaps be unphilosophical to presume upon an immunity of 
 certain plants against the action of certain gall-producers. Why- 
 does the butterfly, again, after having strayed far, far from its 
 native place, deposit its eggs only on certain plants ? Because 
 its fate, or its hereditary memory, or something unconscious 
 within it, tells it that the caterpillars after having escaped from 
 the eggs can only live on the leaves of certain plants. Whether 
 the Rhodites species which produce the elegant moss-galls on 
 roses may not bring about the identical forms on other plants 
 we do not yet know, because this species of wasp never lay 
 their eggs on any other kind of plant. Their larvae, after 
 escaping from the egg, thrive best, or only, on the marrow sub- 
 stance of the rose-galls. 
 
 We cannot well dispense with the teleological speculation for 
 the understanding of most of these processes in the vegetable and 
 animal world without depriving ourselves of a great enjoyment 
 in our investigations. I by no means consider as injurious the 
 teleological speculations on nature which have been for some 
 time so much condemned, provided we always bear in mind that 
 processes like the afore-described are as much necessary effects 
 of the material forces as all the conscious and unconscious acts 
 of volition in general. 
 
 If the wasp, therefore, be obliged to deposit its eggs upon, or 
 into, an oak leaf, a shell will form from the latter (like the egg 
 shell around a bird's egg), which protects them and its contents, 
 and at the same time serves as nourishment for the young maggots. 
 If the same wasp were to lay its eggs, e.g., in the leaf of a horse- 
 chestnut, perhaps also a gall would form, but the hatched maggots 
 would probably die, poisoned from feeding on this gall, or they 
 would probably be unable to assimilate this unsuitable kind of 
 food, and consequently would starve. The undoubtedly specific 
 character in many ways of the formation of galls will not justify 
 the supposition of immunity in any kind of plant, of the absence 
 of a formative irritability against the stimulus proceeding from 
 an animal. Such an immunity may, however, exist, and it 
 would certainly be of great interest to institute experimental 
 studies on this subject. 
 
 If, then, after what we have said, we cannot consider the 
 mechanical stimulus of injuries (the existence of an injury more- 
 over is by no means ascertained in many gall formations) as the 
 
46 
 
 BILLROTH ON THE MUTUAL ACTION OF 
 
 cause of these gall formations, a second alleged cause seems to 
 me likewise of but doubtful' importance. It is asserted by many 
 that the gall formation is caused, and especially its enlargement is 
 brought about, by the suction of the sap, by mites, lice, and larva 
 (maggots). Irrespectively of the fact that galls frequently are 
 already developing before the animals have escaped from their 
 eggs, and of the fact that, e.g., perfectly abnormal gall-hair 
 formations of leaves which are entirely different from the normal 
 hairs of the leaves, may not possibly be produced by the suction 
 of the plant-juice, also in this supposition the production of 
 specifically organised new formations as the galls, remained abso- 
 lutely unexplained. If there occur, e.g., in the lime leaves, 
 according to the action of different kinds of mites, either hair- 
 formations, or pocket-galls, or leaf-rolls, and if we are informed 
 that, e.g., of certain kinds of Goccidce (Brachyscelis pileata, ovicula, 
 and duplex) on the Eucalyptus species in Australia, the males 
 form tubular or trumpet-shaped galls with an opening at the 
 apex, the females on the contrary produce thick utricular galls 
 closing with a lid, we can scarcely understand that this is brought 
 about by suction of the juices alone, if at all. 
 
 If, once more, we inquire into the said mechanical causes, we 
 may have to admit that certain excesses of supply (" Uberschwem- 
 mung") of nutritive material have to be considered of more 
 importance as a cause of irritation for the production of hyper- 
 plasia in vegetable than in animal cells, and that the vegetable 
 cell in general possesses a greater hereditary disposition for it. 
 Still we ought to suppose that in this case at the most only a 
 hypertrophic and hyperplastic process analogous to the formation 
 of callus could be brought about which ought to show the type 
 common to all the new formations which form after injuries in 
 plants. We may imagine the suction-apparatus with its bite 
 never so different, the suction-movement in its intensity and 
 rhythm never so varied, still we could not always understand 
 why so many different forms of galls are thus produced. I will 
 only briefly mention that the suction-action does not all come 
 into consideration in the formation of Mycocecidia* 
 
 *By the suction Of the apple aphis or American blight (" Blutlaus," Schizonewa 
 lanigera) conditions may be produced which are known by the name of canker of 
 the apple-tree; from this formation, however, to the organisation of complicated 
 galls there is a long step. 
 
LIVING VEGETABLE AND ANIMAL CELLS. 47 
 
 After what we have said, the reader will not feel surprised at 
 my expressing the opinion that I consider the action of the insects 
 which produce galls to be ■perfectly specific, and moreover chemically 
 specific, although at present it cannot yet be quite appreciated. 
 The investigations by botanists on the primary processes in the 
 formation of galls and the immediate causes of these, are of but 
 recent date and still far from being conclusive. A. B. Frank, 
 who occupied himself very much with this subject, gives us some 
 hints in this direction. He says in a summary on the gall- 
 formation : " The causes are, first, the still developing state of the 
 part of the plant ; and, secondly, the action of the parasites. We 
 only know the manifestation of the phenomenon ; the nature of 
 the gall-forming stimulus still remains veiled." 
 
 We find in the youngest Acarocecidia that there frequently are 
 no mites within, but that they are occupied by them only at a 
 later period. This observation suggests the probability that 
 the mites scarify these leaves, and at the same time introduce 
 into them a substance which in the manner of a ferment exerts 
 the continuous action of a formative stimulus on the plant cell. 
 If then the cells enlarge after having been occupied by the mites, 
 we must suppose that the latter keep up by their secretions a 
 specific formative stimulus; this stimulus sometimes spreads 
 from one surface of the leaf to the other. 
 
 Particularly interesting are the felt-like diseases (" Filz-Kranh- 
 heiten") of leaves, the hair (" Frineum") formations on leaves, in 
 which the leaf suffers no alterations in shape ; the mites lodge 
 between the hairs and there produce their progeny. These hairs 
 had formerly been considered as fungoid formations ; their colour 
 mostly is very bright. They are very differently shaped on the 
 leaves of different plants, but their form may also vary according 
 to the part of the plant. They generally are unicellular forma- 
 tions with a firm membrane, and frequently containing a coloured 
 cell fluid. They are formed by excrescences of epidermic cells 
 which, in their normal state, do not produce hairs either on the 
 superior or the inferior surface of the leaf-blade before this has 
 reached its normal size. It is still unknown whether these hairs 
 are already produced by the eggs, or later on by the mites them- 
 
 Frank, in a most interesting and convincing manner, describes 
 the origin of the pocket galls and leaf rolls by the prevalence of 
 
48 BILLROTH ON THE MUTUAL ACTION OF 
 
 hyperplasias of the different leaf cells in a perfectly defined 
 direction, whereby not only the formation of the pocket galls 
 with their openings, but also the formation of the leaf roll 
 becomes intelligible. (This interpretation of the mechanism of 
 development vividly reminded me of the first researches by W. 
 His on the mechanical causes of the formation of wrinkles in 
 embryos, which subsequently have proved so extremely suggestive 
 of the evolution of forms of organisms.) Abnormal hair forma- 
 tions occur in both cases. It is still unknown whether the eggs, 
 during their development, or later on the mites, after hatching, 
 call forth this development of cells. 
 
 Parthenogenesis in the Aphidas continuing through many gene- 
 rations having been observed, the formative irritation of the 
 eggs, and of the young mite germs, must in this case be kept 
 strictly separated. (Parthenogenesis may, in many respects, be 
 compared with the vegetative multiplication in plants.) 
 
 " Many Aphidae suck themselves fast singly, in consequence of 
 which these closely circumscribed places alone suffer an exces- 
 sive expansion in the direction of the surface of the leaf blade, 
 whereby the opposite surface of the leaf becomes pushed out, 
 and as it grows forms pockets or bladders which are sessile on 
 the otherwise unaltered side of the leaf, and harbour in their 
 interior the Aphidas and their brood " (Frank). 
 
 The investigations of galls of Diptera {flies) show that the 
 formation of these in single cases had already been incited by 
 the deposition of the eggs (probably by a secretion which, during 
 this act, has been injected into the leaf, or by a secretion attend- 
 ing the growth and development of the eggs). These leaf rolls 
 are even in their younger state frequently found partly empty. 
 " This might be interpreted in this way, that the gall-producing 
 influence may not necessarily be combined with the deposition 
 of the eggs" (Frank). In this case it would only, therefore, 
 consist in a chemical effect preceding the deposition of the egg. 
 
 It has not yet been decided whether in the formation of galls 
 by Diptera, on willows, poplars, beeches, alders, and linden, &c, 
 " the egg has been deposited into the inner tissue at the very 
 spot, or whether the young larva, after its development from the 
 egg deposited already externally, has eaten its way to the site of 
 the gall formation " (Frank). 
 
 The gall wasps lay their eggs into the leaf, e.g., of the oak. 
 
LIVING VEGETABLE AND ANIMAL CELLS. 49 
 
 As the maggots emerging from the eggs must necessarily already 
 find food as soon as they have left the egg it is highly probable 
 that the developing egg has already acted as a formative stimulus 
 upon the leaf cells, and the gall apple has already been formed 
 before the maggots exist. Such a gall apple consists of the 
 following layers: 1. The external layer- of epidermis, which 
 is sometimes strengthened by a corky layer, and by a more or 
 less thick layer of luxuriant parenchymatous cells beneath; 
 2. Of a hard layer of liquefied, thick-walled, and punctated 
 sclerochymatous cells ; and 3. Of an interior (medullary') layer 
 of extremely delicate walled and small parenchymatous cells 
 containing turbid protoplasm which serves as food for the 
 maggots. 
 
 From the afore-stated facts it becomes evident that the question 
 whether the gall formation is incited and sustained by a secretion 
 of the mother animal, or by a growth secretion of the eggs, or 
 by special products in the change of matter of the young animals, 
 is still somewhat far from its solution. 
 
 We may, however, accept as undoubted that the products of the 
 animal cells are able to act as a peculiar (specific) formative stimu- 
 lus upon the vegetable cells in the same manner as the vegetable cells 
 (cocci, bacteria) on animal cells. It is sufficient for me to have 
 here again called to the mind of all the friends of the natural 
 sciences, in the most condensed form possible, this certainly very 
 interesting fact, which brings the animal and vegetable worlds 
 again a step nearer to each other. 
 
 In conclusion, may I be permitted once more to return to the 
 vegetable microbes as excitors of formative (hyperplastic) pro- 
 cesses in animal cells, namely, the animal epithelial cells. 
 
 I had previously always spoken only of the formative action of 
 certain microbes on the cells of the connective tissue and vessels. 
 Now we already find in Baumgarten's treatise some indications 
 that karyokinetic forms in epithelial cells may also bo called 
 forth by bacilli, as in the pulmonary alveolar epithelium by 
 tubercle-bacilli, in the epithelium of the hair-follicles and in the 
 hepatic cells by glanders-bacilli, &c. Bollinger maintains for 
 certain that the questionable bodies observed in the Molluscum 
 contagiosum in man are not degenerated epithelial cells, but 
 some forms of gregarines. " J. Pfeifer , s exhaustive investigations 
 
 E 
 
50 BILLROTH ON THE MUTUAL ACTION OF 
 
 on the etiology and pathogenesis of the infectious epithelioma in 
 birds admit of no further doubt that the epithelioma-formation is 
 brought about by the immigration of the germs of a Protozoon of 
 the class of the Sporozoa (Gregarinos) into the cells of the Bete 
 Malpighii. Whilst the cells affected by the parasites are entirely 
 consumed up to a narrow border-line and the nucleus pressed 
 against the cell-wall, a proliferation of the still intact epithelial 
 cells in the neighbourhood of the invaded region takes place, the 
 progeny of which are then likewise successively invaded by the 
 parasite, until the multiplication of these has ceased, and the 
 process herewith tends towards recovery." (Baumgarten, vol. ii., 
 p. 941.)* 
 
 I freely confess that this apparently fully substantiated 
 observation has greatly impressed me. As long as the formative 
 stimulus confined itself only to the cellular elements of the con- 
 nective tissue, I have considered the existence of a Carcinoma- 
 microbion as utterly impossible. The afore-mentioned observation, 
 however, has rendered this more probable. There are, therefore, 
 microbes which act as a formative stimulus upon animal epithelial 
 cells. This fact being accepted as proved, we of course remember 
 many phenomena by which the carcinomas and their extension 
 are brought into relation with other microbic diseases, especially 
 the tubercle-formations and their propagation. Then we call to 
 mind, first, the presence of the numerous miliary nodules in the 
 skin as they so frequently appear after extirpation of carcinoma 
 of the breast. Then we think of the slowly developing super- 
 ficial epitheliomas of the cutis which commence healing in the 
 centre, whilst they slowly continue to luxuriate in the periphery, 
 exactly as in Lupus, Lepra, and Psoriasis. We remember the 
 numerous nodules in the peritoneum and in the pleura (often 
 enough also accompanied by exudations), in which we sometimes 
 are doubtful whether we have to deal with tubercle or with 
 carcinoma nodules. We recollect the mode of spreading of the 
 mammary carcinoma, which bears a resemblance to the radia- 
 tions of erysipelas ("Erysipelas Mammen"), although they 
 
 * Note by the Translator. — A kind of mysterious parasitic form of animal- 
 culi, known by the name of Gregarines. which merely consist of a homogeneous 
 external membrane containing grannies and a nucleus, which by some are con- 
 sidered as independent animalcnli, by others as intermediate stages of develop- 
 ment of intestinal worms of the order of the Nematoidea (Ascarides). 
 
LIVING VEGETABLE AND ANIMAL CELLS. 51 
 
 spread more slowly over the whole thoracic skin, and in which 
 we may be doubtful whether the hyperemia or the formation of 
 the carcinoma is the primary affection. We also remember the 
 transmission of carcinoma into lymphatic glands, which is equally 
 peculiar to all the microbic diseases of tissue, and in which the 
 lymphatic glands act as, sometimes more, sometimes less, per- 
 meable filters. 
 
 We think of the numerous experiments of direct transmission 
 of carcinoma from man to animals, and from animal to animal of 
 the same species, which at last Hanau has successfully performed 
 in rats. Could not also immunities and predispositions of different 
 species of animal play an important part in these instances, as in 
 the transmission of the tubercle-bacillus and other kind of 
 microbes? Have we not found in carcinoma exactly the same 
 relations of the excessive primary " epithelial " growth with the 
 formation of granulation-tissue in the neighbourhood, as it exists 
 in the case of the formation of a primary " endothelial " tubercle- 
 nodule with the development of the lymphoid (granulation) 
 tissue ? Is there not a certain parallelism between the develop- 
 ment of carcinoma and tubercle propagation in their various 
 degrees of activity ? 
 
 Scheuerlen's Carcinoma-bacillus is supposed to be a very 
 common, harmless saprophyte originating in the epidermis. 
 His careful investigations at any rate deserve every praise. We 
 must not abandon these attempts, nor ought we to be deterred 
 l>y failures. 
 
 If there really exist a carcinoma-microbion it will most pro- 
 bably be a Bacillus or a Sporozoon (Gregarine, Amoeba, Plas- 
 modia). We ought to try to commence our investigations with 
 the acuminate condyloma, with the warts spreading by contact, 
 and with the flat condyloma. 
 
 " He that seekeih, findeih." The success would be glorious, 
 not only in the purely scientific aspect, but also as regards the 
 possible deliverance of mankind from one of its direst scourges. 
 If we have succeeded in discovering the microbion the possibility 
 of killing it without destroying the organism will not be ex- 
 cluded. 
 
 We are able to kill the recently discovered malaria-plasmodia by 
 quinine and arsenic, the (still doubtful) syphilis-bacilli by mer- 
 cury and iodine, without injury to the whole organism. We 
 
52 MUTUAL ACTION OF LIVING VEGETABLE AND ANIMAL CELLS. 
 
 shall also discover means of killing the tubercle-bacillus,* and in 
 like manner we hope to succeed in finding the still perfectly 
 unknown carcinoma microbe in order to save from certain death 
 a body already on the brink of the grave. This is the great task 
 reserved for future generations ! 
 
 * Note by ithe Translator. — This sounds almost prophetic, for since the 
 publication of this essay Dr. C. Koch has discovered a method of treating' 
 tubercle disease, which at least promises remarkable success. 
 
 Abbazia ok the Qtjarnebo, Christmas, 1889. 
 On the Semmeeing, February, 1890. 
 
CWNIOAL LECTURE 
 
 ON 
 
 NEURASTHENIA AND ITS TREATMENT. 
 
 BY 
 
 Prof. H. V. ZIEMSSEN, 
 
 DlEBCTOR OF THE MEDICAL CLINIC IN MUNICH. 
 
 8E00ND EDITION. 
 
 Translated by 
 
 EDMOND J. McWEENEY, M.A, M.D, M.Oh., M.A.O. 
 
 (Royal University of Ireland), Lecturer on Pathology C. TJ. Medical School and Pathologist 
 to the Mater Misericordiee Hospital, Dublin. 
 
NEURASTHENIA AND ITS TREATMENT. 
 
 Gentlemen, 
 
 The era of civilisation in which we live has its distinctive 
 pathological stamp conferred upon it by maladies of the nervous 
 system, and above all by neurasthenia and mental diseases. 
 Statistics have proved the quick increase of psychoses, and 
 expression is given to the fact by the rapid multiplication of 
 lunatic asylums. As regards neurasthenia, statistical demon- 
 stration of its increase in frequency is not forthcoming ; but the 
 experience of physicians, especially of such as enjoy a special 
 confidence on the part of the subjects of nervous disease, indicates 
 quite an appalling frequency of neurasthenic conditions. The 
 causes of this phenomenon are to be looked for in the rapid 
 cultural development of our time. The immense advances all 
 along the line of intellectual, political, and social existence could 
 not have been made without an extraordinary tension of mental 
 forces, and the preservation and development of these new 
 acquisitions entail a continuous exertion both intellectual and 
 psychical on the part of all civilised peoples. The more perfect, 
 the more multifarious the functions of the politician, of the 
 scholar, of the artist, of the merchant, of the artisan, the greater 
 the requirements arising from the exercise and perfection of 
 these functions, so much greater must be the measure of the 
 demands made on the nerve force of the best men in the nation. 
 
 But that is not yet all. Pari passu with the demands on the 
 working strength of the individual, the extent of his require- 
 ments in life, and in the enjoyment of life, grow greater, and 
 that not merely in the coarser, but also in the more delicate 
 forms of enjoyment which consist in the gratification of ambition, 
 in the whole style of existence, in the education of children, and 
 the selection of their walk in life, &c. Contentment in narrow 
 relationships, satisfaction with the performance of duty within 
 the limits of a modest avocation, endeavour to incline children 
 to, and prepare them for, the same sphere, — the same assured 
 
56 ZIEMSSEN ON NEUKASTHEN1A 
 
 walk in life as that which their fathers trod before them— these 
 characteristics are now becoming rarer and rarer day by day. All 
 now desire to get " up higher," not alone for their own sakes, but 
 for their descendants ! No one is contented with his lot. The 
 effects of over-population, the steadily increasing competition, 
 the fear of political, financial, and commercial crises are all 
 tending to the same result. Everything is hurrying onwards in 
 the battle for existence and pleasure, and the very bodily move- 
 ment in our great cities is indicative of this onward rush. There 
 is a universal racing and running to business ; no one has time. 
 Only in small towns is the calm observer struck by the quiet 
 progress of the daily toil. There we still see people moving 
 slowly, there only is there time for conversation, for walks, or 
 other recreations. 
 
 But if, amid the tireless wear and tear of the great cities, 
 running its convulsive course like clockwork, extraordinary 
 events should happen, if the powers which are already taxed to 
 the utmost in the ordinary avocations of life, should, in addition, 
 have to encounter severe disturbances, should illnesses in the 
 family circle, pecuniary cares, anxieties due to unruly children, 
 conjugal differences, hard times, &c, come into play, then the 
 most elastic disposition breaks down beneath the burden of 
 fate. Experience teaches us, in addition, that even the 
 clearest heads, however well fortune may befriend them in their 
 struggle ■ upwards, may nevertheless have their functional ac- 
 tivity impaired by the strenuous and ceaseless character of their 
 labour, through want of repose, and through the unsuitable 
 character of that which they term recreation and enjoyment. 
 Like labour, enjoyment becomes a struggle; where the brain 
 requires rest and indulgence, exciting pleasures and so-called 
 health excursions, accompanied by physical exertion, are taken. 
 Just as too much work is constantly being crammed into too 
 little time, so also is the pleasure of life bolted in concentrated 
 form. The natural consequence is not the repose, strengthening, 
 and invigoration of the overworked nervous system, but a 
 fatiguing exertion in another direction, which leaves in its turn 
 weariness and lassitude behind. 
 
 Nowhere are the results of this struggle for existence, this 
 frantic pursuit of gain and pleasure, seen on so extensive a scale 
 as in the United States. It was there that the concept of neur- 
 
AJVD ITS TREATMENT. 57 
 
 asthenia originated.' and' received, its name from Beard. ,.. Very 
 significant is it that Beard terms it an "American disease," 
 " which is never absent from a house whose inhabitants are intel- 
 lectually active" Of course it occurs in all other civilised 
 countries, but with far from the same enormous frequency as in 
 the United States. The fact is not surprising to any one at all 
 ■acquainted with the social relations which prevail in that country. 
 Intensity and hurry of daily work, restlessness during the time 
 devoted to recreation, short and troubled sleep, the strife of 
 competition, chance, and circumstances impart a peculiar charac- 
 ter to the social relations of North America, at least in manufac- 
 turing and commercial circles. 
 
 I have frequently had occasion to give professional advice to 
 such worn-out American neurasthenics, and could place before 
 you a large number of examples. Two instances, however, will 
 ■suffice. 
 
 A middle-aged merchant who presides over a large business 
 house in New York has been suffering for years from sleepless- 
 ness, feeling of oppression in the head, sudden terrors, &c. The 
 following is his description of his daily life : " I work strenuously 
 from eight in the morning till ten at night. I have no time for 
 meals. I mostly eat standing, and the food is often cold and 
 insipid by the time I am ready for it. By ten o'clock at night 
 I am so wearied out that I can hardly make the effort to close 
 my books. During the night my work whirls confusedly through 
 my brain, so that it is only towards morning that I can get a 
 few hours unquiet sleep. Then in the morning I feel a dreadful 
 lassitude, and have to take a few glasses of cognac in order to 
 get once more into working order." 
 
 A young business man for months incapable of any mental 
 exertion, suffering from sleeplessness and agoraphobia, thus de- 
 picts the mode of life which he has been leading for years : " We 
 work from eight till eight. We only have a quarter of an hour 
 for breakfast. In the evening when the business is over we 
 young fellows go at once to the restaurant, where we eat and 
 drink and amuse ourselves till two or three in the morning. Of 
 course I do not get enough sleep, as I have to get up at seven. 
 When I travel for the business, I always do so at night, so as to 
 utilise the day for work." 
 
 Is it to be wondered at, gentlemen, that a brain maltreated to 
 
58 ZIEMSSEN ON NEURASTHENIA 
 
 suet an extent should at last revolt? What is become of 
 Kant's golden rule of life, which allots to man eight hours out of 
 the twenty-four for work, eight for recreation, and eight for 
 sleep ? It may still prevail among officials who confine them- 
 selves strictly to their allotted work-time, and when it is over 
 have no further need to tax the brain. But these are just the 
 cases in which we do not meet with neurasthenia. In addition 
 to the damage resulting from an exhausting application to busi- 
 ness, from a mayhap joyless family life, from financial difficulties, 
 we find debilitation of the nervous system very largely brought 
 about by abuse of spirits, of morphia, and by sexual excesses. It 
 is above all the concentrated forms of alcoholic liquor which 
 weaken the nervous system, diminish thinking power and memory, 
 and at last totally destroy the whole organism. It is quite true 
 that intellectual energy may be momentarily increased by alco- 
 holic indulgence, nay, excited to a considerable degree of func- 
 tional activity. As time goes on, however, the reaction of the 
 brain to alcohol gradually lessens, and it comes to depend exclu- 
 sively on external matters, above all on the kind of alcoholic 
 beverage indulged in, how long the organism will resist. Some 
 constitutions hold out long; others, on the contrary, succumb 
 just as quickly. 
 
 Still worse are the effects of morphia, because the habit quickly 
 leads to rapid increase in the dose, and the injections are required 
 more and more frequently in order to calm the nervous system 
 and restore its functional activity. The tortures of the morphia- 
 neurasthenic are augmented by the fact that although he fully 
 appreciates the injurious effects of the drug, he cannot withstand 
 his craving for it, and thus his life becomes a continuous struggle 
 with his own conscience. 
 
 Of especial pathogenetic significance are sexual excesses, par- 
 ticularly in adolescents — above all the over-stimulation produced 
 by masturbation, with its consequences, impotence, sperma- 
 torrhoea, &c. Excessive sexual intercourse in the natural way, 
 e.g., among young married couples, certainly leads but seldom 
 to nervous debilitation in the absence of other determining 
 causes. Depression of energy, both intellectual and psychical, is 
 on the contrary very frequent among onanists. They become 
 incapable of continuous mental exertion, their memory seems 
 weakened, their energy extinguished. These conditions are 
 
AND ITS TREATMENT. 59 
 
 doubly injurious, occurring just at the period of mental and 
 bodily development, because the subject, on account of his in- 
 capability of mental labour, gets left behind, and irretrievably 
 loses part of the time spent at school. In addition, he suffers 
 constantly from the moral oppression of remorse, from the con- 
 sciousness that he has deserved his own misfortune, and from all 
 kinds of hypochondriacal ideas about the evil effects of this vice 
 on life and health. This self-torture — which is for the most part 
 quite uncalled for, especially as regards the fear of diseases of 
 the spinal cord — is greatly contributed to by the natural disin- 
 clination on the part of the patient to confide in his medical 
 adviser, which results in his wildly resorting, without effect, to 
 all sorts of reading, quackery, and drugging, which only drag 
 him deeper and deeper into the slough of despond. 
 
 Finally, a factor of the greatest importance for the develop- 
 ment of neurasthenia is hereditary neuropathic predisposition, 
 a congenital tendency to conditions of enfeeblement and ex- 
 haustion either running in families or existing as a racial or 
 ancestral idiosyncrasy, and not unfrequently both together. 
 
 The hereditary stamp is conferred by a neurasthenic father or 
 a hysterical mother. Even in childhood it manifests itself in a 
 marked susceptibility to emotional impressions, but only appears 
 in all completeness during the second decade of years, when 
 intellectual and emotional life attain their riper development. 
 Or it may remain latent under favourable circumstances until a 
 serious misfortune or an unusually great mental exertion or 
 emotional stimulus cause the malady to appear more distinctly. 
 Influences which are supported without difficulty by the con- 
 genitally sound often assume a pathogenic significance in these 
 cases. The therapeutic intractability of the disease and its 
 striking tendency to relapse after complete recovery, even in the 
 midst of quite favourable external surroundings, are also distinc- 
 tive features of hereditary neurasthenia. 
 
 Racial and national peculiarities play an important r6le in the 
 aetiology of neurasthenia. The Semitic race is especially 
 inclined to neurasthenia. A neurotic strain may even be said 
 to pervade the whole people, despite their great capability for work 
 and steady application. Obstacles and difficulties in the ordinary 
 course of events are overcome by the Jew with astonishing 
 energy and good sense, but an emotional depression, an illness 
 
60 ZIEMSSEN ON NEURASTHENIA 
 
 in. the family, may utterly paralyse him. The impression 'made 
 on a susceptible spirit by a melancholy occurrence, for example, 
 the death of a member of the family, especially of a parent, is 
 very profound, and is only very gradually effaced: So also the 
 collapse of a financial speculation, a considerable, nay even a 
 slight pecuniary loss, may elicit all at once the entire group of 
 neurasthenic symptoms. Incapacity for work is not necessarily 
 combined with it; neurasthenia is in these cases principally 
 psychical, manifesting itself by a tendency to mental depression. 
 
 The disease takes a different form among Slavonic and Oriental 
 peoples. Among the Eussians, especially of the higher class, 
 neurasthenia exists as a fundamental all-pervading trait. In no 
 nation are there so many prematurely worn-out brains, so many 
 young-old men. It is not the fact of being blase, which has its 
 origin in a too early and too vigorous indulgence in the pleasures 
 of life, but a primary tendency to exhaustion of the nervous 
 system, which quickly leads to partial, or total mental incapacity. 
 
 The high intellectual productivity and freshness conferred 
 upon advanced age by a healthy frame, by a healthy emotional 
 existence, and by the experience of a laborious life, is rarer in 
 Eussia than elsewhere. The fact is attested by the complaints 
 of the choicest spirits of that nation ; and the great experience 
 which I have had occasion to accumulate as medical adviser (consi- 
 liarhis) of members of Eussian " Society •" fully convinces me of 
 the existence of the evils bewailed by these Russian patriots. 
 
 If now, after the discussion of the most important astiological 
 aspects of neurasthenia, we seek to establish a definition of the 
 essence of these multifarious disturbances, we are at once con- 
 fronted by difficulties, inasmuch as no anatomical changes are 
 hitherto known to correspond to this disease. We must, there- 
 fore, content ourselves with regarding the pathological processes 
 as functional, or nutritive and irritative. And these words 
 signify that, having regard to the variability and multiplicity of 
 the disturbances, and to the absence of actual demonstrable 
 organic lesions, we have merely to deal with slight and readily 
 curable alterations. The capability of recovery, and the 
 variability of the (morbid) phenomena, are distinctive, although 
 we often encounter cases which, owing to hereditary taint and a 
 pronounced tendency to recur, assume a severe and incurable 
 character. 
 
AND ITS TREATMENT. 61 
 
 We must therefore, as I have just said, be satisfied with 
 defining the nature of the disease from the purely clinical 
 standpoint. I therefore characterise neurasthenia as a state 
 of functional debility of the nervous system, varying from the 
 slightest degrees of weakness in a single department, to a con- 
 dition of complete exhaustion of the entire nervous apparatus. 
 This lack of efficiency is sometimes manifested in the functions 
 of the intellectual and psychical centres, sometimes in those of the 
 reflex and inhibitory cenbres, sometimes, finally, in the paths of 
 nervous conductivity. Disturbances can, therefore, occur in every 
 department of nervous existence, and it is easily understood how 
 extraordinarily multifarious and protean must be the forms 
 assumed by the disease, not merely in the degree to which the 
 individual forms of disturbance become developed, bat also in 
 the combination of various lesions and the kaleidoscopic varia- 
 tions of the phenomena. 
 
 It is nevertheless possible to distinguish certain fundamental 
 forms of neurasthenia, as has already been done by Bea/rd in his 
 important works, namely, a cerebral form or cerebrasthenia, a 
 spinal form or myelasthenia, and a universal form in which the 
 entire nervous system participates in the disturbances. To trace 
 an accurate boundary-line between neurasthenic disturbances on 
 the one hand, and the other universal neuroses, especially 
 hysteria and hypochondriasis, and various forms of psychoses, 
 especially melancholia and mania, on the other, is not at present 
 possible. We must content ourselves with admitting that neur- 
 asthenia and hysteria often converge, as do likewise neurasthenia 
 and hypochondriasis, so that numerous authors simply join them 
 together. And as regards its relations with melancholy, mania, 
 and hallucinatory insanity, experience teaches that they may de- 
 velop themselves directly and imperceptibly out of neurasthenia. 
 Less difficult is it to draw the line between spinal neurasthenia 
 and the other diseases of the medulla spinalis, especially tabes, 
 myelitis, and meningo-myelitis. These and other organic 
 derangements of the cord are seldom liable to be confounded 
 with neurasthenia. 
 
 The symptoms of this latter are, as I already mentioned, ex- 
 tremely variable according to the position and character of the 
 most important disturbances. 
 
 We shall be obliged, if perfect accuracy be desired, to dis- 
 
62 ZIEMSSEN ON NEURASTHENIA 
 
 tinguish almost as many forms of neurasthenia as there are 
 organs in the human body, for the majority may become the seat 
 of neurasthenic disturbances. Quite a number of subdivisions 
 have therefore been made — neurasthenia cordis, enterica, sexualis, 
 &c. — but no real advantage is to be expected from such tabulation. 
 It will suffice if I acquaint you with the most important pheno- 
 mena, and lay particular stress on those points which are of 
 special diagnostic significance. 
 
 The cerebral disturbances take the first rank among the symp- 
 toms, not only because they are by far the most frequent, but 
 because they involve the greatest amount of damage to the 
 activity of the individual. 
 
 The most important of these cerebral symptoms are the 
 following : — 
 
 Incapacity for mental work. Here we immediately find count- 
 less modifications : mental impotence in every department, or in 
 that one well-defined direction only, in which excessive calls 
 have been made on the brain by professional activity — for example, 
 incapacity for arithmetic in an overworked clerk, for preaching 
 in a neurasthenic clergyman, &c. The extent to which functional 
 power is lost may also vary. The disease may announce itself 
 first of all in a mere lack of staying -power at intellectual work. 
 The brain of a gifted neurasthenic may yet display a high degree 
 of productivity, for originality, clearness of conception, and rich- 
 ness of imagination, are quite compatible with liability to rapid 
 exhaustion of nerve-power. Beard draws a very pretty comparison 
 between such a brain and a battery of small elements with slight 
 potential power and slight internal resistance, which can develop 
 momentarily an enormous actual power, but quickly become in- 
 constant and prematurely useless. 
 
 In such cases the loss of working power is only too often 
 combated by stimulants, and therefore alcohol and morphia play 
 an important part among these patients. They have an oppres- 
 sive feeling of mental weakness and low-spiritedness, and it is 
 but natural that they should seek to remedy this unpleasant 
 condition so as to be able to discharge their business. It goes 
 without saying that the primary lesion is not removed by such 
 means, which are merely the introduction of fresh' sources of 
 damage, and that the easily-exhausted brain is still further 
 injured. It is the fact, however, that in North America neuras- 
 
AND ITS TREATMENT. 63 
 
 thenia goes hand in hand with alcoholism, with morphinism, with 
 cocainism, and the other morbid offshoots of social pathology. 
 
 With this intellectual exhaustibility are usually conjoined a 
 series of other phenomena which are quite characteristic, above 
 all the so-called " Kopfdruck," the feeling of a permanent pressure 
 on the head which is increased by every mental exertion, also 
 giddiness of the head, pain and tension in the occipital region 
 and nape of the neck, heightened sensitiveness of the eyes to 
 light, sleeplessness, psychical irritability and peevishness. The 
 nervous asthenopia makes reading difficult for the patient, while, 
 on the other hand, the rapid exhaustion of nerve-force renders 
 him incapable of continuous mental exertion. In this pitiable 
 condition, caused, as it usually is, by their own fault, are the 
 numerous sexual neurasthenics, the onanists, who, being forced 
 to intellectual labour by their position, take up their books again 
 and again in order to study, for instance, to read for an exami- 
 nation, and have to lay them aside again very soon because they 
 do not understand what they read, no trace of it is retained by 
 the memory. In sheer desperation they rush out for an hour's 
 walk, and on their return commence the endeavour again, only 
 to abandon it once more. 
 
 In addition there are peculiar paresthesias in the head, 
 feelings as though it were encircled with a hoop, or as if water 
 were shaken up and down in it, or as though the upper eyelids 
 were pressed down. Further, numbness in the face, or in the 
 •extremities, with feeling of pricking, or burning, or cold ; or as 
 if the limbs " went to sleep," even on the slightest pressure 
 •of the bed-cloths against the nerve trunks ; noises in the ears 
 ■and other subjective acoustic sensations ; attacks of palpitation ; 
 also vasomotor disturbances, for example, epigastric pulsation, 
 perceptible and audible pulse-wave in the ear and head when the 
 latter lies at night on the pillow; sudden feeling of chill or 
 prickly heat, momentary blushing, shooting pains, and finally 
 sudden twitchings in certain groups of muscles, which shoot like 
 electric shocks through the body when the patient is going to 
 sleep. 
 
 The multifarious conditions affright and horror with which the 
 patients are afflicted are also characteristic. Sometimes these 
 are to be referred to dreadful occurrences, but generally no 
 cause whatever can be assigned for the special terrifying idea. 
 
64 ZIEMSSEN ON NEURASTHENIA 
 
 The different forms which these states of mental horror assume 
 have given rise to different designations, as if each were, a disease 
 sui generis. The most widely used of these designations is 
 agoraphobia, the fear of public places or wide streets, which the 
 patients imagine they cannot traverse alone, whilst they can do it 
 quite well, although not without some persuasion, leaning on the 
 arm of a companion. It is not a fear of any accident, or any 
 other special idea which underlies this peculiar phenomenon, 
 appearing as it does in so many different shapes, but only an 
 indeterminate feeling of uneasiness which overcomes the patient 
 at the view of the public place. 
 
 Other patients are attacked by unconquerable uneasiness if 
 they find themselves in an enclosed space with a number of 
 other people, for instance in a theatre or concert-hall, especially 
 if they sit in the middle and have the feeling that they could not 
 get out at once, while they can stand it better if they have a 
 place near the door or in a box. 
 
 Others again cannot travel by rail because they have the 
 feeling of being locked into the compartment and could not 
 escape if the uneasy sensations were to come on. I once treated 
 a gentleman who, not because of any dread of a railway accident, 
 but simply through fear at being locked up in the train, per- 
 formed for a lengthy period his numerous business trips, which 
 often extended over hundreds of miles, in a horse-carriage. 
 
 Others suffer, even on slight elevations, from sensations of 
 terror, with vertigo and a feeling of compulsion to throw them- 
 selves down. This is only an exaggeration of the vertigo felt by 
 many healthy persons on steeples, &c. To what a degree this 
 feeling can develop was shown me lately by an observation I had 
 occasion to make on an otherwise healthy, highly intellectual 
 man of business, who, up to a short time previously had always 
 lived on the first floor, and subsequently took a beautiful new 
 lodging on the second floor, which had low open-work window 
 balconies. The windows looked out on a public square in one 
 direction, and on a wide street in the other. From the first day 
 he complained of uneasiness at the sight of these windows, and 
 this terror became almost invincible, and persisted even at night 
 when the patient lay in bed with the shutters closed. In the 
 back room, which looked out on a small court, the feeling did not 
 • come on. 
 
AND ITS TREATMENT. 65 
 
 Many patients become uneasy when they are alone, and require 
 therefore to have always some companion. This fear of loneliness 
 naturally leads to quite peculiar, nay to actually comic situations. 
 Years ago I treated a young neurasthenic physician who could 
 not attend to his country practice without bringing his old house- 
 keeper with him. Once when he had persuaded himself to start 
 without her, the uneasiness seized him a quarter of an hour after 
 leaving the town, and he drove back post haste. 
 
 Other patients again live in perpetual dread of meeting with 
 human beings, and consequently live like the hermits, and walk 
 in the open with bowed heads, turning away the face on the 
 approach of a man. 
 
 Others are afraid of anything and everything which might 
 affect them or make any sort of demand on them, anything which 
 might require a resolution or bring with it responsibility. 
 
 Others are afraid of lightning, of earthquakes, of an accident 
 which might befall absent relations, of dust or defilement either 
 in general or caused by quite special materials. These varieties 
 of monomania, which stand close to the boundary of the psychoses, 
 are frequently observed as the sole morbid phenomenon in other- 
 wise healthy individuals. I knew a lady who went about her 
 house almost the entire day to wipe away the dust, and used to 
 wash her hands countless times. Another, the wife of a landed 
 proprietor, also suffered from exaggerated love of cleanliness, and 
 had a particular horror of cart-wheel tar ; she used always to 
 examine personally for tar stains the outside garments of her 
 relatives and friends who came on visits to her estate ; numerous 
 quarrels between herself and her relatives were thus occasioned. 
 
 The dread of disease, especially of contagious disease, is highly 
 developed in many persons. It is related to hypochondriasis, 
 which deduces the presence of definite diseases from symptoms 
 chiefly subjective and for the most part intangible, watches every 
 function of the body with the utmost attention, and strives to 
 attain certainty of diagnosis by reading medical books and 
 constantly interrogating doctors. Later authors assign to 
 hypochondriasis a place among the symptoms of neurasthenia, 
 and Arndt goes so far as to call it a cardinal symptom. 
 
 I leave it an open question whether there is any use in con- 
 ferring special names on all these individual conditions of fear 
 and uneasiness, as has been done by the partisans of a rigorous 
 
 F 
 
66 ZIEMSSEN ON NEURASTHENIA 
 
 classification. Listen to these designations — " Agoraphobia " or 
 " Topophobia," fear of public places ; " Claustrophobia," fear in 
 an enclosed space; "Monophobia," fear of loneliness; "Anthropo- 
 phobia," fear of meeting with people ; " Mysophobia," fear of 
 dirt; " Phobophobia," fear of attacks of uneasiness; "Patho- 
 phobia," fear of diseases ; " Siderophobia," fear of being struck 
 by lightning; " Siderodromophobia," fear of railways; "Hypso- 
 phobia," fear of heights ; " Batophobia," fear of the collapse of 
 lofty objects ; " Pantophobia," fear of everything possible. You 
 see, gentlemen, the number of these conditions of fright, and of 
 their Greek-derived synonyms, might be still further increased ; 
 but there is no need for such a classification. It suffices to be 
 acquainted with the most important sources of terror with which 
 such patients are tormented. They not unfrequently constitute 
 the most important part of the disease, to such an extent indeed 
 that the other symptoms of neurasthenia are relegated quite to 
 the background. 
 
 The phenomena which are most generally found in conjunc- 
 tion with the conditions of fright just mentioned are vertigo, 
 with attacks of pain and spasm in the stomach, as well as nausea 
 and tendency to swoon. These sensations attain an especially 
 high development if the patient cannot escape from the cause 
 of his uneasiness, or seeks to overcome his dread. At the same 
 time there generally arises in addition a painful restlessness in 
 the limbs, an unquiet tendency to walk up and down, feelings of 
 misery and exhaustion, loss of hope, sudden sensations of heat, 
 and perspiration of the hands. Sleeplessness also accompanies 
 the conditions of uneasiness, when these latter are persistent and 
 do not allow the patient to rest, even at night. The painful 
 ideas attain a gigantic size during the stillness of the night in 
 the imagination of the sufferer, and excite palpitation, sudden 
 feelings of heat, itching of the skin, anxietas tibiarum, so that 
 sleep is driven away for hours and only comes on towards 
 morning. Such conditions are often developed temporarily even 
 among perfectly healthy, men, under the influence of severe 
 mental labour, or through sorrow and anxiety, but disappear at 
 once on removal of the cause. Among neurasthenics, however, 
 the feelings of mental uneasiness and despair are altogether out 
 of proportion to the causes, nay, the latter may even be quite 
 unreal, existinar onlv in the natient's imagination. 
 
AND ITS TREATMENT. 67 
 
 Another form of sleeplessness occurs among such neurasthenics 
 as suffer simply from the excess of mental labour which the brain 
 has for years been compelled to perform, combined with physical 
 exertion and an irregular mode of life. Agrypnia here exists 
 merely in the sense of an absence of sleep ; sleep comes not, the 
 patient is wakeful without feeling a craving for sleep until the 
 morning hours, which at last bring a few hours' repose. It is 
 astonishing to what a degree this sleeplessness may attain in men 
 and women of high intellectual development without seriously 
 interfering with their working power. Even when sleep lasts 
 only for two or three hours each night, the patient may never- 
 theless remain for a long time perfectly vigorous and capable of 
 activity. In the long run, however, this is not kept up, and the 
 longer the disturbance takes to come on, the graver it is. Finally, 
 work is put aside, change of scene resorted to, physical exercise 
 taken, and every other means adopted; but the sleeplessness 
 persists obstinately — more obstinately indeed than any other 
 symptom — especially among patients advanced in years, whose 
 physiological need for sleep is therefore diminishing. The 
 difference in the action of hypnotic drugs in individual cases 
 is also interesting. Whilst the hypnotics proper — morphia, 
 chloral, and paraldehyde — generally act very promptly on patients 
 who lose their sleep through conditions of mental disquietude — 
 however different may be the reaction of individual cases to 
 individual drugs, some who are intolerant of morphia becoming 
 furiously addicted to chloral, and others again attaining sleep only 
 by means of the bromides — the hypnotics have usually no effect 
 worth mentioning on patients who lie awake simply because they 
 feel no need for sleep. They lie, perhaps, more restfully and with 
 pleasanter sensations, but no sleep comes on, so that finally the 
 attempts to produce sleep in such cases by means of drugs are 
 quickly abandoned. 
 
 Among the spinal symptoms, the pain in the back stands in 
 the front rank, in the majority of cases. Sometimes it is a fixed 
 pain in one vertebra or another, sometimes a vague pain in the 
 whole vertebral column, sometimes a feeling of painful fatigue, 
 of creeping, or burning, or pressure; sometimes the pain is called 
 forth by movements, sometimes it is at its worst in the sitting or 
 recumbent posture. Spots painful on pressure are frequently 
 present, especially over the superior dorsal or the cervical 
 
68 ZIEMSSEN ON NEUKASTHENIA 
 
 vertebrae or their neighbourhood, but in other cases pressure over 
 the spines of the vertebrae elicits no pain whatever. 
 
 This pain in the back usually occurs combined with a series of 
 excentric phenomena, and under the name of Spinal Irritation 
 was formerly considered to represent an independent disease. 
 These symptoms are now included within the bounds of 
 Neurasthenia spinalis, and it is advisable to completely abandon 
 any separate idea of spinal irritation, as its introduction is 
 liable to perpetual confusion. 
 
 The clinical significance of this spinal pain is slight from the 
 medical standpoint, but to hypochondriacal masturbators and 
 other neurasthenics it occasions the most cruel anxiety, for they 
 become convinced, through the violence and persistency of the 
 pain, that it is a symptom of an organic disease of the cord. A 
 thorough objective examination is the only thing which can root 
 this anxiety out of the patient's mind ; the lack of all objective 
 anomalies will usually be thus proved for the first time. 
 Diagnostically difficult cases will however sometimes come under 
 observation where a single examination may not suffice to 
 exclude with certainty an anatomical alteration of the cord, 
 especially commencing tabes or myelitis. There are cases in 
 which, in addition to the pains in the back (rachialgia), there 
 are shooting pains and feeling of weakness in the legs, and 
 creeping and crawling sensations in the feet, anaesthesia, 
 impotence, and diminution or exaggeration of the plantar reflexes. 
 Repeated examinations here confirm the diagnosis, on the one 
 hand through the inconstancy of the symptoms both subjective 
 and objective, on the other by the gradual completeness attained 
 by the general neurasthenic impression conveyed. An expe- 
 rienced neurologist will seldom make a diagnostic mistake in 
 such a case. 
 
 The astounding multiplicity of the sensory disturbances is 
 manifested as general hyperesthesia and hyperalgesia especially 
 in the form of a great susceptibility of the skin to touch or 
 pressure, to heat or cold, to changes of the weather, to many 
 varieties of cloth. We further find the most multifarious 
 parcesthesice and ancesthesice in the skin as well as in the deeper 
 soft parts, feelings of cold or heat in the extremities, sweating 
 of the hands and feet or abnormal dryness, creeping or crawling 
 sensations in the skin, transitnrv rKKtnrhanr'.A nf irm^io. „,*».„,• 
 
AND ITS TREATMENT. 69 
 
 bility as though the legs were not felt at all, as of walking on air, 
 as though the ground yielded to the tread, &c, &c. 
 
 Motor disturbances are either absent, or present to a sub- 
 ordinate extent only. A tendency to spasm of the muscles of 
 the calf, of the sole of the foot, of the lower jaw — for example, 
 in the act of yawning — of the intercostal muscles on suddenly 
 turning in bed, of the abdominal muscles in coughing or sneezing, 
 frequently exists. Paralyses are not present ; on the contrary, 
 the muscular system is usually capable of high functional activity, 
 and the patients who feel tired and depressed in the house can 
 take walks for hours together without fatigue. 
 
 Of the internal organs those most frequently implicated are 
 the heart, the stomach, and the genital apparatus. 
 
 The heart usually displays the most varying conditions of 
 innervation, especially distinct hyperexcitability. On the 
 slightest excitement, and even without any at all, well-marked 
 tachycardia comes on, combined with a series of extremely un- 
 pleasant sensations, including not merely the perception of the 
 heart's beat but actual pain, especially in the vicinity of the apex, 
 together with a terrifying irregularity, with the strangest sensa- 
 tions both during and after the pause ; with feelings of stoppage 
 of the heart's action, of pushing, of jumping, of twisting of the heart 
 on its own axis, of its leaping up to the throat, &c, &c. These fits 
 of tachycardia are generally accompanied by vertigo, as well as 
 nausea, sudden exhaustion of strength, and feeling of annihilation. 
 For many such patients when they come to the doctor the 
 diagnosis of organic disease of the heart has been for long a 
 matter of certainty, and they are quite unpleasantly surprised to 
 hear that the physical examination reveals no cardiac abnor- 
 mality. All things considered, cardiac neurasthenia is one of the 
 worst forms, because the patient never gets rid of his uneasiness 
 and anxiety. The mere terror that the palpitation, with its atten- 
 dant nameless discomforts, might come on, suffices to drive the 
 excitable heart at double its normal pulse-rate. 
 
 The sudden effect of psychical influences on the heart's 
 frequency and rhythm are quite characteristic. A pleasant visit, 
 a piece of good news, a short trip to the country, often stills the- 
 most obstinate palpitation. I once treated a neurasthenic man 
 of letters, who after several months' torture from irregularity of 
 the heart, was cured in. a few hours by a railway journey through 
 
70 ZIEMSSEN OX NEURASTHENIA 
 
 a beautiful wintry landscape, and remained for: years free from 
 Lis trouble. 
 
 The stomach disturbances with which bowel troubles are more 
 or less associated are also highly protean. Amongst prevailing 
 forms are, deficient or capricious appetite, digestive troubles in 
 the shape of abnormal sensations of an unpleasant kind ranging 
 to utter depression and misery, restless wandering about, nausea, 
 large development of gas in stomach and intestine, gaping, &c. 
 Such patients think the period of digestion the most uncomfort- 
 able of their existence, while others are attacked on an empty 
 stomach with discomfort or pain in stomach and intestine, or 
 in the head. Many are incapable of any exertion, mental or 
 physical, while fasting,- and only come into possession of their 
 strength when they have breakfasted. Others, again, are occa- 
 sionally seized by ravenous hunger (Bulimia) ("Heisshunger"), 
 which compels them to take food at once and in large quantities. 
 A young man, whom I had occasion to observe with Dr. Von 
 Hosslin in his institution, used to have an entire meal brought 
 up and placed on his night table, and devoured it during the 
 night when awakened by the " Heisshunger." An extremely ' 
 neurasthenic old gentleman of eighty, who had not left his bed 
 for years, would bolt a dozen of eggs at night, when awakened 
 by the " Heisshunger," and would then follow on with soup and 
 other things. 
 
 The appetite is extremely capricious ; according to the 
 subjective impressions of the patients, it is altogether absent, 
 and yet they often consume and assimilate excessive quantities 
 of food without any particular digestive trouble. The culinary 
 satisfaction of their changeable appetites is a trying task for the 
 housekeeper or cook, especially as there exist often idiosyncrasies 
 with regard to individual foods, particular condiments, spices, 
 &c, which are subject to the same capricious variation as the 
 appetite itself. 
 
 Many patients struggle successfully against the digestive 
 troubles by means of bodily exertion, especially by long walks 
 after meals. The comfortable repose beneficial to the healthy 
 after meals does not exist for the nervous dyspeptic ; he is driven 
 out by subjective troubles and uncomfortable sensations. 
 
 In this form of neurasthenia also psychical influences are of 
 
AND ITS TREATMENT. 71. 
 
 afterwards diminish, the troubles, whilst loneliness, severe labour, 
 distressing circumstances, anxieties, and sorrows augment them 
 to a marked extent. Such over-strained natures consume but 
 little even of select, easily digested food when at home, and 
 never without subsequent discomfort, whilst to their own astonish- 
 ment when travelling they can go through the whole table d'hdte 
 from beginning to end, and swallow and digest the most in-, 
 digestible things which they would recoil from with abhorrence 
 at home. 
 
 The neurasthenic dyspepsias seldom react upon the constitu- 
 tion. But when abstinence, due to fear of the pains, gradually 
 increases, when habitual vomiting or obstinate constipation is 
 present, then a state of nutritive cachexia may come on which 
 cause the patient's own diagnosis of "cancer of the stomach" to 
 appear at first sight not impossible. But after careful taking of 
 the history, physical examination of the patient, and investigar 
 tion of the contents of the stomach during and after digestion, 
 have all yielded negative results, and in consequence of the 
 variability of the symptoms and complaints, it soon becomes 
 obvious that there is merely gastro-intestinal neurasthenia, and 
 the result of appropriate treatment usually confirms the diagnosis 
 without delay. 
 
 The symptoms referrible to the intestine consist chiefly of 
 abnormally abundant development of gas, which produces the 
 most unpleasant sensations by distension of the hyper-sensitive 
 intestinal wall. The gas-production may undoubtedly be due to 
 morbid innervation, as is so frequently observed in hysteria. 
 The reason why the gases are not driven out is the extreme 
 tension of the intestinal wall, in consequence of which the 
 muscular coat temporarily loses its contractility. I have proved 
 by experiments on dogs, and also on human beings, that the 
 intestinal wall on being over-distended ceases to react, not only 
 to the motor impulses of the automatic centres, but even to 
 electrical stimuli. Even when the downward passage is perfectly 
 free, in cases of meteorism, the gas does not escape. It is only 
 when part of the gas has been absorbed and the tension some- 
 what diminished that the automatic impulses begin once more to 
 operate, though very feebly at first; at somewhat irregular 
 intervals, on an average once each minute, the wave of contrac- 
 tion progresses from above downwards. These experiments on the 
 
72 ZIEMSSEN ON NEURASTHENIA 
 
 living human subject were restricted, it is true, to the large intes- 
 tine, the inflation of which was carried out from the rectum (after 
 the inflation the sphincters were kept open by means of a stout 
 tube); since, however, in meteorism, and indeed in the majority of 
 cases, the gas development is in the large intestine, these experi- 
 ments might be expected to produce reliable results. At any rate 
 they explain how it is that once the conditions for gas production 
 are afforded, the great distension of the colon is so persistent and 
 yields so gradually. Especially troublesome to the patient are 
 the so-called " displaced inflations," felt in the back under the 
 right or left shoulder-blade; they correspond to collections of 
 gas in the flexures of the colon, which latter represent ob- 
 stacles to the downward passage of the gases. 
 
 Disproportionately intense as are the sufferings occasioned by 
 the gaseous accumulation, the relief afforded by the collapse of the 
 inflation is just as great. For hours the sufferer from intestinal 
 neurasthesia keeps on hoping for such a " displaced " inflation 
 to go down ; its final collapse is greeted with intense joy, for 
 then only does the mind become clear and the patient capable 
 once more of intellectual exertion. 
 
 The obstinate constipation which so generally accompanies 
 intestinal neurasthenia naturally favours, to an extraordinary 
 extent, the development of gas, and is the more intractable 
 because the usual purgatives, even the mildest, are either not 
 tolerated or act very unequally, and thereby produce new 
 troubles, so that the patients soon hold all cathartics in disgust. 
 As regards the Genital Anomalies which come under observation 
 as symptoms of neurasthenia, they must be divided into those 
 which are to be looked upon as causes and as effects respectively 
 of the neurasthenia. 
 
 As sole or partial cause, the masturbational hyper-stimulation 
 and debilitation of genital excitability comes into play in the 
 male as in the female sex, with this difference, that the disturbances 
 of intellectual working-power become much more prominent 
 among males on account of the duties incumbent upon them, 
 while women seem to be affected rather in disposition, &c. 
 
 Impotence of the male, whether complete or incomplete, is 
 a frequent cause of neurasthenic weakness and melancholic 
 depression. Apart from the few who, as old bachelors, do not 
 trouble themselves about their impotence on account of their 
 
AND ITS TREATMENT. 73 
 
 sexually torpid character, men as a rule are excessively sensitive 
 on this point, and the morally depressing influence of this 
 condition is obvious to the experienced eye in the entire 
 individuality and in every action of the subject. It would lead 
 me too far to go deeper into these matters. They deserve 
 earnest attention on the part of the physician, as much mis- 
 fortune arises in the world from that cause. I may perhaps take 
 occasion in a subsequent lecture to give expression to my 
 experience and my views on the topic. 
 
 Treatment. 
 
 The principles of the treatment of neurasthenia are the direct 
 outcome of the observations I have made regarding its causation 
 and symptomatology. Side by side often with a well-preserved, 
 nay, an actually vigorous constitution we have to do with a con- 
 dition of weakness affecting the centres of innervation, not merely 
 the centres of ideation, of volition, and of memory, but also those 
 of sensation and the automatic centres, reflex and inhibitory. This 
 functional weakness is combined with a heightened susceptibility 
 to external stimuli, in consequence of which the reaction of these 
 latter upon the above-mentioned centres, and their functional 
 manifestations, becomes all the more abnormal. 
 
 The treatment must therefore be chiefly directed to restore and 
 strengthen the nervous system, while, on the other hand, it aims 
 at removing the abnormal excitability. Stimuli must therefore 
 be applied, and by their means susceptibility must be lowered. 
 This apparently paradoxical indication may be easily fulfilled if 
 gentle beneficial stimuli be applied which do not increase the 
 excitability, and if the organism be carefully and gradually 
 accustomed to the stronger forms of stimulation by starting 
 with the weaker ones. The habitual sources of injurious 
 excitement ; the unrest of daily life ; excessive labour, anxiety, 
 excitement, cares ; family difficulties ; disturbances of sleep ; 
 excesses ; alcohol ; all these must be eliminated until the 
 nervous system has recovered its strength sufficiently to support 
 them without injury. In consequence of the generally unavoid- 
 able tendency to return to the former conditions, relapses cannot 
 with certainty be prevented. 
 
 If good results are to be obtained, separation from the ha- 
 bitual conditions of life and treatment in institutions specially 
 
74 ZIEMSSEN ON NEURASTHEXIA 
 
 devoted to tlie management of such patients,- and conducted by 
 medical specialists, are indispensable for many cases, especially 
 for severe and obstinate neurasthenia. Milder cases, especially 
 pure cerebral forms due to over-exertion and -chiefly in need of 
 rest, may be very well left free and sent to recuperate in a quiet 
 mountain health-resort where good medical advice is to be had. 
 I will mention later on the external conditions regard to which 
 must be . had. Isolation and asylum-treatment is absolutely 
 indispensable for the more severe cases of the erethic form, with 
 constitutional disturbance, emaciation, sleeplessness, dyspepsia, 
 conditions of uneasiness. No treatment in the family is here of 
 avail, least of all when undertaken amid the usual surroundings. 
 Many cases get on at first quite well at home — a fact patent 
 to every physician who allows himself to be persuaded by patient 
 or friends to attempt a course of home-treatment. The novelty 
 of the treatment exercises a stimulating influence for a while, 
 and the physician's orders are obeyed at first. Soon, however, 
 one recommendation or another is modified or left unfulfilled, 
 the dietetic restrictions are overstepped, and then the relapses 
 come on quickly. At last the treatment is only partly carried 
 out, or given up altogether, because " it is no good." You will 
 therefore do well, gentlemen, no less in your own interest than 
 in that of the patient, not to undertake a thoroughgoing course of 
 this sort of treatment tmless in a private institution, which affords 
 every guarantee for appropriate medical supervision and reliable 
 execution of all recommendations down to the minutest detail. 
 We have in Germany an abundance of good private institutions. 
 Even a Red Cross nursing establishment, or one of the Deaconesses 
 must suffice if need be, although that important requirement, the 
 constant presence of a house-physician, is not there complied 
 with. In such cases an intelligent and reliable nurse must be 
 provided, and all communication with relatives and friends 
 prevented. All experienced neurologists agree that com- 
 plete interruption of communication with the external world 
 forms the foundation of successful treatment, while the 
 factor next in point of importance is the attendance of a 
 well-trained nurse, hitherto unknown to the patient. The well- 
 known Weir-Mitchell treatment, which has also been recom- 
 mended by Charcot, Playfair, Binswanger, Burkart, and others, 
 and which has in my hands also yielded the most excellent 
 
AND ITS TREATMENT. 
 
 results in severe cases, rests on this principle. Absolute calm of 
 mind and spirit quickly pacifies the excited nervous system and 
 gradually softens down the abnormal excitability, as indeed we 
 learn by every-day experience in the treatment of the psychoses. 
 Under- these favourable external conditions we may accurately 
 gauge the effects of suitable psychical and corporal treatment. 
 The administration of appropriate diet, with massage, electricity, 
 hydrotherapeusis, and medication may now be carried out in 
 complete accordance with the individual indications ; especially 
 rest in bed, which is of great value in severe " myelasthenic " 
 cases, may without difficulty be resorted to. 
 
 The majority of cases of cerebro-spinal asthenia do not 
 necessarily call for so rigorous a separation from the outer world, 
 nevertheless many of them require treatment with restricted 
 liberty in an institution. A certain moral restraint and strict 
 medical control are not merely desirable, but actually indis- 
 pensable for the weak-willed patient. The best proof of this is 
 that many patients are quite unwilling at last to leave the 
 institution where at first they had felt very uncomfortable, and 
 immediately return to it in case of a relapse. They are attracted' 
 by the feeling of support which the institution and the careful 
 medical supervision impart to their enfeebled self-confidence, no 
 less than by the immediately favourable effects of the physical 
 means resorted to, and they all preserve after recovery a grateful 
 recollection of the institution. 
 
 Many neurasthenics do not require the institution treatment, 
 and would even derive no benefit from it. Such are the worn- 
 out minds which threaten to succumb to the daily monotony of 
 work and the daily recurrence of annoyance acting on their own 
 relatively slight power of resistance, without, however, presenting 
 any marked alteration of their physical or mental constitution. 
 There exists in the ranks of the learned professions, no less than 
 among officials and the representatives of industry and finance, 
 an incredible number of such neurasthenics, whose irritability, 
 depending no doubt on their numerous bodily complaints, 
 appears to the uninitiated in the light of the most unendurable 
 capriciousness, and renders its possessor a terror to his sub- 
 ordinates. Such dispositions derive amazing benefit from a 
 somewhat lengthy sojourn among the mountains in summer, or on 
 the northern slopes of the Alps in autumn or spring, with careful 
 
76 ZEIMSSEN ON NEURASTHENIA 
 
 tending and pleasant society. The unaccustomed enjoyment of 
 abundant fresh air, a little mountain climbing, the beautiful 
 Alpine scenery, bring about interior satisfaction, good appetite 
 and sleep ; they quickly gain in strength and weight, and feel 
 wonderfully elated by the sensation of renewed freshness and 
 muscular vigour. Climatic treatment of this kind, whenever 
 possible, is essential to such patients twice a year — in spring 
 after the heavy winter's work is done, and in late summer to 
 acquire strength for the coming winter. Even a brain severely 
 burdened with mental toil may thus preserve its functional 
 activity. 
 
 The elevation of the mountainous locality has not, as regards 
 the result, the significance generally attributed to it. The 
 elevated valleys, especially of Graubiinden, are every year visited 
 by thousands of neurasthenics requiring recuperation, and, 
 according to my experience, there is no doubt that very excellent 
 results are obtained at Pontresina, St. Moritz, Samaden, &c. 
 But similar results are just as often observed in health resorts of 
 medium elevation, i.e., between two and four thousand feet, of 
 which there are so many in the Bavarian mountains, in the 
 Baden highlands, in the Salzkammergut, in Tyrol, and in 
 Switzerland. In the selection of the suitable place the only 
 essential conditions are, that it be not inclosed in a narrow valley, 
 but situated rather in the open ; that points from which exten- 
 sive views can be had be readily accessible ; that the residence 
 be not too quiet and monotonous ; and that the attendance be 
 good, especially the cuisine. 
 
 For spring and autumn treatment I prefer the climatic health 
 resorts of the Etschthal, especially Meran, to the places on the 
 North Italian lakes or those on the Riviera. The brisker move- 
 ment of the air, the fresh mountain wind which prevails at 
 Meran during March and April, and which the poitrinaires so 
 often complain of, exercises a much more potent influence on 
 neurasthenics than the relaxing air of Italy. 
 
 I come now to the treatment of the numerous neurasthenics 
 whose circumstances do not permit them to go abroad. In these 
 cases the treatment must be conducted in suitable combination 
 with their professional duties and domestic relations. And here 
 also a very great deal may be accomplished with goodwill on both 
 
AND ITS TREATMENT. 77 
 
 Above all, gentlemen, what I must again and again insist upon 
 is the necessity of individualising. In no disease are the indi- 
 vidual differences in the manifestation of the malady, as well as 
 in its intellectual and psychical sphere, so great as in neuras- 
 thenia. Each individual case has to be separately studied in 
 order that its individual peculiarities may be known, and the 
 best of all means to this end is an accurate history, which, based 
 upon the communicativeness of the patient, places clearly before 
 our eyes the entire man and his circumstances. The profound 
 interest shown by the doctor in the careful taking of the history 
 excites the patient's confidence, and this feeling of confidence 
 and security is still further strengthened by a close examination. 
 As everything depends on the recognition or exclusion of 
 objective lesions, the investigation must be very thoroughgoing. 
 It naturally requires a good deal of time, but it is indispensable 
 to ensure the certainty of the diagnosis and the confidence of the 
 patient. 
 
 It is advisable at the close of the investigation to tell the 
 patient something accurate about the nature of the disease, the 
 prognosis as to cure, and the necessary treatment. All neuras- 
 thenics feel the desire of hearing something definite about their 
 malady, and are heartily grateful to the physician for every 
 explanation and every word which raises their self-confidence 
 and rescues them, out of their often despairing condition. 
 
 You have now to decide, from the state of the case, whether 
 the patient may follow his occupations during the treatment, or 
 whether he must withdraw from them for a shorter or longer 
 period. The decision of this question is very important for the 
 entire result of the treatment. It must be decided by the 
 impression which the physician receives from the history and his 
 investigations into the patient's condition, and the effect of 
 occupational and family influences. If there is sleeplessness and 
 incapacity for work, cessation is absolutely necessary. Each day 
 on which the worn-out and incapable brain is forcibly compelled 
 to work makes the situation worse. On the other hand, milder 
 cases with diminished capacity for exertion may well be per- 
 mitted to exercise the duties of their calling, when it is possible 
 to limit the amount of work and lighten the duties. The hours 
 thus, left vacant may be properly applied to physical exercise 
 suitable to the sex, position, and age of the patient. Walks, riding, 
 
78 ZIEMSSEN ON NEURASTHENIA 
 
 hunting, cycling, bathing, gymnastics, country excursions, 
 moderate mountaineering, &c, are greatly to be recommended. 
 It is of the greatest service to young people to compel them to 
 join a gymnastic club ; they soon acquire an interest in the bodily 
 exercises, while, thanks to the companionship of their fellow- 
 members, they are charmed out of their apathetic and hypochon- 
 driacal state of mind. 
 
 Short trips of a few days' duration are also very suitable — to 
 visit a friend, for instance, or a great city, or a watering-place — 
 the new impressions are wonderfully salutary. I have pre- 
 scribed such short health excursions not unfrequently in mid- 
 winter with good results. 
 
 It is taken for granted in the foregoing that the patient's 
 physical strength is sufficient, that the bodily exertion does not 
 increase his exhaustion. On this important matter a conclusion 
 must in difficult • cases be arrived at by experimentation and 
 observation of results. Beard points out with perfect justice 
 that myelasthenic patients more especially may have their con- 
 dition positively deteriorated by fatiguing journeys, the lack of 
 domestic comforts, and the hardships entailed by visits to 
 picturesque localities, great cities, picture galleries, &c. My 
 experience quite agrees with Beard's. Be very cautious, 
 gentlemen, how you prescribe so-called recruiting trips. Long 
 journeys are to be undertaken only by the healthy. For the 
 sick, when a change of scene is indicated, it is better to assign 
 them an agreeable but not too remote locality, where the patient 
 can stay some time, and whence he can take longer or shorter 
 excursions according to the state of his strength. 
 
 If the patient feels comfortable there, with good lodging and 
 diet, careful attendance and agreeable company, he will also 
 thrive physically, put on weight, he will eat and sleep better ; 
 while, on the other hand, the restless excitement of continual 
 locomotion, with all the consequences it entails, only renders him 
 the more unquiet. 
 
 The sea-coast is very agreeable to some patients as a place of 
 sojourn, and they acquire new strength and freshness every year 
 by sea-bathing. These are for the most part physically robust 
 individuals, who only suffer from a relative excess of mental 
 labour. The stimulating effect exercised by the sea-bathing, and 
 the constant movement through air and water, will be tolerated just 
 
AND ITS TREATMENT. 79 
 
 as easily as the monotony of the daily life and the surroundings. 
 It is, however, not generally advisable to recommend sea-bathing 
 for sensitive, sleepless, psychically excited or depressed neuras- 
 thenics, since it only increases their excitement and sleeplessness. 
 The majestic calm of high mountainous situations acts quite 
 differently. 
 
 I must however confess, gentlemen, that even with very great 
 experience it is often hard indeed to come to a conclusion on the 
 question, " Sea-bathing or the Mountains ? " and that the 
 answer must often depend on the result of a trial of sea-bathing. 
 For such experiments I would recommend the Baltic bathing 
 resorts as being in all respects the quieter — especially the Islands 
 of R'ugen, Usedom, and Wollin, with their magnificent forests 
 stretching almost to the very shore. If the trial turns out 
 favourably, the more strongly stimulating and strengthening 
 North Sea baths may take their turn. 
 
 I come now to the discussion of the physical and pharmacologi- 
 cal curative agents which we have, as auxiliaries, at our disposal, 
 in addition to the therapeutic resources already described. 
 
 The physical agents are of great value in the treatment of 
 neurasthenia ; they are applicable everywhere, whether in an 
 institution or in the patient's private dwelling, but are un- 
 doubtedly more efficacious in an institution because they are 
 carried out regularly and methodically, and the best apparatus 
 and arrangements, as well as a skilled staff of assistants, are there 
 available. It is nevertheless quite possible to apply some of 
 these therapeutic agents in the private dwelling to patients who 
 are not in a position to give up their avocations, or they may be 
 sent for a few hours to the institution in order to undergo the 
 treatment quietly and methodically. That is, however, an ex- 
 pedient which should only be resorted to in mild cases ; in those 
 of medium, or of great severity, it does not suffice. 
 
 Hydrotherapeutics find their application along with procedures 
 which exercise a refreshing and stimulating action on the 
 peripheral nerves, and, centripetally also on the nerve-centres. 
 All shocks and all too strong depressions of temperature must be 
 carefully avoided; both are badly borne by a sensitive and 
 enfeebled nervous system. 
 
 The procedure which is at once the gentlest and the most 
 efficacious is the simple tepid sheet-bath ivith shampooing. As it 
 
80 ZIEMSSEN ON NEURASTHENIA 
 
 can be done anywhere and costs nothing it is highly applicable in 
 private practice, even among the poorer classes. It is carried 
 out the first thing in the morning. First of all I cause the sheet, 
 which must be large enough to envelope the whole body, to be 
 dipped in water at 24° E. (86° F.) and thoroughly wrung out. 
 With this wet cloth, the rubber — any domestic or servant man 
 can be trained for the purpose — stands before the patient's bed 
 and spreads it out, holding it by two corners with upraised 
 hands, while the patient gets out of bed and lets fall his 
 linen ; the operator then wraps it from behind round the 
 whole body of the patient, and rubs his back and legs with 
 the wet cloth, while the patient rubs his own chest and ab- 
 domen. The wet sheet is let fall after a minute's rubbing and 
 is replaced by a dry sheet, previously got ready and warmed 
 gently with a hot water bottle or in an oven. The skin is then 
 dried by means of gentle pressure and stroking, and without, 
 vigorous rubbing. 
 
 I know that professional hydrotherapeutists do not consider 
 this modification of the wet shampoo as efficacious ; but I have 
 most distinctly convinced myself in many hundreds of cases that 
 it is this gentle form of rubbing down only which can overcome the 
 first repugnance and render it possible to pursue the treatment. 
 Each day the temperature of the water is lowered by 0'5° E. 
 until 15° E. (65-75° F.) is reached. It is not generally 
 advisable to employ a lower temperature in neurasthenic cases 
 unless the patients are quite hardened lovers of cold water. A 
 moderate addition of common salt to the water heightens its 
 stimulating, action, but it should only be commenced after two or 
 three weeks. After the rubbing down the patient should dress 
 at once, and if possible go out into the open air for a while. 
 
 If the procedure has been rightly carried out, the patient ought 
 to experience an agreeable sensation of warmth, freshness, and 
 elasticity after being rubbed down. If he feels chilly and 
 uncomfortable the water should be used warmer on the next 
 occasion. 
 
 This operation should be continued every morning for months. 
 In milder cases it suffices, combined with suitable diet, to effect 
 complete recovery. 
 
 Half-baths, and cold shower baths with previous wet-pacMng, 
 or after a short vapour or steam-chamber bath, are more energetic 
 
AND ITS TREATMENT. 81 
 
 measures. These procedures may prove very efficacious in 
 somewhat torpid forms of neurasthenia, but on account of the 
 necessity of careful supervision during and after the bath, they 
 should be reserved exclusively for institution treatment. 
 
 Short "full-baths" river-baths, and still better sea-bathing, are 
 also very valuable methods of treatment, and cannot be too 
 strongly recommended. Many patients, however, have an 
 idiosyncrasy with regard to river and sea baths, and regularly 
 get chills and feel giddy afterwards. Such patients should nob 
 be forced to persist, but their treatment should rather be limited 
 to frictions, &c. 
 
 Electricity is also very valuable, as well for generalised appli- 
 cation according to Beard and Eockwell's method as for local 
 application in localised forms of neurasthenia, especially those 
 affecting the heart and the digestive tract. 
 
 'Beard's "general electrisation"' has been specially devised 
 for neurasthenics, and the enthusiastic recommendations with 
 which this procedure has come to us from America have also 
 found justification in Europe. ■ The method consists in passing 
 the widely expanded electrode of the positive pole over the 
 entire body-surface, while the soles of the feet are placed upon a 
 damped and warm metal' plate, which is covered with flannel 
 and contains the kathode. The ari-electrode may suitably 
 be shaped as a roller, so as to glide' quickly over the cutaneous 
 surface. According to Beard and Bockwell the current must 
 be strong enough to induce powerful contractions of the 
 superficial muscles. I would recommend this counsel to be 
 adopted cum cjrano salis, at least in the beginning of the treat- 
 ment. The current ought in my opinion to act only as a moment 
 tary stimulus to the peripheral nerves ; it is then propagated 
 centripetally to the central nervous system, and leaves behind it 
 a feeling of general freshness and invigoration, and-also perhaps 
 desire to' sleep and renewed appetite. If a too intense current has 
 been adopted the unpleasant symptoms of reaction which the 
 above-mentioned American authors have described are sure to 
 come on — trembling of the' legs, coldness of hands and feet, pains 
 in the muscles and in the head, general nervous excitement, &c. 
 These symptoms of reaction may be almost- certainly avoided by 
 beginning with a weak current, not continuing the sitting for 
 longer than five minutes, and repeating it only on every second 
 
 G 
 
82 ZIEMSSEN ON NEURASTHENIA 
 
 day. When the subject is very sensitive the physician will do 
 well to include himself at first in the chain, and to go over the 
 patient's skin with his own damped hand for an electrode. That 
 is certainly the mildest, the most soothing form of superficial 
 electrisation. 
 
 The constant current has no special effect applied in this way. 
 Its application in obstinate organic neurasthenias, e.g., of the 
 stomach, intestine, sexual organs, heart, or head, is much more 
 important. The constant current is here of inestimable value 
 as a sedative. In order to develop its full effects however — a 
 point to which I drew attention a considerable time ago — it is 
 absolutely necessary to introduce the current by means of very 
 large electrodes, i.e., with a large sectional area, or else in great 
 quantity, but with slight tension, at any one point of the surface 
 of contact. The effects on pain or uneasiness affecting these 
 organs, on their functions and on the general condition, are in 
 the majority of cases very favourable, in many, actually brilliant. 
 I cannot go further into detail in this place ; you will find par- 
 ticulars about mode of application and effects in my work 
 " Electricity in Medicine." 
 
 Massage is the third member of the alliance, and is just as 
 useful as the agents just named, and for that reason suitably 
 combined with them, at least at first, in the following way: 
 massage and general electrisation should be applied on alternate 
 days, while hydrotherapy should be daily carried out. In the 
 beginning massage ought to be used gently, and for a short 
 time only (fifteen to twenty minutes), and be gradually extended 
 to one or two hours daily. It is proper to begin with gentle 
 pinching of the skin, in other words with purely mechanical 
 stimulation of the sensory nerves, and with gentle pressing and 
 kneading of the muscles. The vigour of, and the extent of sur- 
 face included in, the movements of pinching, stroking, kneading, 
 percussion, and squeezing, should be gradually increased, so that 
 the patient finally gets to feel after the massage as though he 
 had been thoroughly beaten. 
 
 The effect is very favourable and lasting. The sensibility of 
 the body, the pains, the nervous unrest and sleeplessness, are 
 favourably influenced by massage, whilst on account of the in- 
 creased muscular metabolism, food-requirement, and assimilation 
 are promoted. These effects are explicable on the one hand by 
 
AND ITS TREATMENT. 88 
 
 the strong stimulation of the sensory nerves and reaction of 
 these latter on all the innervation centres and their functions 
 collectively, and on the other by the vigorous promotion of the 
 blood and lymph circulation in the skin, subcutaneous tissue, 
 and muscles, whereby tissue change and restitution are actively 
 assisted. 
 
 Massage is of the first importance in those severe cases where 
 absolute rest in bed is necessary, and abstention from all bodily 
 and mental activity, even the slightest. Accordingly it plays a 
 leading part in the Weir-Mitchell treatment. Here voluntary 
 muscular action is completely replaced by massage, without 
 resorting in the smallest degree to central impulses. 
 
 With regard to the duration of the electrical and massage 
 treatment I would counsel moderation. After from three to four 
 weeks one may try an experimental cessation for one or two 
 weeks, during which the patient may undertake a little excursion 
 to test his strength, and, if need be, to acquire renewed patience 
 for a continuance of the treatment. 
 
 The drugs which may be administered in neurasthenia belong 
 to the classes of nervine sedatives, tonics, and hypnotics. Do not 
 expect too much, gentlemen, from medication in this disease. 
 The bromides alone are frequently very valuable, but only when 
 exhibited in large doses (2 to 3 grams several times daily), 
 especially in the evening, when there is nervous excitement 
 and sleeplessness. They suffice but very seldom, however, as 
 the sole curative agent ; they are to be looked , upon as mere 
 adjuvants in the complete course of treatment. I prescribe, when 
 necessary in such cases, a mixture of bromide of sodium, bromide 
 of potassium, bromide of ammonium, and sometimes also bromide 
 of lithium in moderate doses, and keep this prescription in force 
 often for several weeks when -the result is satisfactory. Some 
 patients like to order something for themselves when they feel 
 miserable, or resort to some previous prescription. Bromides are 
 highly suitable for this purpose. I am in the habit of recom- 
 mending people who suffer from attacks of terror, or who go 
 about the world in constant dread of such attacks, always to carry 
 about boxes of starch-capsules of bromide in their waistcoat or 
 coat pocket, and take some when the dread of the dread comes 
 on. Water, to drink afterwards, is to be had everywhere. Others 
 who suffer from attacks of weakness, " Heisshunger," and such 
 
84 ZIEMSSEN ON NEURASTHENIA 
 
 like, I recommend to carry in their pocket a little bottle of 
 tinct. valerian, tinct. castorei, and sp. aether, aa 5 grams, 
 and a few lumps of sugar, which they can take any time and any- 
 where. My idea is not so much to assist the patient in the 
 attack as to arouse his self-confidence by the knowledge that he 
 possesses a remedy which may be resorted to at any moment. 
 In cases of " Heisshunger " I get them to carry a little bread 
 or the like in their pockets. 
 
 I do not think much of the other nervine drugs by which 
 Beard sets great store — arsenic, cannabis indica, ergotin, caffein. 
 In rare cases they may be of some use, but for the most part 
 they serve only for the satisfaction of drug-craving patients. 
 
 Beard asserts that he has obtained results from frequently 
 changing the drugs ; often he gave sedatives for one week, the 
 second week tonics, the third week he stopped, and then began 
 once more. No German physician will attach any value to such 
 an example ; but it must be borne in mind that the Americans 
 are inclined and accustomed to take a great deal of medicine, 
 while in Germany the opposite tendency — a distinct disinclination 
 to employ drugs — is prevalent. 
 
 The hypnotic drugs, morphia, chloral, paraldehyde, I only 
 employ in cases of extremest necessity, and then temporarily. To 
 patients suffering from sleeplessness, who have the most intense 
 oraving for sleep, I administer chloral or paraldehyde once or 
 twice a week, but then in so powerful a dose that a lengthy and 
 quiet repose is- occasioned, and for that purpose a very large 
 dose is often required. The patient must then manage to get 
 along without hypnotics for a couple of days, and this method is 
 continued until the general treatment induces natural sleep. In 
 this connection I should like to point out that a warm bath, or a 
 weak galvanic current diagonally 'through the head, taken in the 
 evening, act as excellent hypnotics. Others take so much 
 alcoholic drink, and in so short a time, that a sort of intoxication 
 is set up. Beer more especially acts in large quantities as a 
 hypnotic. An old neurasthenic gentleman whom I treated a 
 long time ago had for years been unable to sleep unless he had 
 quickly drank a whole litre of beer lying in bed. 
 
 I warn you pressingly, gentlemen, against the administration 
 of narcotics in gastro-intestinal neurasthenia, however bad the 
 pains may be — in any case the complaints are not to be taken as 
 
AND ITS TREATMENT. 85 
 
 seriously as they are made ; also against exhibiting digitalis and 
 other cardiac drugs in cardiac neurasthenia with arhythmia and 
 tachycardia. If the attacks are severe a weak galvanic current 
 may be steadily applied to the heart several times daily. It 
 often produces an excellent result, as do also the bromides. 
 
 I would also warn you against purgatives in general, and 
 especially against their regular administration. Tonics, es- 
 pecially bitters with a weak cathartic action (e.g., tinct. rhei 
 vinos., with tinct. chinas comp. or elixir aurantior. comp. aa a 
 teaspoonful several times daily), may be occasionally effectual. 
 
 External applications, especially the so-called revulsives, are 
 sometimes not to be avoided absolutely, but they exercise usually 
 a very slight and temporary effect. They are properly suitable 
 only for very intense and sharply localised neuralgias, especially 
 rachialgia. Violently irritating applications, blisters, and even 
 the actual cautery, applied by means of Paquelin's method, act 
 indeed rather by terrifying or punishing the patient than as 
 curative agents. 
 
 Very beneficial, on the contrary, are external applications of 
 heat and cold according to the particular indication, whether in 
 the form of rubber bags, which can be carried about and applied, 
 more especially along the spinal column, or as hot or cold jet- 
 douches, which are especially applied to the back, or finally as 
 the so-called " Scottish douche," i.e., alternating small hot and 
 cold water jets, each to be continued for eight to ten seconds, 
 and the whole procedure to last from eight to ten minutes. The 
 continuous change of temperature with the constant stimulation 
 is greatly praised by many nervous dyspeptics for its beneficial 
 effects on their digestive troubles and appetite. 
 
 To conclude now with the diet. Here it is difficult to lay 
 down general rules, because the indications may be different in 
 each case. For this very reason it is only in relatively few 
 cases that value can be ascribed to so regular a course as is 
 prescribed in the Weir-Mitchell treatment, as milk more 
 especially is absolutely intolerable to many persons. Neverthe- 
 less the prescriptions of Weir-Mitchell are valuable as showing 
 what quantities of food may be introduced into a stomach almost 
 unaccustomed to nourishment, and what favourable effects on the 
 general body-nutrition and towards strengthening the constitu- 
 tion may thereby be attained. I can heartily recommend to you 
 
86 NEURASTHENIA AND ITS TREATMENT. 
 
 Weir-Mitchell's work, " Fat and Blood," and also Beard's on 
 Neurasthenia — both have appeared in German dress — as being 
 really most interesting books. I am not thereby prevented from 
 warning you most urgently against the straitlaced systematic 
 methods of treatment which are flourishing just now and doing 
 much damage in the world. Could we but compute how many 
 people have had their lives sacrificed to irrational fat-reducing 
 treatment and its accompaniments, you would assuredly be 
 astonished at the high mortality. Systematic methods of 
 treatment constitute a great danger in the hands of a physician 
 who does not individualise, and especially in those of a layman. 
 
CLINICAL LECTURE 
 
 ON 
 
 THE CAUSES OF TUBERCULOSIS. 
 
 BY 
 
 Peof. H. von ZIEMSSEN, 
 
 DlEECTOE OF THE MEDICAL CLINIC IN MUNICH. 
 
 Translated iy 
 A. M. STALKER, M.A., M.D. 
 
 Physician to the Dundee R >yal Infirmary. 
 
THE CAUSES OF TUBERCULOSIS. 
 
 The complete change which Koch's famous investigations have 
 wrought in our theoretical views of tuberculosis have also power- 
 fully influenced, indeed completely revolutionised, our ideas of 
 practice regarding it. So long as the nature of tuberculosis was 
 unknown, the hypotheses in regard to it were formed in accord- 
 ance with the notions fashionable at the time. At one time 
 tubercle was a neoplasm, at another a specific infectious forma- 
 tion, at another an inflammatory product. It was asserted — and 
 simultaneously denied — that it originated from bronchial catarrh, 
 from pulmonary haemorrhage, from pneumonia, from inhalation 
 of dust. Its contagiousness, too, was the subject of controversy. 
 Its hereditary character alone was the one thing about it that 
 always passed as incontestable, and recently this last also had 
 been called in question. 
 
 On this chaos of hypothesis and empiricism Koch's discovery 
 suddenly threw a brilliant light, which has not only cleared up 
 the heart of the matter, but has purified and advanced our 
 knowledge of the subject in all directions. At one blow the 
 old much-debated problem of the nature of tuberculosis was 
 solved, and its parasitic character, and that of scrofula in all its 
 forms and localisations, determined. 
 
 I remember the great impression which Koch's first demon- 
 stration in the laboratory of the Imperial Health Office made on 
 myself and on the other members of the Pharmacopoeia Commis- 
 sion. Up to that time he had allowed nothing of his investigation 
 to become public, and in demonstrating to us his preparations, 
 and showing the way by which he had arrived at his discovery, 
 he only yielded to our wish and that of the then director of the 
 Health Office, Dr. Struck. We saw laid bare before us in that 
 unpretending laboratory, and in the most unassuming way, one 
 of the greatest enigmas in pathology, the real character of the 
 sorest scourge that afflicts mankind. And the completeness and 
 trustworthiness of Koch's solution of the problem was made 
 
90 ZIEMSSEN ON THE CAUSES OF TUBERCULOSIS. 
 
 manifest when it was found that all the criticism and investiga- 
 tion which followed not only made no essential change but made 
 no important addition to his statements. Every link in the chain 
 of evidence was as firm as the whole. 
 
 Physicians immediately accepted the new doctrine, and honour- 
 ably set themselves to transform their conceptions in accordance 
 with the bacillary hypothesis. That many obstacles to the 
 acceptance of the entire theory existed at first was quite obvious, 
 and the elucidation of separate problems connected with tuber- 
 culosis, when regarded from this point of view, seemed attended 
 with insurmountable difficulty. 
 
 This was the case in the first instance with the theory of 
 heredity. There is perhaps no fact which has been considered so 
 completely beyond doubt as the hereditary character of tubercu- 
 losis. It was the daily observation of the physician that this disease 
 gathered its harvest among the children of tubercular parents. 
 Scrofulous in childhood and tubercular in youth, he saw them 
 grow up and fade away. How, then, is this axiom of experience 
 to be brought into agreement with the bacillary theory ? 
 
 Different ways of reconciliation have been proposed. Most of 
 them rest on hypotheses which, though supported by some 
 facts, are yet as a whole unsubstantiated. The transmission of 
 tubercle through the father is explained by the supposition that 
 at the time of conception the bacilli are introduced within the 
 spermatozoa. The only argument assigned for this is that bacilli 
 have been found in the testicles of men affected with tubercle. 
 Transmission through the mother, if coincident with concep- 
 tion, requires the assumption that the ovum is infected before 
 fertilisation, or on the passage into the womb. Intrauterine 
 infection is also possible at a later date from the seminal fluid of 
 the father or the blood of the mother. But all these suppositions 
 are only makeshifts, and the want of direct proof for any of them 
 has driven physicians to seek other explanations of the occur- 
 rence of tubercle in families. The endeavour to replace the 
 germinal and intrauterine by extrauterine infection is exemplified 
 by the suggestion that has been made by See in his work on 
 " Bacillary Tuberculosis," and by Biihle in his lecture before the 
 sixth Medical Congress, and in his article on " Tuberculosis " in 
 my Cyclopaedia. This suggestion deserves the greatest attention, 
 were it on this ground alone, that we can do much more to free 
 
MODES OF INFECTION. 91 
 
 mankind from tuberculosis, if in place of a heredity which we 
 can only with difficulty modify, we have to deal with various 
 modes of extrauterine infection, the influence of which we can 
 more readily examine and restrict. 
 
 As a matter of fact, the means of infection in the child lie very 
 close at hand and in great number. The intimate contact between 
 the infant and its diseased mother or nurse, the kisses of its 
 infected father, the contamination of its food with the bacilli, and 
 the entry of the latter into wounds, all these are modes of 
 infection against which the helpless child has no protection, and 
 the weaker and the less capable of resistance its constitution is, 
 the less protection can it have. 
 
 Perhaps infection by means of milk containing bacilli or their 
 spores comes in importance immediately after the direct infec- 
 tion from the relatives. From the frequency of tuberculosis 
 among cattle, the danger from this source is very great, as milk 
 coming from a diseased cow, when perhaps the udders themselves 
 are the seat of tubercle, is infective in a very high degree. The 
 recent experiments of Bollinger and his pupils in this direction 
 have yielded noteworthy results. They found that the milk of 
 cows affected with pleural «r pulmonary tuberculosis can infect 
 guinea-pigs, even when the udders are perfectly normal, and the 
 animals themselves are in a very good state of nutrition. Of 
 course the risk from this source is very much lessened on account 
 of the custom of mixing up the milk of diseased with that of 
 sound animals, and five minutes boiling gets rid of the danger 
 altogether. People, however, are apt to display very great 
 indifference towards insidious perils of this kind ; even in edu- 
 cated families far too little attention is paid to the source of 
 the milk on which the infant is fed, and the regular boiling, 
 where that is practised, is not looked after with the requisite 
 strictness and care. If this last precaution is left to the cook, 
 then it may be taken as tolerably certain that it is imperfectly 
 done, and I advise you always, gentlemen, to urge on the mother 
 the necessity of preparing the milk with her own hands. This 
 can be best done by means of Soxhlet's apparatus, which, on 
 the supposition that the mother looks after the cleaning of it 
 herself, effectively excludes the possibility of danger to the 
 infant from any micro-organic or chemical source. 
 
 On the whole, as we stand at present, we are not yet in a 
 
92 ZIEMSSEN ON THE CAUSES OF TUBERCULOSIS. 
 
 position to estimate the extent of this danger from the food. It 
 is possible, no doubt, that the dread of milk-infection has gone 
 too far, but the frequency of mesenteric disease in children 
 always throws us back on the food as the origin of the mischief. 
 And seeing that the infective influence of the milk of tubercular 
 cattle upon other animals has been pointed out, and that no 
 objection can lie against the validity of the application of those 
 observations to human beings, it is the medical attendant's busi- 
 ness to point out to his patients the great dangers to which they 
 are exposed. 
 
 There are many other ways of extrauterine infection which can 
 simulate hereditary transmission, and the close intercourse among 
 the members of a family offers abundant possibilities for the 
 exercise of a harmful influence where the parents are tuberculous. 
 Furthermore, if the furniture, the utensils, or the food, are con- 
 taminated with sputa containing bacilli, the predisposed children 
 will the more easily be infected, the smaller the dwelling, the larger 
 the family, and the less are decency and cleanliness considered. 
 
 But obvious as all these channels of infection may appear from 
 the theoretical point of view, yet practically their influence is of 
 no great importance. Such is the 'testimony of the results of 
 collective investigation and of the practitioner's daily experience. 
 The transmission of tubercle from diseased persons to others 
 living with them, more especially to husband, or wife, or servants, 
 is so extremely uncommon that the direct infectiveness of the 
 disease from man to man can hardly be so powerful as now and 
 then on & priori grounds has been assumed. We must still look 
 to. the heredity theory for the explanation of its very common 
 occurrence in the oflspring of tubercular parents, and the solution 
 of the many difficulties which surround the question must be 
 sought in the further development of our science. 
 
 One special stumbling-block is the long period during which 
 tuberculosis is latent in childhood. Were it the case in con- 
 genital tuberculosis, as in syphilis or small-pox, that the foetus 
 brought with it into the world the symptoms of the disease, the 
 question were easy to decide. But tubercle in the new-born is 
 not plain to the light of day ; it behaves somewhat like those 
 rare cases of syphilis congenita tarda, where the symptoms do 
 not appear till the second decennium of life, and in which the 
 question whether we have actually to do with congenital or extra- 
 
PREDISPOSITION. 98 
 
 uterine infection is yet matter of controversy. That a child is 
 often tubercular, and has been so for years, while it is all the 
 while held as perfectly sound, we sometimes see proved by acci- 
 dent. The examination of a single swollen gland, taken with 
 every precaution from a child apparently in the best of health, 
 will reveal in its interior giant-cells and bacilli. How long have 
 these already been in the body ? And are there still other foci 
 of infection in the glands ? Who can determine these points ? 
 
 One more fact deserves mention here. During the last great 
 epidemic of measles in Munich, Bollinger (I learned this in con- 
 versation with him), when examining the bodies of children who 
 had died of measles, was able on several occasions to demonstrate 
 the presence of tubercle bacilli in the lymphatic glands, especially 
 in those at the root of the lung and in the mediastinum. The 
 children in question were said to have been previously quite 
 healthy, and more particularly had not been scrofulous. This 
 important statement places in quite a new light the fact that 
 children so frequently fall into tubercular disease after measles. 
 The measles has not caused the tuberculosis ; the latent tuber- 
 culosis is merely brought to light by the measles. Probably the 
 majority of the cases of tuberculosis in youth are preceded by 
 an affection of the glands of many years standing, the latter so 
 frequently manifesting itself as the scrofula of childhood. 
 
 All this, nevertheless, does not prove that the infective agent 
 is present at conception, or in utero. It might quite well be 
 that the bacillary invasion has taken place in the first or second 
 years of life, either through a slight wound, a method which some 
 observations render probable, or through infected milk, &c. But 
 we always come back upon the fact that all these possible ways 
 are of actual importance only in the case of children of tuber- 
 cular or latently tubercular parents. Experience forces on us 
 the assumption that the absolutely sound human organism must 
 have a very great power of resisting the lodgment of the bacillus, 
 and that the latter only finds a permanent abode in the lungs, 
 intestines, &c, when certain conditions are present favourable to 
 the settlement and propagation of the micro-organism. These 
 unknown pathological conditions we call the predisposition to 
 tuberculosis, and mean by that a certain constitution of the 
 tissues of the organism, in virtue of which they afford a favour- 
 able soil for the settlement of the virus. Without the assumption 
 
94 ZIEMSSEN ON THE CAUSES OF TUBERCULOSIS. 
 
 of this predisposition, which may be either inherited or acquired, 
 we cannot proceed. Such a predisposition exists for other infec- 
 tious diseases, such as typhoid, cholera, and dysentery ; why not 
 also for tuberculosis ? 
 
 What this predisposition really is which plays a part in the 
 theory of the etiology of tuberculosis, second only to that of 
 heredity, we do not know. We know of course in a general way 
 how a man looks who bears a hereditary burden of this sort ; we 
 know, further, what causes combine to produce the predisposition ; 
 but as to wherein its real nature consists, and as to what are the 
 morphological, chemical, or physiological changes to which it 
 owes its origin, we are quite in the dark. Even the external 
 appearances characteristic of the hereditary tendency, and forming 
 the phthisical habit as it is called, often help us very little. The 
 slender frame, flat chest, thin limbs, and delicate complexion, the 
 weakness of the blood-vessels in the mucous membranes and 
 proneness to epistaxis, the liability to laryngeal catarrh, the 
 frequent attacks of palpitation and flushing, the circumscribed 
 malar redness, and so forth, all these are certainly very marked 
 in many cases, but we often also see several or all of them absent. 
 Look at the number of young people in robust health who become 
 tubercular in spite of a well-knit frame, firm muscles, a good 
 complexion, and all the other marks of health ! 
 
 As for the acquired predisposition, all the weakening influences 
 which attend in so rich measure on human life are the agents for 
 its production. Among these are insufficient food, insanitary 
 dwellings and ways of life, too little sleep, want of fresh air, 
 worries, sorrows, looking after and sitting up at night with the 
 sick, bodily and mental strain, previous illness, childbed, &c. 
 There is no single one of the list that has so deleterious an effect 
 on the resisting power of the tissues and the cells as the want of 
 fresh air and sufficient exercise. The working of these injurious 
 agencies can be most accurately studied among the inhabitants 
 of such places as prisons, convict establishments, and religious 
 houses. Here the restrictions on free movement and the enjoy- 
 ment of fresh air work in a great many ways, though it may be 
 difficult to estimate the share each of them has in the total result. 
 The essential considerations are these : the air in the apartments 
 which are kept closed, especially in the sleeping rooms, is impure 
 and malodorous, contains dust and low forms of life, is poor in 
 
MORTALITY IN PRISONS. 95 
 
 oxygen and rich in carbonic acid ; the inspirations with the 
 sedentary mode of life are not deep enough, the lungs are not 
 properly expanded, the metabolism of the tissues in consequence 
 of the want of open air exercise is limited to that attendant on 
 arduous muscular toil, the desire for food becomes less, and its 
 appetising power is diminished by the monotonous character of 
 the dietary. The preparation also of the meals and the quantities 
 allowed often leave a good deal to be desired. 
 
 In addition to these in the case of prisoners we have the mental 
 factors : remorse, longing for freedom, desire to see their families, 
 the compulsory intercourse with the scum of mankind, solitary 
 confinement, and the absence of any stimulus whatever. Sur- 
 rounded by this set of weakening influences the whole organism 
 gets into a lowered condition, in which the ever-present tubercle 
 bacilli readily find admission. It is no doubt generally allowed 
 that in establishments of this kind consumption has gained a 
 firm footing, but the enormous extent to which the inmates fall 
 victims is not perhaps known as it should be. The figures which 
 V. Baer gives in his article in the " Zeitschrift fur klinische 
 Medicin" bring out that in prisons the death-rate from con- 
 sumption is three to four times as high as it is outside. Beckon- 
 ing the general mortality from consumption as one-seventh, or 
 from fourteen to fifteen per cent., we find that in prisons tubercle 
 is the cause of from forty to fifty per cent., or about half of the 
 total number of deaths. The numbers, of course, vary. For 
 example, in the Austrian prisons the deaths due to consumption 
 in a period of four years amount to 61 per cent, of the whole, 
 while in the Bavarian prisons for a period of eight years they 
 only amount to 38 - 2 per cent. The death-rate in the different 
 penal institutions also seems to vary according to their construc- 
 tion and organisation. At any rate it is stated that tuberculosis 
 accounts for far more than 60 per cent, of the deaths in the 
 prisons arranged for solitary confinement in cells. 
 
 The fact that the mortality reaches its maximum in the later 
 years of confinement is very striking. The infection is thus not 
 simply communicated in these confined quarters as soon as the 
 prisoner sets foot in the establishment ; in the majority of in- 
 stances it requires a process of lowering of the constitution going 
 on for some time to prepare the organism for the settlement of 
 the bacilli. 
 
96 ZIEMSSEN ON THE CAUSES OF TUBERCULOSIS. 
 
 Many individuals, however, with low resisting power of the 
 tissues fall victims quite early, especially when the contrast 
 between the prison air and the country air they have been used 
 to is a very sharp one, as it is in the case of prisoners from a 
 rural district. This observation is confirmed by the statistics of 
 French and English Army surgeons, which bring out the fact 
 that cases of tubercular disease and deaths from it quickly 
 diminish in number during war or during manoeuvres, while in 
 times of peace, especially in winter, when the men are in 
 barracks, they very distinctly increase. Similar causes imperil 
 the lives of the industrial classes in large towns, where they spend 
 their days in dusty, overcrowded workshops, and sleep in close 
 and not very clean rooms at night. 
 
 The comparison of the numbers of cases of tuberculosis among 
 industrial and agricultural populations is also favourable to the 
 assumption that the quality and quantity of the respired air are 
 the deciding influences. For example, in Switzerland the 
 mortality from consumption in the former class is more than 
 double that in the latter; the industrial population shows a 
 death-rate from tubercular disease of 2-55 per thousand, the 
 purely agricultural 1-1, while a mixed population gives a rate of 
 1-7. 
 
 Lastly, the statistics from high altitudes distinctly indicate the 
 frequency of phthisis to be in inverse proportion to the elevation. 
 And at very great heights, e.g., in Mexico, in the towns of 
 Mexico, Puebla, Quito, Potosi, and Bogota, all standing at an 
 elevation of from 8,000 to 18,000 feet, tuberculosis is very rare; 
 in spite of the hurtful character of the mining industries it does 
 not occur to any extent even among the labouring classes. 
 
 A retarding influence on the development of consumption is 
 observed at an elevation of 1,600 feet, and much more distinctly 
 at one of 3,200 feet. Among the climatic peculiarities of such 
 heights to which this influence may be due we may, I think, 
 discount the effect of the rarified air, for both sea voyages and 
 residence in the Steppes give like favourable results ; stress is to 
 be laid rather on the maintenance of the purity of the air by 
 its rapid movement, and on its freedom from micro-organisms. 
 The investigations into the micro-organisms of the atmosphere, 
 undertaken by Miguel and Freudenreich, give, for heights of over 
 6,500 feet, a complete absence of microbes, and even at a height 
 
VARIOUS SOCIAL INFLUENCES. 97 
 
 of 1,820 feet there were very few. Mareau and Miguel also 
 found them nearly altogether absent in the air on the surface 
 of the ocean, and at certain spots on the sea-coast. These results 
 of bacteriological research are, it will be seen, in complete har- 
 mony with the physician's experience. No doubt the relative 
 immunity from infection, which we know is enjoyed by residence 
 at high altitudes or on the sea-coast, is assisted by the other 
 aerial agencies at work in such places, the air-pressure, the force 
 of the winds, the amount of contained moisture, and to a certain 
 extent also the energetic pulmonary movements, which are 
 favoured by the co-existence of all these factors. 
 
 We stall return to this point when we deal with the treatment 
 of tuberculosis, and go back now to the sources in social life of 
 the tubercular infection. We have spoken of prisons and badly- 
 constructed barracks as such sources. In a similar way tuber- 
 culosis may take origin in convents, educational boarding 
 establishments, orphanages, and to some degree in over-crowded 
 day-schools. This happens just in so far as there is insufficient 
 enjoyment of fresh air as a compensation for residence in the 
 infected atmosphere, the insufficiency arising either from the 
 want of proper hygienic arrangements in the buildings them- 
 selves, or in the ordering of the daily life of the inhabitants. 
 Convents are the most defective in this respect, and come next 
 after the prisons, the majority of their inhabitants falling victims 
 to tubercle. The life in small badly-ventilated cells, the want of 
 the open air, and the complete absence of bodily exercise and all 
 movements calculated to increase the depth of the inspiration, 
 are the principal factors in bringing about the disease. 
 
 The same holds good of orphanages and boarding-schools, in 
 which the pupils are brought up in a monastic seclusion, and 
 partake only to a very limited extent in the benefits of moving 
 about and playing outside the buildings. That the numbers 
 indicating disease in these places are not higher is due partly to 
 the fact that the confinement is not too strictly kept up, but 
 chiefly to the circumstance that the young people do not remain 
 very long in the institutions. Mo'st persons withstand the bad 
 effects of confinement even in prisons for months and years with- 
 out suffering visibly, and only when the deterioration of the 
 constitution has reached a certain point do the tubercle bacilli 
 begin their destructive work. Statistics of disease in prisons 
 
98 ZIEMSSEN ON THE CAUSES OF TUBERCULOSIS. 
 
 show further that the entry of tubercle into the system is fre- 
 quently aided by the occurrence of inflammatory attacks in the 
 respiratory organs. Pneumonias which do not regress in the 
 regular way play a prominent part here. No doubt many of 
 these attacks are not merely conditions favouring infection, but 
 the results of an infection which has already taken place. Cases 
 of pneumonia of this kind frequently fall under our observation 
 in hospital. They quite resemble, to begin with, the genuine 
 croupous type, and only the presence of bacilli in the sputum 
 enables us to stamp them as of tubercular origin. 
 
 The experience of hospitals in which there are a large number 
 of phthisical cases, either mixed up among the other cases or in 
 special divisions by themselves, is of peculiar value in this dis- 
 cussion. The numbers indicating tubercular disease among the 
 other patients in such hospitals, or among the nurses and servants, 
 are not greater than they are among the general population 
 outside. The physicians, nurses, and officials of the Brompton 
 Hospital for Consumption — the largest consumption hospital in 
 the world — do not, according to Williams's statements, in spite 
 of the bad ventilation and the imperfect cleansing of the spittoons, 
 &c, fall victims to tuberculosis more readily than the inhabitants 
 of populous towns in general, and only three or four cases of the 
 disease could be attributed to infection received in the house. 
 Yet we must not attach too much importance to these numbers, 
 for the attendants in large hospitals, as we know, very frequently 
 change, and it is only rarely that nurses remain for a long period 
 of years in the service. When they do, the number of instances 
 of infection met with is greater. 
 
 The religious nursing sisterhoods are in the worst case. Their 
 members (except in the case of those orders who take in hand the 
 attendance on the sick at their own homes) are very little in the 
 open air, and are exposed to all the hurtful influences which I 
 have already shown predispose to phthisis : hard work from early 
 morning to late at night, frequent sitting up during the night, 
 restricted diet, much time consumed in religious exercises, and 
 lastly, too little time for recreation in the fresh air and in the 
 country. Exposed to such a strain as this, it is certainly not 
 surprising if their bodily frames suffer, and offer an easy lodg- 
 ment to the tubercle bacillus. Here in Munich, among the 
 Sisters of Mercy in our own large hospital, we have seen one after 
 
LUNG INFECTION. 99 
 
 another succumb in the years of youth ; we can assume without 
 hesitation that 50 per cent, of them die of tuberculosis. And 
 this not with any hereditary predisposition, but solely as a conse- 
 quence of work in the hospital and strict obedience to the rules 
 of their order. The young girls who pass into their ranks as 
 candidates come almost without exception from the country. 
 These enter on their work with fresh red cheeks and vigorous 
 frames. After the lapse of a few months, in rare cases after the 
 lapse of years, appears the ominous pallor, which is generally the 
 forerunner of pulmonary haemorrhage. It would be really too 
 absurd to suppose that these healthy, fresh, country girls were 
 all hereditarily predisposed to tuberculosis ; but, in spite of sound 
 constitutions, one after another with dreadful regularity falls a 
 victim. 
 
 Is anything more required to prove the direct infectiveness of 
 tuberculosis, or the dangers which attach to the deprivation of 
 fresh air and exercise, the limitation of the hours of sleep, and 
 the want of rest and recreation attendant on the harassing duties 
 of the sick-chamber ? I shall return to this question when dis- 
 cussing the prophylaxis ; it is so serious a one that all in whose 
 power it lies to change things for the better must lay it to heart. 
 
 The final proofs of the direct communication of tuberculosis to 
 the previously healthy are the cases of unintended inoculation of 
 tubercle, cases where a trifling lesion, such as the extraction of a 
 tooth or a slight cut, has led to secondary swelling of the lym- 
 phatic glands, and where these glands, when removed, showed 
 giant-cells with tubercle bacilli in their interior. But cases like 
 this are all susceptible of varying interpretation, since the bacilli 
 in them may date their origin from an earlier period, and may 
 have been first brought to light merely through the traumatic 
 lymphadenitis. Doubt can always be thrown on the convincing 
 character of such an experiment, so long as we have no certain 
 criterion of the complete, absence of bacilli in the lymphatic glands 
 ^previous to the occurrence of the accidental inoculation. And we 
 can scarcely indulge the hope of ever attaining to such a criterion. 
 
 We have now described all the essential conditions which 
 favour the lodgment of the tubercle bacillus in the human body. 
 It only remains to relate what we know of the way in which the 
 bacilli settle, grow, and spread, and of the forces which the 
 organism can depend upon to guard against them. 
 
100 ZIEMSSEN ON THE CAUSES OF TUBERCULOSIS. 
 
 The most usual paths of approach into the body seem to be for 
 children the alimentary tract, and for adults the respiratory 
 passages, though departures from these rules probably occur. 
 In the case of the former, the children, the food is probably the 
 medium in which the infective material is conveyed, and tuber- 
 culosis of the intestine and mesenteric glands is the result ; in 
 adults direct inspiration of the bacilli results in tuberculosis of the 
 lung and bronchial glands. In order that the bacilli may find 
 lodgment in these organs, and multiply there, we require to 
 postulate pathological conditions in the tissues in which the pro- 
 pagation takes place. Pathogenic micro-organisms, which may 
 pass into the various organs in a healthy body, are probably easily 
 shaken off, partly through the activity of its secreting and 
 excreting apparatus, partly also by being taken up into, cells, 
 which in all likelihood destroy them, or at all events lower their 
 vitality. Were the normal body not in possession of such 
 defences, the maintenance of its organs in their integrity in the 
 midst of so many microbes would become impossible. In parti- 
 cular, the tubercle bacillus would exercise a most hurtful influence 
 in places like consumption hospitals on those who remained 
 within the walls for a longer or shorter time. And yet from the 
 Brompton Hospital, as I previously mentioned, Dr. Williams 
 reports the opposite, namely, the fact, established by statistics, 
 that tubercular disease among the physicians, nurses, and officials 
 there does not occur oftener than among the town-population in 
 general. Only when we add to the opportunity for infection the 
 fatal predisposition, in which we must assume the existence of 
 small defensive power in the cells against a hostile substance, can 
 we understand the power of the germ to obtain a firm hold of the 
 tissues, and find the necessary conditions for its growth and spread. 
 
 I have said that for the protection of the body we must rely, 
 according to our present knowledge, on the maintenance of 
 normal digestion, on the healthy activity of secretion from the,~ 
 bronchial mucous membrane, and on the vital energy of the 
 amoeboid cells. We may now consider it as proved that the 
 normal gastric juice digests the bacteria introduced along with 
 the food, or at any rate renders them incapable of reproduction. 
 But on the other hand the various disturbances of function in the 
 stomach, a neutral or alkaline character of the juice, processes 
 of fermentation or decomposition among the contents, all these 
 
LUNG INFECTION. 101 
 
 open the door, and allow the bacteria to pass unhindered. As 
 to their passage into the respiratory tract, the danger of this is 
 a very pressing one, from the ' fact that the bacilli exist every- 
 where. The means we possess of guarding against the entrance 
 of foreign bodies with the inspired air are to some extent known, 
 from the examination of sputa from certain persons during life, 
 coupled with the examination of their lungs after death. Very 
 small foreign bodies, such as particles of dust, are, we know, 
 taken up into certain large cells. Nothing is positively known 
 of the origin of these latter, but my own opinion, as I shall 
 explain further on, is that they certainly do not all take rise 
 from the alveolar epithelium, but are probably produced from 
 the flask-shaped cells of the bronchial mucous membrane, perhaps 
 also from the sub-epithelial layer of cells. If dust is inhaled to 
 a moderate extent, for example, by remaining in rooms filled 
 with tobacco smoke, or the smoke of coal or charcoal fires, as 
 among bakers and blacksmiths, we find in the daily expecto- 
 ration masses of these large round cells, containing the carbon 
 particles enclosed in their interior. In such cases they are got 
 rid of in this way, but when the dust is for ever being inhaled, 
 as among miners and glass-polishers, this process does not nearly 
 suffice. The particles are then taken up by the epithelial layer 
 of the alveoli, and carried through the lymph-stomata into the 
 interstitial tissue, and from there are partly excreted, partly carried 
 along the lymphatics into the bronchial glands. The most con- 
 vincing illustrations of this are given by the beautiful observations 
 of Zenker and Merkel, who took as the subject of their study the 
 impregnation of the lung tissue with rouge, in the case of 
 women engaged in polishing glass mirrors. Thus the capacity 
 of the lungs for defending themselves by eliminating foreign 
 bodies is, though very considerable, yet limited. Very probably, 
 again, the numbers of these dust-consuming cells and their power 
 of swallowing the foreign bodies are dependent on a certain 
 degree of reactive energy in the bronchial mucous membrane 
 and alveolar walls, while the excretion of the cells themselves is 
 proportioned to the health of the ciliated epithelium and the force 
 of expectoration. A lowering of this reactive energy is the 
 essential condition for the settlement of the bacilli. This view 
 is supported by the fact that there does exist at the beginning 
 of the onset of tuberculosis a want of reactive force in the system, 
 
102 ZIEMSSEN ON THE CAUSES OF TUBERCULOSIS. 
 
 as Baer found among prisoners, and as we see among our Sisters 
 of Mercy. The patients get thin and anasmic, they lose their 
 appetite and strength. There is no cough, no shortness of breath, 
 no respiratory difficulty of any kind, and yet physical examination 
 already reveals infiltration in one or both apices. This is charac- 
 teristic, of course, only of the more profound degrees of weakness 
 in the cells, such as we get in prisons and nunneries, but in such 
 cases of great weakness we are entitled to infer a lowered measure 
 of resisting power. 
 
 I wish here to bring into the discussion a question of practical 
 importance, namely, the causes of the predilection for the apices 
 which tuberculosis shows. That such a predilection exists does 
 not require to be proved ; it is the physician's daily experience. 
 Hitherto it has been assumed that the tubercle bacilli settle in 
 the apices on' account of the want of inspiratory expansion in 
 these regions, in consequence of which the movement of the air 
 in the bronchioles and alveoli is defective, and this in turn leads 
 to stagnation of the secretions and inflammatory products. On 
 these grounds the frequency of phthisis was explained in people 
 whose occupations entailed sedentary habits and stooping posi- 
 tions, as, for example, tailors. 
 
 Hanau, however, has lately expressed an opinion, and sup- 
 ported it as I believe with sound reasons, that the predisposition 
 of the apices depends not on any shortcoming in inspiration, but 
 on the fact that expiration is more difficult in these parts. That 
 the inspiratory powers of the apices are fully developed, we can 
 see very well in a disease like coal-miner's phthisis, where these 
 portions are the first and most seriously affected, and Arnold's 
 experiments on animals are in agreement herewith. And as to 
 the effect of the stooping position in the case of men, this will 
 simply convert the costo-abdominal into almost a purely costal 
 type of respiration, seeing that the downward movement of the 
 diaphragm will be much hindered by the narrowing of the space 
 in the abdomen. Among women, again, the costal is the normal 
 type, and the supposition that in this sex there is insufficient 
 expansion at the apices is & prion quite unjustifiable. 
 
 "While, then, there is no sufficient foundation for the inspiration 
 theory, the expiration theory has all the more to be said for it. 
 Mendelssohn deduced theoretically, and observations made by 
 me on individuals whose thoracic muscles were deficient, definitely 
 
INFECTION BY THE LUNGS. 103 
 
 proved that in forced expiration the air goes back into the upper 
 lobes, from the want at that part of the thorax of a contractile 
 muscular wall. In this way, during the impulse of coughing, the 
 air there remains stagnant, and for the moment is under high 
 atmospheric pressure. But what is of most consequence to us at 
 present is that the removal, by expectoration, of foreign bodies 
 and micro-organisms from the apices is prevented by the regur- 
 gitant current of air, and the contents of the bronchi are thrown 
 right back into the alveoli. No doubt the spiral course of the 
 smallest bronchioles, while it may prove to be in the apex a 
 hindrance to the expulsion of dust and bacilli in expiration, may 
 equally well prevent their being sucked in during inspiration ; 
 but it is to be noted that this feature in the anatomical structure 
 of the lung is in any case distinctly unfavourable to the dislodg- 
 ment of any foreign bodies which have once gained admission. 
 I can therefore only express agreement with Hanau, when he 
 says that the apices are the parts of the lungs which relatively 
 present the most favourable conditions for the entrance of dust 
 and micro-organisms in inspiration, and the most unfavourable 
 conditions for the expulsion of these in expiration. If the 
 tubercle bacilli once gain entrance into these regions, they pass 
 into a state of rest which makes it possible for them to penetrate 
 into the lymph-spaces in the epithelial layer, and fix themselves 
 in the sub-epithelial cellular layer. 
 
 Besides this mode of entrance into the system, there is no 
 doubt that invasion may also take place by means of the lymph 
 and blood currents, and we may conclude that this has been the 
 case in the lungs when we find the walls of the lymph and blood 
 vessels the first to be attacked. 
 
 After its entrance into the tissues the bacillus, by means of its 
 biological properties, of which as yet we do not know very much, 
 produces an irritant effect, and, as a result of this, reactive inflam- 
 mation. At this point the struggle between the living cell and 
 the parasite begins, which has been the object of so much recent 
 discussion. 
 
 It was observed by Nageli that this struggle is the very process, 
 in infective diseases, the issues of which are life, disease, and death. 
 The outcome of the contest depends upon the vitality of the cell 
 on the one hand, and the infective force of the schizomycete on 
 the other. If the cell is victorious, the fungus is destroyed ere 
 
104 ZIEMSSEN OX THE CAUSES OF TUBERCULOSIS. 
 
 it has had time to damage the organism ; while if the cell 
 succumbs nothing stands in the way of the settlement, multipli- 
 cation, and spread of the fungus. This idea of Nageli's (which 
 was held by him in a very general sort of way) in regard to the 
 nature of infection, and the part played by the living cell in the 
 struggle against it, has received a great development in Metschni- 
 koff's phagocyte theory. With all the ambiguity which attaches 
 to the phenomena observed by Metschnikoff, his theory is yet 
 very attractive. 
 
 According to him, the function of warding off infection is 
 fulfilled by the phagocytes, as he terms them, cells which are 
 recruited from among the number of leucocytes and fixed con- 
 nective tissue cells. They appear on the scene on the outbreak 
 of the irritation caused by the invasion of the bacilli, and proceed 
 forthwith to devour the intruders — that is to say, they take them 
 up into their own cell-bodies, and digest them or destroy their 
 reproductive power. They are divided into two groups, large 
 and small phagocytes, macrophagi and microphagi. Among the 
 former Metschnikoff reckons, for example, the epithelioid cells of 
 the connective tissue, among the latter the nucleated leucocytes. 
 These two forms, according to him, play different parts among 
 ' the different infectious diseases. In his most recent publication 
 he says, for instance, that the streptococci of erysipelas are 
 devoured by microphagi only, but that these latter in their turn 
 are then taken up into the substance of macrophagi, and there 
 digested. In like manner microphagi alone devour the gono- 
 coccus, macrophagi the bacillus of the splenic fever of rabbits and 
 guinea-pigs. 
 
 According to this author both kinds of phagocytes take part in 
 the struggle against tuberculosis. The macrophagi in the form 
 of epithelioid cells and giant-cells take the principal share in the 
 contest, but the microphagi also are there in great numbers, and 
 indeed are the first to begin the fight. On introducing pure 
 cultures of the tubercle bacilli into the anterior chamber, or under 
 the skin of the rabbit, Metschnikoff found numbers of microphagi 
 stuffed with bacilli as early as twenty hours after the inoculation, 
 this therefore at a time when there could yet be no word of 
 any reaction on the part of the fixed cells. Afterwards the 
 macrophagi make their appearance, and swallow both bacilli and 
 dead microphagi. In this way, according to Metschnikoff, charac- 
 
ACTION OF PHAGOCYTES. 105 
 
 teristic conglomerate structures originate, in which we find whole 
 heaps of objects that have been eaten, but in which the nucleus 
 of the macrophagus, though hidden, can always be demonstrated. 
 
 This theory has met with very active opposition from various 
 quarters. Its opponents allow that schizomycetes are taken up 
 into the bodies of small and large cells, but decline to see in this 
 any tendency to a healing process, preferring to view it as merely 
 a mechanical intussusception of the bacilli, by means of which 
 they gradually undergo certain changes of form. According to 
 Metschnikoff the protoplasm of the cell kills the schizomycetes, 
 so that they are gradually broken up into debris, or at any rate 
 their virulence is so weakened that they are incapable of pro- 
 ducing infection. The interesting facts bearing on the relation 
 of phagocytes to tubercular attacks, which Metschnikoff brings 
 forward in his latest publications, are of especial interest as bear- 
 ing on our subject, and we look forward with some impatience to 
 his promised further contributions on the whole question, and to 
 the controversy to which they will give rise. 
 
 It would correspond with the knowledge of the subject of tuber- 
 cular infection which we gain in practice, were we to assume, 
 first, that a bacillary attack on a perfectly healthy organism is at 
 once turned off and rendered innocuous ; secondly, that on a pre- 
 disposed organism, with a weak cellular energy, while it may not 
 be completely deprived of its virulence, it is made harmless for 
 the moment through the isolative action of the fixed connective 
 tissue-cells ; and lastly, that when the bacilli are in great num- 
 bers, and the organs are weakened, all opposition is overcome, 
 and death rapidly follows. 
 
 In this last connection I may direct your attention to the fact, 
 that it is possible that patients with rapid softening may aspirate 
 pulmonary debris from the cavities into all parts of the air- 
 passages. Such debris contains bacilli, and this autoinfection 
 of parts of the lungs previously sound, explains quite clearly the 
 extensive tubercular pneumonias which are so common in the later 
 stages of chronic phthisis. 
 
 Tuberculosis of the larynx is almost without exception a 
 secondary affection following on primary tubercle of the lung. 
 Primary laryngeal tuberculosis, of course, if looked at as a pro- 
 duct of infection by inhalation, cannot be said to be impossible, 
 but as a matter of fact the epithelium here seems to present very 
 
106 ZIEMSSEN ON THE CAUSES OF TUBERCULOSIS. 
 
 powerful obstacles to the attack of the enemy. Dr. Kukoff, who 
 has subjected the question to anatomical investigation in our 
 pathological institute, working with the freezing microtome on 
 fresh larynxes from cases that had died of phthisis, could in no 
 single case prove the entrance of bacilli from without, that is, 
 from the sputum hanging about the larynx. On the contrary, 
 the epithelium was in a good state of preservation, and the bacilli 
 that were found had penetrated from the sub-epithelial cellular 
 layer towards the periphery into the intercellular lymph-spaces. 
 There is, of course, no doubt that local infection through the 
 bacilli of the sputum does take place as soon as we have the 
 smallest erosion formed, but this plays no part whatever in the 
 initial stages of laryngeal phthisis. For the explanation of these 
 stages we must refer exclusively to the blood and lymph currents 
 in the laryngeal mucous membrane. 
 
 The question of the curability of laryngeal phthisis is now 
 answered in the affirmative. Of course this only in a general 
 way, just in the same way as I have explained above we affirm 
 the curability of pulmonary phthisis. It is certainly not common 
 for tubercular ulcers of the larynx to heal, but I have not the 
 slightest doubt it may occur. I have seen several instances of 
 the affection where, along with a general quieting-down of the . 
 tubercular process, the ulcers in the larynx healed up in a short 
 time, and on the death of the patients some years after from 
 repeated phthisical attacks, the cicatrices of these ulcers could be 
 demonstrated. All experienced laryngologists will have seen 
 similar cases. 
 
 You see, gentlemen, from what I have said how many ques- 
 tions there are yet to be settled in this great subject before we 
 shall have such a thorough knowledge of all the conditions of the 
 life, activity, and death of the tubercle bacillus, that it will be 
 possible to cut the ground from beneath the feet of this heredi- 
 tary foe of the human race. But you see also, gentlemen, the 
 immense strides which the theory of the astiology and the pathology 
 of tuberculosis has made in these last six years, thanks to Koch's 
 discovery. The ardour with which the work is carried on, and 
 the rigidly scientific character of the methods applied, are the 
 best guarantee we have for continuous further progress. This 
 progress practical medicine, in so far as it is interested, will 
 watch with lively sympathy. 
 
ON THE 
 
 HEALING-IN OF FOREIGN BODIES. 
 
 BY 
 
 Dr. FRITZ A. SALZER, 
 
 Professor op Surgery at the University or Utrecht. 
 
 Translated from the German by 
 
 FEED. ADALBERT JUNKER VON LANGEGG, 
 M.D., M.B.C.S., Engd. 
 
ON THE HEALING-IN OF FOREIGN BODIES. 
 
 Foreign bodies which have gained an entrance into the human 
 organism call forth disturbances and alterations which, in the 
 first place, depend essentially on the locality, that is, the organ 
 concerned, or in other words, on the kind of injury ; in the 
 second place, on the nature of the foreign body. As in the 
 following we shall especially consider the reaction of the 
 organism against these foreign bodies with regard to their 
 physical condition, but without reference to the danger of the 
 injury itself, we shall have, in a more restricted sense, to dis- 
 tinguish between the effects of unclean foreign bodies (as we call, 
 for the sake of brevity, those which do not carry with them 
 pathogenic germs), and of clean foreign bodies acting either 
 mechanically or chemically. 
 
 The former, i.e., the unclean foreign bodies, have been considered 
 from the oldest times as the deplorable cause of the interest and 
 the treatment in every kind of retention of foreign bodies. The 
 belief in the danger from foreign bodies is mostly based on the 
 experience of the injurious consequences of this first-mentioned 
 kind. At present, however, both the estimate of the case and its 
 treatment begin more and more to agree that these represent 
 merely a fraction of the foreign bodies which come under obser- 
 vation, although already in former times, ever since Aiiibroise 
 Pare, and especially since the time of the great John Hunter, the 
 expectant treatment has found observant and thoughtful advocates. 
 The reaction of the organism, apart from the traumatic inflam- 
 mation, which is eventually due to the specific pathogenic germs, 
 as a rule does not lead to healing-in, and will therefore not come 
 within the scope of this paper. 
 
 The reaction in the case of clean foreign bodies, so far as they 
 act in an essentially chemical or toxic manner, experimental 
 pathology has elucidated a3 regards the effect on the general 
 organism. The knowledge of the local alterations, as a rule, 
 
110 SALZEE ON THE HEALING-IN OF FOREIGN BODIES. 
 
 concerns the demonstration of the death of the tissue brought 
 about by certain animal or organic poisons, and the inflammatory 
 reaction of the tissues with exudation, infiltration, and subsequent 
 formation of callosities, or suppuration. The local treatment of 
 the rarer kinds of chemical noxious matter, owing to our still 
 imperfect experience, leaves much to be desired. In the 
 following I shall treat of this group of foreign bodies merely 
 in a cursory way. only so far as they act in consequence of their 
 prolonged presence. 
 
 Concerning the pathology of foreign bodies simply acting 
 mechanically, as we shall not consider the injury itself, we have 
 especially to occupy ourselves with the alterations produced by 
 the specific weight, the form, anrl the surface of the body in 
 question, at the same time we - shall, however, not entirely lose 
 sight of the eventual resorbability, i.e., its solubility in the fluids 
 of the body. 
 
 The number of instances of healing-in of foreign bodies in the 
 organism is an extremely large one, and the reports on the same, 
 especially in the earlier decades of this century, played an 
 important part in surgical literature. But the older examples 
 have for us lost much of their marvellous character since the 
 conditions of the healing process in wounds has • become better 
 understood. 
 
 We know that foreign bodies, with the exception of some 
 which act chemically, do not possess as such qualities which 
 cause suppuration, and we are therefore not astonished if they 
 do not produce a violent reaction. 
 
 Leber has demonstrated as regards the eye that copper and 
 mercury act as exciters of suppuration. Grawitz especially has 
 recently shown that nitrate of silver, croton-oil, ammonia, and 
 turpentine produce suppuration in certain species of animals. 
 Some ptomains have, according to Scheuerlen, similar effects. 
 These, of course, may not be instances of progressive suppuration, 
 as no ferment-like substance comes into action. 
 
 Older Observations. 
 The older observations are of but slight importance for the 
 purpose I have in view, because for the most part the anatomico- 
 pathological conditions are not entered into, and only the 
 previous history, the course, and the treatment have been con- 
 
SALZER ON THE HEALING-IN OF FOREIGN BODIES. Ill 
 
 sidered. I shall therefore select only a few, but in their way 
 instructive examples. 
 
 The foreign body which is mentioned as having been most 
 frequently healed over without reaction is evidently the steel 
 needle, especially the sewing-needle. It is certain that in a very 
 large number, if not the majority of these cases, needles healed 
 in without causing suppuration. We barely find from the older 
 reports anything worth mentioning as to the kind of reaction. 
 Bresdhet speaks of a white mucus around the needles healed-in 
 under the skin, and states that the metal had become oxydised. 
 A. Dor an believes that such small inorganic foreign bodies may 
 remain in the tissues without giving rise to any kind of sup- 
 puration and without becoming encapsuled. G. T. Weiss also 
 states that needles have been found '' almost " free. Hodge' 
 accidentally discovered, while dissecting a man, a sewing-needle 
 in the hemisphere of the cerebrum with its point directed back- 
 wards, which had been fixed to the dura mater by old cicatricial 
 bands. Von Bergmanrt quotesfrom Th. Simon a second similar case. 
 There was in the left hemisphere of a woman, seventy-three years 
 of age, a needle resting upright on its eye, with the point in the 
 left lateral ventricle. There was no defect on the skull above, 
 only a minute external depression, and inside, corresponding to 
 the latter, an exostosis. Marine found needles in the meninges 
 near the vertex, which had been the cause of epileptic fits. The 
 needles, according to the supposition of the authors, had been 
 pushed through the fontanelles before the period of ossification. 
 
 M. Huppert accidentally found in the heart of an elderly man 
 a sewing-needle sticking in the posterior wall of the left ventricle, 
 and protruding into it with its free end 5 — 6 mm. It was of jet- 
 black colour, neither rough nor perfectly smooth, and was, as far 
 as it penetrated the wall of the ventricle, covered by a thin, 
 easily cut, bluish-white pellicle ; whilst the extremely delicate 
 sheath-like investment of the protruding portion of the needle 
 was identified by the microscope as the pushed-up endocardium. 
 This was whitish-opaque and covered with pavement epithelium. 
 Sandborg, who found a needle 9 cm. long firmly sticking in the 
 cardiac muscle, affirms the absence of great reaction after a 
 similar injury. The head of the needle lay in the left ventricle,: 
 the remaining portion perforated the pericardium, the diaphragma, 
 the liver, and the wall of the stomach, all which organs were 
 
112 SALZER ON THE HEALING-IN OF FOREIGN BODIES. 
 
 glued to each other. Gerard, six years after the injury, found 
 the handle, of a knitting-needle in the wall of the left ventricle 
 covered by fibrinous organised growths; and Neill a much oxydised 
 needle in a cyst of the wall of the left ventricle. In ruminants 
 needles have frequently been discovered in the heart healed in. 
 
 The healing-in of halls has for a long time been a well-known 
 fact. There are reports of the encapsulation of balls in wheals 
 and sclerotic osseous tissue, or in cystic cavities. Fabricius 
 Hildanus long ago stated that a leaden ball might remain for 
 many years in the cavities of the body, or under the fleshy part 
 of the muscles. He once found a ball, half a year after the 
 injury, healed-in between the roof of the skull and the dura 
 mater, " nature having in this place provided a hard substance 
 which lay under the dura mater like a pad or a cushion in order 
 to protect it against harm." Von Bergmann discovered a revolver- 
 ■ bullet perfectly encapsuled in connective tissue in the brain, 
 05 cm. distant from a cerebral abscess. Koch likewise found a 
 perfectly encapsuled revolver-bullet in the brain. Malle relates 
 that an officer with a gunshot-wound had attained a very old 
 age. The bullet lay in the left hemisphere of the cerebellum. 
 Gortese found, nineteen years and a half after the injury, under a 
 defect of the squamous portion of the temporal bone, a protu- 
 berance 3 cm. in length, protruding into the substance of the brain, 
 which enclosed fragments of bone, and the ball from which the 
 track of the bullet through the right hemisphere measured 10 cm. 
 to the falx magna cerebri, to which again a pointed, irregularly 
 shaped piece of bone was adherent. The walls of the track, into 
 which the finger could be introduced, showed under the microscope 
 an unaltered condition of the cerebral par ■emchyma. Hutin mentions 
 that a ball had remained fourteen years in the vertebral canal 
 healed-in, where it was very firmly impacted ; and Breschet reports 
 a similar case. Also von Bruns speaks of the healing-in of balls 
 in the brain. 
 
 Bland, Bavaton, Baudens, and Larrey report numerous cases of 
 healing-in, in closely adherent cicatricial capsules, of bullets in 
 the lungs, supporting the assertion of Koenig that clean foreign 
 bodies readily become encapsuled in the lungs, by pouches con- 
 sisting of connective tissue. Nissel found a bullet in a cavity of 
 the size of a hen's egg, sixteen years after the injury; and Guy on 
 likewise found one in a cyst of the lung. Suchong discovered a 
 
SALZER ON THE HEALING-IN OF FOREIGN BODIES. 113 
 
 bullet, bone-splinters, a piece of linen, and a small rag of cloth 
 in a smooth-walled cavity of the right lung ten years after the 
 injury. Demme also observed encapsulation of projectiles in 
 the lungs. 
 
 The number of instances of healing-in of bullets in the internal 
 organs is altogether very large. Guthrie, Baroisse, Thompson, 
 and Bilguer found bullets lodged in the gall-bladder and the liver. 
 Arnold found a Ohassepot bullet in a cavity separated by a capsule 
 from the surrounding tissue of the liver. Von Bergmann and Socin 
 found a bullet in the normal paremchyma of the kidney, merely 
 surrounded by a thin capsule of connective tissue. 
 
 Percy and Bojer observed that in the muscles of the tongue, as 
 in general, according to Ferry, lead is readily enclosed in the 
 fleshy part of the muscles. In contradiction to Baudens, who 
 maintains that shot easily becomes encapsuled in muscular tissue, 
 Demme holds that this rarely happens, but he frequently observed 
 their wandering. 
 
 The healing-in of bullets in callosities of the heart is well- 
 known to sportsmen. Bullets and wood have been found 
 completely encapsuled in the heart of stags and wild boars. 
 
 G. Fischer has collected twelve cases of healed gunshot-wounds 
 of the heart in man ; of these there are five in which the shot 
 remained lodged in the heart, and in one of these the patient 
 survived his injury fifty-two years. Latour describes a case in 
 which a bullet remained six years encapsuled in the right 
 ventricle of the heart. Galusha discovered, twenty years after 
 the injury, a bullet encapsuled in the wall of the right ventricle. 
 Randall found small shot free in the cavities of the right ventricle 
 and auricle of the heart, and Vandelli a bullet free in the right 
 ventricle several years after the injury. 
 
 Both Longmore and Demme observed healing-in by encap- 
 sulation of a bullet in the spleen. 
 
 Demme reports three cases of healing-in of solid shot in the 
 cancellous tissue of the head of the thigh bone and tibia. Simon 
 had already previously demonstrated the encapsulation of spher- 
 ical projectiles in the cancellous tissue of the broad articular 
 extremities. Dementiew enumerates a great number of instances 
 of projectiles healed-in in joints and bones without causing 
 suppuration. Several authors mention the formation of callous 
 wheals and of a massive callus. G. Weiss states that projectiles 
 
 i 
 
114 SALZER ON THE HEALING-IN OF FOREIGN BODIES. 
 
 produce in bones a rarefying ostitis, but that they eventually are 
 for the most part fixed by eburnified tissue, or embedded in larger 
 or smaller capsules or strata of fibrous tissue. Fischer observed 
 that shot which had penetrated into bone are mostly enclosed by 
 fragments of bone; and on the other hand, it has been stated 
 that bone-splinters had been enclosed within the projectile. 
 
 Arnold found a bullet lodged on the uninjured seventh rib, 
 clothed by almost unaltered cellular tissue, with which it was 
 intimately connected, whilst it could be moved about upon the rib. 
 The surrounding cellular tissue was only slightly thickened. Weiss 
 mentions the healing-in of a bullet in the hand; and von Bergmann 
 once found a revolver-ball between the second and third meta- 
 carpal bone in a firm capsule of connective tissue, which contained 
 besides the ball a few drops of serous fluid. Szydlowsky found a 
 piece of shell connected with the periost of the rib by a band- 
 shaped callous adhesion. There was also an angular piece of bone 
 impacted in the metal. 
 
 Very frequently in prolonged suppuration only partial healing- 
 in into solid hardened osseous tissue takes place, as, e.g., in the 
 case in which Kroenlein extracted a Minie-ball which had kept 
 up suppuration for eleven years. 
 
 Ehrmann found a revolver-ball free in the knee-joint. 
 
 Fischer diagnosed, in the year 1878, a bullet in an officer 
 which lay under the great pectoral muscle from 1866 to 1876 
 without causing any reaction, but which afterwards produced 
 suppuration. It was covered by calcareous deposits, and Fischer 
 states that he constantly found lime on bullets which had produced 
 suppuration during many years. 
 
 It may here be mentioned that wandering of bullets has, if not 
 frequently, still undoubtedly been observed; the tissue having 
 been worn away by the continued pressure of heavy bullets, which 
 gravitate deeper whilst their track is closed by granulations. I 
 have not yet been able to ascertain in many instances the wander- 
 ing of small bullets or small shot, which so frequently heal in. 
 Von Bergmann is of opinion that gravitation of bullets does not 
 take place as a rule even in soft tissues, viz., the substance of 
 the brain, although Flourens had observed it. 
 
 Numerous post-mortem examinations prove that smooth knife- 
 bladesh&d, without causing suppuration, or any kind of symptoms, 
 healed-in in the cranium, the back, and particularly when 
 
SALZEE ON THE HEALING-IN OF FOEEIGN BODIES. 115 
 
 impacted in the bone. Monod found a piece of a sword-blade 
 9 cm. in length soldered by osteophytes, and thereby fixed to 
 the inner surface of the left thoracic wall and the ribs. Gerster 
 excised a knife-blade 8 cm. in length which had remained 
 healed-in during two years in the fore-arm. H. Larrey describes 
 a preparatien in Florence, a stiletto sticking for two years in the 
 parietal bone and in the brain ; a pseudo-membrane protected 
 like a sheath the cerebral substance. Cuvilliers extracted the 
 blade of a rapier which, perforating the spinal cord, was healed 
 in the vertebral column ; and Hager mentions a piece of wire, the 
 presence of which in the thigh had been diagnosed by acupunc- 
 ture after two years, and which had been removed by an incision 
 " after dividing the capsule formed by inspissated lymph." 
 
 Other kind of foreign bodies, remaining without reaction in 
 the body, may be mentioned as curiosities. A particularly 
 remarkable instance from modern reports is the following case 
 of Huppert: 
 
 At a post-mortem examination of a maniac, aged 42, who in 
 previous years had been mentally normal, was found a slate-pencil 
 7"3 cm. in length, very slightly movable, in the cerebral substance 
 close beneath the floor of the right descending and posterior 
 cornu, with its anterior end touching and fixed to the temporal 
 bone, and with its posterior end embedded in the medullary 
 substance of the posterior lobe, apparently without causing further 
 anatomical changes, except the immediate displacement of sub- 
 stance and a very slight proliferation of connective tissue. The 
 brain in its neighbourhood was not altered, in the closely 
 surrounding medullary substance there was neither atrophy nor 
 sclerotic thickening, not even any abnormal colouring, there was 
 only on the interior surface of the temporal bone a small osteo- 
 phyte with remnants of tough white connective tissue to which 
 the anterior end of the foreign body had evidently been fixed. 
 Huppert supposes that the slate-pencil, no traces of injury of the 
 bones having been discovered, had been pushed through one of 
 the then still existent fontanelles into the skull, and had remained 
 there latent for so long a period. 
 
 Wood heals-in with relative rarity. Billroth extracted a thorn 
 1"6 cm. in length, which had been lodged for eleven years close 
 under the integument of the leg. Desir de Fortunet reports a 
 similar case, in which a thorn was removed fifteen years after 
 
116 SALZER ON THE HEALING-IN OF FOREIGN BODIES. 
 
 having penetrated into the latissimus dorsi muscle, where it had 
 caused the development of a fibroma-like tumour. Klebs found 
 cotton-thread of 2'3 mm. in diameter healed-in in the soft parts 
 of the fore-arm. If, according to Bardeleben's statement, foreign 
 bodies which had entered from the outside into the skin, connective 
 tissue, muscle, bone, nerve, and even brain-tissue, the intestines 
 or also the serous cavities, provided they are of insignificant size, 
 smooth surface, and but slightly irritating quality, cause only an 
 inflammation in their environs of so moderate a degree that they 
 become encapsuled, and if, as he says, small shot particularly 
 lends itself to this, other kind of smooth foreign bodies, such as 
 needles and ligature-thread, most of all glass-splinters, had most 
 frequently been found in such like cystic capsules, in cysts, in 
 reference to the formation of which Gussenbauer asserts that the 
 question here is not of the formation of fibrous membrane invested 
 with endothelium at the surface directed towards the foreign body. 
 Von Dumreicher found a piece of glass, 2 - 5 cm. in length and 
 2 cm. in width, in the region of the spine of the left scapula 
 encapsuled in a cavity by a delicate membrane. Weiss likewise 
 found a glass-splinter 8 cm. in length in the humeral region, 
 which had not given rise to inflammatory symptoms. Hager and 
 many others discovered in the foot and in the hand healed-in 
 glass-splinters which had lodged there many years. 
 
 We find in the more recent surgical literature a large series of 
 healing-in of foreign bodies, with detailed microscopic examinations 
 in reference to the behaviour of silk, catgut, wire, ivory-pegs, and 
 nails, &c, since the introduction of the antiseptic treatment. 
 The respective alterations had been studied most accurately in 
 experiments on animals, with the view of settling important 
 questions of general surgical pathology. 
 
 In reviewing the surgical literature of the last decade on this 
 subject, we find descriptions of the minute alterations of tissue 
 in the healing-in of foreign bodies, especially in the abdominal 
 cavity, in the subcutaneous cellular tissue, and in the bone. As 
 regards the healing in the peritoneal cavity, it has been proved 
 by 8'jpiegelberg and Waldeyer, who made experiments analogous to 
 those of Bud. Wagner, Burdach, and Mitteldorpf, that ligatures are 
 encapsuled in the abdominal cavity. Silk and linen fibres showed 
 during the first twenty-one days only a slight swelling, and 
 afterwards a number of cells immigrating from the neighbourhood 
 
SALZER ON THE HEALING-IN OF FOREIGN BODIES. 117 
 
 between the individual fibres. Later on the threads were com- 
 pletely separated, and at odd places totally unravelled. 
 
 The surrounding tissues behaved very differently in the sundry 
 experiments : (1) the ligature was encapsuled by newly-formed 
 thick connective tissue, between the threads there was young 
 granulation tissue; (2) the ligature lay free in the abdominal 
 cavity after having slipped off from the tied portion, but after- 
 wards it became adherent to other parts, that is, by young cells 
 from the serous membrane growing into it ; (3) it lay within a 
 small cystic cavity of the ligatured tissue. 
 
 Maslowshi proved experimentally that, compared with man, 
 dogs more easily bear metallic ligatures than silk ones, that silk, 
 iron, copper, silver, and silkworm-gut ligatures are invariably 
 encapsuled by newly-formed connective tissue (there being at the 
 same time a small quantity of pus around the silk). In dogs 
 the eschar at the cornu of the uterus is not separated by sup- 
 puration, but is encapsuled by newly-formed connective tissue, 
 thus uniting it with the surrounding parts. 
 
 Wegner found granules of Indian ink which had been injected 
 into the abdominal cavity, and of which only part had been 
 absorbed, enclosed partly in the endothelial cells of the serous 
 membrane, partly in delicate connective tissue. They lay, forming 
 isolated coarser black bodies, close to the abdominal wall or the 
 peritoneal coat of the liver, on which they were encapsuled by a 
 thin layer of serous-like tissue. 
 
 Tillmanns implanted pieces of dead tissue, of liver, kidney, &c, 
 hardened in alcohol, into the abdominal cavity of animals, in 
 order to study the process of cicatrisation. He found that the 
 interstices of these foreign bodies actually fill up with colourless 
 blood-cells, and vascular connective tissue finally forms within 
 them. Catgut was absorbed after seventeen days; silk was 
 still unchanged after six weeks, whilst the dead tissue sur- 
 rounding the silk had long disappeared. Tillmanns believes 
 that catgut, and very likely later on the silk also, is destroyed 
 by the intrusion of wandering cells, and is replaced by connective 
 tissue, in a similar way as in the case of the ligatured ovarian 
 pedicle ; this view, however, does not agree with the afore-men- 
 tioned experiments of Waldeyer. 
 
 Hallwachs found in dogs, around silk healed-in for eight months 
 in the peritoneal cavity, in close contact with the foreign body a 
 
118 SALZEK ON THE HEALING-IN OF FOREIGN BODIES. 
 
 very vascular connective tissue, much resembling granulation 
 tissue, rich in cells, but poor in fibres. Beyond this thin layer 
 there was firm fibrous tissue. He observed between the fibrillas 
 of a single silk thread small cells embedded in a transparent 
 substance. Around a sponge encapsuled for eight months in the 
 abdominal cavity there was likewise an interior, more injected, 
 and an external firm whitish-yellow layer. Here and there the 
 tissue around the sponge undergoing absorption, resembled 
 organised exudative masses or coagulated fibrine; some particles 
 of the sponge were entirely surrounded by, and interwoven with, 
 vascular granulation tissue. In another experiment catgut had 
 bealed-in in a dog six months after the operation ; there was at 
 the places concerned young granulation tissue enclosed in tissue 
 composed of irregular fibrous cells — that was the site of the 
 catgut. In a fifth case an elastic ligature had healed-in ; in this 
 dog five months after the operation, it was found enclosed in 
 tissue resembling that of the above-described cases, with this 
 difference, however, that numerous crystals and yellow particles, 
 similar to those on the rough surface of the ligature itself, could 
 be recognised within it. Hallwachs draws the conclusion that 
 catgut is absorbed and replaced by well vascularised fibrous 
 tissue after six months ; that sponges are broken up, silk is 
 encapsuled and unravelled, and elastic ligatures are likewise 
 encapsuled ; that the bulk of these objects has decreased in 
 consequence of compression by the living tissue. If an organic 
 substance be enclosed, inflammation sets in, and with an increased 
 flow of fluid, luxuriant granulation and new formation of vascular 
 tissue take place until all the interstices are filled up. In the 
 most minute interstices this is brought about by the tissue-fluids 
 containing cells. No suppuration follows; the foreign body is 
 broken up into most delicate particles (as demonstrated for silk 
 by Lister), these are carried away by the flow of blood or fluids, 
 or by the wandering cells, and the cicatricial tissue resulting from 
 it probably disappears at last. 
 
 Rosenberger, who introduced sometimes fresh, sometimes dead 
 tissue into the abdominal cavity, observed that dead tissue is 
 enclosed within three to four days by a capsule from which cells 
 immigrate into the foreign tissue ; he frequently found giant-cells 
 between the capsule and the foreign body, of which he supposes, 
 agreeing with Langhanns, that they act as absorbent organs. 
 
SALZER ON THE HEALING-IN OF FOREIGN BODIES. 119 
 
 (The implanted fresh tissue continues to live in the abdominal 
 cavity after having undergone a loose connection with the 
 abdominal organs. Sometimes a purulent dissolving process 
 takes place in the centre.) 
 
 Von Bemhowski found that foreign bodies, as ligatures, dead 
 tissue, eschars, certainly produce adhesions, whilst jodoform, 
 blood-coagula, and irritating antiseptic fluids do not. Foreign 
 bodies simply placed into the abdominal cavity always become 
 encapsuled in the mesenteric folds or in the omentum. Jodoform- 
 gauze stitched to the abdominal serous membrane of the right 
 hypogastric region, was after eight days glued to, encapsuled, and 
 adherent to the thickened border of the liver. Jodoform-gauze, 
 sewn from the inside of the internal orifice of the inguinal canal, 
 was healed-in after two weeks between the parietal peritoneum 
 and the omentum, which had assumed the thickness of 3 mm. ; 
 the abdominal wall at the site of the gauze had thickened to 
 5 mm. Catgut ligatures and portions of ligatured tissue are as 
 a rule encapsuled after ten days. Eschars give rise to adhesions 
 with the omentum and the intestines, but not with the liver ; 
 they seem, according to von DembowsMs view, to be less irritating 
 than the afore-mentioned jodoform-gauze, as has been ascertained 
 after eight days, and also after two months. Solutions of sub- 
 limate or carbolic acid, turpentine, and oil of marjoram (Oleum 
 Origani cretici, German pharmacopoeia) caused no adhesions. 
 Celloidin favours this, but these adhesions seem to break up 
 again after some time. Whilst in dogs the soldering of eschars 
 to the abdominal wall persisted after several months after the 
 carbonised portion of these had long been absorbed, the celloidin 
 had completely loosened and only the serous membrane still 
 remained much thickened and covered with connective tissue- 
 like layers. 
 
 Stern demonstrated that vaseline, mutton-fat, paraffin, olive- 
 oil, and collodium prevent the formation of adhesions of the 
 peritoneum, and are in no manner encapsuled. 
 
 Councilman, Seheuerlen, and others, introduced under the skin 
 or under the superficial fascia? glass phials, glass tubes, and 
 similar foreign bodies containing chemically irritating sub- 
 stances. They state that these foreign bodies lay in a cystic 
 space, but that at the same time bands of connective tissue 
 passed through their lumina. 
 
120 SALZER ON THE HEALING-IN OF FOREIGN BODIES. 
 
 Marchand experimentally investigated the most minute his- 
 tological alterations. He demonstrated the development of giant- 
 cells, viz., of genuine formations analogous to the giant-cells of 
 tubercle, after introducing silk ligatures or hair, a discovery 
 affirmed by many observers, who found also in man after many 
 years, at a greater or lesser distance from the silk ligatures, 
 isolated giant-cells. Marchand made the interesting observation, 
 that the formation of giant-cells is interfered with, and prevented 
 by, the jodoform, which adheres to the silk. As soon, however, as 
 the jodoform has been absorbed, the development of giant-cells 
 commences. In the healing-in of sponges, the giant-cells first 
 form at the periphery coincidently with the development of fibro- 
 blasts and connective tissue. 
 
 As regards the structure of the capsule around foreign bodies 
 formed by connective tissue in the peritoneal cavity, as well as 
 in the subcutaneous cellular tissue, it has been stated that its 
 external layers consist of concentrically arranged fibrous con- 
 nective tissue, poor in cells, whilst the innermost, more vas- 
 cularised layer; which is also very rich in cells, gradually loses 
 its fibrillar structure and assumes an endothelial character. 
 
 Dementiew introduced iron into the cavity of the knee-joint 
 of a dog ; after three months it lay surrounded by coagulated 
 fibrine still free in the otherwise healthy joint. Around nickel- 
 plated nails which had been driven from the cavity of the knee- 
 joint into the thigh-bone, the cartilage cells were found perfectly 
 unaltered, but in the epiphysis there was red marrow devoid of fat, 
 consisting of spherical cells and numerous osteoblasts in the place 
 of the yellow marrow. He also states that the osseous tissue in 
 the intermediate neighbourhood of the nails was more densely 
 hardened. The same alterations were observed around a small 
 shot healed-in in the medullary cavity. (The observation concern- 
 ing the formation of osseous substance in the marrow is contradic- 
 tory to Tauber, who experimented, as is stated, on older animals.) 
 
 Waldenbwrg investigated the tissue alterations around parasites 
 in the Oyprinese, and found mucous tissue around the homogeneous 
 inner membrane. 
 
 It appears from the above observations with regard to the 
 different foreign bodies, if they remain long enough lodged in the 
 body to speak of their healing-in, 1st, that they produce no 
 
SALZER ON THE HEALING-IN OF FOREIGN BODIES. 121 
 
 perceptible reaction, as, e.g., the sewing-needle, for which there is 
 no histological evidence (this has been ascertained for steel in 
 cartilages by Bementiew, and for jodoform-powder in the cavities of 
 the body by Marchand) ; or 2nd, that they are encapsuled. The latter 
 is brought about in that manner, viz., that the newly-formed con- 
 nective tissue encompasses the foreign body, or that a larger amount 
 of serous fluid is found between the capsule formed of connective 
 tissue and the foreign body, in which case we have to speak either 
 of the healing-in in a more or less massy cicatrice, or of cyst formation. 
 
 It is remarkable that at one side the nature of the healing-in 
 of similar foreign bodies in different animals experimented on, as 
 well as in the same individual in different organs, may differ ; 
 but that also, on the other hand, certain foreign bodies are found 
 with special frequency in cysts, others again in wheals, which not 
 only lead to the conclusion that the varieties of the injured 
 organisms and organs decide the question, but also that the 
 physical, or as far as the foreign bodies are somewhat soluble, 
 as well as the chemical properties may be of decisive importance. 
 
 It must here be pointed out, that very probably a third cause 
 may be of importance for the manner of healing-in, as the 
 organism under different mechanical conditions also differently 
 reacts against the irritation from one and the same external injury. 
 
 Whilst stiff bandages, which are equally applied in a larger 
 extent to the surface of the body, even if they fit very tightly, 
 call forth no inflammatory reaction of the skin, the latter will 
 very soon react against the never so slight unequal pressure of a 
 hard foreign body. The effect of that will be materially assisted if 
 the part of the body in question is moved, and thereby at one side 
 the eroding effect of the foreign body, and on the other hand the 
 increased hydrodynamic factors in the body tissues act injuriously. 
 The pressure on the skin is particularly dangerous in portions of 
 the body in which a thin layer of soft parts immediately lies on 
 the skeleton, as in this case even the slightest effect of pressure 
 can barely be counteracted by the elasticity of the thin layers of 
 soft tissue, as from daily experience every coachman knows. 
 Under the stated conditions, as is well known, either erosions or 
 necrosis of the tissue, or formation of wheals, takes place, or that 
 peculiar reaction of the organism consisting in the development 
 of a cystic tumour in the depth between the soft and the hard 
 layers, which we know by the name of bursa mucosa (hygroma). 
 
122 SALZER ON THE HEALING-IN OF FOREIGN BODIES. 
 
 These apparently digressive statements may indicate the stand- 
 point from which the effect of the foreign bodies remaining inside 
 the body ought to be considered and estimated. 
 
 A light, chemically indifferent, small foreign body introduced 
 into a perfectly quiet tissue calls forth no reaction perceptible to 
 the naked eye, as is shown by the behaviour of fine superficial 
 sutures. With the increased size, hardness, and weight of the 
 foreign body, and with the increase of movements, and the 
 fluctuation of pressure of the encompassing living tissue, trau- 
 matic inflammation and erosion around the foreign body is 
 gradually brought about, exactly as occurs after external injuries 
 on the surface of the body. As secondary formation of wheals 
 and loss of substance may result on the skin, so we have to 
 expect exactly opposite alterations in the interior of the organism ; 
 provided that no kind of tissue alteration takes place, as has been 
 asserted by some authors about needles, and in rare instances also 
 for other foreign bodies, especially as regards the connective tissue, 
 the epidermis, and even the brain and the cartilages. 
 
 Personal Observations. 
 Histological investigations on the encapsulation of foreign bodies. 
 
 The older statements on the alterations of the different tissues, 
 on the development of wheals and cysts, on the formation of 
 giant-cells, and the origin of the endothelium in cysts, may be 
 completed by my own observations and investigations. 
 
 The following up of the observations of the healing-in of 
 foreign bodies was suggested by a case in the clinical ambulance 
 of Prof. Billroth, at Vienna, four years ago. A lad presented 
 himself with a thin-walled cystic tumour, of about the size of a 
 pigeon's egg, in the bend of the elbow ; the skin over it was 
 supple and movable. An injury was inflicted by a piece of a 
 broken window-pane several months previously. The small 
 wound had soon healed by first intention, the tumour gradually 
 formed, and only caused unimportant inconvenience by its size. 
 The smooth-walled cyst was emptied of its clear serous contents 
 by an incision, and a perfectly loose, evidently movable, sharply 
 pointed glass-splinter was extracted. 
 
 This observation was followed by a series of similar cases, of 
 which only those in which glass lodged for many months in the 
 
SALZER ON THE HEALING-IN OF FOREIGN BODIES. 123 
 
 body shall be reported more fully, and supplementary to those 
 an account of the description of histological and other details. 
 Besides the above-mentioned case, the following may be of 
 interest : — 
 
 (2) A boy aged thirteen years (Ambulance case-book No. 1844 
 of Prof. Billroth's clinic for the year 1888) had for eight months 
 healed in the subcutaneous cellular tissue of the head a triangular 
 glass-splinter, about 1 cm. long and 05 cm. broad at the base, 
 which was surrounded by a very minute quantity of serum, in a 
 capsule of delicate connective tissue. 
 
 (3) A tiler, K. G., twenty-six 3 ? ears of age, presented himself in 
 May, 1889, stating that five months previously he had received from 
 a blow with a beer-glass against the fingers of the right hand a 
 small wound on the dorsal side of the first metacarpophalangeal 
 articulation of the first finger, which had soon healed up. Four 
 weeks ago, for the first time he felt inconvenience, and a sensation 
 of pricking accompanied by a resistent infiltration of the skin at 
 the injured place set in, pressure called forth intense stabbing 
 pain. An incision having been made through the firm infiltration, 
 a piece of glass, sharply pointed at one end, about 7 mm. long 
 and 4 mm. broad, surrounded by a most minute quantity of 
 serous fluid, was removed. 
 
 (4) A girl, 10 years of age (Amb. C. B. No. 1604, for 1889), 
 ran five weeks ago against a window pane, a splinter of which 
 remained under the frontal integument. It healed up without 
 reaction; later on the cicatrice opened, and a splinter became 
 visible, but soon disappeared again. At present it sticks out from 
 a small opening in the skin. Dilatation of the hole by incision ; 
 extraction of the splinter, which was lodged in a cavity moistened 
 hy serum ; no pus. 
 
 (5) A man of the fire-brigade, aged thirty-three (Amb. C. B. 
 No. 1983, f. 1889), some months ago, whilst entering through a 
 window, had a glass-splinter thrust into the left knee immediately 
 above the patella. Ointments were applied, and the wound 
 healed without pain, but there remained at the place an induration. 
 Two months ago pricking pain was brought about by bending 
 the leg, or by kneeling. A longish nodosity obliquely above the 
 patella was extirpated, inside which a glass-splinter 16 mm. in 
 length was found in a small cystic space. The capsule consisting 
 of connective tissue having been excised in toto, was divided, its 
 
124 SALZER ON THE HEALDfG-IN OF FOREIGN BODIES. 
 
 inner surface treated with a solution of 5 per 1,000 of nitrate of 
 silver, washed with a solution of 7 per cent, of common kitchen 
 salt, and hardened in alcohol, after which sections of the interior 
 wall were made. The microscopical examination of the horizontal 
 and diagonal sections, stained with picro-carmine, showed the 
 external layers of the cyst-wall, consisting of fibrous connective 
 tissue, blending towards the inner surface into a more vascular 
 tissue, poorer in fibres but richer in cells. The cells of the con- 
 nective tissue increased in size and roundness, so that at the inner 
 surface eventually they reached a diameter of 30 millimetres, but 
 in general they were of different sizes ; they varied from spherical to 
 pear-shapes, and possessed larger elliptical nuclei, some of them 
 even 2 — 8. They were arranged in endothelial manner, and lay 
 so closely together that no interstitial fibrous tissue between 
 them could be seen. The staining by the silver process, although 
 somewhat diffused, still rendered recognisible distinct cell-borders. 
 It appears from the vertical section as if the most superficial cells, 
 i.e., those situated towards the free surface, did not possess any 
 margin, so that the body of the cell seemed directly to pass 
 over into a substance dotted with silver granules. Close under 
 the endothelioid layer there was a very vascular stratum. (See 
 Tab. I., fig. 1.) 
 
 (6) A young man, A. 0. (Amb. C. B. No. 2699, f. 1889), fell 
 four weeks previously into a shop window. The wound at the 
 right wrist-joint, situated towards the dorsal side of the epiphysis 
 of the radius, and which bled profusely, was painless, but later 
 on, he stated, it suppurated slightly. He feels in the centre of 
 it a circumscribed hardness. When he presented himself, the 
 wound was covered with a crust of blood, and 1 cm. above it, the 
 point of a foreign body lodged under the skin could be felt. An 
 incision revealed a glass-splinter 2 cm. in length, lying under 
 the superficial fascia in a cystic space, which communicated with 
 the sheath of the tendon of the external radial muscle. The 
 somewhat closely fitting capsule of connective tissue contained a 
 small quantity of pure serous fluid. No trace of pus, no com- 
 munication, altogether no connection with the small suppurating 
 external wound. The capsule of connective tissue was hardened 
 first in sublimed picric acid, and then in alcohol. The vertical 
 sections, stained with haematoxyline or lithion carmine, showed 
 in the external layers fibrous connective tissue; the cells, 
 
SALZER ON THE HEALING-IN OF FOREIGN BODIES. 125 
 
 increasing in size towards the interior, assumed a spherical 
 or polygonal shape, became larger, and so numerous that at 
 some places no distinct fibrous tissue between was any longer 
 visible. Very rich vascularisation of the endothelioid layer 
 continued close to the inner surface. At the sharply defined 
 inner border, here and there flattened cells, and regular though 
 extremely delicate bands of fibres. (See Tab. I., fig. 5.) 
 
 (7) A lad, seventeen years old (Ambulance, May, 1889), two 
 months ago run his hand through a window-pane, inflicting a 
 small wound, which bled profusely, but healed up in eight days. 
 Swelling followed, impeding the movability of the fingers, but 
 soon commenced to mend again, so that the patient was able 
 to do any kind of work (chopping wood, cleaning boots, &c.) 
 Later on the swelling returned. After an incision through the 
 thickened callous skin on the palmar side of the hand, a glass 
 splinter 2 - 5 cm. long became visible, which stood almost upright 
 on the surface. No fluid escaped from the incision, only the 
 membranaceous investment of the splinter was seen ; the latter at 
 one side appeared dull, as if ground. 
 
 (8) Steel needles. It is to be mentioned, as regards excised 
 needles, which had been healed-in for a longer period, that these 
 lay in a small canal of connective tissue, with walls of different 
 thickness, containing serum, or directly in a small callosity 
 without any considerable exudation of fluid. A needle which 
 lodged for six months in the cutis of the thumb was tightly 
 enclosed by a firm, but at the same time delicate capsule of 
 connective tissue. Another needle sticking in the thumb was 
 enclosed by a cystic capsule. I extirpated from the palmar side 
 of the hand, near the wrist, a firm capsule of connective tissue, 
 containing a needle healed-in for several months, and a small 
 quantity of serum. The microscopical examination of its walls 
 hardened in sublimed picric acid, and afterwards in alcohol, 
 showed in the external layers concentric bands of connective 
 tissue, with a great amount of pigment, and in the inner vascular 
 layer large cells with a distinct nucleus undergoing division, 
 embedded in the meshes of the scarce, irregularly arranged 
 connective tissue. The innermost border consisted in some 
 places of endothelioid connective tissue corpuscles, or of a delicate 
 fibrous layer. (See Tab. II., figs. 2 and 3.) Eespecting the above- 
 mentioned abundant brownish-red pigmentation in the external 
 
126 SALZER ON THE HEALING-IN OF FOREIGN BODIES. 
 
 fibrous layers, I have to add that these gave an intense iron- 
 reaction (with yellow prussiate of potash and hydrochloric acid), 
 as was not the case with an old hematoma, which was examined 
 for the purpose of control. It remained, therefore, doubtful whence 
 the iron was obtained, whether it may not have been deposited 
 from the foreign body. 
 
 A piece of a needle a few millimetres long was found in a 
 callous cicatrice at the ulnar border of the metacarpus of an 
 hysterical woman.* 
 
 An irregular iron splinter in the phalanx of an artisan was 
 likewise healed-in, in a hard callous nodule. Here it may be 
 remarked that iron is always found oxydised, even after remaining 
 only a short time in the body. 
 
 In a child, twelve months of age (Amb. C. B. No. 3483, f. 
 1889), was found a fragment of a needle, 2 - l cm. long, sticking 
 vertically ill the abdomen, above the umbilicus. Its end could 
 just be felt through the abdominal wall. During the incision 
 through the skin and muscles, the needle showed movements 
 corresponding to the respiration. It was easily extracted from 
 the depth of the abdomen by a moderate traction. It was re- 
 markable that the portion of the needle sticking in the abdominal 
 wall was much more oxydised than that which undoubtedly had 
 entered the peritoneal cavity. The needle had been embedded 
 only twenty-four hours. It was observed in rabbits, seven to 
 eight hours after iron needles had been stuck into and through 
 the abdominal wall, that the degree of oxydation of the needles is 
 very different, according to whether the needle stuck in the 
 abdominal wall, in the abdominal cavity, or in one of the abdo- 
 minal organs. Especially remarkable is the minute degree of 
 oxydation of the portion of the needle which lay free between 
 the coils of the fat small intestine, whilst the portion situated 
 within the layers of the abdominal wall shows a very strong 
 oxydation. This observation is not without significance in forensic 
 
 * This case was of some practical interest, as it was perfectly impossible 
 to feel the foreign body. Here the nse of the astatic needle, after previous mag- 
 netisation of the fragment, proved efficient, a proceeding which I learned at 
 Prof. Kocher's clinic at Bern, and which had already been practised in England. 
 The needle had already been searched after, but had not been detected by several 
 surgeons. Guided by the astatic needle, I succeeded in discovering it without a 
 longer exploration. (See A. Smee: On the detention of needles and other steel 
 instruments impacted in the human body. H. Renshaw, Strand, London, 1875 J 
 
SALZER ON THE HEALING-IN OF FOREIGN BODIES. 127 
 
 medicine, especially if the chemical condition is constant in the 
 individual regions of the body or organs. 
 
 (9) The following case of healing-in of a piece of lead is 
 interesting on account of its anatomico-pathological condition. 
 
 (Prof. Billroth's clinic, case-booh No. 379, /. 1889), V. H., a 
 cabinet-maker's workman, twenty-one years of age, from Moravia, 
 descended from a healthy family, received seven years ago a gun- 
 shot injury from a pistol made out of a key, in the first inter- 
 metacarpal space. The barrel of the key, after the removal of 
 the handle, was closed up at one end with lead, and a touch-hole 
 had been filed into it above the leaden plug ; the tube was filled 
 with gunpowder, and closed with a piece of fresh clay. The 
 patient whilst holding this improvised pistol with the left hand, 
 ignited the touch-hole with the right hand. The explosion pro- 
 duced a wound near the ulnar side of the base of the left thumb, 
 which bled but very little, and healed under a dressing with arnica 
 and onions (a popular remedy) in three weeks. Later on the 
 patient noticed in the small cicatrice a hard knob, which only 
 caused pain when knocked against. This knob gradually grew 
 within the last ten months into a tumour, in which the patient feels 
 when rapidly moving the hand a pushing sensation. There was at 
 the palmar side of this powerful artisan's hand, between the thumb 
 and the index finger, a slightly movable, fluctuating tumour of 
 the size of a hen's egg, the pale skin over it was thickened and 
 stretched. "When shaking the hand a rumbling sound was heard, 
 and the ballotement of a foreign body distinctly felt. The adduction 
 of the thumb was prevented by the size of the tumour. (See 
 Tab. III., fig. 6.) 
 
 On the 8th of July, 1889, under anaesthesia and Esmarch's 
 bloodless method, at the palmar side, a longitudinal incision was 
 made across the tumour, by which the bluish-white walls of 
 connective tissue of a pear-shaped cyst, situated in the subcu- 
 taneous cellular tissue, was exposed. The skin was somewhat 
 more closely connected with the cyst-wall, only at the part of 
 the small cicatrice at the base of the first phalanx of the thumb, 
 but could be easily and rapidly dissected from this adhesion. 
 The central pointed portion of the cyst was crossed by the fibres 
 of the adductor muscle of the thumb, which for the purpose of 
 the removal of the cyst had to be drawn towards the radius. 
 The whole cyst with its continuation, which reached into the 
 
128 SALZER ON THE HEALING-IN OF FOREIGN BODIES. 
 
 carpus, was peeled out without opening the sheath of the tendon 
 or the articulation. Drainage and union by sutures of the 
 wound. The patient was discharged cured on July 15th. The 
 extirpated tumour was distinctly pear-shaped; an hour-glass- 
 like constriction, which existed whilst the tumour remained in its 
 site, disappeared after. dividing a few muscular fasciculi. (See 
 
 fig. 7-) 
 
 On opening the cyst an amber-yellow serous fluid, whitish- 
 yellow grumous masses, and a piece of metal escaped. The firm 
 interior wall of the cyst was of yellowish-white colour, uneven, 
 with, at some places, trabecular or wrinkled prominences, of a 
 nodular surface, whilst the other places were perfectly smooth. 
 
 The chemical examination of the amber-yellow fluid proved its 
 richness in albumen and mucin. There were, moreover, traces of 
 dissolved lead (Dr. Smita), but there was no sugar. The micro- 
 scopical examination of the soft grumous substance showed detritus 
 of disintegrated granular cells, and red and white blood-corpuscles. 
 The latter may have found admission in the opening of the cyst, 
 as some blood oozed from the incision of its walls. The foreign 
 body lodged in the cavity was of cylindrical shape, 21 mm. long, 
 9 mm. in diameter, and consisted principally of lead. The 
 almost perfect smoothness of its surface was only interrupted 
 by shallow furrows and pits ; it was of grey, at some places of 
 pale brown colour, and nowhere encrusted. (See fig. 8.) 
 
 The cyst-wall, with the view of histological examination, was 
 treated, one portion with a solution of - 5 per cent, of nitrate of 
 silver (a few minutes after with a solution of 07 per cent, of 
 common salt) ; another with a solution of - 5 per cent, of hyper- 
 osmic acid (and hardened after that in alcohol) ; and another 
 portion was directly preserved in Mueller's fluid. Sections made 
 in different directions and stained with haematophylin or lithion 
 carmine, showed that the cyst wall consisted in the greater part 
 of concentrically arranged connective tissue, poor in blood-vessels 
 and cells; only the innermost layers were richer in cells; the 
 fibrous tissue loses, when approaching the surface, its regular 
 concentrical arrangement, and at some places appears to radiate, 
 but in a very irregular manner. Finally, the fibrillar structure 
 disappears, so that in the innermost strata, around the cellular 
 nuclei, only an indistinct mass, no longer of a defined structure, 
 can be perceived, an interstitial tissue between the irregular 
 
SALZEE ON THE HEALING-IN OF FOREIGN BODIES. 129 
 
 cells. These cells possess a distinct nucleus, whilst the outline of 
 the cell is not always clearly visible. Between this innermost 
 layer and the afore-mentioned vascular structure there is at some 
 places a layer of varying thickness of closely packed endothelioid 
 cells, the cementing intercellular substance (" Kittsubstanz") 
 of which is rendered distinct on staining by the silver process, 
 whilst the nuclei at the surface are here and there in the act of 
 division. (See figs. 9 and 10.) 
 
 There was no trace of lime-deposits on the piece of lead. I 
 had no opportunity of observing deposits of lime on healed-in 
 foreign bodies, but I once found a considerable quantity around 
 a steel needle, lodged in an abscess in the right iliac fossa, which 
 evidently had perforated from the caecum. Fischer states that 
 incrustation of lime on bullets only takes place in cases of long 
 persistent suppuration. 
 
 Another foreign body which I have seen encapsuled in a cystic 
 space was a long steel nail, which was left in a resection-wound, 
 and which was extirpated by Mr. MacEwen. Steel nails which 
 had been fastened into bones are frequently so firmly impacted 
 in the bone after five to six weeks, that their extraction may be 
 attended with considerable difficulty. 
 
 These observations on human preparations were completed by 
 the investigation of animal preparations. The experiments 
 referring to them were instituted with the view of studying 
 more exactly the tissue alterations around some kinds of foreign 
 bodies, especially of glass, and of testing their fitness for thera- 
 peutical purposes. 
 
 I shall give in the following some observations as examples : — 
 
 (1) Glass splinters introduced into the cellular tissue of the 
 neck, the back, or under the fascia of the gluteal region of 
 rabbits, healed-in by first intention. Two months after the 
 operation the following was found : the sharply-edged splinters 
 lay in the aforesaid parts of the body, in cysts containing very 
 little fluid, the walls of which consisted of a white thin capsule of 
 connective tissue, with an inner surface, resembling and shining 
 like a serous membrane. After hardening in alcohol, vertical 
 and horizontal sections were made through the capsule ; in the 
 vertical sections were seen distinctly concentric layers of con- 
 nective tissue, near the inner surface numerous round cells, but 
 no endothelial arrangement of these cells. It was remarkable of 
 
 E 
 
130 SALZER ON THE HEALING-IN OF FOREIGN BODIES. 
 
 the most superficial layers of the horizontal sections that the 
 fibrillation became less distinct, and that there were relatively 
 large, mostly fusiform cells and an extraordinary abundant, very 
 delicate vascularisation. 
 
 (2) Three sharply-edged glass splinters implanted in the left 
 gluteal region, under the abdominal integument, and in the right 
 axilla of a dog, lay after twelve days in a cystic capsule of 
 connective tissue, containing serous fluid rich in albumen. 
 After being hardened in alcohol, the innermost layer presented 
 numerous large-celled formations of endothelioid character, and 
 numerous vessels which with manifold ramifications reached the 
 surface, so that the vessels sometimes seemed to lie free. At 
 many places there were red blood-corpuscles between the endo- 
 thelioid cells. 
 
 (3) A glass splinter healed-in between the abdominal muscles 
 of a rabbit, was enclosed after two months by a thin-walled 
 capsule of connective tissue, containing serum, the inner surface 
 of which was smooth and shining. 
 
 (4) A glass splinter in the abdominal cavity of a rabbit, after 
 nine days was enveloped in, and fixed to the omentum. 
 
 (5) A cylindrical solidpiece of glass with rounded edges had been 
 placed in the interstice, between the fractured ends of the left 
 thigh-bone of a dog (from which a piece had been resected with 
 a chain-saw). Sutures in stages ; jodoform-gauze ; plaster of 
 Paris bandage. After six weeks pseudo-arthrosis in a high 
 degree, considerable shortening of the limb, cystic spaces around 
 the cicatrised displaced ends of the bones, which protruded into 
 these about 1 cm. The glass cylinder lodged in a recess of this 
 space, above the peripheric fragment. A portion of the wall 
 hardened, first in sublimed picric acid, and afterwards in alcohol, 
 presented under the microscope thin layers of fibrillated connective 
 tissue, with numerous connective tissue corpuscles, unequally 
 distributed, most abundant only in certain places, e.g., especially 
 in the recess around the foreign body on the inner surface, 
 without, however, possessing a decidedly endothelioid character. 
 It was remarkable that the fibrillation of the interstitial tissue 
 between the nuclei disappeared at the surface, so that here no 
 distinct structure could be seen. The microscopical examination 
 of the superficial cicatrix of the bone only showed fibrous tissue. 
 
 (6) A glass splinter was placed between the fractured ends of 
 
SALZER ON THE HEALING-IN OF FOREIGN BODIES. 181 
 
 the humerus of a dog. After two months, likewise, pseudo- 
 arthrosis had formed, but only with very little suppuration. 
 
 (7) A rounded glass cylinder was placed between the fragments 
 of the leg of another dog. The wound healed by first intention 
 in a dressing of soluble glass. Pseudo -arthrosis after five months. 
 
 (8) A thin-walled glass shell was inserted between the frac- 
 tured ends of the bone of the fore-arm of a rabbit. Plaster of 
 Paris bandage. The fracture, was united after two months. At 
 the post-mortem examination, five months after the operation, 
 the numerous delicate splinters of the broken glass shell were 
 found embedded in the abundant callus of the bone. 
 
 (9) Experiment on a rabbit. Glass-wool was plugged into the 
 knee-joint, in place of the resected left external articular condyle 
 of the femur. The muscles and the skin were united by sutures. 
 Condition four weeks after the operation: The knee-joint externally, 
 and in its movability, unaltered. After the removal of the skin, 
 no signs of a preceding injury in the deeper soft parts. A 
 vertical section through the knee below the semi-lunar cartilages 
 brought the latter into view, which, like the tibial articular 
 surface, were pale and moistened with serum, but there was no 
 abnormal effusion, or dropsy of the joint. After the removal of 
 the semi-lunar cartilages, the pale, smooth surface of the internal 
 articular condyle was found unaltered ; in the place of the ex- 
 ternal condyle there was a mass resembling masticated white 
 bread, approaching in shape that of the external condyle, by 
 having its surface rounded. The patella with its tendon glides 
 in a shallow groove of this mass, between both condyles. The 
 line of demarcation of the bone, towards this foreign mass being 
 more vascular than the remaining portion of the bone-surface is 
 visible as a narrow red line. Nowhere extravasated blood or 
 pus, only articular moisture. 
 
 The microscopical examination : (1) Between the fibres of a 
 small portion of the glass-wool, taken from the superficial layer 
 and stained with hematoxylin, only detritus, but no stained 
 cells were visible. (2) In the prepared section of the knee-joint, 
 decalcined in a \ per cent, solution of chromic acid, especially at 
 the border-zone of the defect of the bone, rich vascularisation 
 between the glass-fibres and the endothelioid cells with a glassy 
 intercellular substance. The osseous structure rarefied. Nowhere 
 marrow containing fat. 
 
132 SALZER ON THE HEALING-IN OF FOREIGN BODIES. 
 
 (10) Glass-wool was placed between the adductor muscles of 
 the thigh of a rabbit ; sutures in stages. Six weeks after complete 
 healing-in had taken place, so that the incisions in the several 
 layers of the soft parts could no longer be perceived. The wool 
 was intimately attached to the muscles, no trace of cystic spaces, 
 altogether no serum. The centre of the foreign body (glass- 
 wool), which was also perfectly dry, was at the same time of 
 brownish-black colour, and on superficial examination apparently 
 not grown through by connective tissue. Hardened in a ^ per 
 cent, solution of chromic acid, in the sections, the muscular 
 fibres entering between the glass-threads show no transverse 
 bands, but longitudinal fibrillation. More distant from the 
 muscles there was connective tissue between the glass-fibres, 
 roundish cells of endothelial character, here and there at the 
 same time very numerous vessels in an indistinct clear inter- 
 stitial substance. On the glass-fibres, as well as on the cells, 
 frequently amorphous pigment. The centre of the glass-wool 
 contained only detritus and pigment. {See Tab. II., fig. 4.) 
 
 (11) Glass-wool placed in the defect of the cancellated portion 
 of a vertebra of a dog, was found intimately adherent after eight 
 days, and permeated by wandering cells. In the microscopical 
 section, after hardening in chromic acid, besides the wandering 
 cells, the fibrillation of the coagulated fibrine could also be easily 
 recognised. The marrow in the neighbourhood of the injury of 
 the bone contained no fat-cells, whilst these were distinctly 
 present at some greater distance. 
 
 (12) Glass-wool placed in the abdominal cavity of rabbits was 
 found intimately adherent, mostly to the intestines and the ab- 
 dominal wound. 
 
 (13) Leaden projectiles, and especially conical bullets with a 
 circular groove at the blunt end, were in several instances 
 placed in the subcutaneous cellular tissue of rabbits. In the 
 region of the adductor muscles, and in the groin, they were 
 found after four weeks in a cystic space with moderately firm 
 walls, the inner surface of which presented a velvet-like gloss. 
 Under the microscope, enlarged connective tissue corpuscles 
 were visible in the innermost layers, of which again the innermost 
 boundary was undergoing molecular disintegration. A bullet 
 healed-in under the skin of the back, showing numerous cracks 
 and roughnesses, appeared on superficial examination after five 
 
SALZER ON THE HEALING-IN OF FOREIGN BODIES. 133 
 
 weeks as freely movable and as easily displaced as was the 
 case with the afore-mentioned bullets ; on careful preparation, 
 however, it was found that the bullet did not lodge in a cystic 
 space, but was invested by a delicate fine layer of connective 
 tissue, it was grown into the loose subcutaneous fibrous tissue, 
 and was movable with this. 
 
 (14) A 'cylindrical piece of wood about 1 cm. long and a few 
 millimetres thick, remained one year and a half healed-in under 
 the dorsal skin of a rabbit. There having been no trace of 
 inflammation, this foreign body only lay in an extremely thin, but 
 distinctly circumscribed white capsule of connective tissue. This 
 was not in immediate contact with the smooth surface of the 
 wood, as there was some serum in the cyst ; the two uneven 
 vertical sections of the wood, however, were so intimately ad- 
 herent to the capsule that they had to be torn off, whereby 
 some blood escaped from the villus-like formations which had 
 grown into the pores of the wood. The cyst-wall was treated 
 with a solution of 2 per cent, of nitrate of silver, stretched across 
 a piece of cork and washed with a solution of 6 per cent, of 
 common salt. It was possible to remove the silver-stained inner 
 pellicle. In horizontal sections, the fibrous tissue, and not very 
 numerous cells of different sizes, without any endothelioid arrange- 
 ment could be recognised. Vertical sections through the smooth 
 portion of the cyst presented extremely loose tracts of connective 
 tissue and numerous vessels; the interior showed somewhat 
 larger endothelioid cells, and between these structureless inter- 
 stitial tissue. The place where the wood adhered contained very 
 numerous and large multinuclear cells, and numerous blood- 
 vessels, which also entered the villus-like growths of the con- 
 nective tissue. 
 
 (All the foreign bodies employed in the experiments on animals 
 had previously been sterilised.) 
 
 With glass splinters, in general with smooth surfaces or sharp 
 edges of a not too heavy foreign body, encapsulation in a delicate 
 capsule of connective tissue with a smooth internal wall will 
 always take place, provided that the part of the body be not 
 exposed to other kinds of injuries ; if, however, the latter be the 
 case, a larger quantity of serum will form, or the capsule will 
 become thickened. Heavier pieces of lead lie in a coarse-walled, 
 not perfectly smooth cyst, or they are closely surrounded by a 
 
.134 SALZEE ON THE HEALING-IN OF FOREIGN BODIES. 
 
 capsule of connective tissue, which is movable in the cellular 
 tissue. Needles lodge, according to mobility of the soft parts, in 
 thin or thick capsules of connective tissue, which mostly contain 
 distinct serum. Porous fibrous substances are permeated by 
 large-celled connective tissue. 
 
 The investigations on the histogenesis of the investments of 
 foreign bodies have already been partially mentioned. 
 
 Tillmanns in his treatises on the investments of serous cavities, 
 and again in those on the healing-in of foreign substances, 
 especially of dead tissue in the peritoneal cavity, has in the 
 most exact manner elucidated the more minute histo-pathological 
 alterations. As to the encapsulation of dead bodies in the abdo- 
 minal cavity, he explained the formation of capsules of connective 
 tissue in the following manner : The formative cells of these 
 are emigrated colourless blood-corpuscles, which in the begin- 
 ning are round, then so much pressed together that they 
 assume an epithelial appearance, much granulated, possess 
 one large or several smaller nuclei, and sometimes melt together 
 in larger numbers into a homogeneously granular formative 
 material. The formation of the fibrillary substance (respecting 
 which Tillmcmns coincides with the views of Ziegler, Schwan, 
 and Schuhe) is always brought about by differentiation of 
 their protoplasm, whilst in the intercellular substance, so far 
 as it is not understood as a metamorphosed cell-protoplasm, 
 according to Tillmcmns and Ziegler, no formation of fibrillae is 
 produced. Without exception, the surface of the implanted 
 tissue will be covered in a certain time with cells placed 
 together, in the manner of endothelium. 
 
 Quite contrary to this explanation of the mode of origin of the 
 fibrillary substance in the case of foreign bodies, is the view of 
 Weiss (Padua), who introduced hair or cotton-threads under the 
 skin of dogs or pigeons, in order to examine the tissue alterations 
 after fifteen, thirty, to forty-five days. (He produced, however, 
 with the exception of one single case, always suppuration.) Weiss 
 states that in immediate connection with the foreign body giant- 
 cells form, the origin of which he explains by the confluence of 
 several smaller cells; the latter because the foreign body fre- 
 quently lies in giant-cells. Further, the cells which serve as 
 formative material are granulation-cells. These in time are 
 converted into epithelioid cells, round or polygonous, with finely 
 
SALZER ON THE HEALING-IN OF FOREIGN BODIES. 135 
 
 granular contents, with from two to five finely granulated nuclei, 
 and these epithelioid-cells finally run into giant-cells. Thirdly, 
 the giant-cells are always doomed to fatty metamorphosis, and 
 are converted neither into connective tissue, nor into blood-vessels. 
 Ziegler makes the giant-cells form from white blood- corpuscles 
 between glass slides. Weiss believes that Ziegler might have 
 found giant-cells also outside that capillary space. 
 
 As regards the formation of giant-cells, it may be mentioned 
 that Haidenhain was the first who observed the development of 
 giant-cells in connection with foreign bodies. Baumgarten found 
 such around the ligature after tying arteries, and considers them 
 to be genuine tubercule giant-cells (Langhanns), with nuclei 
 attached to the cell-wall (" wandstaendige Kerne"). Mwrchand, 
 in his experiments on animals, found likewise genuine giant-cells 
 with twenty to thirty and more nuclei attached to the cell-wall, 
 around healed-in silk fibres, or particles of sponge, besides multi- 
 nuclear epithelial cells. In contradiction to Ziegler, Tillmanns, 
 and Gonheim, who will have them developing from white blood- 
 corpuscles, he considers the foreign body giant-cells to be formed 
 from fixed tissue-cells, not like Weiss, from lyphoid, i.e., granu- 
 lation-cells, but from endothelioid-cells. Thus considering the 
 giant-cells as really living cells, and not like others (Arnold, 
 Thoma) as a product of degeneration, he believes with Virchow, 
 Baumgarten, Flemming, and others, that they were produced by 
 the growth of one single cell. 
 
 The purpose of my own investigations was the study of the 
 microscopic alterations in the environs of the foreign bodies, and 
 at the same time of the histological conditions after healing-in 
 had taken place. On the real nature of the healing-in process, 
 and the participation of the different tissue elements on the 
 above-mentioned theories, on the formation of connective tissue 
 and giant-cells I shall therefore only in passing state my views. 
 
 In the microscopic appearances which I observed in the sur- 
 rounding tissues in the earlier stages of the healing-in of solid 
 foreign bodies, the closely contiguous cells presented, with the 
 vascular loops between them, a kind of granulation-tissue. In 
 the third week the inner layer already showed the character of 
 endothelioid-cells of different size, with or without scanty fibrillae 
 between them, unless the most superficial layer undergoing con- 
 tinual disintegration presents a structureless substance. 
 
186 SALZER ON THE HEALING-1N OF FOREIGN BODIES. 
 
 As in older preparations, the gradual transitions from the 
 endothelioid-cells of the inner layer to the delicate connective- 
 tissue corpuscles of the external fibrous layers are perceptible ; 
 moreover, as in the more recent preparations of cysts enclosing 
 foreign bodies, as also in the case of healed-in glass-wool, the 
 endothelioid cells have been observed at the same time with the 
 development of a very rich vascular network, I have no reason to 
 doubt the origin of endothelioid-cells for the connective-tissue' 
 cells, by proliferation of the latter. 
 
 The older preparations are distinguished from the more recent 
 by their relative poverty in vessels. 
 
 I have further to remark, as regards the formation of giant- 
 cells, that I have never found genuine tubercle giant-cells in the 
 innermost layer of cysts enclosing foreign bodies, but I have ob- 
 served larger multinuclear endothelioid cells. The innermost layer 
 at any rate does not so very regularly present the formation of 
 giant-cells, as Weiss supposes. At the utmost, such formations 
 might be spoken of in some isolated places. Appearances of a 
 sharply-circumscribed mass of protoplasm, with a few spherical 
 cells, were several times observed in the endothelioid layer, in, 
 places where the vascularisation was becoming indistinct. The 
 explanation of these as sections through the not yet canalised 
 sprouts of vessels, may not be discarded without further con- 
 sideration. 
 
 The microscopical examination of the cyst-wall around foreign 
 bodies demonstrated mostly large endothelioid-cells, and in 
 many instances also an arrangement of the bands of the con- 
 nective tissue of the inner layer, which materially differed from 
 that of the external layers of the capsule. As a rule, in each of 
 such cysts, around concentrically arranged tracts of fibres of 
 connective tissue (which in the case of objects which produce 
 very little irritation by their weight or irregular surface, or in 
 quiet animals, e.g., rabbits, are moderately poor in cells ; but in 
 the case of heavy rough foreign bodies, and when there is much 
 movement, as, e.g., in an artisan's hand, are moderately rich in 
 nuclei), and also on the inner aspect of these layers of connective 
 tissue in which the concentric arrangement of the fibrillaa is lost, 
 and the fibrillse themselves become irregular, the lumen of num- 
 erous vessels is observed, while at the same time the cells around 
 the connective-tissue nuclei become more distinct and more 
 
SALZER ON THE HEALING-IN OF FOREIGN BODIES. 137 
 
 rounded, until finally immediately at the surface they are less 
 densely packed together, and show quite irregular conditions of 
 growth and multiplication. Frequently the increase in size of 
 the cell is associated with so considerable a decrease of the fibril- 
 lary intercellular substance that a whole layer of cells appears to 
 be in direct contact with it, or at least only separated from it by 
 a very minute amount of intercellular substance, structureless, or 
 consisting of extremely delicate fibres. 
 
 A sharp boundary -line towards the interior is frequently absent, 
 in many instances there may be seen a granular mass, which 
 perhaps may have been produced by the disintegration of the 
 cells and intercellular substance, in which here and there a 
 larger nucleus may still remain visible. Moreover, if the cells 
 have no endothelioid arrangement, and if between them there 
 are still visible distinct connective-rtissue fibres (not arranged 
 concentrically, but rather radially), then the more or less smooth 
 inner surface may also be formed by such a layer of most delicate 
 fibres. In closely-adjacent delicately- walled connective tissue 
 capsules around quiescent smooth foreign bodies, the layer of 
 the enlarged connective-tissue corpuscles and their increase in 
 number are very inconsiderable ; the delicate fibre-bands are 
 concentrically arranged almost up to the inner surface. 
 
 In the examination of older cases, a condition which might 
 indicate cellular infiltration of the walls could never be de- 
 monstrated ; it is only a question of increasing growth of the 
 connective-tissue cells and final proliferation of these (and 
 degeneration of the protoplasm), and in the same succession of 
 retrogressive metamorphoses of the intercellular substance from 
 the gradual indistinctness to the complete disappearance of the 
 fibrillary structure. 
 
 I never succeeded in finding a genuine endothelial layer in 
 a cyst formed around foreign bodies, as had been demonstrated 
 by Landzert, Boll, Brueche, Reichert, Koellilter, Heineke, and 
 especially by Tillmanns, for the inner surface of articulations, 
 in contradiction to Albert, Hueter, Oerlach, and others. 
 
 It barely needs mentioning that the same beautiful appearances 
 which Tillmanns and others of the afore-named authors have 
 seen in articulations, had likewise repeatedly been produced and 
 observed in favourable preparations. In the cas6 of cysts around 
 foreign bodies, even if they contained the clearest serum, and if 
 
133 SALZER ON THE HEALING-IN OF FOREIGN BODIES. 
 
 their walls appeared perfectly smooth and shining, the most 
 varied preparations, also those produced by the very unreliable 
 silver-process (" Silberbilder"), never yielded similar results, as, 
 e.g., in surface preparations (" Absbreifpraepcuraten") , including 
 the transition from articular cartilage to synovial capsule. It 
 seems that there is never a cellular-investment layer strictly 
 differentiated from the other kinds of connective tissue. 
 
 As little can an endothelial investment of the kind be observed, 
 as has been found in hygroma of the sheaths of the tendons (in 
 tenosynovitis). In these, by an injection of a solution of \ per 
 cent, of silver, an endothelial layer of two to three strata of large 
 pear-shaped, also of spherical cells with large distinct nuclei, can 
 be demonstrated in glycerine preparations, a condition which 
 cannot be found in secondary hygromas, so-called " bursas 
 mucosas," or accessory bursas, the inner wall of which rather 
 reminds one of the afore-described capsules around foreign 
 bodies, as the large, irregular, densely-arranged cells of their 
 inner wall, the trabeculi and septa, possess in every respect the 
 character of the connective-tissue cells. 
 
 In the case of foreign bodies partially lodged in physiological 
 cavities with epithelial or endothelial investment, an advance 
 of this epithelium or endothelium to the remainder of the wound 
 — a genuine epithelial investment of walls being thus formed — 
 is, from a theoretical standpoint, certainly admissible. I myself 
 have no experience of this occurrence. 
 
 If the injury be considerable, the inner wall presents the 
 appearance of wearing away of the connective tissue with 
 persistent irritation and disintegration of the innermost layer ; 
 if the injury, however, be but slight, there will be signs of a 
 lesser degree of irritation (of cell proliferation) in the fibrillary 
 tissue. 
 
 The distribution of the vessels is highly remarkable. There 
 is in every case a poverty of vessels in the external layers of the 
 capsule, and an extraordinary richness in the inner layers ; but 
 there are also varieties of termination and distribution of the 
 vessels in the richly vascularised inner layer, and whilst in 
 some cases the ends of the vessels evidently do not advance 
 to the surface, where, on the contrary, they are wanting between 
 the most superficial endothelioid cells, the particularly rich 
 vascular network is in other cases of more recent origin so 
 
SALZER ON THE HEALING-IN OF FOREIGN BODIES. 139 
 
 superficial that in general there can be no certainty that there 
 is still another layer of cells above the vascular wall. 
 
 If we examine from the teleological standpoint the tissue 
 alterations at the end of the process of healing-in of foreign 
 bodies, we shall find that the organism in general strives firmly 
 to encompass the foreign object in order not to give it room 
 to have wearing-away or eroding effects. This will not occur 
 in the case of relatively heavy, very pointed or sharp foreign 
 bodies, or under all circumstances, though the weight may be 
 never so slight, in the case of perfectly smooth foreign bodies, 
 as in this case there will be no absolute and persistent contact 
 between the object and the same portion of tissue. Again, 
 profuse exudation may, to a certain degree, in a movable organ 
 protect the tissue against the mechanical effects, as the foreign 
 body balloting in a large cyst cavity will, at least not con- 
 tinuously, prick, cut, or in general touch the same spot ; under 
 complete rest the amount of serum will be reduced to a 
 minimum. 
 
 Even the silk thread, which in the cutis or in the fatty tissue 
 in most cases heals-in in a small callosity, may be found in a 
 cyst in the neighbourhood of a pulsating blood-vessel or in the 
 muscles. In this case it is not the movement of the foreign 
 body, but the movement of the tissue itself which causes this 
 condition. On the other hand, the heavy leaden bullet, the 
 smooth-walled pointed needle, or other similar objects, which, 
 as a rule, are found lying in cysts, may be firmly impacted in 
 the bone, or in a similar, but little movable tissue, without any 
 kind of cyst-formation being perceivable. 
 
 Therapeutic deductions from these observations. 
 
 If we wish to draw practical conclusions from the preceding 
 observations, we may from the contemplation, especially of the 
 erosion caused by bullets and needles in cystic cavities, in 
 regard to the possibility of an erosion of blood-vessels or of 
 the intestines, be convinced of the necessity for extirpation 
 of these foreign bodies under all circumstances, even in the 
 absence of any kind of objective signs of irritation, — of course 
 only in regions of the body where this danger is imminent. 
 
 Apart from similar, so to say, defensive conclusions, however, 
 we ought to weigh in our mind whether we may not take 
 
140 SALZER ON THE HEALING-IN OF FOREIGN BODIES. 
 
 advantage of this kind of experience of healing-in of foreign 
 bodies for therapeutic purposes. 
 
 The successful experiments in the healing-in of foreign bodies 
 have been ever since the introduction of the antiseptic method, 
 and evidently only through this, on the increase, whilst formerly 
 foreign bodies were exclusively employed only as unfailing exciters 
 of suppuration (setons), or, at the most, in order to produce a 
 cicatricial canal (lead- wire in webbing of the fingers) . Now-a-day s 
 silk, catgut, decalcified bone, elastic ligatures, wire, steel nails, 
 jodoform gauze (Winiwarter), and even fluids, as blood and jodo- 
 form-glycerine and other substances, are employed for healing-in. 
 The healing-in of these substances has only partly in view 
 their persistent action as ligature, suture (Lister's silver-wire 
 suture of the patella), local irritation (ivory-pegs in the broken 
 ends of the bone), tampon, &c. The healing-in is here only 
 a more or less unpleasant necessity in order to bring about 
 in deep-seated injuries, in spite of the introduced foreign body, 
 a definite, complete union by first intention of the skin or soft 
 parts, and thus to shorten the duration of the cure. 
 
 The experience that heavy foreign bodies, leaden bullets, in 
 moving parts of the body, and in soft tissues, are found in cystic 
 spaces, in capsules of connective tissue, moreover, older and 
 personal observations on the mode of healing-in of smooth 
 (pointed, sharp-edged) pieces of glass, lead to the conviction 
 that by a similar process of healing-in, artificial cavities might 
 be produced which would be of great importance for securing 
 a cavity after resection in the joints, especially for the establish- 
 ment of artificial joints, and which, moreover, would probably 
 be of value in regions of the body in which, according to 
 experience, cicatricial traction is fraught with danger, as in 
 serous cavities, in articulations, in the sheath of tendons, and 
 in the meningeal space. For the latter especially the employ- 
 ment of glass-plates for the protection of the adherent brain- 
 cicatrices seems to be not a hopeless proceeding. 
 
 We have succeeded in producing in animals the wished-for 
 result of the formation of pseudo-arthroses. In man a similar 
 effect was attempted in a case of resection of the elbow ; several 
 layers of gutta-percha tissue were placed between the smoothly 
 sawn-off surfaces of the bones, with the view of preventing, by 
 the temporary insertion of a smooth foreign body, the primary 
 
SALZER ON THE HEALING-IN OF FOREIGN BODIES. 141 
 
 union of the wounds of the bones. When, however, after a 
 fortnight the foreign body was removed, the result appeared 
 by no means quite satisfactory. There was no osseous anchylosis, 
 but the mobility was slight. It would certainly be better to 
 permit a suitably-shaped larger glass piece to heal-in perfectly, 
 or, at least, to remove it after a longer lapse of time. Every 
 one who possesses practical experience will feel the desirability 
 of the improvement of our present methods for the establishment 
 of artificial articulations and the prevention of anchylosis. Did 
 not a past master in resection like Oilier report only last year 
 that he was obliged in one case to operate three times in the 
 elbow in order to obtain finally a movable joint ? 
 
 I recently tried to prevent, by insertion of gutta-percha in a 
 secondary suture of the tendons, the union between the tendinous 
 and cutaneous cicatrices, on the final results of which experiment 
 I shall report later on. The twice-repeated attempt to replace 
 the defect of the cranium and the dura mater by glass failed 
 in consequence of the animals experimented on (cats) having 
 soon after died of mange. These experiments will be repeated, 
 but their good result is already anticipated by the favourable 
 observations on tissue-alteration produced by glass in other 
 parts of the body, and, on the other hand, by the successful 
 healing-in of india-rubber plates in defects from trephining 
 (Lesser).* Successful trials have been instituted by Stern to 
 prevent adhesions in the abdominal cavity by means of collodium. 
 It is only questionable whether this kind of proceeding as regards 
 the peritoneal cavity will find practical advocates, as the un- 
 favourable results caused by the formation of adhesions after 
 laparotomy are in reality very exceptional. 
 
 Apart from the healing-in of glass in view of the formation 
 of cavities, this might certainly also be employed as an innocuous 
 material, especially ,in the form of glass-wool, for filling up 
 
 * Note by the Translator. — Dr. von Eisehberg, Lecturer, on Surgery at the Vienna 
 University, recently (May 28th, 1891) demonstrated before the Society of Physicians 
 of Vienna two oases in which defects of the cranial bones had been successfully 
 replaced by the healing-in of celluloid plates. In one of these, a case of caries, 
 the diseased bone was removed, and a plate was substituted with complete 
 success. In the second case there was a cicatrix and depression of the frontal 
 bone from the kick of a horse, which had caused epileptic fits. The cicatrix 
 of the bone was removed by trephining, and the defect remedied by the healing- 
 in of such a plate, with a technically perfect success, though there is no security 
 against the return of the fits. — D. J. v. L. 
 
142 SALZER ON THE HEALING-IN OF FOREIGN BODIES. 
 
 defects of bone ; e.g., after operations for necrosis, after the 
 removal of tuberculous foci, or as supports in the form of 
 round pieces of glass for filling up the spaces left by the removal 
 of the metatarsal or metacarpal bones. In animals the glass- 
 wool, employed as a substitute for the resected femoral condyle, 
 answered the purpose, a normally movable healthy knee-joint 
 having been produced. 
 
 For filling up cavities in bones Winiwarter employed jodoform- 
 gauze, and N. Senn decalcified bone-shavings; for a similar 
 purpose, as filling material, Schede used blood, and Billroth 
 employed jodoform-glycerine, both successfully — jodoform- 
 glycerine principally owing to its antiseptic action. On the 
 other hand, blood and other kinds of absorbable substances are, 
 of course, not to be used as supports for thin shells of bone, as 
 would be desirable in caries, e.g., of the calcaneum, and, of 
 course, also not as substitutes for the extirpated bone. Only 
 ivory has hitherto, as far as I know, been used for supports. 
 Professor Rose, of Berlin, showed me two years ago a patient in 
 whom the shaft of the tibia had been replaced by an ivory rod. 
 
 I have been led by manifold considerations to a future employ- 
 ment of glass in the form of glass-wool. 
 
 Porous, fibrous materials, silk, gauze, as a rule, heal-in by 
 being permeated by connective tissue, in such manner that they 
 finally grow into a more or less firm cicatrix. A similar result 
 was to be anticipated from the glass-wool. The production 
 of firm resistent tissue, i.e., cicatrices, is the aim of all the 
 so-called radical operations for hernia. I, therefore, two years 
 ago, introduced glass-wool into the aperture of a crural hernia, 
 in order to produce, by means of an inabsorbable material, 
 consisting of delicate fibres, a persistent cicatrix. 
 
 Seven years ago I tried Schwalbe's method of injecting alcohol 
 in inguinal hernia, in a greater number of cases, both in 
 Professor Billroth's clinic and in the out-door patient depart- 
 ment. The immediate results were very satisfactory ; callous 
 shrivelling of the hernial opening took place (never accompanied 
 by any unfavourable incidents), although the final result must 
 be considered as perfectly unsatisfactory, as the callosity and 
 the constriction of the hernial opening had in every case dis- 
 appeared in a few months, and the hernia, consequently, had 
 formed again. In two cases, afterwards, the production of 
 
SALZER ON THE HEALING-IN OF FOREIGN BODIES. 143 
 
 induration in the hernial opening was attempted by keeping 
 up, after the ligature of the hernial sac, granulation for many 
 weeks by the application of jodoform-gauze, a proceeding which 
 proved so successful that a very strong cicatrix actually formed, 
 which, after twelve months, had become so very delicate as to 
 permit the skin to be taken up in folds over the deeper layers. 
 
 As it is well known, in Czerny's method for the radical 
 operation for hernia, it is intended to produce a resistent ■ 
 cicatrix by burying the silk ligatures applied to the ring of 
 the inguinal canal. Professor Billroth, for this reason, always 
 employs for the sutures very thick silk threads, like those used 
 for the sutures of the fascia after laparotomy. I repeatedly 
 convinced myself that in these cases, although a very violent 
 inflammatory reaction had been set up, after a year or so no 
 continuous induration around the silk threads could be discovered, 
 at the utmost only small nodules. Although Czerny's operation 
 for the inguinal hernia may frequently have a radical effect, 
 the hernial sac having been tied and the hernial opening thus 
 having been directly closed up, on the other hand, in crural 
 hernia, the difficulty of sewing up the hernial opening suggests 
 the trial of another method. 
 
 I tried glass-wool in the following case (Clinical Case Booh 
 No. 147, of the year 1887) : M. S., a maid-servant, thirty years 
 of age, suffering for ten years from a crural hernia at the left 
 side, produced by lifting a heavy weight. It was small at the 
 beginning, nor did it cause any inconvenience or pain until 
 six years ago it had suddenly reached the size of an apple, 
 when it became irreducible, and brought on symptoms of 
 incarceration. Herniotomy was performed at Professor von 
 Bumreicher's clinic, and the patient was discharged with a 
 truss three weeks after the operation. The truss broke (?) a 
 few hours after her discharge, and the hernia reappeared on 
 the same day in its former size (?). Notwithstanding her 
 hard work, however, the patient felt no kind of inconvenience 
 from the progressive enlargement of the hernial tumour until 
 on the 2nd of May, 1887, the hernia suddenly assumed the size 
 of a child's head, and repeated vomiting and obstruction of the 
 bowels took place. These symptoms, however, soon ceased. 
 The patient, owing to the size of the hernial tumour, decided 
 to submit to the radical treatment. 
 
144 SALZER ON THE HEALING-IN OF FOEEIGN BODIES. 
 
 Condition of the patient: A middle-sized, thin, delicate woman. 
 In front, at the apex of the lungs, sharp, rough vesicular 
 respiratory sounds ; otherwise, nothing abnormal in the internal 
 organs. In the left crural region a soft elastic tumour of the 
 size of a child's head, giving on percussion a tympanitic sound. 
 The integument above it, showing numerous lineae albicantes 
 from former pregnancies, is so thin as to permit the intestinal 
 coils to be distinctly felt. The reposition of the hernial contents 
 was easily effected. The hernial opening, formed by a hard 
 ring, admits three fingers. 
 
 On May 17th, 1887, the radical operation for hernia was 
 performed under anaesthesia. After the reposition of the hernia, 
 the now emptied hernial sac was excised by eliptical incisions. 
 On opening the hernial sac, which had been freely exposed 
 during the operation, an adherent omental band was tied and 
 divided by means of the thermo-cautery. The neck of the 
 hernial sac was secured by a kind of purse-string suture, and 
 the hernial sac separated and divided by Paquelin's cautery. The 
 remainder of the hernial sac was stitched to the hernial ring, 
 plugged with jodoform-gauze, and the greater part of the 
 cutaneous wound united by interrupted silk sutures ; jodoform- 
 gauze, carbolic-gauze dressing. Four days after, the dressing, 
 which had been soiled by the menstrual secretion, was removed. 
 The strips of jodoform-gauze were pulled out from the wound, 
 and replaced by sterilised glass-wool, which was done that it 
 might heal-in and produce a solid closure of the hernial opening. 
 On changing the dressing on June 1st, the suture line was 
 so firmly united that the stitches could be removed ; the as 
 yet ununited portion of the wound was granulating. The 
 glass-wool healed-in most successfully ; its protruding fibres 
 were removed. 
 
 The patient left her bed with a truss (with a concave pad), 
 on June 15th, and the wound was completely cicatrised on June 
 27th, when the patient was discharged. 
 
 She died of tuberculosis, in the General Hospital at Wiener 
 Neustadt, on September 22nd, 1888. 
 
 Regarding an examination at a shorter period after the operation 
 as premature, I intended to summon the patient to Vienna after 
 twelve months, but, to my regret, I could not find her residence, 
 and was subsequently informed of her death by the provincial 
 
SALZER ON THE HEALING-IN OF FOREIGN BODIES. 145 
 
 authorities. Neither the medical officers of the Hospital at 
 Wiener Nemtadi, nor the patient's own relations, knew of the 
 existence of a hernia. I therefore mention this case merely as 
 an instance of an attempt to employ glass-wool for the radical 
 cure of a relapsing, exceptionally large crural hernia, without, 
 however, being able to report positively as to the final result. 
 
 Thiem, acting on the suggestion of Gluck, recently allowed a 
 bundle of catgut to heal-in in the opening of an inguinal hernia, 
 endeavouring thus to bring about the formation of induration in 
 the hernial opening, viz., to effect the radical cure of the hernia. 
 Probably the secondary pathological tissue-formation, the resistant 
 cicatrix, will also disappear at the same time with the absorption 
 of this tampon, as we have seen take place after injecting 
 alcohol. And Thiem actually reports that half a year after his 
 first, the oldest, radical operation, the cicatrix was apparently 
 considerably thinner.* 
 
 The pieces of fresh bone employed for filling-in the defects in 
 bones cannot be regarded as carrying out the views of MacEwen 
 and Adamkiewicz. 
 
 By the use of absorbable tampons, as in hsematoma, the firm 
 union of the surrounding tissue may be prevented, and on the 
 other hand the reactive alteration of the soft parts of the organised 
 infiltrate may be transient. 
 
 It may, however, appear hazardous to enclose larger and heavy 
 foreign bodies in the organism, on account of the danger of 
 subsequent suppuration. Billroth, twenty years ago, directed 
 particular attention to the frequent formation of abscesses around 
 bullets, which had long lodged without any reaction, or healed-in. 
 The late setting in of suppuration in these traumatic cases may, 
 
 * The absorbable tampon has been more frequently proposed in recent times. 
 Besides the older suggestion of Gluck, to use catgut, the Americans especi- 
 ally have invented various methods, viz., N. Serm, decalcified discs of bone 
 hardened in alcohol, and Dr. Halstead at the New Hospital at Baltimore, demon- 
 strated to me in the course of this year a material for tampons, consisting of 
 delicate threads prepared from the submucous membrane of the pig, and likewise 
 sterilised in alcohol. I have convinced myself of the absorption of this material 
 within two months and a half, in the abdominal cavity of a rabbit, without 
 causing any perceptible reaction. But I have not yet had an opportunity of 
 employing it, notwithstanding the very rich material of the clinic. 
 
 In England for arresting haemorrhage in uranoplastic operations, and in 
 bleeding from the descending palatine artery, in the canal of the bone, carbo- 
 lised or sublimated wax is employed, which is plugged into the canal, where 
 it may heal-in. But this method of arresting haemorrhage may be dispensed with. 
 
146 SALZER ON THE HEALING-IN OF FOREIGN BODIES. 
 
 apart from other possibilities, in most instances be explained on 
 the supposition that splintered, rough bullets, or pieces of metal, 
 by energetic movements of the injured individual, subsequently 
 cause haemorrhage in the surrounding tissue, especially if they 
 had reached the surface of the body, in consequence of frequent 
 injuries. Again, suppuration may be induced in these haematomas 
 by cocci temporarily circulating in the blood. It seems to me 
 unquestionable that the physical condition of the enclosed foreign 
 body is therefore of the greatest importance, though Bementiew, 
 in contradiction to Billroth, doubts it. A rounded piece of glass 
 will, in the above sense, be less fraught with danger than a 
 splintered leaden bullet. Moreover, by the excision after many 
 months of the foreign body, introduced for the purpose of 
 forming a cyst, we ought not to sacrifice the result aimed at, 
 as French authors have pointed out, as regards large hematomas, 
 that a pathological tissue-cavity may persist notwithstanding 
 the disappearance of the effused blood in the course of time. 
 
 Albeit the expectations as to the suitableness of glass above 
 described may not be realised in every respect, still the accurate 
 description of the results arrived at by the healing-in of foreign 
 bodies may encourage to successful experiments. 
 
 The review of the anatomical observations on chemically 
 indifferent, not readily soluble, heavy foreign bodies, shows that 
 (1) if of but slight weight and circumference, and in perfect rest, 
 they will readily heaUin in cicatricial tissue, provided they are 
 porous, fibrous, or rough ; they, therefore, may be suitable for the 
 production of indurations. 
 
 (2) foreign bodies of moderate weight and more compact con- 
 sistence, if smooth-walled, heal-in into capsules of delicate connective 
 tissue; if the surface be porous and rough, the capsule will be 
 denser, the cicatrix firmer ; these Knds of foreign bodies may, 
 
 ■ therefore, serve as suitable supports in soft pa/rts or in bone. 
 
 (3) High specific weight, presenting everywhere a smooth surface, 
 sharp edges or points, cure conditions of a foreign body which 
 render probable its healing-in in capsules of connective tissue 
 containing fluids ; the more so, if the injured part be not at rest. 
 Such foreign bodies may prove particularly suitable for the pre- 
 vention of adhesions in wounded parts, and likewise for the 
 formation of pseudo-arthrosis. 
 
 Vienna, December, 1889. 
 
SALZEK ON THE HEALING-IN OF FOREIGN BODIES. 147 
 
 LITERATURE. 
 
 E. Albert : Zur Hiatologie der Synovialhaute. — Sitzungsberichte der k. k. 
 
 Akademie der Wissenschaften, 64. 
 Arnold : Anatomiache Beitrage zur Lehre von den Sehuaawunden. Heidelberg, 
 
 1873. 
 A. Bardeleben : Beferate iiber allgemeine Chirurgie in Virchow-Hirsch'a Jahres- 
 
 berichten der gesammten Mediein. — Lehrbuch der Chirurgie, 1874. 
 E. v. Bergmann : Die Lehre Ton den Kopfverletzungen. Stuttgart, 1880. 
 Th. Billroth : Ueber die relative Seltenheit der Kugeleinheilung. Wiener med. 
 
 Wochenschrift, 1870, Nr. 49. 
 Th. Billroth tind A. von Winiwarter : Die allgemeine chirurgische Pathologie 
 
 und Therapie, 14. Auflage, Berlin, 1889. 
 P. Boll: Unterauchungen ilber den Bau und die Entwioklung der Gewebe. 
 
 Arohiv fur mikr. Anatomic, vii. pp. 301, 325. 
 Bresohet : Des corps etrangers place's sous la peau, &c. — Dictionnaire de sciences 
 
 medicales. Paris, 1813. VII. 65—69. 
 Cortese : Schusswunde im Gehirn. Referirt im Centralblatt fUr medic. Wissen- 
 schaften, 1871. 
 Th. v. Dembowski: Ueber die Ursachen der peritonealen Adhasionen nach 
 
 chirurgiachen Eingriffen. Langenbeck'a Archiv, xxxvii. 
 Dementiew: Die Einheilung von Fremdkfirpern in Knochen und Gelenken' 
 
 Deutsche Zeitschrift fur Chir., xvi. 
 H. Demme : Allgemeine Chirurgie der Kriegswunden. Wiirzburg, 1863. 
 A. Doran : On certain foreign bodies embedded in the tiaauea without producing 
 
 inflammatory symptoms. — St. Bartholomew Hoapital Reports. London, 1876. 
 
 XDZ. 
 v. Dumreicher : Ueber fremde KSrper. Allg. Wiener med. Zeitung, 1866, p. 52. 
 Fabriciua von Hilden : Wundarznay, uberaetzt von Greiffen. Frankfurt a. 
 
 M., 1652. 
 G. Fiacher: Die Wunden dea Herzens und des Herzbeutels. Langenbeck'a 
 
 Archiv, ix. 
 H. Fischer : Handbuch der Kriegschirurgie. Stuttgart, 1882. 
 Gluck: Ueber reaorbirbare antiseptiache Tamponade. Deutsche mediein. 
 
 Wochenschrift, 1888, Nr. 39. 
 P. Grawitz : Beitrag zur Aetiologie der Eiterung. Virchow's Archiv, 116. 
 P. Grawitz und W. de Bary : Ueber die Uraaohen der subcutanen Entzundung 
 
 und Eiterung. Virchow's Archiv, 108. 
 K. Guasenbauer : Die traumatiachen Verletzungen. Stuttgart, 1880. 
 M. Hager : Die fremden Ebrper im Menaohen. 8° Wien, 1844. 
 Haidenhain : Ueber die Verfettung fremder Korper in der Bauchhohle. Breslau, 
 
 1872. 
 H. Hallwachs : Ueber Einheilung von organischem Materiale unter antiseptischen 
 
 Cautelen. Langenbeck's Archiv, xxiv. 
 Hartmann : Ueber die durch den Gebrauch der Hollensteinlosung kiinstlich 
 
 dargestellten Lymphgefassanhange, Saftcanalchen und scheinbaren Epithelien. 
 
 Archiv fur Anat. u. Phyaiologie, 1864. 
 Heineke: Anatomic und Pathologie der Sehnenacheiden und Schleimbeutel. 
 
 Erlangen, 1868. 
 W. Hie : Ueber das Verhalten dea salpetersauren Silberoxydes, &c. Virchow'a 
 
 Archiv, 20. 
 
148 SALZER ON THE HEALING-IN OF FOREIGN BODIES. 
 
 Hueter : Klinik der Gelenkskrankheiten, 1876, 1. 
 
 M. Huppert: Fremde Korper im Gehirn. Wagner's Archiv fur Heilkunde. 
 Leipzig, 1875, p. 9.— Eine Nadel im lebenden Herzen. Archiv der Heilkunde, 
 1878, p. 517. 
 
 Hutin : Kugel im Wirbelcanal. Gaz. m<5d. do Paris, 1849, p. 765. 
 
 H. Kiimmel: Ueber eine neue Verbandmethode, &o. Langenbeok's Archiv, 
 xxviii. 
 
 U. Kronlein : Klinischer Bericht. Langenbeok's Archiv, xxi. Suppl. 
 
 Landzert : Zur Histologie der Synovialhaut. Centralblatt fUr medioin. Wissen- 
 sehaften, 1867, Nr. 24. 
 
 Leber : Ueber die Wirkung der EremdkBrper im Innern des Auges. Inter- 
 national Medical Congress, London, 1881 (Erganzung des Anfsatzes, 1882). 
 
 L. v. Lesser : Ueber das Verhalten des Catgut im Organismus und iiber Hetero- 
 plastik. Virchow's Arohiv, 95. 
 
 E. Marohand : Ueber die Bildungsweise von Riesenzellen ran FremdkSrper und 
 den Einfluss des Jodoform hierauf. Virchow's Archiv, 93. 
 
 J. Maslowski : Extirpation beider Ovarien mit einem kurzen Berichte Uber die 
 Geschichte der Ovariotomie in Russland. Langenbeck's Archiv, 1868, ix. 
 p. 527. 
 
 N. Naegeli: Ueber den Einfluss der Pilze auf die Bildung von Riesenzellen. 
 Iuaug. Dissertation. Leipzig, 1885. 
 
 A. Rosenberger : Ueber Einheilen unter antiseptischen Cautelen, &c. Langen- 
 beck's Archiv, xxv. 
 
 E. Scheuerlen : Die Entstehung und Erzeugung der Eiterung durch chemische 
 Reizmittel. Langenbeck's Archiv, f . kl. Ch. 32, p. 500. — Weitere Untersuchungen 
 tiber die Entstehung der Eiterung. Langenbeck's Arohiv, 36, p. 929. 
 
 N. Semi : On the healing of aseptic bone cavities by implantation of antiseptic 
 
 decalcified bone. 1889. 
 Simon (Darmstadt) : Ueber das Einheilen von Gewehrkugeln, 1853, Prager 
 
 Vierteljahresschrift, i. 170. 
 0. Spiegelberg und W. Waldeyer: Untersuchungen iiber das Verhalten abge- 
 
 schniirter Gewebspartien in der Bauchhohle, &c. Virchow's Archiv, 44. 
 H. Stern: Ueber pseudomembranBse Verwachsungen bei intraperitonealen 
 
 Wunden. Beitrige zur klinischen Chirurgie, iv. 3 Heft. 
 C. Thiem : Ueber aseptische resorbirbare Tamponade. Langenbeck's Archiv, 
 
 xxxix. 
 H. Tillmanns : Zur Histologie der Synovialmembranen. Langenbeck's Archiv, 
 
 six. — Experimentelle und anatomische Untersuchungen uber Wunden der 
 
 Leber und Niere. Virchow's Archiv, 78. 
 L. Waldenburg : Ueber Structur und Ursprung wurmhaltiger Cysten. Vir- 
 chow's Archiv, 24. 
 G. Wegner : Chirurgische Bemerkungen Uber die Peritonealhohle, mit beson- 
 
 derer Beriicksichtigung der Ovariotomie. Langenbeck's Archiv, xx. 
 
 C. Weigert : Ueber Metschnikofl's Theorie der tnberoulb'sen Riesenzellen. 
 
 Portschritte der Medicin, 1888. 
 Weiss (Padua) : Ueber die Bildung und Bedentung von Riesenzellen und iiber 
 
 epithelahnliche Zellen, welche urn Fremdkorper im Organismus sich bilden. 
 
 Virchow's Archiv, 68. 
 G. T. Weiss: De la tolerance des tissus pour les corps strangers, 4°. Paris, 
 
 1880. 
 
SALZER ON THE HEALING-IN OF FOREIGN BODIES. 149 
 
 EXPLANATION OF THE PLATES. 
 
 Plate 1., figure 1 (to page 124, case 5).— Section through the innermost layers 
 of a cyst formed around a glass splinter, silver-staining on the surface. 
 Vertical section in A through the superficial cellular layer; in B hori- 
 zontal section ; in C the subjacent vascular fibrous tissue-layer not reached 
 by the silver staining. 
 
 (Seichert: Ocular 3, objective 8, X 500.) 
 
 Plate II., figure 2 (to page 125). — Vertical section through the connective tissue 
 canal around a steel needle. Internally, numerous large cells with an ex- 
 tremely scanty, delicately fibrillated interstitial substance, vascular connective 
 tissue beneath ; externally, many layers of scantily vascularised, concentric- 
 ally arranged fibrons tissue, in which large quantities of brown pigment are. 
 imbedded. 
 
 (Reichert : Ocular 1, objective 1, X 20.) 
 Figure 3. — The internal layers of the former preparation (fig. 2). 
 
 (Reichert: Ocular 3, objective 5, X 170.) 
 Figure i (to page 132, case 16). — Glass-wool healed-in in the muscles of a rabbit';. 
 Section through the interior of the glass-wool pellet, showing glass-fibres, a ■ 
 rich vascular network, large cells and scanty fibrous tissue; reddish-brown 
 pigment in the large cells as well as on the glass fibres. 
 (Reichert : Ocular 3, objective 5, X 170.) 
 Figure 5 (to page 125, case 6). — Vertical section of the inner layers of a capsule 
 of connective tissue around a glass splinter, of more recent origin than that ■ 
 seen in fig. 1. 
 
 (Reichert: Ocular 3, objective 5, X 170.) 
 
 Plate III. shows representations of case 9 (pages 127 and 128). 
 
 Figure 6. — The hand of the patient. The skin over the cyst between the ball 
 of the thumb and the palmar aspect of the hand is divided in order to show 
 the smooth external wall of the cyst. 
 
 Figure 7. — The cyst hardened in alcohol, natural size ; its interior wall has been." 
 cut away in order to show the inner surface. 
 
 Figure 8. — The piece of lead, natural size. 
 
 Figure 9. — A diagonal section through the innermost layers of the cyst-wall. 
 Above the structureless innermost layer ; downwards large uni- and multi- 
 nucleated cells, the interstitial tissue of which is faintly stained with silver. 
 (The horizontal section of the uppermost cellular stratum of this layer is 
 represented in fig. 10.) In the drawing below, vascular irregular fibrous 
 tissue is shown, whilst the numerous layers of concentrically arranged con- 
 nective tissue externally to the former are not represented. 
 (Reichert : Ocular 1, objective 8, X 330.) 
 
rSalzer on the healing in oF Foreign bodies. 
 
 Plate I. 
 
 A. 
 
 B 
 
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 ^ 
 
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 (9), 
 
 ^j€L\j( 
 
 
 
 
 
 
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 St^"*^ 
 
 *■*&■ v. 
 s^W 8 ■ 
 
 ' ■ «.'■?■ r, ■ --is.. „-*.-. . ^ 
 
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 9^S 
 
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 c^ 
 
 ■ *?< 
 
 ■2-:' 1/^ 
 
 
 %./. 
 
 
 
 
 Verlag von Alfred Holder k.u.k.Hof-u.Uniwsrsitats-Buehhandler in Wien. 
 
FSalzer on the healing in oF Foreign bodies. 
 
 Plate II. 
 
 Fia. 2 
 
 Fuj 3. 
 
 
 Fig. 5. 
 
 Verlag von Alfred Holder kAi.k.HoF-u.Unirarsifits-BuehhBndler in Wien. 
 
DIABETES MELLITUS. 
 
 Dr. B. HOFMEISTER, 
 
 Primararzt, Carlsbad. 
 
F.Salzer. on the healing in oF Foreign bodies. 
 
 Plate III 
 
 '*/> 
 
 
 ^«v«SS 
 
 t^. s. 
 
 Verlag von Alfred Holder k.u.k.Hof-u.Unireraitats-Buehhandler in Wien. 
 
DIABETES MELLITUS. 
 
 It is not. so very long since all those pathological conditions in 
 which polyuria was accompanied by the excretion of sugar in 
 sufficient quantity as to he recognised chemically or by polarisa- 
 tion were known under the name of Diabetes mellitus, to 
 distinguish them from Diabetes insipidus, the leading symp- 
 tom of which is also Polyuria. 
 
 During the early decades of our century, Diabetes mellitus 
 was still considered an extremely rare disease, and many a phy- 
 sician had become grey in his practice without having observed 
 a single case. It was only when Claude Bernard, by means of 
 his now famous " Diabetic Puncture," brought the disease within 
 the pale of experimental research, and also owing to the improved 
 chemical methods of discovering grape sugar becoming more 
 generally known, that observations upon the excretion of sugar 
 accumulated to an unexpected extent. 
 
 It was found that not only a number of different operations 
 (e.g., puncture of medulla oblongata, lesion of the lowest cervical 
 and first dorsal ganglion on both sides, section of the medulla 
 oblongata, and of the cceliac plexus, &c), but also injuries (such 
 as injuries to the skull, concussion of the spine, contusion of the 
 liver, and other abdominal organs, &c.) are capable of producing 
 a discharge of sugar into the urine. Further, it was noticed in 
 a number of diseases that sugar appeared at times, e.g., before 
 or after an attack of epilepsy, in ague, cerebral disease, sciatica, 
 gout, angina pectoris, neurasthenia, &c, and also during con- 
 valescence after exhausting and febrile diseases. 
 
 Agam, in poisoning by curare, chloral, sulphuric acid, arsenic, 
 alcohol, carbon, monoxide, &c, in fact, after simple injection of 
 salt water into the blood, sugar is excreted. Lastly, in pregnant 
 and suckling women, in persons who consume an extraordinary 
 amount of sugar and starchy foods, a small amount of sugar 
 appears at times in the urine. Hence it was customary to speak 
 of a Diabetes artificialis, D. symptomaticus, D. traumaticus, D. 
 
154 HOFMEISTER ON DIABETES MELLITUS. 
 
 alimentaris, D. intoxicativus, &c. But it soon appeared that all 
 these forms of sugar excretion, whether artificially produced or 
 connected with other pathological conditions, have nothing what- 
 ever to do with Diabetes proper — a disease sui generis — and 
 differ from it essentially in three important points. 
 
 I. They are merely transient, they disappear after the 
 cessation of the disease that produced them, or shortly after the 
 healing of the injury that caused them. 
 
 II. They are quite independent of the nature of the food 
 administered. 
 
 III. They cause none of that profound disturbance of the 
 general health which as a rule accompanies true Diabetes. 
 
 In order to distinguish these forms of sugar excretion from 
 Diabetes mellitus, the name Glycosuria is now generally ap- 
 plied to them. 
 
 Under Diabetesmellitus (sugar-flux) , or Diabetes gravis, we 
 understand therefore only that slowly developing afebrile chronic 
 disease in which grape sugar, varying in quantity with 
 the amount of carbo-hydrates ingested, is constantly 
 present in the urine, and in which the general health suffers 
 very seriously from the nutritive disturbances in the various 
 organs. of the body. Although my object is only to deal with 
 this disease, and ignore all other forms of Glycosuria, I must 
 mention two forms of sugar excretion experimentally produced. 
 These have recently been discovered, are in many respects of 
 great interest, and possibly destined to throw a ray of light into 
 the obscure pathology of the disease. The first form was com- 
 municated by Mering of Strassburg, three years ago. Mering 
 gave a dog after seven days' fasting, whose body consisted simply 
 of albumen and fat, and was therefore free from carbo-hydrates, 
 a daily dose of 20 grams (about 300 grs.) of Phloridzin, a 
 glucoside contained in the cortex of the root of the apple-tree. 
 As a result a large amount of sugar, from 10 to 19 per cent., was 
 excreted. This form of glycosuria differs from other artificially 
 produced forms, as also from Diabetes verus, in that the normal 
 quantity of sugar in the blood is diminished. But as the con- 
 tinuous administration of Phloridzin does not produce a perma- 
 nent excretion of sugar, it must be regarded as a form of 
 glycosuria rather than diabetes. However, this experiment 
 would seem to prove the assertion of later investigators (notably 
 
HOFMEISTER ON DIABETES MELLITUS. 155 
 
 Seegen) tliat sugar is, or at any rate may be, formed out of 
 albumen and fat. 
 
 The second form results from experiments by Mering and 
 Minkovski, who excised the pancreas. Immediately after 
 the operation sugar appeared in the urine and persisted for weeks 
 until the death of the animal. Simultaneously, dther leading 
 features of Diabetes are said to have been present: Polyuria, 
 Polydipsia, insatiable hunger, and great emaciation in spite of 
 abundant nutriment. Glycogen disappeared from the organs, 
 sugar was largely increased in the blood, and a considerable 
 quantity of acetone found in the urine. These experimenters 
 state that the solar ganglion was not injured during the opera- 
 tion, and therefore the Diabetes is to be considered as a pure 
 consequence of the arrest of the functions of the pancreas. They 
 look upon the secretion of the Pancreas — Trypsin — as the most 
 powerful diastatic ferment, and that which alone effects the 
 conversion of maltose, formed during digestion from carbo- 
 hydrates, into grape sugar. Their statements are confirmed by 
 Lepine, who performed antiseptically excision of the pancreas 
 without injuring the Solar Plexus, and obtained similar results. 
 Further researches in this direction should throw some light 
 upon the still obscure data of Diabetes. 
 
 HISTORY AND THEORIES OF DIABETES MELLITUS. 
 
 The various theories of Diabetes are intimately connected with 
 the history of the disease. Although it is beyond doubt that 
 physicians of old were well aware that in rare cases sweet- 
 tasting urine was excreted, yet this phenomenon was not con- 
 sidered worthy of any particular attention, and indeed it is still 
 uncertain whether the ancients meant to indicate " sugar-flux " 
 by diabetes or simple polyuria, now termed Diabetes insipidus. 
 To Thomas Willis, an Englishman, is due the merit of being the 
 first (in 1674) to describe and recognise Diabetes as a disease, 
 with sugar in the urine as its chief symptom. Still, it was not 
 until 100 years later, after Dobson and Pole had succeeded in 
 demonstrating directly sugar in the urine, and John Hollo had 
 confirmed the injurious influence of starchy foods in the course 
 of Diabetes, thus directing treatment into the right path, that 
 physicians really began to take a closer interest in this disease. 
 Its symptoms were thoroughly noted, and valuable experience in 
 
156 HOFMEISTER ON DIABETES MELLITOS. 
 
 astiology as well as in therapeusis was gained, but the pathology 
 of the disease remained veiled in complete obscurity. All the 
 theories that have been advanced from that time to the middle of 
 the present century rested on purely hypothetical grounds. 
 Every one of them started from the supposition that carbo-hydrates 
 of the food were abnormally speedily converted into sugar by 
 means of some ferment (Bouchardat), or that the normal quantity 
 of sugar was less rapidly consumed owing to diminished alkal- 
 inity of the blood (Mialhe). Not only was there then, as now, 
 no anatomical ground for these theories, but also no scientific 
 basis in the absence of information concerning the origin and 
 consumption of sugar in the animal economy. The enumeration 
 of all these theories, and of the names of their propounders, has 
 but a historic value, and cannot be given within the limits of 
 this article. The researches of Claude Bernard are the first to 
 bear a scientific character, as set forth in his fundamental treatises : 
 "The Formation of Sugar in the Liver, 1848"; "Glycogen found 
 in the Liver, 1850 " ; "Artificial Excretion of Sugar by means of 
 puncture of the floor of the fourth ventricle, 1854." 
 
 C. Schmidt and Thompson had already demonstrated that 
 sugar is a normal constituent of the blood, though this was not 
 definitely ascertained to be grape sugar till 1875 by Abeles. 
 At the outset an exact determination of the amount in the blood 
 was surrounded with difficulties. No chemical method was 
 known by which sugar could be isolated from the blood owing to 
 the albumens having a disturbing influence in the reduction of 
 the copper (Fehling's test). It was not until Schmidt-Miilheim 
 published their method of eliminating the albumens that the 
 statements of workers came into general agreement. The 
 physiological amount of sugar present in the blood varies from 
 •08^- - 15 per cent. These variations are due to the quality and 
 quantity of food, to the time when taken, to the condition of the 
 muscles, and to other factors of which we know but little. 
 
 The most important questions then to solve, were, I. Where 
 is the seat of the manufacture of sugar ? II. What are its ante- 
 cedents ? III. What nervous influence is at work during the 
 formation of sugar ? Claude Bernard answered these questions 
 categorically. He maintained that the liver is exclusively 
 the seat of the formation of sugar, as is proved, first, 
 because the liver itself contains sugar ; second, because the blood 
 
HOFMEISTER ON DIABETES MELLITUS. 157 
 
 in the hepatic veins contains more sugar than that in the portal 
 system, which scarcely shows a trace. Bernard, therefore, inferred 
 that sugar formed in the hepatic cells, passed along the hepatic 
 veins into the inferior vena cava to the right side of the heart, 
 and reached the pulmonary circulation, where the greater portion 
 underwent oxidation, and the rest was distributed through the 
 arterial system. 
 
 The second question, What is the source of the sugar ? Claude 
 Bernard believed he had solved completely, when he and Hensen 
 succeeded in discovering a substance in the liver which bore a 
 strong relationship to sugar. He regarded this substance, which 
 he found only in the liver and nowhere else, as the material 
 from which the liver prepares the sugar by means of an 
 (animal) ferment, likewise present, and he consequently termed it 
 glycogen (sugar-generating). Finally, he believed he had 
 demonstrated by "the diabetic puncture " that the nerve centre 
 regulating the formation of sugar has its site in the floor of the 
 fourth ventricle. 
 
 These statements of Bernard, which prevailed for several years, 
 were much shaken by control experiments, and by the more 
 extensive researches of succeeding physiologists. In the first 
 place the English physician Pavy, in 1860, confirmed the state- 
 ment of Bernard, that sugar could be obtained from the liver of 
 an animal recently killed, which increased in quantity the later 
 the examination was deferred after the death of the animal. On 
 the other hand he soon arrived at the conviction that the blood 
 of the hepatic veins did not differ as regards the amount of sugar 
 from that of other blood-vessels. Further, that the slight increase 
 of sugar in the liver was due to the struggles of the animal 
 during the removal of the organ, which was forthwith placed in 
 boiling water so as to destroy any ferment or post-mortem 
 influence. 
 
 Still Pavy believed that, although under physiological 
 conditions exceedingly slight traces of sugar circulate in the 
 blood, the excess in the blood of diabetics originates in the 
 liver. In fact, by stating that the circulating blood contains a 
 ferment capable of converting hepatic glycogen into sugar, he 
 thus placed his views in accordance with the correct theory of 
 diabetes. Through nerve-influence the efficacy of the ferment 
 is inhibited ; should this influence fail, as after death, or become 
 
158 HOFMEISTER ON DIABETES MELLITUS. 
 
 weakened, as in diabetes, a continuous formation of sugar takes 
 place in the liver, the blood becomes surcharged with sugar, and 
 the urine carries off the excess. Shortly after this, glycogen 
 was found to exist in other organs of the body besides the liver, 
 in the lungs, spleen, kidneys, cartilage, leucocytes, and particu- 
 larly in all striated muscular tissue. In consequence Pavy's 
 theory was modified to include all the above-mentioned organs 
 as sources of origin for the formation of sugar. This modified 
 theory held sway for nearly twenty years : under physiological 
 conditions, no formation of sugar in the liver and only 
 slight traces in the blood, in diabetes all glycogen- 
 bearing organs become sources of sugar. 
 
 In 1875 Seegen, who up till then accepted the above theory, 
 discovered that sugar formed from glycogen with the help of 
 animal ferments (saliva, pancreatic juice) is not grape sugar, 
 but one of less reducing power (Maltose, Ptyalose, Pancreatose, 
 &c), whereas hepatic sugar undoubtedly is grape sugar. Thence 
 he concluded that hepatic sugar could not be formed through a 
 ferment ; he denied, moreover, the existence of the latter, as he 
 had not succeeded in isolating it. Furthermore, he found by 
 his experiments, without exception, "4 to "5 per cent, of sugar 
 in the liver. This amount increases considerably after death, 
 owing to the continued activity of the hepatic tissue, but the 
 amount of glycogen actually remains the same. Seegen 
 consequently deduces that hepatic sugar is not formed from 
 glycogen but from some other material. 
 
 As a result Seegen restored to a great extent the doctrine of 
 Bernard as regards the seat of sugar formation in the liver, and 
 confirmed it through the repetition of the fundamental experiment 
 of Bernard, i.e., comparing the blood from the distal with that 
 from the proximal hepatic venous system, by means of a very 
 perfect technical method. He was able to withdraw blood 
 direct from the hepatic veins (not from the vena cava, where 
 the blood is already mixed), and prove that without exception 
 the quantity of sugar contained was nearly double that in the 
 portal blood — on the average '230 per cent, in hepatic blood, as 
 against -119 per cent, in portal blood. Having at the same 
 time determined how much blood flows during a given time 
 through the portal system into the liver, he calculated the 
 quantity of sugar formed during 24 hours in the liver, and 
 
HOFMEISTEK ON DIABETES MELLITUS. 159 
 
 conveyed thence to the tissues. In an animal weighing 
 40 kilograms, he found the surprising amount of 433 grms. of 
 sugar. In order to keep so great an amount of sugar in 
 equilibrium in the body a very large proportion of carbo-hydrate 
 material must be used up for the formation of sugar, and con- 
 sequently this must be one of the most important 
 functions of metabolism. 
 
 As regards the use of sugar in the body, Seegen believes that 
 it serves for the generation of heat and energy. As to what is 
 the origin of the sugar, as already mentioned, he takes up quite 
 an opposite standpoint to Bernard. He maintains sugar is not 
 formed in the liver from glycogen, but from albumen (Pep ton) 
 and fat, although no one has succeeded in obtaining it chemi- 
 cally from albuminous substances outside the body. He supports 
 his statements by a series of feeding experiments on animals. 
 His conclusions are — 
 
 First. That the carbo-hydrates of the food are converted in 
 the liver into glycogen, which is thence carried by the blood- 
 stream to the muscles, lungs, cartilages, &c, and deposited 
 there. 
 
 Second. That glycogen is in all probability the material for 
 fat formation, and is stored up in the body with that object. 
 In fasting, glycogen disappears, and, indirectly owing to failure 
 of supply, so does the fat. 
 
 When the hepatic cells lose their function of converting 
 sugar, already formed in the alimentary canal during digestion 
 and brought by the portal system to the liver, into glycogen, 
 so that it reaches the general circulation, and is, to a certain 
 extent, excreted in the urine, then the slight form of Diabetes 
 is said to exist, in which, namely, the excretion of sugar ceases 
 as soon as the sugar-forming element in the nutriment is cur- 
 tailed. 
 
 If, however, the organism fails to consume the sugar 
 normally formed from albumen and fat (in the process of meta- 
 bolism), the grave form of Diabetes arises, where sugar is 
 excreted even with an exclusive meat diet. The setiological 
 factor in both forms lies in the nervous system. 
 
 Seegen's theory, which, to a large extent, rests on speculation, 
 has experienced several attacks, and the disputes concerning it 
 are still far from settled. The blood of Diabetics has been 
 
160 HOFMEISTER ON DIABETES MELLITUS. 
 
 examined by Seegen and others, who found it contains nearly 
 twice the normal quantity of sugar. According to the severity 
 of the case, the condition of the patient at the time, and the hour 
 of the examination, the amount varies from - 15 to '33 per cent. 
 (Frerichs "28 to "43 per cent.). The other organs contain ap- 
 proximately as much, Liver, Brain, Lungs, Spleen, &c, besides 
 lymph secretions, pathological exudations, and the cerebrospinal 
 fluid. Owing to its extreme diffusibility, whenever there is an 
 excess of sugar in the blood, it makes its way into the various 
 tissues and fluids of the body. 
 
 Naturally, in connection with this fact, the question arises, Is 
 the abnormal quantity of sugar due to an increased produc- 
 tion, or the result of the non-consumption of the normal 
 amount, part of which is stored up and part excreted in the 
 urine ? 
 
 This is still a matter of controversy, and will remain so as 
 long as obscurity reigns over the cause and intimate processes of 
 sugar formation, and over the part played by sugar in the animal 
 economy. The fact remains that the circulating blood is only 
 capable of harbouring normally a certain quantity, should this 
 be exceeded, the excess is carried off by the kidneys. In grave 
 cases of Diabetes, sugar taken as nutriment appears in the 
 shortest interval in 30 minutes in the urine, and is entirely 
 excreted within 1J to 2 hours. 
 
 Passing over a number of ingeniously worked out hypotheses 
 which have not withstood the test of time, I should like to 
 draw attention to the views of two distinguished men upon 
 increased sugar formation — Senator, of Berlin; and Eb- 
 stein, of Gottingen. 
 
 Senator shows, that without excluding other possibilities, 
 in the majority of cases two causal conditions are the most pro- 
 bable. 
 
 I. The sugar in the food passes into the lacteals and portal 
 system* in a larger than normal quantity, either be- 
 cause its conversion into lactic acid is prevented, or because it is 
 too speedily absorbed. 
 
 II. The portal circulation is accelerated abnormally; 
 hence, on the one hand, more sugar reaches the liver and passes 
 
 * According to latest researches the greater part reaches the portal rein, and 
 only a small fraction the lacteals. 
 
HOFMEISTER ON DIABETES MELLITUS. 161 
 
 on into the systemic circulation without undergoing change into 
 glycogen, on the other hand hepatic glycogen is more rapidly 
 converted into sugar and carried away. The first source depends 
 on the nervous system, the second on a local disturbance in the 
 intestinal and hepatic circulation. Consequently, Senator dis- 
 tinguishes a neurogenic, a gastro-enterogenic and a 
 hepatogenic form of Diabetes. 
 
 Ebstein's theory refers the origin of the disease to the proto- 
 plasm of the cells of most of the organs and tissues. 
 In Diabetics, through abnormal nerve-influence, protoplasm has 
 lost the property of producing as much carbonic acid from 
 an equal quantity of carbohydrates as in healthy persons. 
 Ebstein says he has found by experiment that the action of 
 diastatic ferments is impeded by the presence of a certain amount 
 of carbonic acid. In diabetics, owing to deficiency of car- 
 bonic acid, carbohydrate material, especially glycogen, is 
 insufficiently protected from their influence, and is conse- 
 quently converted prematurely and in relatively large quantities, 
 into easily diffusible carbohydrates, particularly sugar, and this 
 passing from the tissues into the circulation is rapidly excreted 
 with the urine. Furthermore, owing to diminished oxidation 
 and formation of carbonic acid, the need of oxygen in diabetes 
 is decreased, and consequently the bodily temperature is lowered.* 
 On this view Ebstein proposes to administer carbonic acid con- 
 stantly, viz., by means of injection into the rectum. How far 
 this theory is justified depends on further researches in this 
 direction. I will now return to those investigators who regard 
 a diminished consumption rather than an increased forma- 
 tion of sugar as the proximate cause of diabetes, such as the 
 majority of recent writers, and also Mering and Minkovski, 
 whose reiy important experiments were mentioned at the outset. 
 
 Should it be settled beyond cavil that after excision of the 
 pancreas either with or without injury to the coeliac plexus, not 
 only artificial glycosuria occurs constantly, with perhaps a small 
 quantity of sugar and of transient duration, but also genuine 
 diabetes with its cardinal symptoms : persistent excretion of 
 sugar in great abundance, intolerance of carbohydrates, progres- 
 sive proteid waste and abnormal amount. of sugar in the blood, 
 
 * Voit and Pettenkofer have found by direct analysis that diabetics consume 
 less oxygen and exhale less carbonic acid and watery vapour. 
 
 M 
 
162 HOFMEISTER ON DIABETES MELLITUS. 
 
 then considerable strides will have been made towards the know- 
 ledge of a disease still enshrouded in mystery. 
 
 Here we should also mention a very recent experiment, where, 
 after removal of the cceliac plexus, 'acetonuria is a constant 
 . result. 
 
 PATHOLOGICAL ANATOMY AND AETIOLOGY. 
 
 Pathological Anatomy, as a rule the safest guide in the search 
 for the seat and origin of disease, leaves us completely in the 
 lurch. Tissue changes are from time to time noted, amidst 
 numerous negative results, in one or other organ, but constant 
 changes -in any .particular organ have never been observed. 
 Neither in the central nervous system (brain, spinal cord) to which 
 the origin of diabetes has been ascribed, nor in the liver, which 
 we suppose to be the seat of sugar formation, nor in the pancreas, 
 where atrophy, fatty degeneration, or cancerous infiltration occur 
 relatively frequently, nor in the kidneys, nor even in the organs 
 of respiration or circulation — in short, nowhere are we in a 
 position to show a constant abnormal condition. 
 
 Iti would, therefore, be idle to enumerate all the anatomical 
 changes which occur now and again in diabetes,, as it is not 
 known with certainty whether these in isolated cases bear a 
 causal relation to the disease or are simply coincidences; 
 
 The glycogenic degeneration of Henle's loops in the kidney 
 discovered by Bhrlich, which had previously been described. by 
 Ebstein as necrosis of the epithelium, is most worthy of note. 
 At any rate, this change is one of the most frequent. 
 : The only method of determining post mortem the diagnosis of 
 diabetes -would be by examination of the blood, which, if it 
 contained twice the normal amount of sugar, would prove; the 
 case to be one of diabetes. Unfortunately, up to the present 
 comparative analyses of the blood before and after death, in 
 diabetics, as also in healthy individuals, have been made, too 
 seldom to render conclusions trustworthy. Where the patho- 
 logical anatomy of a disease is not yet known, its astiology as 
 a rule- is not in a much better plight. It has not yet been settled 
 definitely, whether diabetes can arise suddenly from; any given 
 cause. In the majority of cases, it develops very gradually, 
 and .as,. vibe., beginning is n °t accompanied by any pain- or 
 striking malaise, the exact starting point of the .affection is 
 rarely ascertainable. Where the patient is inclined to date.the , 
 
HOFMEISTER ON DIABETES MELLITUS. 163 
 
 commencement of his illness from some external cause, e.g., severe 
 shock to the nerves, thorough drenching, serious injury, &c, it 
 is much more likely that the disease, already in existence, has 
 suddenly been aggravated, just as we observe in the more 
 advanced stages of diabetes that a severe shock may suddenly 
 increase the amount of sugar by 2 or 3 per cent. Nevertheless 
 there are always circumstances and conditions, as manifold 
 experience shows, which can be regarded as predisposing 
 factors. 
 
 1. Hereditary Influence. The disease may pass from 
 either parent to one, two, or all the children, sometimes from the 
 grand and 'great-grand parents. Frequently it is confined only 
 to a side branch. Such families generally show a neurotic taint. 
 As regards age, it was thought formerly that children were not 
 attacked, now the number of observations of diabetes in children 
 of tender age increases with every year. Even extreme old age 
 does not enjoy immunity. The greatest number of cases occur 
 between the ages of 30 and 50. The age of diabetics has always 
 an important bearing on prognosis (v. prognosis). 
 
 As regards sex, it is remarkable that twice as many males 
 as females become diabetic ; in children the reverse is said to 
 hold good (3 to 5). The reason for this is unknown, as also 
 whether Diabetes mellitus is infective. No bacillus diabeticus; 
 or its toxic products, has been hitherto discovered. At the same 
 time, it is worth mentioning that, of 200 cases carefully noted 
 by myself during the last ten years, I find four married couples, 
 in which the wife first suffered from diabetes, and the husband 
 from 3 to 5 years later. In all four cases no common cause 
 could be ascertained.* 
 
 2. Psychical disturbances, not so often the transient, e.g., 
 fright, anger, vexation, as the long persistent and deep-seated, e.g., 
 grief, care, bereavement, melancholy, &c. It is easily under- 
 stood that when there is hereditary predisposition to neurosis, 
 the tendency is all the stronger. All conditions arising from 
 nervous exhaustion, e.g., neurasthenia, sluggish convalescence 
 after serious illness, mental strain, especially connected with the 
 emotions, sexual excess, &c, must be also included. 
 
 3. Obesity arising from luxurious living and sedentary habits 
 is decidedly a predisposing factor. The percentage of obese 
 
 * De Bove and Leoorcbi also mention some cases of conjugal diabetes. 
 
164 HOFMEISTER ON DIABETES MELLITUS. 
 
 individuals in diabetes is so considerable that Hoffmann in fact 
 divides diabetics into two groups, according to their symptoms. 
 
 I. The neurogenous or accidental, due to injuries of, and 
 changes in the nerves ; this group is chiefly seen in males. 
 Furunculosis is almost never present, albuminuria and cataract 
 exceedingly rare, and the pancreas is at times atrophied. With 
 the cure of the nerve affection, diabetes disappears (slight form). 
 
 II.' Diabetes of the obese, or constitutional diabetes, 
 more frequent in women, tendency to furunculosis and cataract, 
 often complicated by gout and nephritis (severe form). 
 
 4. Injuries, especially after concussion of the brain, spinal 
 cord, and abdominal ganglia, with subsequent glycosuria and 
 Diabetes insipidus, particularly if for any reason the latter 
 persist for a long period. 
 
 5. Irritation of the female generative organs, accord- 
 ing to Imlach, may produce diabetes. He published a striking 
 case where, after removal of some extensive uterine adhesion, 
 diabetes of long standing completely disappeared (Glycosuria ?) 
 For this reason diabetes is stated to occur not only less frequently 
 and in a milder form after the climacteric period, but also to run 
 a more favourable course. 
 
 6. The excessive use of saccharine and amylaceous 
 food-stuffs may be a predisposing factor. I had opportunities 
 of convincing myself of this in some cases in which no other 
 detrimental factor could possibly be adduced. 
 
 Lastly, diabetes has been noticed to occur in a number of 
 different diseases : in ague, epilepsy, alcoholism, syphilis, &c. 
 But it would indeed be an error to conclude that post hoc propter 
 hoc. If the above diseases, which are widespread enough in all 
 classes of patients, did render the ground suitable for the pro- 
 duction of diabetes, this would certainly figure in their statistics, 
 but in spite of the remarkable increase of diabetes during the 
 last decades we know that this is not the case. It is very difficult 
 to determine whether the cause of this increase is due to the 
 simultaneous increase in insanity; or to the more burdensome 
 conditions of modern life involving trouble, care, mental and 
 bodily strain, or else to circumstances which still elude observa- 
 tion. Carefully compiled statistics, embracing towns and villages 
 in various countries, would best help us to a conclusion on these 
 points ; but so far these are wanting. 
 
HOFMEISTER ON DIABETES MELLITUS. 165 
 
 SYMPTOMS. 
 
 The first disturbance of Health the patient experiences is 
 generally so trifling, and connected^with so little discomfort, that 
 it is either ignored by him or misinterpreted by his physician. 
 Even should the latter consider it necessary to examine the 
 urine, the small quantity of sugar that may be present is easily 
 overlooked in employing the usual tests (Heller's or Trommer's). 
 It is only when symptoms persist in spite of treatment for months, 
 when fresh ones arise, and troublesome or even painful sensations 
 appear, in which case the urine contains a larger quantity of 
 sugar, that the " surprising discovery" is made. In but a very 
 few cases is the physician led deductively to the probable 
 diagnosis of " diabetes." It is only when careful examination 
 of the urine is made as much a matter of course even in trivial 
 ailments, as feeling the pulse, inspection of the tongue, and pal- 
 pation of the painful region, or even as frequently as thorough 
 percussion and auscultation, that it will be possible to escape 
 from committing, I might almost say, the " blunder " of not 
 recognising the disease early. It must, however, be admitted 
 that the early phenomena are masked in many respects. Patients- 
 complain either of digestive troubles, loss of appetite, heartburn, 
 nausea, vomiting, irregular action of the bowels, colic, &c, or of 
 rheumatism in this or that muscular region, or still more fre- 
 quently of nerve disturbances — hebetude, headache, indifferent 
 sleep, heat of palms and of soles, depression, no desire for work,. 
 &c. When, however, the excretion of sugar is appreciably 
 increased, then all those changes which aroused suspicion of" 
 diabetes, acquire greater prominence. They result partly from 
 the nature of the disease itself, i.e., from the incapacity of the 
 body to assimilate the sugar that is taken in the nutriment, partly 
 also from the direct overloading of the blood with sugar, or from 
 its excretion through the urinary system. As the various sources 
 of the symptoms do not permit of easy separation, and there are 
 also " mixed " symptoms, it will be more desirable to discuss 
 them in the order of their frequency and diagnostic value, and 
 then to consider the condition of the various organs. But it 
 must again be emphasised, that there is no fixed rule in this 
 respect, and that exceptions are met with in every case. In fact, 
 with the exception of sugar in the urine, there is scarcely a 
 
166 HOFMEISTER ON DIABETES MELLITUS. 
 
 symptom the presence of which can be reckoned upon with 
 certainty, or which may not be so faintly indicated as to be of 
 doubtful diagnostic value. Again, many & symptom which as a 
 rule is met with at the very outset of diabetes may appear late 
 or not at all. On the other hand, many late symptoms may be 
 observed quite early, which, however, goes to show that we are 
 rarely in a position to determine precisely the commencement of 
 the disease. 
 
 1. Polyuria. The patient's attention is generally drawn to 
 this symptom by being awaked through distension of the bladder 
 once or twice during the night, and by the chamber vessel being 
 fuller than usual. The painlessness of micturition and the 
 uninterrupted stream on the one hand, the striking abundance 
 of the voided urine on the other, show that the distension does 
 not depend upon any local cause, such as incontinence or stone. 
 The quantity may be five or six times the normal amount (1500 
 to 2000 ccm. (50 to 68 oz.) in 24 hours). In diabetes more 
 fluid is got rid of by the urine than is taken into the body in the 
 form of liquid, and is only slightly less than the total amount of 
 water taken, including that contained in the solids. Enuresis 
 nocturnais a frequent observation in children with polyuria, 
 and therefore in such cases the urine should be always examined. 
 Polyuria generally bears a direct relation to the amount of sugar 
 in the urine ; exceptions are, however, occasionally met with. 
 
 2. Polydipsia and Polyphagia are among the initial 
 symptoms ; beginning with dryness of the mouth, excessive thirst 
 is gradually developed. Patients are continually drinking 
 without being able to quench thirst. Appetite increases till it 
 becomes at times bulimia, and especially when meat diet is taken 
 to the exclusion of all starchy foods, many patients cease to know 
 what satiety means. In a minority the opposite condition holds 
 good, viz., complete abeyance of appetite. Even polydipsia 
 alone or together with polyuria may be absent in some cases. 
 Like appetite, the feeling of thirst may be lost (Diabetes 
 decipiens, according to P. Prank). 
 
 3. Emaciation. This is not so striking to the eye in many 
 cases of diabetes as in several other chronic affections, e.g., tuber- 
 culosis, carcinoma, dyspepsia gravis. Indeed many patients 
 retain their former healthy appearance even at the height of the 
 disease, but more or less decrease in weight is always observable. 
 
HOFMEISTER ON DIABETES MELLITUS. 167' 
 
 Emaciation 'progresses continually as long as a compensating 
 diet is not followed, or if the disease is not held in check. In 
 my ' experience, 1 this symptom is one of the earliest and most 
 constant. ■ I well remember a patient, " male, astat. 46, well 
 nourished,' whose case I very carefully observed. The only 
 symptom he complained of, was a small but continual decrease 
 in weight during' the previous two years. No catise for this loss 
 of flesh could be at all discovered. From time to time traces of 
 sugar were said to have been found in the urine, treatment there- 
 fore could only be of an expectant nature. As he was in good 
 circumstances, he retired from business, lived free from anxiety, 
 and was only, concerned about attaining his former weight. He 
 consulted several leading physicians in Germany, no diagnosis 
 could be made. Suddenly, after a very severe mental shock, 
 thirst and polyuria appeared, and immediately the very first 
 examination of the urine showed 3" 5 per cent, of sugar. 
 
 4. Languor. In contrast to healthy persons, who only ■ feel 
 tired after heavy muscular exertion, the diabetic feels weakest 
 and most languid in the morning, even after an undisturbed 
 night's rest. ' In the course of the day, the languor may disappear, 
 but there' is a disinclination for the usual daily occupation, or ' 
 even for simple outdoor exercise. Slight muscular exertion tires 
 him sooner than formerly. These symptoms are complained of, 
 even at a period when there can be no question of emaciation or 
 muscidar atrophy. They are said by certain authors to depend 
 upon an accumulation of the so-called fatigue substances" (waste- 
 products : lactic acid, &c.) in the muscles owing to deficient 
 oxidation. However, they may preferably be referred to disturb- 
 ance of the regions supplied by the nerves of sensation of the 
 muscles similar to that affecting other nerve-territories, which so 
 frequently happens in diabetes. 
 
 All the remaining symptoms, of which a short description will 
 be given, belong more or less to the later and last stages of the 
 disease, and many of these may be regarded as sequelae rather 
 than manifestations of diabetes. 
 
 Once more emphasis must be laid upon the fact that, with the 
 exception of sugar in the urine after carbo-hydrates, ; there is no 
 single symptom which is constantly present. 
 
 As regards the symptoms presented by the alimentary 
 tract, those of the buccal cavity are most characteristic. The 
 
168 HOFMEISTER ON DIABETES MELLITUS. 
 
 mucous membrane throughout is generally dry, and the secretion 
 of all the glands is strongly acid (lactic acid?). The tongue is 
 frequently enlarged in breadth as well as in thickness, dry, 
 fissured at the sides, rough at the apex, and bright red. The 
 gums are spongy, discoloured, and tend to bleed; the teeth 
 carious and loosened; and the soft palate presents a white 
 appearance due to slight thrush. Leucoplakia of the tongue and 
 buccal mucous membrane is observed at times, and irregular 
 shrivelling of its papillee. 
 
 Other disturbances of digestion, as loss of appetite, nausea, 
 eructation, vomiting, constipation, or diarrhoea are as frequently 
 present as absent. From personal experience I cannot accept 
 the statement of many observers that digestive troubles are 
 scarcely ever absent in diabetes. 
 
 The skin suifers from several affections. As a rule it is cool 
 and dry to the touch, harsh, lax, and branny. In a few cases 
 there is a tendency to frequent and excessive perspiration, either 
 locally or universally. Pruritus (itching) may appear any- 
 where, but especially in those regions which are liable to come 
 in contact with the sugar-laden urine; thus in the male, the 
 praeputium and glans penis (often producing balanitis) ; in the 
 female, the vulva. Pruritus pudendi is so frequently present in 
 diabetes that it would be a grave error of omission in such cases 
 not to examine the urine. 
 
 Furunculosis (frequently recurring boils in various regions, 
 which heal with difficulty) has been observed in diabetes from 
 the very earliest times, and in fact it may precede the disease by 
 along interval. Carbuncle, however, is a much later affection, 
 and often indeed the immediate cause of death. 
 
 The temperature of the body is subnormal in most 
 diabetics ; it may sink 2° C. (3 - 6 P.) below normal, and in coma 
 diabeticorum actually as low as 80° C. (86° P.) in the axilla. 
 Hence patients feel cold even in summer and wrap themselves 
 up in warm clothes, as they learn by experience that their 
 condition becomes worse whenever they get a chill. It is still 
 uncertain what is the cause of the depression of temperature. 
 Some refer it to the non-consumption of sugar as a heat producer, 
 others to the copious cold drinks, to diminished intake of oxygen, 
 or lastly to a disturbance of the thermic centre. At any rate, 
 no constant relation exists between bodily temperature and 
 
HOFMEISTER ON DIABETES MELL1TUS. 169 
 
 amount of sugar excreted. The temperature rises only when 
 intercurrent febrile affections attack the patients. It is interest- 
 ing here to note that many fevers, presumably those that are 
 accompanied .by profound tissue changes, during their continua- 
 tion cause the sugar to disappear from the urine. 
 
 The great vulnerability of the skin and other organic 
 tissues is noteworthy. Wounds and ulcers heal exceeding slowly ; 
 the greater the amount of sugar, the greater the difficulty in 
 healing. In fact, there is a tendency for injuries to become 
 gangrenous, especially the toes, where a slight wound while 
 paring a corn is sufficient to produce progressive gangrene which 
 cannot always be checked. Moreover, gangrene makes its 
 appearance spontaneously in serious cases, in various regions. 
 Incised wounds rarely heal by first intention. Even scratch 
 marks on the skin, due to pruritus, heal slowly, and readily fester. 
 Hence the urine should be carefully examined every time before 
 resorting to the knife or cautery. Operations which are not very 
 pressing should be postponed until the last traces of sugar have 
 disappeared, and if an operation has been performed, the diet 
 should be most stringently regulated, until the wound has 
 completely healed. 
 
 As regards the organs of respiration we have already 
 mentioned that less oxygen is taken up and less carbonic acid 
 and watery vapour given off, than in healthy persons. To what 
 extent this weakened function in diabetes predisposes to lung 
 disease is not yet ascertained. It is remarkable that almost half 
 the number of patients become tubercular and die from phthisis, 
 and that intercurrent croupous pneumonia and gangrene of the 
 lungs are by no means so rare. If acetonemia is present, as 
 happens most frequently in threatening coma, the breath of the 
 patient becomes tainted with a peculiarly insipid, sour, fruity 
 odour (like must or decaying apples). This is characteristic of 
 diabetes, and is often so powerful as to diffuse itself in the room 
 in a very short time. 
 
 As regards the urinary and sexual organs, the nature of 
 the urine is the leading feature ; as this is of pathognomonic 
 importance it will be considered later on more fully. Impotence 
 in men is a very important symptom, on account of its frequently 
 being an early one. It varies from defective power of erection, 
 to complete extinction of sexual desire ; any change in the 
 
170 HOFMEISTER ON DIABETES MELLITUS. 
 
 testicles or their secretion has only rarely been noted. In 
 females, sterility and abortion frequently occur. Under 
 treatment, sexual power may return. It is but seldom that 
 increase of sexual power with erection and emission, has been 
 observed. 
 
 Albuminuria, that at times accompanies diabetes, is of no 
 serious import. It is not connected with any textural change in 
 the kidneys, for pus, blood, and casts are absent from the urine, 
 nor is it constant, often disappearing for some time. Finally, it 
 is of no importance as regards the loss of nitrogen the body 
 suffers from, as the percentage never exceeds -fa per cent., and 
 this waste of albumen is amply compensated for by the increased 
 meat diet. 
 
 Some regard albuminuria as a consequence of the exalted 
 function of the kidneys, which are generally found enlarged post 
 mortem, others as the result of swelling and fatty degeneration 
 of the renal epithelium. Naturally, albuminuria is important in 
 those exceptional cases of diabetes which are complicated by 
 granular contracted kidneys (Bright's disease). - ' 
 
 Changes in the organs of sense. Of these, the eye is 
 most frequently involved. Either visual power suffers^ 
 (amblyopia), or accommodation becomes weakened at an 
 earlier period than usual. Many patients even are compelled to 
 resort to correction lenses when they are between 80 and 40 
 years of age. Palsy of the sixth nerve (abducens, external 
 rectus) occurs very seldom, and still seldomer of the other ocular 
 muscles. Cataract is of most frequent occurrence, and one eye 
 usually loses its sight long before the other. From statistics of 
 a large number of cases compiled by various authors, the average 
 percentage of cataracts due to diabetes varies from 6 to 7 per 
 cent. The cataract which begins at the periphery of the lens 
 often remains stationary for a long period. With improvement 
 in the disease, i.e., disappearance of sugar, complete involution 
 of the cataract may actually take place and cloudy areae clear 
 up. Amblyopia and paresis of accommodation may likewise 
 improve. 
 
 Retinitis diabetica is not so frequent, but all the more 
 characteristic when present ; ophthalmoscopically it very much 
 resembles Retinitis albuminurica. It oftens happens that the 
 ophthalmic surgeon is the very first to have the urine tested for' 
 
HOFMEISTER ON DIABETES MELLITUS. 171 
 
 sugar, his suspicions being aroused by the results of his 
 examination. 
 
 Besides the eye, the gustatory nerve is liable to be affected. 
 A mawkish and sweet taste is constantly present, so that patients 
 either do not taste their food at all, or everything seems sweet- 
 ened. To many this even amounts to loathing, which is all the 
 stronger the longer they have been deprived of sugar. It is 
 remarkable that many diabetics without any gustatory affection, 
 who have discarded the use of sugar for some time, are not able 
 to enjoy anything sweet, and least of all saccharin offered as a 
 substitute. Griesinger reports some cases of dulness of 
 hearing in diabetes. Hitherto I have not observed a single 
 case, although I have noted here and there tinnitus aurium in 
 the absence of other signs of disease of the middle or internal 
 ear. 
 
 Condition of the nervous system. On account of the 
 almost positive ^etiological relationship between diabetes and 
 disease of the central nervous system, several forms of nerve 
 disturbance may be expected a priori. In fact there is probably 
 no single case in which one nervous symptom or another is not 
 prominent. Owing to their somewhat frequent occurrence, some 
 of these have already been described at length, e.g., impotence, 
 amblyopia, languor, &c. Next in importance is agrypnia, 
 which may exist to a very marked degree. I remember some 
 cases where, according to the statements of the patients and 
 their friends, for several years 2 hours sleep out of 24 was quite 
 sufficient for their requirements. Insomnia is very difficult to 
 surmount, even when every trace of sugar has disappeared from 
 the urine and the general condition improved. 
 
 Disturbances of common sensation are not infrequent. 
 Parassthesise, pins and needles, formication, sensation of 
 oppression at the joints, of heat, and of cold, in various regions. 
 Hypersesthesiae, or even severe neuralgia generally in the 
 course of the great sciatic nerve, in the occiput, or under the 
 well-known form of hemicrania, besides in various joints 
 as well as in internal organs, e.g., stomach, uterus, ovaries, 
 kidneys, &c. Their spontaneous and bilateral appearance, the 
 severity and long duration of the paroxysms, accompanied by the 
 rapid development of vaso-motor disturbances in the affected 
 regions, are characteristic of diabetic neuralgias. 
 
172 HOFMEISTEK ON DIABETES MELLITUS. 
 
 Motor disturbances, in the form of Pseudo-tabes, slight 
 ataxia, and diminished patellar reflexes, are rarely seen, paralysis 
 practically never, while cramp and clonic muscular twitching are 
 met with occasionally. (Coma diabeticorum must be 
 regarded as a nerve symptom. This, which usually forms the 
 tragic end of diabetes, will be depicted separately in dealing with 
 the course of the disease.) Changes in metabolic activity, 
 emaciation, diminished consumption of oxygen, and depression of 
 temperature, &c, have already been referred to. Other symp- 
 toms, of which mention is made in the literature of the subject, 
 may be dismissed on account of their rarity and transient 
 character. 
 
 DIAGNOSIS — EXAMINATION OF URINE. 
 
 The diagnosis of Diabetes mellitus can only be thoroughly and 
 satisfactorily established by demonstrating the presence of 
 a considerable physiological excess of grape sugar in 
 the urine. Without this proof, even in the presence of other 
 symptoms of diabetes, there is at most only room for suspicion. 
 For there are several conditions of ill-health accompanied by a 
 temporary excretion of sugar which must be distinguished 
 pathologically, prognostically, and therapeutically from true 
 diabetes, , and which we designate Glycosuria. Hence the 
 differential diagnosis must be sharply defined and the latter 
 positively excluded ; of course this cannot always be determined 
 after one or even several examinations. In fact it may require 
 weeks of careful observation before the physician can certify 
 that his patient is suffering from diabetes ; a hasty opinion has 
 often caused a good deal of distress. The consciousness of 
 suffering from an incurable disease produces a severe shock at 
 all times which must not be overlooked, and it must also be 
 borne in mind- that long persistent mental depression may 
 actually induce diabetes from glycosuria. (The essential 
 difference between the two has already been sufficiently set 
 forth, v. supra.) 
 
 Again, diabetes should not be excluded because a single 
 examination of the urine reveals a negative result, for by far the 
 great majority of cases (the slight form of diabetes) excrete no 
 sugar in the absence of carbo-hydrates and when the muscular 
 system is active. If we examine the urine after an interval of 
 some ten to twelve hours without food — for instance, that passed 
 
HOFMEISTER ON DIABETES MELLITUS. 173 
 
 on rising in the morning — only slight traces of sugar, or none 
 at all, may be discovered.; but an hour after breakfast (generally 
 white bread and sweetened coffee) it may disclose 4 to 5 per cent, 
 of sugar. 
 
 Therefore each examination should be made some 
 two or three hours after a full meal, which for purposes of 
 greater certainty should consist of well-sweetened and farinaceous 
 food. It should not be made after a long fatiguing journey or 
 after severe mental strain, for both these factors may temporarily 
 cause a marked increase in the amount of sugar, and thus lead 
 to an error in diagnosis. It is particularly difficult to decide 
 between accidental glycosuria and diabetes, when only a small 
 quantity of sugar is present (from - 5 to 1"5 per cent.), contrariwise, 
 it is quite easy when the amount exceeds 2 per cent. Urine 
 which contains more than 2 per cent, of grape sugar 
 can only be that of a diabetic patient. All the forms of 
 glycosuria — artificial, symptomatic, toxic, and traumatic — show 
 at most only slight traces of sugar. The single .exception is the 
 glycosuria produced by phloridzin, when an enormous quantity 
 of sugar (from 10 to 19 per cent.) may be excreted. 
 
 The question arises, whether those cases where only a very 
 small quantity ( - 1 to - 2 per cent.), or even a distinct though 
 inappreciable trace of sugar is found are to be regarded as 
 diabetic ? Many authors are decidedly of the opinion that such 
 traces should not be viewed as diabetes, but as symptomatic 
 glycosuria, accompanying some latent or as yet unrecognised 
 disease. I cannot subscribe to this view. . Several cases are 
 known to me — among others the one mentioned above — 
 where quite insignificant traces of sugar were accompanied by 
 serious symptoms peculiar to diabetes (emaciation, languor, 
 sleeplessness, &c.) , and where these troubles only yielded, or at 
 any rate improved, from the moment the patient was placed on 
 strict anti-diabetic diet. Every physician who has had oppor- 
 tunities of observing a large number of cases of diabetes, will 
 probably have come across some in which long persistent traces 
 of sugar left the diagnosis doubtful, but where a casual shock to 
 the nervous system has suddenly caused a considerable increase. 
 In my opinion even the slightest trace of sugar that can 
 be distinctly recognised should not be lightly considered, 
 but rather the case should be attentively watched for some 
 
174 HOFMEISTER ON DIABETES MELLITUS. 
 
 time, and the urine passed at different times during the 
 day examined at least twice a week. Although exact proof 
 of grape sugar in the urine can only he determined by 
 chemical examination, yet its physical characters afford several 
 grounds for inferring its presence. Chief among these is its 
 high specific gravity, for whereas normal urine has a sp.gr. 
 of 1015 to 1020, which when concentrated from diminished 
 imbibition of fluids may rise from 1024 to 1026, diabetic urine 
 may show a sp.gr. of 1045 and upwards. In many pathological 
 conditions, such as high fever, lead colic, acute Bright's disease, 
 &c, the urine is laden with uric acid, but the specific gravity is 
 never as high as that of diabetic urine. Where the urinometer, 
 which is usually first employed, shows a very high specific gravity, 
 strong suspicion of the presence of sugar is aroused. This 
 speedy and easy method of examination is not only of relatively 
 great value as a qualitative test, but, as we shall see later on, 
 may be used to estimate the quantity of sugar. The colour 
 often offers another mode of recognition, this is, from the pre- 
 sence of polyuria, pale yellow with a greenish tinge, and some- 
 times as clear as water. When such pale urine has also a high 
 specific gravity, there is no doubt about the presence of 
 sugar, for with the exception of uric acid there is no other 
 substance in urine able to raise it so much, and dilute urine 
 contains only little uric acid. As a rule it is clear; after long 
 standing acid fermentation readily takes place, and it becomes 
 cloudy owing to fermentation products. The reaction of diabetic 
 urine is almost without exception acid, and this persists for a 
 very long time in spite of the large amount of ammonia present, 
 and the constant use of alkalies. As is well known, normal urine 
 becomes alkaline very soon after the administration of alkaline 
 waters. The odour is peculiarly aromatic, smelling of hay, 
 and when fermentation begins, of sour wine. The taste is 
 distinctly sweet when a fair amount of sugar is present. White 
 spots (deposit of sugar, on the evaporation of urine) are not 
 unfrequently seen, when it is abundant, in the immediate 
 neighbourhood of the urethra, on the linen, and even inside the 
 chamber vessel. 
 
 The sugar excreted in diabetes is termed grape sugar, starch 
 sugar, glucose, or dextrose ; it is characterised by its solubility 
 in water and alcohol, by its property of undergoing fermentation, 
 
HOFMEISTER ON DIABETES MELLITUS. 175 
 
 and of turning the plane of polarised light to the right, and by 
 its power of reducing the salts of copper in alkaline solutions. 
 Other forms of sugar produced from glycogen by the action of 
 animal and so-called diastatic ferments, capable of isolation 
 (saliva, pancreatic juice), possess greater rotatory, but much 
 feebler reducing powers. Besides sugar the amount of urinary 
 solids is increased above the normal ; this is easily explained by 
 the increased proteid waste, as well as by the increased amount 
 of nitrogenous food generally consumed, even the excess of water 
 drunk is, sufficient to effect a greater elimination of urinary solids. 
 Uric acid is- constantly present, although apparently in smaller 
 quantity than normal. The important rdle the increase of 
 ammonia plays, as regards coma diabeticorum, will be more 
 fully explained in connection with the latter. 
 > The knowledge of the relation of other urinary constituents 
 (sulphuric and phosphoric acids, chlorine, and the alkaline earths, 
 &c.) in diabetes has more scientific than practical value. Of 
 abnormal elements calcium oxalate is fairly frequent, and 
 in such abundance that the microscopic field always shows a few 
 crystals easily recognised by the envelope pattern. Oxaluria is 
 therefore important, and its significance is heightened, as it not 
 infrequently precedes diabetes for some time, and may even 
 alternate with, the excretion of sugar. 
 
 Acetone and diacetic acid may be met with in the slighter 
 as iwell as in the graver forms of the disease, naturally more 
 often in the latter; they are, however, frequently absent in both. 
 Albumen, has already been mentioned; it is important to test 
 for this before commencing to examine for sugar, and if the 
 former be present it must be got rid of, so as not to interfere 
 with: the sugar tests. 
 
 Fungiand bacteria grow very soon in diabetic urine, 
 especially if kept standing in a warm place. For the sake of 
 completeness, allusion must be made to a recent communication 
 of Professor Miiller's, of Bonn, concerning an exceedingly rare 
 case of pneumaturia. Here acid fermentation had already 
 .commenced in the bladder, and the evolved gases — carbonic acid 
 and hydrogen— were voided with the urine, making a loud re- 
 port. It sometimes happens that if fermenting urine be allowed 
 to stand in a warm place no sugar can be detected after a time, 
 owing to complete fermentation. 
 
176 HOFMEISTER ON DIABETES MELLITIS. 
 
 CHEMICAL EXAMINATION OF URINE. 
 
 Examination must be preceded by removal of any albumen 
 that may be present. This is best effected by boiling. Nor- 
 mally acid urine is heated in a test-tube up to boiling point ; if 
 it be neutral or alkaline a few drops of dilute acetic acid must 
 first be added. The coagulated albumen is removed by filtering, 
 and the filtrate is then ready for carrying out the following 
 qualitative tests. 
 
 1. Heller's— also called Moore's— test. From 5 to 10 ccm. 
 (m. 81 to in 162) of urine are poured into a test-tube and one- 
 third its volume of concentrated solution of caustic potash fliq. 
 potassse B.P.) is added. The two are well shaken together, and 
 half is poured into another test-tube and then boiled. If sugar 
 is present it becomes distinctly darker than the unboiled half. 
 This change is the result of the action of caustic potash on sugar 
 during boiling ; the depth of colour varies as the amount of sugar 
 present, and when it is abundant, the fluid has the colour of 
 Jamaica rum. However, as almost every specimen of urine after 
 addition of caiistic potash and subjected to heat becomes brown, 
 this should only be used as a preliminary or control test. 
 
 2. Trommer's test. 5 to 10 ccm. of urine are placed in a 
 test-tube along with one-third its volume of caustic potash or 
 soda ; after thorough agitation a few drops of a solution of cupric 
 sulphate (cupric sulphate 1 part, distilled water 10 parts) are 
 added. The pale blue flocculent precipitate of hydrated oxide 
 of copper dissolves on shaking if sugar be present in any quan- 
 tity. The copper sulphate solution is added drop by drop, the 
 mixture shaken, until a trace of cloudiness persists in spite of 
 repeated agitation. Heat is now applied to the upper layer 
 until boiling is nearly reached, when a yellow or red precipitate 
 of hydrated suboxide of copper appears, formed by the reducing 
 action of the sugar upon the cupric oxide in an alkaline solution. 
 
 3. Fekling's solution test. This rests upon the same principle 
 as the preceding test, but the necessary reagents (an alkaline 
 solution of sal seignette [sodium potassio-tartrate] and a dilute 
 solution of cupric sulphate) are freshly mixed every time. The 
 resulting fluid — the so-called Fehling's solution — has a beautiful 
 azure blue colour, in , which precipitation of the suboxide of 
 copper is prevented by the presence of tartaric acid. In order 
 
HOFMEISTER ON DIABETES MELLITUS. 177 
 
 to ensure success of the test the following conditions must be 
 observed. 
 
 (1) The solution must be well diluted;- though of course it must 
 retain its alkaline reaction. ; • 
 
 (2) The dilute solution must be heated before the addition of 
 urine, in order to be quite certain that the fluid itself has not 
 become capable of reducing the copper' owing to decomposition 
 of the tartaric acid. 
 
 If to the heated solution a few drops of urine are added, a 
 precipitate similar to that in Trommer'stest appears if sugar is 
 present. • 
 
 The two last-mentioned tests are the most frequently used as 
 comparatively convenient and trustworthy when there is a fair 
 amount of sugar. The following are severer tests to determine 
 traces of sugar. : 
 
 4. Bottger's test. From 5 to 10 ccm. of urine are placed 
 in a test-tube together with a quarter its volume of concentrated 
 caustic potash. A small piece, about the size of two pins' heads, 
 of magisterium bismuthi (basic nitrate of bismuth) is dropped 
 into the test-tube and the whole heated for some minutes up to 
 100° C. In the presence of a large quantity of sugar, metallic 
 bismuth is thrown down, recognised by the sudden turbidity of 
 the fluid and the collection of a black precipitate at the bottom 
 of the test-tube; if there is only a small quantity of sugar 
 present, the precipitate is of a grey colour (suboxide of bis- 
 muth). In the presence of albumen this otherwise reliable test 
 may undergo serious modifications, and on this account is seldom 
 used in practice. 
 
 5. But for demonstrating traces of sugar, Seegen's test is to 
 be preferred. The urine is passed through a covered filter 
 made of thoroughly purified blood charcoal. The filtrate 
 contains a small portion of the sugar arid other constituents of 
 the urine ; all the colouring matter and the bulk of the sugar 
 are retained in the charcoal. This is well washed with water, 
 which dissolves out the , sugar ; the first washing consists almost 
 of a pure solution of sugar, which, even when the quantity is 
 quite small, gives indubitable results with Trommer's or Fehling's 
 test. The second and third washings often yield distinct re- 
 actions ; hence Seegen's blood-charcoal test is specially suited 
 to the detection of mere traces of sugar, and its use should not 
 
 N 
 
178 HOFMEISTER OS DIABETES MELLITUS. 
 
 be omitted when the results of the previous mentioned ones are 
 at all doubtful. 
 
 6. Fisher- Jaksch's test. 50 ccm. of urine are decomposed by 2 
 grams (about 30 grs.) of phenylhydrazin hydrochlorate 
 and 8 grams (about 45 grs.) of sodium acetate and heated for 
 some thirty minutes in a water bath. On cooling, which may 
 be accelerated by immersion in cold water, a yellow precipitate 
 appears easily recognisable when there is a large quantity of 
 sugar present. Microscopically, it consists of yellow needles 
 and spheroids, and from its combination with the sugar is termed 
 by B. Fisher Phenylglycosazine. The applicability of this very 
 favourite test has lately been questioned, owing to the discovery 
 made in Plosz's laboratory, that besides sugar, another constituent 
 of normal urine — probably a compound of glycuronic acid — also 
 has the property of forming with phenylhydrazin, a yellow sub- 
 stance consisting of acicular crystals. 
 
 For the purposes of exact diagnosis a quantitative deter- 
 mination of the sugar must be based upon all the urine passed 
 in 24 hours, as it is not so much a question of the percentage of 
 sugar in any given specimen, as of the quantity excreted with 
 the urine during the whole period. For instance, should the urine 
 show 4 per cent, of sugar, and the amount passed in 24 hours be 
 5 litres (about 169J fl. oz.), then 4 x 50 = 200 grms. (about 3,000 
 grs.) of sugar are excreted ; again, if the amount of sugar be 7 
 per cent, and the urine passed 1\ litres (about 84J fl. oz.), then 
 70x2£ = 175 grms. (about 2,630 grs.) are excreted daily. 
 
 The following are the methods of estimating the sugar in the 
 urine quantitatively : — 
 
 1. By employment of Fehling's solution. — The prin- 
 ciple is the same as that of Trommer's test, namely, the reduc- 
 tion of the oxide of copper to the suboxide by grape sugar in an 
 alkaline medium. As five parts by weight of grape sugar free 
 from water reduce 34-639 parts by weight of pure copper sul- 
 phate, the two solutions are made in the following proportions : — 
 
 I. 34 - 639 grms. of pure copper sulphate are dissolved in water 
 by heat, and then diluted to form 500 ccm. 
 
 II. 173 grms. of sal seignette (sodium potassio-tartrate) are 
 dissolved in 350 grms. of pure caustic soda (sp. gr. 1-14) and 
 diluted with water to form 500 ccm. 
 
 Both solutions must be kept in well-stoppered bottles. Before. 
 
HOFMEISTER ON DIABETES MELLITUS. 179 
 
 each examination, equal portions are mixed together (forming 
 Fehling's solution) and heated ; no suboxide of copper should 
 be thrown down. 
 
 Five com. of each solution are taken, diluted fourfold with 
 water, and placed in a porcelain evaporating dish. Then a 
 portion of the whole urine passed in 24 hours is diluted ten 
 times with water (1 urine to 9 water) and poured into a burette. 
 The contents of the evaporating dish are brought to the boiling 
 point, the dilute urine in the burette is added, drop by drop, 
 and the gradual decoloration of the blue liquid by the suboxide 
 of copper watched for. Oausse proposes by adding 4 ccm. of a 
 5 per cent, solution of ferro-cyanide, diluted with 10 ccm. of 
 water to the 10 ccm. of Fehling's solution, in order to render 
 the suboxide of copper colourless, so that the disappearance 
 of the blue colour may be all the more striking. The moment 
 the solution is completely decolorised (ascertained by tilting 
 the evaporating dish) reduction is complete, and the amount of 
 diluted urine used is read off from the burette. 
 
 Calculation. — Since 10 ccm. of Fehling's solution contains 
 •34639 grms. of copper sulphate, - 05 grms. of grape sugar are 
 required for its complete reduction. For instance, if 12 ccm. of 
 dilute urine have been used, then this amount represents - 05 grms. 
 of grape sugar, and as the urine was tenfold diluted, l - 2 ccm. 
 of urine contain - 05 grm. of grape sugar. By proportion, 
 1-2 : - 05 : : 100 : x, x = 4 - 16 grms. in 100 ccm. of urine. If 
 3-5 litres of urine are passed in 24 hours, the total amount of 
 sugar excreted per diem would be 4; 16 x 35 = 145 - 6 grms. 
 (about 2,185 grs.). Errors of this method : the presence of 
 other substances capable of reducing the copper (uric acid, 
 creatinin, glycuronic acid). 
 
 2. The amount determined by fermentation. — This 
 depends upon the fact that sugar is split up into alcohol and 
 carbonic acid by yeast fermentation. An apparatus consisting 
 of two small bulbs connected by a glass tube is used. From 
 10 to 20 ccm. of urine is placed in one bulb, together with yeast 
 and a little tartaric acid, the other is half filled with concentrated 
 sulphuric acid. The whole is then weighed and set aside for 
 some days in a temperature of 20° to 25° C. When the evolu- 
 tion of carbonic acid is complete, which is recognised by the 
 clearing up of the cloudy fluid, the bulb may be gently heated in 
 
180 HOFMEISTEE ON DIABETES MELLITUS. 
 
 order to get rid of any remaining carbonic acid ; any water of 
 evaporation is retained by the sulphuric acid. The apparatus is 
 then weighed, and the loss of weight corresponds to the amount 
 of carbonic acid evolved — 48 - 89 parts by weight of carbonic acid 
 being equivalent to 100 parts by weight of grape sugar* 
 
 Errors of this method : formation of a small amount of 
 glycerine and succinic acid from the sugar, and possible evolu- 
 tion of carbonic acid from the yeast. 
 
 Both these methods, which occupy a considerable amount of 
 time and require great precaution so as to yield satisfactory 
 results, are only suited for scientific research. In general prac- 
 tice, the polarisation method meets all the requirements of easy 
 and rapid execution and sufficient exactness. 
 
 3. Determination by the polariscope. — This method 
 depends upon the property of grape sugar deflecting the plane of 
 polarised light to the right. The production of polarised light 
 by means of a Nicol's prism, is common to every apparatus. A 
 6econd one is so placed that every possible rotation is com- 
 pensated and the so-called normal state is created. Any changes 
 from the normal state caused by a saccharine solution of a certain 
 thickness (usually one or two dcm.) are counterbalanced by a 
 corresponding rotation of the second prism. When the apparatus 
 is set, the index points to or the scale, and when rotated, the 
 index moves (up to 50 or over). 
 
 The usual instruments are : — 
 
 1. Mitcherlich's older apparatus. — Normal state : field 
 of vision, in homogeneous light, dark, the ray, in daylight 
 purple- violet. Change: field of vision, at first bright, then 
 coloured. Calculation, p = ^^, where p = percentage, 
 a = the indicated rotation, a = specific rotatory power of grape 
 sugar, 1 = length of tube. 
 
 2. Soleil-Ventzke's saccharimeter. — Normal state : field 
 of vision, both halves coloured the same. Change : dissimilar 
 colouration. Calculation : each division of the scale indicated 
 1 per cent., i.e., 1 gram of sugar in 100 ccm. of fluid. 
 
 3. Laurent's half-shadow apparatus. — Normal state: 
 field of vision, both halves equally bright. Change : unequally 
 bright. Calculation : each degree = 1 per cent, of sugar, if 
 1 = 1 dcm. 
 
 4. Wild-Savart's Polaristrobometer.— Normal state: 
 
HOFMEISTER ON DIABETES MELLITUS. 181 
 
 field of vision, uniformly bright. Change : appearance of parallel 
 black streaks. Each division = - 2 per cent, of sugar. 
 
 Errors of the polarisation method : presence of other sub- 
 stances, dextro- or laevo-rotatory, difficulty of fixation of the 
 instrument with dark-coloured urine (if this is decolourised by 
 acetate of lead, as is usually the case, a considerable quantity of 
 sugar is lost in the process). 
 
 In the absence of other means, the urinometer may be used as 
 an indicator, where the quantity of sugar excreted is consider- 
 able. For, with a large amount of sugar in greatly diluted 
 urine, the change in the specific gravity, which varies tolerably 
 regularly with the quantity of sugar, and by means of Haser's 
 coefficient 2-33, an approximately serviceable conclusion may be 
 arrived at. Thus if urine after considerable dilution show a 
 sp. gr. of 1030, then 30 x 2-33 = 69'9 grms. in a litre, or 6'99 
 per cent, of sugar will not be far from correct. 
 
 The perchloride of iron reaction serves to demon- 
 strate the presence of diacetic acid (acetic vinegar, 
 according to Gerhardt, aethyl-diacetic acid). On the addition 
 of this reagent the urine assumes a red-brown colour, which 
 disappears on adding hydrochloric acid. If the urine be pre- 
 viously boiled for half-an-hour, no reaction with the perchloride 
 of iron takes place, but an odour of acetone is frequently given off. 
 
 For the demonstration of acetone in the urine : — 
 
 I. The so-called Iodoform reaction maybe employed. 
 A small quantity of urine is decomposed by caustic potash and 
 by excess of a solution of potassium iodide containing iodine. 
 After standing for a short time, six-sided crystals of iodoform 
 separate out, and its characteristic odour is perceptible. 
 
 II. The nitro-prussiate of Sodium reaction. A 
 beautiful red cloud is obtained on adding to the urine caustic 
 potash and a solution of nitro-prussiate of sodium. 
 
 Schlossing-Neubauer's method maybe used for determining 
 the presence of ammonia in the urine. This depends upon 
 the ammonia, which exists free in a watery fluid, evaporating and 
 subsequently undergoing absorption by dilute sulphuric acid in 
 a confined space. For the execution of this test, the following 
 reagents are necessary: 1. Normal sulphuric acid (1 ccm. of 
 the acid containing '04 grm. of SO s ) ; 2. Freshly prepared 
 lime water ; 3. Normal caustic soda solution (1 ccm. neutralising 
 
182 HOFMEISTER ON DIABETES MELLITUS. 
 
 1 ccm. of oxalic acid solution containing -063 grm. of oxalic 
 acid), of which 1 ccm. neutralises 1 ccm. of sulphuric acid. 
 
 From 10 to 20 ccm. of urine are poured into a small 
 evaporating dish, together with an equal quantity of lime water. 
 On this a glass triangle is placed, ■ supporting a shallow dish 
 containing 10 ccm. of normal sulphuric acid. The whole is set 
 under an air-tight bell-jar. After 48 hours, the sulphuric acid 
 will have absorbed all the ammonia. The amount of sulphuric 
 acid that remains free is then ascertained by neutralising with 
 normal caustic soda solution. For instance, if 9 - 5 ccm. of soda 
 solution are required to neutralise the sulphuric acid, then 
 9 - 5 ccm. of the latter were present, and consequently - 5 ccm. 
 were used to neutralise the ammonia in the urine. Since 1 ccm. of 
 normal sulphuric acid solution neutralises - 01 7 grm. of ammonia, 
 then the 10 ccm. of the mixed urine contain - 017 x '5 = "0085, 
 and a litre therefore "85 grm. of ammonia. Patients who 
 pass from 3 to 4 litres (100 fl. oz. to 133 fl. oz.) of urine daily 
 would therefore excrete from 2 - 45 to 3 - 40 grms. (36f gr. to 
 60 gr.) during that time. 
 
 PROGNOSIS AND COURSE. 
 
 ■Prognosis manifestly depends on the answer to the question 
 whether Diabetes mellitus is a curable disease or not. The 
 word " cure " scientifically means " restitutio ad integrum," that 
 is to say, the materies morbi, whether organic or not, is removed 
 from the body, or destroyed and rendered innocuous, and the 
 various tissues healed so as to allow the exercise of their func- 
 tions, even if with diminished vigour. For the idea of " cure " 
 no more excludes recurrence or diminished resistance to other 
 diseases (in an Organ previously attacked) than it does the 
 destructive sequelae in the organ primarily affected or in others. 
 Such sequelae often represent a new disease. For example, a 
 patient, after having passed through an attack of pneumonia or 
 typhoid fever may possibly feel the consequences of these 
 diseases for some time to come. The lungs may be impaired, as 
 is shown by a tendency to bronchial catarrh, or the bowels may 
 be affected with enteric catarrh. Still he is regarded as having 
 recovered from pneumonia or from typhoid fever. With 
 diabetes it is otherwise. Even if, after suitable treatment and 
 regulated diet, a patient is able to assimilate a fair amount of 
 
HOFMEISTER ON DIABETES MELLITUS. 183 
 
 carbo-hydrates and feels well enough to resume his occupation, 
 the disease is only at a standstill or latent, and certainly 
 cannot be said to have ceased. For the moment he exceeds, 
 by ever so little, the small amount of carbo-hydrates he can 
 safely digest, or is attacked by any fresh predisposing cause, 
 diabetes ever and anon occurs in spite of quiescence 
 of many months' or even years' duration. Senator compares 
 diabetics to bleeders, who remain free from danger as long as 
 they avoid injury — apparently healthy, they still suffer from 
 haemophilia. As little as the latter are able to protect them- 
 selves for their whole life against accidental injury, just as little, 
 or even less so, are diabetics from dangers which constantly lurk 
 under the ordinary conditions of life. In this sense, therefore, 
 diabetes must be regarded as incurable; all diabetics, if not 
 carried off by some intercurrent affection or by a violent death, 
 succumb sooner or later to the usual termination of the 
 disease. Those occasional cases of complete cure reported of 
 late must be consequently regarded with a certain amount of 
 suspicion. Every experienced physician in Carlsbad must know 
 how many of the so-called cured patients return thither after 
 a few years as genuine diabetics. And Seegen, among 800 
 carefully observed cases, has not seen a single one cured. This 
 may be taken as deciding the question. Hence the prognosis 
 in Diabetes mellitus must be considered throughout 
 as unfavourable. The mean duration of the disease 
 could only approximately be determined, were it possible to place 
 all the observed cases under similar conditions of life. The 
 poorer classes, who are not in a position to avoid danger by 
 adhering to a preponderating meat diet, succumb sooner to the 
 disease than the well-to-do, who are able to regulate their lives 
 accordingly and thus take care of themselves. While for 
 the former, life may average a duration of three years, for the 
 latter, it may last twice as long. Gases are exceedingly rare 
 where death takes place within a few months or even weeks. 
 Age has a great influence over the duration of diabetes. In 
 young persons (from 20 to 35 years) the prognosis is decidedly 
 more unfavourable than in older. Symptoms are not only 
 severer and more numerous, but the danger of early and speedy 
 death is greater. In children (under 12) it is still a somewhat 
 rare disease; out of 117 cases collected by 0. Stern from the 
 
184 HOFMEISTER ON DIABETES MELLITUS. 
 
 literature on the subject, prognosis is far away most unfavourable 
 in childhood. Positively remarkable and inexplicable is the 
 great tolerance of old age (about 70). It is not rare to find 
 among the last cases, in the presence of very considerable 
 quantity of sugar (300 grms. [4,500 grs.J and more per diem), 
 quite insignificant symptoms — somewhat disturbed sleep, slight 
 languor, slight increase of thirst and of appetite, &c. 
 
 I know an old lady who has been diabetic for 10 years, 
 where the urine shows an amount of sugar from 4 to 7 per cent., 
 and in addition contains albumen, who will not submit to anti- 
 diabetic regimen, and whose general condition is so good, in 
 spite of slight oedema of the ankles, that she is able to go about 
 enjoying without hindrance all the pleasures of society, and will 
 have nothing to do with any medical treatment. 
 
 As regards prognosis and duration, it is of great importance 
 to determine whether diabetes at the outset is of the grave 
 form, i.e., whether from the very beginning sugar is excreted, 
 in spite of exclusive meat diet. Such cases are the saddest of all. 
 Even in the slight form of the disease, the prognosis must 
 be guarded ; for, in the first place, the patient may unexpectedly 
 succumb quickly to one or other of the terminations of diabetes ; 
 and secondly, because the grave form may suddenly appear 
 from some severe injury, or even without any manifest cause. 
 Conversely, I have also noticed some cases which passed into 
 the grave form after a severe nervous shock, and continuing so 
 for some weeks, returned to the slight form with subsidence of 
 the nervous disturbance. Last summer, in Carlsbad, I observed 
 a very striking case of this kind. A lady, whose statements may 
 be thoroughly relied upon, had been suffering for three years 
 from a very slight form of the disease, inasmuch as every trace of 
 sugar disappeared as soon as she was placed on anti-diabetic diet. 
 At the beginning of the Carlsbad treatment in the previous year 
 she was much distressed at the sudden death of a member of her 
 family, and passed several sleepless nights. Thereupon, sugar re- 
 appeared in the urine (3 to 4 per cent.), and the excretion persisted 
 for 14 days, in spite of rigid observance of Cantani's diet. No 
 one could doubt that the grave form arose out of the slight ; 
 14 days after, however, the sugar gradually decreased, and at 
 the end of the third week the slight form returned, and during 
 the last days of treatment the patient was even able to enjoy 
 
HOFMEISTER ON DIABETES MELLITUS. 185 
 
 a moderate amount of carbo-hydrates without excreting a trace 
 of sugar. It is difficult, in the light of such experience, to accept 
 the division by Seegen of diabetes into two sharply denned forms; 
 it is much better to regard them as differing in degree only. 
 The percentage of sugar taken in connection with the 
 amount excreted per diem is often of little value as regards 
 prognosis. Not every diabetic with 6 to 7 per cent, of sugar is 
 threatened with imminent danger; on the other side, patients 
 with 1 to 2 per cent, may be attacked by serious symptoms. In 
 the majority of cases, however, the percentage of sugar is a fairly 
 reliable guide in judging of the gravity of a case. Of the 
 symptoms of diabetes, rapid emaciation and the presence of 
 nerve disturbances, e.g., persistent sleeplessness, neuralgia, 
 &c, are of the gravest significance. The diseases to which 
 diabetics usually succumb may be regarded as the direct con- 
 sequences and results of diabetes ; they are the immediate cause 
 of death. 
 
 1. Pulmonary Phthisis (almost half of the autopsies). 
 The well-known, picture of consumption is gradually developed, 
 even in those where there is no family history of tubercle — 
 apical catarrh, haemoptysis, night-sweats, &c. Tubercle bacilli 
 are very rarely absent. 
 
 2. Croupous Pneumonia and gangrene of the lungs. 
 In the latter the characteristic odour of the expectoration is 
 almost masked by the presence of acetone in the expiratory air. 
 
 3. Early Marasmus — extreme exhaustion, sloughing of the 
 skin, and necrosis of bone. 
 
 4. Formation of Carbuncles. 
 
 5. Albuminuria. Even without serious renal lesion, large 
 quantities of albumen may be excreted quite sufficient to bring 
 about death. Senator holds that the albuminuria may possibly 
 depend on irritation of the floor of the fourth ventricle, which has 
 spread forward from the diabetic centre to that spot where, by 
 means of experiment, albuminuria is produced. 
 
 6. Patty degeneration and malignant disease of the 
 pancreas accompanied by occlusion of the bile-duct and well- 
 marked icterus. Griesinger's statement that Diabetes mellitus 
 confers a kind of immunity from heart disease, rheumatism, 
 "and cancer, appears to be erroneous, at least as regards the last- 
 named. 
 
186 HOFMEISTEK OX DIABETES MELLITUS. 
 
 7. Transition of Diabetes mellitus into Diabetes 
 insipidus. An exceedingly interesting but extremely rare 
 result of diabetes. Frerichs has observed a few cases, which he 
 has described in his book on the subject. This gain is not of 
 much value, as Diabetes insipidus is likewise incurable. 
 
 8. Coma diabeticorum. Next to pulmonary phthisis this 
 is the most frequent termination of the disease. Coma some- 
 times overwhelms the patient suddenly in the midst of his 
 usual activity, or whilst quite cheerful and free from mental or 
 bodily worry. Often, however, excess of various kinds, hard 
 work, fatigue from travelling, over-indulgence of the sexual 
 passion, &c, precede coma, which is sometimes ushered in by 
 brief prodromata (malaise, anxiousness, stomach-ache). The 
 patient passes into sleep which, at first interrupted by grave 
 excitement, soon assumes a comatose character. The pulse 
 becomes small and rapid, respiration is very deep, at times 
 normal in rate, at times very hurried. The bodily temperature 
 gradually sinks as low as 30° C. (86° P.), and the extremities are 
 quite cold to the touch. The urine, which dribbles away 
 involuntarily or is drawn off by the catheter, gives almost always 
 the reaction of diacetic acid on addition of perchloride of iron. 
 This condition may last from one to three days without any return 
 to consciousness, but generally terminates much more speedily 
 in death. 
 
 The cause of coma diabeticorum is not yet fully explained. 
 The former view that it is caused by the poisoning of the 
 blood with acetone or diacetic acid has been discarded, as the 
 injection of these substances into the circulation of lower animals 
 failed to produce similar phenomena. Abeles found in some 
 cases of coma diabeticorum considerable quantities of 
 glycogen in the brain, which normally contains none. But 
 he does not ascribe to its presence any influence in the produc- 
 tion of this state ; rather he believes that in every grave form of 
 diabetes, glycogen exists in the brain, and its demonstration is 
 rendered possible only by rapid death due to coma. It is well 
 known that usually even the sugar disappears a few days before 
 death. 
 
 Stadelmann, of Dorpat, has lately noted the presence of an 
 acid in diabetic urine which he at first regarded as crotonic acid, 
 afterwards asoxy-butyricacid, previously found by Kiilz and 
 
HOFMEISTEK OX DIABETES MELLITUS. 187 
 
 Minkowski. He refers the origin of coma to this acid ; he found 
 whenever the urine contains diacetic acid, oxy-fcratyric acid is 
 also always present, even if the former be absent. In his opinion 
 the perchloride of iron reaction has a very important significa- 
 tion, as it betrays the presence at the same time of oxy-butyric 
 acid. Pari passu there is an increased excretion of 
 ammonia (8 to 4 grms [about 46 to 62 grs.] of ammonia to 80 
 grms [about 450 grs.] of oxy-butyric acid). Stadelmann 
 considers the increase of ammonia in the urine as one of the 
 most important prognostic signs. If more than 1 - 10 grms (16g 
 grs.) are excreted daily, the danger threatens that diabetes will 
 pass into the grave form. Should it amount to 2 — 4 — 6 grms. 
 (about 31 — 62 — 93 grs.) daily, the sudden appearance of coma 
 may be constantly expected, and the friends of the patient should 
 be warned. 
 
 Treatment of coma diabeticorum. If the ammonia is 
 on the increase the meat diet must be diminished forthwith, 
 bread, vegetables, and fruit substituted in moderation, and the 
 following draught ordered : — 
 
 R 
 
 Spiritus menthse Piperita gtt iij. 
 
 S. To be taken two or three times in 24 hours. 
 
 If coma is already present, Stadelmann recommends without 
 delay intravenous injection of a solution of carbonate and chloride 
 of sodium (7 to 10 grms. [about 108 to 150 grs.] of sodium 
 carbonate to every 100 grms. [about 1,500 grs.] of normal sodium 
 chloride solution) varying from 1 to 1£ litres [about 33| fl. oz. to 
 50| oz.] which should be discontinued the moment threatening 
 symptoms manifest themselves — stopping of the pulse or of the 
 respiration, or presence of convulsions — to be renewed after an 
 interval or so. Formerly subcutaneous injections of camphor, 
 ether, cold affusion, and other excitants were employed, 
 unfortunately without success. It remains to be seen whether 
 the intravenous injection of alkalis is followed by better 
 results. 
 
 
 
 About. 
 
 Acidi citrici 
 
 ... grm viij. 
 
 (123 grs.). 
 
 Sodii carbonatis ... 
 
 grm xviij. 
 
 (278 grs.). 
 
 Saccharini 
 
 ... grm - 1 
 
 (H g«0. 
 
 AquK destillatsB ... 
 
 ... grm cl / 
 
 (5 oz.). 
 
188 HOFMEISTER ON DIABETES MELLITUS. 
 
 TREATMENT. 
 
 Since John Eollo made the important discovery at the close of 
 the 18th century that in every case of diabetes the consumption 
 of sweet and starchy foods greatly increased the quantity of sugar 
 excreted, it was thought that by simply withdrawing these articles 
 of diet the disease could be cured. The object of the physician 
 was to hit the right choice of food and of beverage, so as to 
 prevent the entrance of as little carbo-hydrate material as 
 possible. The conviction was soon reached that although the 
 patient's condition could be much ameliorated, still complete 
 cure could not be attained. Now, alas, we must confess with 
 regret that even after the lapse of a century we are still very 
 far from the desired goal, and at present have no well founded 
 hope of ever reaching it. Modern treatment, however, has 
 certainly been able materially to alleviate the condition of 
 the patient as well as to considerably prolong his life. 
 
 The following fundamental principle of universal value to 
 medical men has been the greatest acquisition in later years: 
 no routine treatment, but each case to be treated in 
 strict accordance with the form of diabetes it presents. 
 Of the numerous ones that have been constructed analytically 
 and synthetically none has hitherto proved to be universally 
 applicable ; for what may be useful in one case, may be harmful 
 in another. This holds good, not only in medicinal, but also 
 in hygienic and dietetic treatment. For even though it be 
 beyond dispute that anti-diabetic diet, consisting of vegetable and 
 animal products which contain the least possible amount of sugar 
 and of sugar-forming substances, plays the most important part 
 of all in the treatment of the disease — which moreover in the 
 great majority of cases is of distinct benefit — still cases are met 
 with in practice in which a rigid diet is not only of no use, 
 but is absolutely harmful, does not relieve symptoms, but 
 actually aggravates them. This is chiefly true of the graver form 
 of the disease, but especially so when prodromata of coma are 
 present (v. supra). If a less rigid diet be allowed, e.g., bread, 
 vegetables, fruit, although the amount of sugar may be increased 
 the patient will feel considerably better, and may recover to a 
 certain extent. In any case, the improvement of the general 
 health and nutrition of the patient is of the first importance rather 
 
HOFMEISTER ON DIABETES MELLITUS. 189 
 
 than the diminution of sugar. On the above principle every 
 method of treatment of diabetes has therefore only a limited value. 
 
 Priorry's proposal to replace the loss of sugar by increasing 
 the amount taken as food, like the attempt to replace the 
 loss of proteid material in albuminuria by increasing the amount 
 of meat, may be dismissed " a limine," for could the loss of sugar 
 be compensated, none would be excreted. The same holds good 
 with glycerine, which Schutzen recommended on erroneous 
 theoretical premisses as a substitute. Even Donkin has but 
 few followers of his treatment, consisting exclusively of skimmed 
 milk ; it can scarcely be imagined that nutrition would not suffer 
 severely in a very short time. The injuriousness of this method 
 has already been demonstrated by several writers. 
 
 The hygienic-dietetic natural method' of treatment of A. v. 
 Diihring is simply paradoxical. He allows his patients rather 
 large quantities of carbo-hydrates in the shape of stale white 
 bread, rice, peas, haricot-beans, and dried fruits, and only 
 excludes sugar. He maintains that these vegetables, dried 
 apples, plums, and cherries, when soaked in cold water for a day 
 and then well cooked over a slow fire for several hours, in spite 
 of the large amount of carbo-hydrates, form no derivatives of 
 sugar, but are digested and assimilated (?). Several control 
 experiments discountenanced this supposition. On the other hand 
 v. Diihring's hygienic treatment — the use of cold water in the 
 form of wet pack and cold friction, plenty of muscular exercise 
 in the open air, home gymnastics, and respiratory exercises — is 
 quite rational in suitable cases, and its efficacy cannot be 
 gainsaid. It remains uncertain whether the successful results, 
 even in the grave forms that v. Diihring's method boasts, are 
 true recoveries or only temporary ameliorations. 
 
 Similar routine methods of treatment, wrongly termed syste- 
 matic, should have no place in diabetes — a disease, as aetiology 
 tells us, which appears at one time to develop from nervous causes 
 (psychoses), at another from constitutional (obesity, gout), and 
 again from organic disease (pancreas and liver). Moreover, when 
 we take into consideration how different the nature of every 
 individual and the predisposing causes (diminished power of 
 resistance, inherited disposition, conditions of life) that influence 
 the disease are, we can easily understand why the symptoms 
 which a given treatment is to suit are so diverse in each case. 
 
190 HOFMEISTER ON DIABETES MELLITUS. 
 
 Nevertheless there are certain general measures, hygienic, dietetic, 
 and medicinal, which should regulate treatment at the beginning, 
 and in the further course of the disease may be variously modified 
 according to the nature of the case. 
 
 A. DIETETIC TREATMENT. 
 
 Foremost stands the principle of eliminating as much as 
 possible the carbo-hydrates from the nutriment. It is 
 absolutely impossible to get rid of them entirely, as even purely 
 animal fare, meat and eggs contains carbo-hydrates. Chemically 
 pure albumen would have to be administered, which, however, 
 would not maintain the bodily condition, let alone improve it. 
 
 The various forms of sugar — cane, fruit, grape and, milk sugar — 
 are the most harmful. Inosite, inulin, and lasvulose, which 
 are also sugars, form an exception, inasmuch as, from experience, 
 their consumption is not attended by any excretion of sugar in 
 the urine. The same holds good for mannite, which, though 
 sweet, is an alcohol and not a sugar. Practically these, together 
 with glycerine, Which is harmless to many, are readily used by 
 many diabetics, while others do not find them a substitute for 
 cane and fruit sugar. Honey, on account of its chiefly con- 
 taining lasvulose, may be allowed in moderation. All these sugar 
 substitutes have been thrown into the shade owing to the 
 discovery of saccharin a few years ago. This substance 
 exceeds all other known kinds of sugar in sweetness some 300 
 times ; very little is needed to confer the usual amount of sweet- 
 ness to food and drink. At first, from its being difficult to 
 dissolve, it was little used, now it has become general owing to 
 its solubility being increased through combination with soda, and 
 its cost being much reduced. All diabetics may take it 
 without restriction. I have never been able to detect any 
 injurious effect, either in digestion or in any. other respect, but 
 where from its great sweetness it may nauseate, it is better to 
 dispense with it. 
 
 Next to sugar, bread and other farinaceous articles are most 
 harmful owing to the abundance of starch they contain. The 
 deprivation of bread is the most difficult to bear, for the patient 
 can give up everything else, e.g., farinaceous foods, confectionery, 
 and sweet fruits, much more easily than bread. This great 
 longing for bread must always be borne in mind by the physician. 
 
HOFMEISTER ON DIABETES MELLITUS. 191 
 
 For while the use of sugar and other carbo-hydrates can at once 
 be stopped as soon as the diagnosis of the disease is confirmed, 
 bread must only gradually be withdrawn. Even the most in- 
 telligent and strong-minded patients will declare they cannot go 
 on without bread, and consequently often become refractory 
 towards other prescribed measures. Every fortnight the amount 
 of bread taken in 24 hours may be lessened by 50 grms. (about 
 1J oz.). If the patient was accustomed to consume daily 300 
 grms. (about 10* oz.), in the course of two months it will have 
 dropped to 100 grms. per diem (about 3£ oz.). If the amount 
 of sugar in the urine is found to have decreased during this period 
 to 1 per cent, or below, then the 100 grms. (circa 3£ oz.) may 
 be continued for some time ; but, with an increase of sugar the 
 supply of bread must be still further reduced to a roll per 
 diem, weighing 30 to 40 grms. (from 1 oz. to 1J oz.), or, if 
 necessary, bread must be forbidden altogether. By this gradual 
 method the patient does not feel the loss so much. If the sugar 
 diminishes in consequence of this line of treatment until traces 
 only can be recognised, some months should be allowed to elapse 
 before bread is resumed in the diet. It must then be given 
 tentatively and with great caution. After a few grams of bread 
 the urine should be examined two hours later, in the following 
 days it may be slowly increased by a few grams until the 
 limit of toleration for amylaceous food is reached. What holds 
 good in the case of bread is equally true of other carbo-hydrates 
 i.e., those kinds of vegetables and fruits which we shall mention 
 more succinctly later on. An examination of the urine after 
 eating any of these is in fact the best indication of the amount 
 of carbo-hydrates the patient may safely partake of without 
 materially increasing the quantity of sugar excreted. 
 
 Instead of ordinary bread several substitutes have been 
 proposed, either by freeing the flour from starch through washing 
 (gluten bread) , or by adding so much bran to the flour that the 
 percentage of starch is greatly diminished (bran bread). An 
 artificial bread may be prepared from lichenin (Icelandic moss) 
 and its congener inulin, which have no influence on the excre- 
 tion of sugar. Lastly, there is almond bread, made with almond 
 meal, eggs, and fat, which is almost destitute of starch. The so- 
 called Graham bread appears to be confused with bran bread, 
 and is regarded as a bread substitute. It is, however, nothing 
 
192 HOFMEISTER ON DIABETES MELLITUS. 
 
 but bread, made from fine wheat which has been coarsely ground 
 (hence termed whole meal bread) without separating the bran. 
 The meal simply retains the bran, the chief constituent being 
 flour for all that, whereas in bran bread, the bran, to which only 
 a small amount of starch unavoidably adheres, is the chief ingre- 
 dient. This error appears to be pretty prevalent with the public, 
 and hence it is never superfluous to mention this matter to the 
 patient. All such bread substitutes are only useful in a small 
 number of cases, partly owing to their insipidity, partly to their 
 high price, and still more on account of their indigestibility. 
 Usually patients give them up after a short time, and whenever 
 I can, I avoid even mentioning them. Other cereals (rye, oats, 
 barley, &c, and their various preparations) of course are just 
 as harmful as wheat and its products. Next to these in point of 
 starch contents come pulse, peas, beans, and lentils, then 
 rice, potatoes, maize, sago, tapioca, arrowroot, and other 
 tree and field produce, which are scarcely known by name in 
 this country and need not be mentioned. Each and all are to be 
 struck out of the dietary, as they contain from 50 to 80 per cent, 
 of starch. 
 
 Of other vegetables generally used as articles of diet, the 
 following must be avoided on account of their relative richness 
 in carbo-hydrates : carrots, kale-turnips (kohl-rabi), horse- 
 radish, garlic, onions, and celery. The following maybe 
 permitted in moderation : sour-kraut, cauliflower, 
 broad-beans, turnips, mushrooms, truffles, artichokes, 
 radishes and black radish (a large turnip radish). The 
 following may be used in larger quantities: spinach, 
 French beans, cabbage, lettuce and other greens used 
 in salads (cabbage-lettuce, endive), watercress, seakale, 
 gherkins, asparagus, and sorrel. The last must be 
 avoided if oxaluria be present. Of the various kinds of fruits 
 the following must be forbidden under all circumstances as the 
 most harmful: grapes, melons, plums, figs, bananas, 
 pears, chestnuts, peaches, apricots, and other sweet indi- 
 genous and foreign fruits. Strawberries, raspberries, 
 currants, crab-apples, bitter cherries, oranges, al- 
 monds, and hazel-nuts in moderation may be allowed. 
 Walnuts may be eaten with impunity. 
 
 As regards beverages, milk must be considered first and 
 
HOFMEISTER ON DIABETES MELLITOS. 193 
 
 foremost. Milk contains all the elements of nutrition in the 
 most compact and digestible form, which not only maintain the 
 nitrogenous equilibrium of the body, but even considerably 
 increase its weight, as is seen in the rapid growth of the suckling 
 infant. To deprive diabetics entirely of so admirable a form 
 of nutriment on account of lactose, as Cantani and others recom- 
 mend, seems to me going too far. The amount should be limited 
 to an average 1 20 grms. (about 4 fl. oz.) per diem, which will do 
 the patient more good than harm. The following milk products 
 are quite permissible: cream, butter, sour milk in which 
 lactose has been converted into lactic acid, curds, and cheese, 
 as well as koumiss and kefir. On the other hand, buttermilk 
 and whey are not allowable. Tea and coffee may be taken 
 as usual, with or without milk, and saccharin according to taste. 
 The taste of unsweetened black coffee may be improved, according 
 to some, by adding the yolk or the well-whisked white of an egg. 
 Cocoa prepared from the nibs is harmless, but chocolate 
 manufactured from the bean should be forbidden in toto. 
 Lemonade unsweetened, or sweetened with saccharin, should 
 only be taken in moderation and not allowed to touch the 
 teeth, as these tend to decay in any case. Almond- milk and 
 the various aerated, soda and mineral, waters may be used 
 without restriction. The case is different with alcohol. The 
 more or less pure forms of spirit, e.g., cognac, rum, corn-spirit, 
 slibowitz, whisky, brandy, &c, are considered by all to be harm- 
 ful to diabetics, even when the quantity of sugar excreted is 
 not thereby increased. The general condition of the patient 
 decidedly deteriorates, and even the feeling of languor and loss 
 of strength is not removed, by the administration of alcohol. 
 With reference to wine opinions differ. Of course all wines 
 artificially sweetened, French and other champagnes, Malaga, 
 Tokay, Bust, &c, as well as those partially fermented and the 
 sweetish fruit wines, should be rigorously excluded from the 
 dietary. 
 
 Whereas some writers have noticed no injurious effect even 
 after excessive wine-drinking, others have remarked just the 
 contrary. This is after all not surprising, for, like the who]e 
 question of diet, it is solely a matter of individual idiosyncrasy. 
 It is evident that if wine be allowed in moderation, in most cases 
 it should be given tentatively at first, and those should be 
 
 
 
194 H0FNEI3TER ON DIABETES MELLITDS. 
 
 preferred which contain least alcohol and sugar. Therefore 
 genuine Bordeaux and Austrian mountain-wines are more 
 suitable than Port and Burgundy. Hungarian and Bhenish 
 wines are generally somewhat sweeter, containing more than 
 1 per cent, sugar. Beer, which besides alcohol and sugar 
 contains dextrin, should not be taken at all as long as sugar is 
 being excreted. Should traces only be present, the patient may 
 take now and then a glass of well-brewed beer (preferably Pilsen) 
 and not too rich in malt. As for taking beer regularly, he must 
 not entertain the idea for a moment. Thirst is quenched most 
 satisfactorily by pure spring or well water, and with pieces of ice 
 should polydipsia be distressing. Spices of every descrip- 
 tion (pepper, chillis, ginger, cinnamon, vanilla, and curry) 
 should be cut down to a minimum. Salt, less harmful than any, 
 should, however, be taken sparingly, as it increases thirst, which 
 at all times is difficult to allay. If we cut off in this manner the 
 supply of carbo-hydrates, the chief nutriment of the diabetic will 
 consist of meat, eggs, and fats. Meat, moreover, is not 
 quite free from carbo-hydrates ; it contains small quantities ot 
 dextrin, maltose, and grape sugar, the influence of which is, how- 
 ever, completely counteracted in the body. The various kinds of 
 meat of all mammals, birds, fish, amphibia,. reptilia, and shellfish — 
 turtle, crabs, lobsters, frog's legs, oysters, snails, &c. — may be 
 taken, as well as the various organs used as food, brain, lungs, 
 pancreas (sweetbread), kidneys, and spleen, except the liver, 
 which contains sugar in the normal state. There is also no 
 objection to the use of the various meat salts and extractives in 
 , the form of soups, broths, beef-tea, Liebig's extract of meat, and 
 Leube-Bosenthal's solution of meat. It may seem superfluous to 
 mention that in the preparation of various dishes, the customary 
 addition of flour must be strictly avoided, still there are many 
 persons ignorant enough in culinary matters who have no idea 
 that dressed meat (baked fowl, baked fish, the so-called Viennese 
 cutlets), as well as most vegetables, thick sauces,* and soups, are 
 prepared with flour, and are frequently partaken of in blissful 
 ignorance, especially in hotels and abroad. Hence the physician 
 should make it a rule not to place implicit confidence in the 
 assurances of his patient that he is dieting himself very strictly, 
 but should always obtain from him what and how much he eats and 
 * Both these may be made tasty with yolk of egg and cream. 
 
HOFMEISTER ON DIABETES MELLITUS. 195 
 
 drinks at the Various meals, down to the minutest detail. Many 
 a surprise and explanation will be in store for him ! Next to 
 meat, eggs, uncooked, soft or hard boiled, or prepared with 
 butter, are most nutritious. As regards fa t, in the earlier writings 
 most divergent views are met with, some deeming it useful, 
 others harmful. More abundant experience of later, years has 
 clearly proved that fat is exceedingly useful in diabetes, and in 
 very many cases absolutely indispensable. Carlsbad physicians 
 in particular, who prohibit the use of fat of every description to 
 all other patients, as it disagrees with them while taking the 
 waters, find to their surprise that diabetics can consume an 
 extraordinary amount without interfering in the least either with 
 digestion or with the treatment they are undergoing. I know 
 some patients who actually had a great distaste for fat and rich 
 dishes before they became diabetic, but now evince quite a strong 
 desire for them. Some exceptions there may be, but these only 
 prove the rule. In this question clinical experience has more 
 claim to speak decisively than any theory, no matter how 
 well based, that tries to prove actually in the digestion of fats 
 glycerine is formed in large quantities, and consequently the 
 excretion of sugar must increase. Moreover, fat possesses a 
 valuable property, and one which cannot be too highly prized, of 
 inducing satiety much more quickly than meat. The patient 
 thus escapes the danger arising from eating too much meat 
 and of overtaxing the digestive powers, producing loss of appetite. 
 This latter may be fraught with peril to him ; to preserve the 
 appetite and digestion intact should ever be his main object. 
 
 According to Seegen, sugar is formed in the liver from peptones 
 and fat; if the body be deprived of fat, more meat will be 
 required to form sugar, and, owing to proteid disintegration, 
 emaciation would rapidly proceed, as is seen in the Banting 
 system, where the diet is exclusively meat. Even obese patients 
 benefit from the preserving property of fatty food, for they 
 retain their embonpoint for a long time, which contributes to 
 their peace of mind in no small degree. 
 
 As a rule from 150 to 200 grms. of fat (from £ lb. to | -lb.) may 
 be taken with the food in 24 hours. In the majority of cases I 
 do not consider it necessary at all to regulate the amount, but 
 leave it simply to the judgment and taste of the patient. It 
 should be seen that it is always fresh and sweet, and due regard 
 
196 HOFMEISTER ON DIABETES MELLITUS. 
 
 should be paid to the digestibility of the various animal and 
 vegetable fats (oils), which is by no means equal, and those 
 should be chosen which from experience are most easily borne 
 by the patient, e.g., olive oil, fresh butter, pork dripping, and 
 sardine oil. The various jellies prepared from cartilaginous 
 and connective tissues, aspic brawn and the Hungarian Kocsonya, 
 are quite harmless, and may be eaten without restriction. 
 Mixed with a little vinegar and oil, diabetics relish them as an 
 agreeable addition to fish and cold meats. It remains to be 
 discussed as regards diet whether it is advisable to allow the 
 patient to eat so much as to satisfy appetite or not. In this 
 question again opinion has quite changed of late. For results 
 have shown that the excessive diet of meat and eggs which 
 patients were usually placed upon, gave rise to loathing and 
 distaste, and from the greater difficulty in digestion caused 
 dyspepsia with its sequelae, . besides increasing the amount of 
 sugar. Now it is preferable to allow him to feel a little hungry 
 than satisfy appetite completely. However, to make him fast 
 once or twice a week, as some propose, I consider cruel, and at 
 the same time harmful to the patient. Frequent and small meals 
 are most suitable, generally five are sufficient during the day, 
 bearing in mind to vary them as much as possible. Culinary 
 invention will find no difficulty in preparing for several days 
 various appetising menus from the many kinds of meat and fish, 
 from lobsters, crabs, oysters, eggs, aspic, and from the permis- 
 sible vegetables, fruits, and beverages mentioned above. 
 
 Finally, every patient should make it a rule to eat slowly, take 
 small mouthfuls, and masticate thoroughly in order that the 
 influence of the saliva may be complete. 
 
 B. HYGIENIC TREATMENT. 
 
 Here again no hard and fast rules can be laid down, each 
 individual should be treated most carefully according . to the 
 special necessities of the case. For instance, one of the most 
 important hygienic measures, the methodical invigoration 
 of the system, cannot be carried out in every case of diabetes. 
 It is only in those cases where the temperature is but little below 
 normal, cold hands and feet are not complained of, and where the 
 constitution is naturally robust, that cold baths, douches, 
 wet friction, and aeropathic treatment can be resorted 
 
HOFMEISTER ON DIABETES MELLITUS. 197 
 
 to for their bracing effects. Where a tendency to furunculosis 
 exists, any powerful stimulus to the skin must be avoided, e.g., 
 wet pack, a prolonged use of which will even in healthy subjects 
 produce an outbreak of boils. 
 
 For thepreservation of the skin, which may require special 
 attention on account of its dry and harsh character, ordinary 
 luke-warm baths, 26°— 27° K. (90^°— 92|° F.), with perhaps 
 a little mild hard soap, maybe taken once or twice a week. The 
 most scrupulous attention to the mouth and teeth cannot 
 be too strongly insisted upon. Formation of aphthae, sponginess 
 of the gums, the great tendency to caries of the teeth due to 
 acid secretions of the buccal cavity, may be best prevented by 
 frequently rinsing out the mouth and throat with a lotion of 
 chlorate of potash or of salicylic acid to which a little bicarbonate 
 of soda is added. The teeth and gums should be brushed with a 
 soft tooth-brush, and the interstices freed from any particles of 
 food, which become so soon offensive. According to experience 
 catching cold always renders the diabetic's condition worse ; 
 he clothes himself instinctively in thick garments, even in warm 
 seasons, and during winter does not care to leave the heated 
 room. The best protection against cold is after all the tone 
 imparted by hydropathy. Those patients, however, to whom this 
 treatment is inappropriate, or are disinclined to follow it, should 
 spend at least several hours daily in the open air, e.g., in light 
 gardening, farming pursuits, hunting, fishing, riding, and driving, 
 at first in fine weather, later on at all times. 
 
 The well-to-do may pass the winter in one of the Southern 
 health resorts. Care must be constantly exercised in having the 
 sitting and bedrooms well aired. Active muscular 
 exercise is of very great value in those strong enough to take 
 it ; it always diminishes the excretion of sugar, and improves the 
 general well-being of the patient. Any muscular over-exertion 
 must be avoided, and extended intervals of rest from bodily as 
 well as mental exercise should always be allowed. From expe- 
 rience, a long unbroken journey, especially when accompanied 
 by worry and trouble of all kinds, is very detrimental as regards 
 the amount of sugar excreted. To introduce regularity in work 
 is best wherever possible. For weak and debilitated patients 
 unable to work, passive movements and easy Swedish 
 gymnastic exercises form a good substitute. In such cases 
 
198 HOFMEISTER ON DIABETES MELL1TUS. 
 
 massage is of special value, applied daily for twenty minutes. 
 It is not necessary to strip the body, but all the muscles may be 
 thoroughly, one by one, grasped, squeezed, and kneaded through 
 a light garment. The discomfort after the first sitting dis- 
 appears in the course of a few days. The effect of massage is 
 strikingly beneficial and often has a very favourable influence on 
 the excretion of sugar. It stands to reason that excesses of 
 every description — pleasures of the table, sexual indulgence, 
 smoking, gambling, as well as muscular and brain activity — • 
 must be most harmful, accompanied as they generally are by 
 much excitement. 
 
 C. MEDICINAL TREATMENT. 
 
 Pharmacotherapy is far behind dietetic treatment in impor- 
 tance. Since we are successful in the slighter forms of diabetes 
 — and these are the great majority — by means of withdrawing 
 more or less the carbo-hydrates from the regimen, in causing the 
 disappearance of the sugar and relieving most of the other 
 symptoms, we really do not require any medicines, for they 
 could do no more. Still, ,the withdrawal of bread and other 
 carbo-hydrates is not a matter of no consequence, or indeed 
 easily accomplished. An inestimable boon would be conferred 
 on patients, if this restrictive treatment could be replaced by a 
 medicament. But so far, unfortunately, none has been dis- 
 covered. It is true, we know, that certain drugs are able to 
 diminish the sugar, even with ordinary diet, still, either their 
 effect is transitory or they are successful only as long as they 
 are used, and, if persisted in, may seriously injure the health in 
 other ways. The drugs whose effects are temporary are simply 
 endless. There is scarcely a remedy in the old as well as in the 
 new Pharmacopoeias of every country which has not been tried 
 by one or other physician, and pronounced efficacious, at least 
 for a time, but even here superficial observation often went hand 
 in hand with mistaken conclusions. One remedy gave way to 
 another, and none remained long in the field. I need not allude 
 to the older physicians and their blind empiricism, but even 
 disciples of the new scientific school, who have been guided in 
 their choice of drugs by theoretical considerations, have not fared 
 much better — for instance, Cantani and his much-lauded lactic 
 acid. As the sugar in the body passes directly into lactic acid, 
 
HOFMEISTER ON DIABETES MELLITUS. 199 
 
 it appeared very reasonable to administer the latter instead of 
 sugar, just as we endeavoured to lighten the work of the stomach 
 in cases of feeble digestion by giving peptones. Experience, 
 however, left the theory in the lurch — lactic acid proved to be 
 more harmful than useful. 
 
 The antiseptics, phenol, salicylic acid, quinine, iodo- 
 form, the modern panacea antipyrin, and all the rest, fared no 
 better. Even the powerful drugs strychnine, arsenic, pilo- 
 carpin, &c, have been long ago abandoned by most physicians, as 
 their continued administration is an obstacle in itself. I find that 
 an English physician, Squire, latterly has strongly recommended 
 phosphorus -005 to - 01 grm. (^ gr. to & gr.) twice daily. 
 Corrosive sublimate finds support from some author whose 
 name shall not be mentioned, who without any justification regards 
 syphilis as a cause of diabetes in the majority of cases. Let us 
 hope he will not entertain this opinion too long. The adminis- 
 tration of cod-liver oil, which was undoubtedly of great benefit 
 in former times, has now become superfluous, owing to the 
 admission of fat into the dietary. Hitherto only three remedies 
 have stood in any degree the test of experience, and are most 
 frequently prescribed. They are opium, morphine, and the 
 alkaline waters which Carlsbad, Vals, Vichy, and Neuenahr 
 offer. Opium, and still more so morphine, diminish the 
 excretion of sugar with ordinary diet, at times completely arrest 
 it. improve the nutrition and bodily weight, and cause the most 
 troublesome symptoms to disappear, as long as they are adminis- 
 tered, and even some time after they have been discontinued. 
 Unfortunately, however, we are obliged to stop them after 
 some months if we are not to make our patients opium-eaters or 
 morphinomaniacs. Still, for a short period (4 to 6 weeks), or 
 used alternately with alkaline waters and diabetic diet, they are 
 extremely valuable, and in many cases indispensable. It is not 
 yet explained whether they act by diminishing metabolism, or 
 calming the nervous system, or have a specific influence over 
 the disease itself. The great toleration of the two drugs is quite 
 remarkable in diabetes. Incredibly large doses may be given 
 without causing any of the usual drawbacks — obstinate consti- 
 pation, drowsiness, and lethargy. Large doses can be given at 
 the outset, opium 1 dcgrm. (1^), morphine 5 cgrm. (j gr.), and 
 they may be increased till treble the amount is taken at each dose 
 
200 HOFMEISTER ON DIABETES MELLITUS. 
 
 morning and evening. However, as soon as the first symptoms 
 of craving appear, restlessness, irritability, and painful sensations 
 about the time usual for their administration, they must at once be 
 stopped. As regards the alkaline mineral springs, 
 Carlsbad stands first on account of its beautiful situation, its 
 excellent arrangements for treatment, and the confidence which 
 its old repute inspires in patients. It is undeniable that 
 alkalies, in whatever combination, are sometimes capable of 
 completely arresting, though only in the slighter forms of the 
 disease, the secretion of sugar without resorting to anti-diabetic 
 regimen. But in Carlsbad treatment almost always begins with 
 placing the patient on rigid diet, and then gradually relaxing 
 this until the limit of toleration of carbo-hydrates is reached. 
 The inestimable value of this method consists in the period of 
 toleration lasting much longer than with any other line of 
 treatment. For once having determined the amount of bread, 
 vegetables, and fruit the patient is ableto take with impunity, 
 provided he does not exceed this limit after tbe course of treat- 
 ment, he may go on for some years, excreting either no sugar 
 or but a small quantity, without feeling any the worse. This is 
 not only the experience of Carlsbad physicians, but has been con- 
 firmed by the most eminent members of the profession in 
 Germany, whence the largest number of patients come. For 
 many reasons it is preferable that the waters should be taken at 
 the springs; where this is not practicable the patient should 
 order twice a year twenty to twenty-five bottles — either Sprudel, 
 Schloss, or Muhl water — gently Warm the water to 40° E. 
 (122° F.) and take it according to the prescribed rules in Carlsbad. 
 If the physician makes periodic and judicious changes in the use 
 of these three powerful therapeutic, agents — anti-diabetic diet, 
 opium, and alkalies — he will be able in many cases to prolong 
 life considerably. This line of treatment does not prevent 
 attention to symptoms. Hence sleeplessness should be 
 combated by sulphonal, chloralamid, excitement by bromide 
 of potassium, neuralgia by antipyrin, &c. Electricity may be 
 used in cases of impotence, spirit lotions containing salicylic 
 acid in pruritus universalis, and local treatment must not 
 be omitted in eczema and furunculosis, &c. 
 
 These are the leading features of rational therapeutics in 
 Diabetes mellitus from the present stand-point. 
 
HOFMEISTER ON DIABETES MELLITUS. 201 
 
 ADDENDUM. 
 
 I greatly regret, owing to this paper being already in print, 
 not to have been able to allude to the latest work of Seegen's 
 " On Sugar Formation in the Animal Body." It only remains 
 for me to refer the reader to this book, whose author has already 
 gained great repute for his researches in Diabetes. 
 
SYPHILIS OF THE NERVOUS SYSTEM. 
 
 BY 
 
 Prof. H. vox ZIEMSSEN, 
 
 Director of the Medical Clinic in Munich. 
 
 Translated by 
 A. M. STALKER, M.A., M.D., 
 
 Physician to the Dundee Royal Infirmary. 
 
SYPHILIS OF THE NBEVOUS SYSTEM. 
 
 The pathology of the nervous system is one of the favoured 
 children of our present-day medicine. Hardly any other branch 
 of our studies from a condition of complete chaos has attained in 
 so short a time so high a degree of development. If we compare 
 the text-books of Marshall Hall and Romberg, both dating from the 
 forties, and both standard treatises for their time, with the works 
 of Erb and others of to-day, what a revolution there has been in 
 something like forty years ! 
 
 Histological investigation has gone hand-in-hand with experi- 
 mental researches into the functions of the nervous system under 
 normal and morbid conditions; new and more exact methods 
 have promoted clinical study and given certainty to its results ; 
 and the therapeutics of the various affections has received an 
 immense impulse through the perfection at which the physical 
 methods of treatment have arrived. 
 
 Relatively the least positive advance has been made in aetiology, 
 a fact which is explained by the great difficulties which surround 
 the subject. These difficulties are particularly great when we 
 come to consider the causes of diseases of the central nervous 
 system. We must not, however, omit to notice that even on this 
 line of investigation there are already several landmarks laid 
 down which form the beginnings of a scientific treatment. I call 
 to mind the important work that Dejerine lately showed has 
 been done in regard to the influence of heredity on the origin of 
 nervous disease ; the investigations into the causes of general 
 paralysis of the insane and of locomotor ataxia ; the investigations 
 into the effects of chronic lead poisoning and the abuse of alcohol 
 and tobacco ; and lastly, the researches into the influence which 
 acute and chronic infectious disease may exercise on the nervous 
 system. 
 
 We do not frequently see, as you know, disease of the central 
 or peripheral nervous system follow from acute infectious disease. 
 The nervous disturbances which result from enteric fever. 
 
206 ZIEMSSEX ON SYPHILIS OF THE NERVOUS SYSTEM. 
 
 puerperal fever, smallpox, measles, scarlet fever, and acute 
 rheumatism are on the whole of rare occurrence ; relatively the 
 most common are the paralyses after diphtheria. 
 
 Of all infectious diseases syphilis is undoubtedly the most 
 important in the present connection. Its causal relations to 
 nervous disease have become during the last twenty years an 
 object of continually increasing attention, and although in the 
 conflict of opinion here and there there has been some shooting 
 beyond the mark, yet we can no longer doubt that in the 
 aetiology of this class of diseases syphilis is an element of great 
 consequence. The multitude of important facts which recent 
 times have brought to light, and the eminently practical 
 character of the question, make it a duty for us all to study these 
 things more carefully for our guidance both in diagnosis and 
 treatment. Of course it must not be forgotten that we are often 
 moving on uncertain ground, and that many, and those too the 
 most important, questions are still matters of controversy. On 
 this account the greatest caution is necessary in the interpretation 
 of appearances, and in the estimate of their practical worth. 
 
 The historical development of the knowledge of the relation of 
 syphilis to the nervous system may be summarised in a few words. 
 It belongs wholly to our century, for what has come down to us 
 from the 17th and 18th centuries represent conjectures rather 
 than facts. As in other departments, so here also we can 
 recognise very distinctly the absence of scientific verification in 
 the eccentricities in which physicians of eminence indulged in 
 their statements about these matters. 
 
 The whole question was first subjected to a thorough study by 
 Virchow. His investigations referred chiefly to the late forms of 
 syphilis in the periosteum, the cartilages, the bones, and the 
 viscera. The particular character of the changes in the brain and 
 its membranes, especially in the vessels supplying them, has been 
 since determined by B. Wagner, Steenberg, Heubner, and others, 
 not to mention Virchow himself. Eminent clinical teachers 
 and neurologists in all countries have taken part in the further 
 development of the questions at issue; besides E. Wagner, 
 there are among others Westphal, Leyden, Erb, Mendel, Kumpf, 
 Charcot, Eournier, and Clifford Albutt. To Rumpf especially 
 we owe lately an excellent exposition of all that has been hitherto 
 known, with the addition of a large number of new observations 
 
ZIEMSSEN ON SYPHILIS OF THE NERVOUS SYSTEM. 207 
 
 and discoveries. The question started by Fournier as to the 
 causal relations between syphilis and locomotor ataxia has given 
 rise to a very active discussion; and the connection between 
 syphilis and general paralysis of the insane is a subject which is 
 already represented by a literature of its own. I shall begin with 
 consideration of Syphilis of the Brain. 
 
 Syphilis may make its appearance within the cranium in four 
 different forms. 
 
 1. As syphilitic disease of the bones of the skull and its 
 internal periosteum the dura. 
 
 2. As chronic syphilitic lepto-meningitis, in other words, as a 
 true periencephalitis analogous to syphilitic perihepatitis. 
 
 3. As syphilitic disease of the arteries. 
 
 4. As syphilitic disease of the substance of the brain itself, 
 infective granuloma. This appears either as a circumscribed 
 gumma or as a more diffused infiltration of the brain substance. 
 
 The two last-named forms, syphiloma of the brain and 
 syphiloma of the cerebral arteries, are not only by far the most 
 common, but it seems generally occur in association. For the 
 understanding of the multiform almost kaleidoscopic pictures 
 presented by the symptoms of cerebral syphilis, this is of some 
 importance. 
 
 Let us look first at the general features of these affections. 
 Syphilitic disease either of the dura or pia is attended with the 
 symptoms of chronic meningitis. The evidences are those of diffuse 
 or circumscribed irritation of the membranes, combined with 
 irritative disturbances of the cortical functions, with absence of 
 localising symptoms. Taking precedence of all the symptoms is 
 the violent headache which at times, especially during the night, 
 becomes intolerable. Thereafter the other features of irritation of 
 the cortex, sleeplessness, excitement, inability to think, weakness 
 of memory, hallucinations, and illusions. Focal lesions may be 
 added if the meningeal process penetrates into the brain-substance. 
 This last-named occurrence, which appears to be not at all 
 uncommon, will give rise, if at the base or in the motor areas of 
 the cortex, to distinct motor and sensory derangements which 
 may form a guide to the localisation of the lesion. Or, on the 
 other hand, the hypertrophied tissue of the pia may gradually 
 shrink, producing, if on the convex surface, lesion of the cortical 
 centres, and if at the base, constriction of the cranial nerves. As 
 
208 ZIEMSSEN ON SYPHILIS OF THE NERVOUS SYSTEM. 
 
 far back as 1858 I drew attention to the occurrence of this kind 
 of basal syphilitic lepto-meningitis. I published at that time in 
 Virchow's Archives an observation showing how this variety 
 comes to be of importance for the cranial nerves. 
 
 The case was that of a man 33 years of age, who had passed 
 through an attack of syphilis a year before. With violent headaches 
 there came on diplopia, ptosis on the left side, paresis of the 
 right facial, paralysis of the palate, and difficulty in speaking. 
 The examination showed complete paralysis of the left 3rd, the 
 right 4th, the 6th on both sides, and the right facial, paresis of 
 the right 3rd and left facial, and lastly paresis of the right upper 
 extremity. Severe vertigo, staggering gait walking being only 
 possible when he was supported on either side. Death from 
 pulmonary phthisis followed. 
 
 The post-mortem showed considerable thickening of the pia at 
 the base and constriction of the cranial nerves. With the 
 microscope could be made out degenerative atrophy of those that 
 had been completely paralysed, and partial degeneration of those 
 that had been merely paretic. The olfactory, optic, trigeminal, 
 hypoglossal, glosso-pharyngeal, and spinal nerves and the right 
 vagus were intact. The brain substance showed nothing abnor- 
 mal. No attention was paid at that time (1858) to the arteries. 
 
 Griesinger published an analogous case shortly after this one. 
 While on the whole such instances as those of syphilitic perien- 
 cephalitis are of rare occurrence, yet there are a number of recent 
 clinical and anatomical observations which go to confirm my own 
 and Griesinger's statements. 
 
 The diagnosis is determined apart from the history by the 
 initial headache and the progressive paralysis of many of the 
 cerebral nerves, especially the third ; further, by the condition of 
 the pupils and the reaction of the paralysed nerves to electricity. 
 The result of antisyphilitic treatment may also give considerable 
 aid, but if the case is far advanced, as the preceding was, our 
 experience hitherto has been that this may not be of much 
 assistance. , 
 
 The syphiloma of the brain substance, a specific infective 
 granuloma, pursues its course, on the other hand, with the 
 features of a circumscribed cerebral tumour. The headache, the 
 epileptiform convulsions, the monoplegic or hemiplegic pareses 
 or paralyses, with subsequent spasmodic attacks in the paralysed 
 muscles, the cortical speech-derangements, the condition of 
 intellectual and mental weakness, and the apoplectiform attacks 
 
ZIEMSSEN ON SYPHILIS OF THE NERVOUS SYSTEM. 209 
 
 — these symptoms warrant the diagnosis of a syphilitic cerebral 
 tumour, if it is certain there has been previous syphilis, and if the 
 patient is still young or not past middle life. Of course in a case 
 like this the favourable result of antisyphilitic treatment after- 
 wards is of great value for the confirmation of the diagnosis. 
 
 I would like, however, further to draw your attention to some 
 general considerations which may be important in this connec- 
 tion. In a case of syphilitic disease of the brain substance, as a 
 rule the symptoms are not so purely those of cerebral tumour 
 as in other kinds of growth, for in addition to these we have those 
 produced by the lesions in the vessels and membranes. Besides 
 focal symptoms, therefore, we have disturbances in the circulation, 
 in the sensations, and in the intelligence. Again, the epilepti- 
 form attacks are generally very severe, of long duration, and often 
 followed by after-pain persisting for several days. Between the 
 more serious attacks there may come numerous slighter fits of an 
 apoplectic and epileptiform nature, pareses of single cranial 
 nerves, attacks of giddiness or sensory disturbance, often only 
 lasting for a moment, variations in the intensity of the headache 
 and in the general motor and intellectual weakness. 
 
 When cerebral syphilis takes the form, not of tumour, but of 
 syphilitic disease of the vessels, the diagnosis is more difficult. 
 The importance of this arteritis luetica for the central nervous 
 system becomes more evident the more thoroughly it is studied. 
 Attention has only been turned to the affection during the last 
 thirty or forty years, and we may perhaps consider the Danish 
 physician Steenberg the proper discoverer of the connection of this 
 form of arteritis with syphilis. Before his work, which appeared 
 in 1860, isolated observations of disease in the larger arteries of 
 the brain had indeed been published by Virchow, Dittrich, 
 Bristowe, Graefe, and others ; but Steenberg was the first to 
 distinctly recognise the alterations in the vessel-walls as syphilitic 
 and thus give a definite direction to the whole, inquiry. Since 
 then E. Wagner and his pupil Heubner have made a careful 
 study of the finer structural changes in the vessel-wall, and it is 
 especially to Heubner's work, which appeared in 1874, on syphilis 
 of the cerebral arteries that this association, at once so interesting 
 and so practically important, has been generally recognised. 
 
 The discussion on the point whether this specific process begins 
 in the intima as Heubner thinks, or in the media or adventitia as 
 
 p 
 
210 ZIEMSSEX ON SYPHILIS OF THE NERVOUS SYSTEM. 
 
 his opponents suppose, has no great clinical importance. Of 
 much greater consequence is the question as to what constitutes 
 the specific character of the inflammation of the vessel-wall and of 
 the syphilitic granulation tissue. That it depends on invasion 
 by a parasitic infectious germ the pathogenic micro-organism of 
 syphilis can to-day be no longer a matter of doubt. Microscopic 
 evidence of such invasion has been brought forward in various 
 forms, first by Lustgarten, then by Doutrelepont and Schtitz, and 
 finally by Disse and Taguchi, but the needful confirmation is 
 still wanting. 
 
 The study of this syphilitic vascular change and its conse- 
 quences has very great clinical significance. If we simply keep 
 to the facts as they have been established we have the following : 
 syphilitic arteritis leads to narrowing of the vessel-wall, and 
 ultimately to its obliteration; the necessary consequence is 
 limitation of the blood supply and diminished nutrition of the 
 brain substance, and proceeding a step further, anasmic necrosis 
 or white softening. These circ alatory derangements are of the more 
 serious moment that the arteritis has a special preference for the 
 region of the great arteries at the basa, especially the basilar and 
 its branches. In this way the centres of vegetative life in the 
 medulla and the great motor paths in the pons are in danger. 
 At the same time we are not to undervalue the practical 
 significance which attaches to the consecutive atrophy of the 
 different layers in the wall of the larger arteries, especially the 
 fenestrated membrane and the muscular coat. It is this atrophy 
 which gives the conditions for the formation of aneurisms on the 
 one hand, and for rupture of the arteries on the other. 
 
 It has been repeatedly asserted that this arteritis obliterans 
 which occurs in the syphilitic brain is anatomically only slightly 
 different from the endarteritis deformans of old age. As long 
 certainly as we are unable to demonstrate the existence of the 
 pathogenic infective germ of syphilis in the infiltrated tissue 
 in the vessel-wall, to draw the anatomical distinction in any 
 particular case, especially if it is far advanced, will be often a 
 matter of difficulty. Clinically, however, the features of endar- 
 teritis deformans are as a rule very different from those of 
 syphilitic endo- and periarteritis. In the first place, in syphilis 
 the base and the cortex are preferred, while in senile endarteritis 
 it is mostly the region of the distribution of the sylvian artery 
 
ZIEMSSEN ON SYPHILIS OF THE NERVOUS SYSTEM. 211 
 
 which is affected. There are no doubt cases in which, as we at 
 present stand, it is impossible to draw a distinction between the 
 two forms daring life. Those well on in years who have 
 contracted syphilis in earlier life are instances of this. In 
 them thromboses or haemorrhages in the neighbourhood of the 
 sylvian fissure, or aneurisms of the basilar or internal carotid 
 may occur, and without prodromal symptoms for any length of 
 time quickly lead to a fatal issue. Prodromal symptoms going on 
 for a long time have appeared to many to be elements of 
 particular importance in the diagnosis of syphilitic vascular 
 disease ; and they are unquestionably of some value in cases 
 occurring in younger individuals, but they cannot lay claim to 
 much significance in those more advanced in years, for in the 
 case of atheroma occurring in the latter long before the larger 
 branches are completely obliterated we may have symptoms of 
 ischssmia in regions supplied by the smaller twigs. These 
 symptoms may completely disappear through establishment of 
 the collateral circulation, but may again and again recur in the 
 same or some other way, always, however, by preference in the 
 region of the sylvian artery. 
 
 Valuable indications may be gained by the results of ophthal- 
 moscopic examination of the arteria centralis retinas and its 
 branches. At any rate that is my deduction from an observa- 
 tion, which, in association with Dr. v. Hosslin and Surgeon-Major 
 Seggel, I have had an opportunity of making on a patient of my 
 own. 
 
 In this case, that of a robust gentleman of about 35 years of age, 
 the diagnosis of brain syphilis was previously tolerably certain. 
 Besides the history, we had the occurrence of severe epileptiform 
 attacks, various pareses, &c. Intelligence and mental functions 
 were quite normal. Complaints of disturbances of vision led to 
 repeated examinations of the fundus by Surgeon-Major Seggel. 
 The first examination about the end of the second week of treat- 
 ment, showed thickening of the walls of the arteries, absence of 
 the double contour in their outline, and a rather washed-out 
 papilla. Ten days later, during which the mercury and iodide were 
 continued, the double contour was again indicated, though the 
 walls were still thickened and the papillae were more distinct. 
 After another ten days, during which inunction and internal 
 administration of the iodide were continued with great energy, 
 examination showed the thickening of the walls gone, the double 
 contour even in the smaller vessels again distinctly visible, and 
 
212 ZIEMSSEN ON SYPHILIS OF THE NERVOUS SYSTEM'. 
 
 • the papillae of perfectly normal aspect. The arteritic change 
 .therefore had regressed towards the end of the fourth week of 
 , treatment. At the same time the other symptoms had improved ; 
 more especially there were no further convulsive attacks, and the 
 headache, which had previously been permanent, disappeared all 
 "but a trace. 
 
 Should it be shown that this ophthalmoscopic proof of the 
 thickening in the arterial wall and its regression under specific 
 treatment is constantly present in analogous cases, we should 
 have a valuable aid where the diagnosis was otherwise doubtful ; 
 its presence at least would decide in a positive sense the existence 
 of cerebral syphilis. Changes in the fundus have no doubt been 
 previously described in cases here and there, but these have been 
 instances, some of optic nerve atrophy (Laschkiewitsch), others 
 of choked disc, with very dilated and tortuous veins. Fiirstner's 
 case (D. Archiv fur klin. Med., Bd. xxx.) was one of the latter 
 kind, though no doubt there was general thickening of the 
 vessel walls. Choked disc and optic nerve atrophy may, however, 
 as you know, result from any of the very varied lesions which 
 cause increased intracranial pressure or inflammatory and 
 degenerative changes in the intracranial contents. In Fiirstner's 
 case, which Becker in Heidelberg examined along with him, 
 the thickening in the vessel wall persisted up to the time of 
 death. In our case it yielded to specific treatment giving in 
 this way one reason for its diagnosis as syphilitic. For the 
 future in all cases of brain syphilis the condition of the retinal 
 artery should receive special attention throughout the whole 
 course of the disease. 
 
 I have already mentioned the preference which syphilitic 
 disease of the vessels shows for the great arteries at the base, 
 especially for the vertebrals and basilar. The endarteritis 
 deformans of old age occurs frequently enough in these vascular 
 districts also, and in the circle of Willis, but does not readily 
 bring about such a degree of disturbance of the circulation as 
 the syphilitic disease. The significance which disease of the 
 basilar artery has for the vital centres in the medulla is plain 
 when we consider that the twigs going off from it are as Duret and 
 Heubner have shown, mostly terminal arteries. Narrowing of 
 these, or their complete closure, must of necessity lead to 
 necroboisis of those centres on account of the absence of a 
 
•ZIEMSSEN ON SYPHILIS OK THE NERVOUS SYSTEM. '213 
 
 collateral circulation. Putting aside the inferior and superior 
 cerebellar arteries, the branches to the pons are particularly 
 important. These go off from the basilar at a right angle to 
 supply the pons and upper part of the medulla. Cases in which 
 blocking of some of these branches has led to insular softening in 
 the areas supplied have been repeatedly observed. There are, 
 in particular, the cases in which the well-known pontine symptoms 
 occur — difficulties in swallowing, in respiration, and in articula- 
 tion, disturbances of the heart's action, and of the regulation ot 
 heat, polyuria, and alternate paralysis in the great motor paths. 
 The whole complex of symptoms may appear at once, or they 
 may follow one another, in either case without intellectual or 
 mental disturbance. The cases of this kind hitherto known have 
 had a somewhat chronic course, and most of them a fatal termina- 
 • tion ; while a few, with timely antisyphilitic treatment, have for 
 the most part incompletely recovered. I may here put along 
 with these cases one of my own. In this the symptoms developed 
 themselves rather acutely with the features of pseudo-bulbar 
 paralysis, and within a few days reached a height that threatened 
 life. Treatment with iodide of potash produced speedy and almost 
 complete recovery. 
 
 A journeyman locksmith, 29 years of age, acquired a hard sore 
 in his 21st year during his military service. For this he had 
 specific treatment for 14 days in hospital. He was again under 
 treatment six months later for a skin eruption on the back. On 
 the 15th May, 1887, eight years after the infection, he was seized 
 with violent headaches, becoming worse at night. In the after- 
 noon of the 17th May, sudden extreme faintness and violent ringing 
 in the head. In the evening giddiness, diplopia, paresis of the 
 right side of the body with numbness. In the course of the 
 following day paresis of the right side increased, and in the 
 evening complete paralysis. Then parsesthesiaa in the right side of 
 the face, and difficulty in speaking ; 24 hours after the latter began 
 what he said could hardly be made out. No disturbance of 
 consciousness. Admitted on the 20th May. On that day circula- 
 tion hurried, respiration laboured, sensorium quite free. Eight 
 side of face paretic in lower half. Left eyeball imperfectly 
 movable in any direction, rectus cxternus muscle completely 
 paralysed, left pupil extremely contracted with hardly any 
 reaction to light. Tongue moved with difficulty, trembling some- 
 what when pushed out; speech very difficult and scarcely 
 intelligible ; pursing of the mouth for whistling impossible ; taste, 
 smell, and hearing normal ; arch of the palate paretic on left side, 
 
214 ZIEMSSEN ON SYPHILIS OF THE NERVOUS SYSTEM. 
 
 closure of the posterior nares in deglutition imperfectly produced, 
 swallowing of solid food impossible ; sensibility of the mucous 
 membrane of the throat and entrance to the larynx distinctly 
 lowered ; epiglottis immovable and turned to the right ; right vocal 
 cord sluggish, left completely paralysed in the cadaveric position ; 
 staggering gait, inclination to fall backward, especially when eyes 
 are shut ; upper and lower extremities on right side very paretic ; 
 sensibility and electrical reactions normal, knee-jerk exaggerated, 
 ankle clonus not elicited on either side. Old consolidation at right 
 apex, herpetic eruption on left upper eyelid. On the 23rd, all the 
 symptoms especially those connected with the circulation and 
 respiration much worse. Condition in the highest degree 
 threatening. From this day onwards had 45 grains of iodide of 
 potash daily. By the 25th distinct improvement could be noted, 
 especially in the speech and in the difficulty of swallowing. On 
 the 26th, improvement in those two respects still more marked, 
 and rather more power of movement in tongue and left half of 
 palate. Paralysis of left external rectus and left vocal cord still 
 complete. Ineffective coughing efforts followed by noisy inspira- 
 tions ; latter also present in laughing. In the next few days the 
 ptosis in the left side disappeared, the anaesthesia and absence of 
 reflexes in the mucous membrane of the throat and larynx and the 
 paralysis of the extremities in the right side all improved. By 
 the end of the month patient could walk about in the room without 
 a stick ; right leg dragged a little in walking, and strength for 
 coarse movements in left upper extremity still subnormal. Prom 
 the end of May to the beginning of July, when the patient by his 
 own desire was dismissed, there was little further change in his 
 condition though the iodide was continued throughout. 
 
 Patient was seen again on the 29th April, 1888, that is, a year 
 after the appearance of the first symptoms. His condition then was 
 as follows : left external rectus still paralysed. On the attempt 
 to look to the left the eyeball is slightly rotated upwards; 
 left pupil still distinctly smaller than the right, reacts slowly to 
 light, rather better to accommodation for distance. Facial paresis 
 is gone, whistling quite normal; tongue can be moved in all 
 directions, but points slightly to the right when protruded. 
 Speech still somewhat indistinct, slight slurring of the syllables, 
 and after speaking for a time easily exhausted. Care is necessary 
 in swallowing, and if it is quickly done he chokes himself. 
 Sensory and reflex activity of mucous membrane of the throat and 
 entrance to the larnyx still under the normal. Uvula turned to the 
 right, arch of the palate standing a little lower on the left than on 
 the right side, and in vocalizing movement on left side lags behind. 
 Strength of the upper extremity for coarse movements not yet 
 properly restored, but patient works the whole day at his employ- 
 ment as a locksmith. Arm can be lifted to the vertical position 
 without pain. Eight leg can be lifted, though with some effort, 
 
ZIEMSSEN" ON SYPHILIS OF THE NERVOUS SYSTEM. 215 
 
 almost as high as the left. In walking right leg moves stiffly and 
 drags a little with lifting of the pelvis. Fairly nourished, appetite 
 good, no disturbances of sight or hearing. Still headaches brought 
 on without any special cause, and with nocturnal exacerbations. 
 These were very bad at the beginning of this year, and on that 
 account he took to the iodide of potash again. No giddiness as a 
 rule, but it comes on when he stands upon the slightest elevation 
 (e.g., even when he gets up upon a chair). No other pains com- 
 plained of. Feeling in arm and foot normally acute. 
 
 The features of interest in this case are the rapid development 
 and the great diversity of the pontine symptoms — paralysis of the 
 left sixth, paresis of the left third, both facials, the hypoglossal, 
 the glossopharyngeal, the inferior and superior laryngeal; 
 hemiparesis of right half of the body ; involuntary movement 
 backwards, vertigo, headache. Of this group of varied symptoms, 
 which developed within less than a fortnight, those which gave 
 rise to most alarm disappeared under the use of iodide of potash 
 in the course of a few weeks. There remained after that only 
 the paralysis of the left sixth, a slight degree of left hemiparesis, 
 and traces of the difficulty in articulation and deglutition. 
 
 The assumption is that the primary lesion in this case was a 
 syphilitic arteritis, running a tolerably acute course, and affecting 
 the basilar or its branches, together with all the consequences 
 of such a lesion. This receives support from the variety of the 
 symptoms referable to disturbances in both halves of the pons 
 and medulla, with preference of the left half, and from the rapid 
 success which attended the treatment by iodide of potash. We 
 have ajfew similar instances recorded by Heubner, Leyden, 
 Eisenlohr, Eichhorst, and Buttersack, some of which have been 
 completed by autopsy. 
 
 Another case which came under our notice during life (already 
 published by Dr. Rudolf v. Hbsslin in the D. Archiv fur klin. 
 Medicin, vol. xxxvii.) had, besides other cerebral symptoms, 
 great polyuria, and a course attended by fever. 
 
 A man aged 34 contracted syphilis in the camp before Paris in 
 1871. In 1885, 14 years after, he was seized — he said in conse- 
 quence of an injury to the head (a scalp wound from a blow with 
 an iron bar) — with the following symptoms : violent headache 
 and sickness, fainting fits, followed by tremors, giddiness, stagger- 
 ing gait, especially when the eyes were shut, persistent fever of 
 moderate height, and polyuria, the daily urine amounting to 210 
 
216 ZIEMSSEN ON SYPHILIS OF THE NERVOUS SYSTEM. 
 
 ounces with sp. gr. 1002—1005. The only signs of syphilis were 
 an old scar on the fraenum and swelling of the cervical glands. 
 After attempts with various remedies had been made in vain, 
 iodide of potassium was given, and with this there was so manifest 
 an improvement in the principal symptoms in the course of a 
 week that, by way of clearing up the question, the administration 
 of the iodide was then stopped. Immediately the headache, 
 giddiness, polyuria, and fever returned. The diagnosis having 
 been established by this experiment, the iodide was resumed 
 along with mercuric inunction. The striking results of specific 
 treatment on the polyuria and fever are very well brought out by 
 means of diagrams iu the article by v. Hosslin referred to. Four 
 weeks after the antisyphilitic treatment was begun, patient was 
 able to leave cured. As he was subsequently employed as an 
 attendant in the hospital we were in a position to assure ourselves 
 for a year afterwards that the recovery was permanent. Three 
 years later, we have found on recent inquiry, he died of tuberculosis, 
 unfortunately without a post-mortem. 
 
 In. regard to the localisation of the intracephalic changes in 
 this case we must — taking account of the giddiness, the stagger- 
 ing gait, &c. — place the vascular lesion in the basilar and 
 superior cerebellar arteries, as these symptoms point to affection 
 of the pons, medulla, and cerebellum. 
 
 A similar case, affecting a man about 40 years of age, came to a 
 post-mortem lately, after having been under our observation for 
 2 years. In him also an attack of syphilis some years before had 
 been followed by fainting and epileptiform attacks, difficulty in 
 s wallowin g and breathing, staggering gait, at first with involuntary 
 movement backwards and to the left side, and, to begin with, mental 
 disturbance in the form of maniacal attacks, &c. The mental 
 derangement disappeared under the use of iodide of potash, and 
 the other symptoms improved, but only temporarily. Increasing 
 motor weakness in the lower .extremities made walking more and 
 more difficult ; the speech became harder to understand and the 
 breathing more troublesome. Death resulted from pleurisy. The 
 post-mortem, besides demonstrating the pleural effusion and 
 considerable cardiac hypertrophy, showed the walls of all the 
 arteries at the base of the brain greatly thickened, stiff, and 
 gaping, the pons and medulla fallen in and soft. The microscopic 
 examination, after the parts had been completely hardened, un- 
 fortunately miscarried. 
 
 If cases like those of brain syphilis, setting in with definite 
 localising symptoms, can present difficulties in the way of a 
 diagnosis, and can frequently be only lightly interpreted by the 
 
ZIE.MSSEN ON SYPHILIS OF THE NERVOUS SYSTEM. 217 
 
 success of specific treatment, the difficulties are very mucli 
 increased when we have only general symptoms to go upon. 
 The occurrence of headache, giddiness, neurasthenic conditions, 
 intellectual and mental weakness, but too often leave us in doubt, 
 and usually it is only in the sequel, when localising symptoms 
 occur, or a tentative course of iodide of potash succeeds, that the 
 diagnosis is made certain. The difficulties are increased if the 
 patient is up in years, if there is extensive atheroma, if there is 
 present at the same time any cardiac or renal disease, if there 
 has been previous neurasthenia, &c. 
 
 A question of great importance which forces itself on our 
 notice here is that of the causal connection between syphilis 
 and general paralysis of the insane. It has already produced a 
 copious literature, but nevertheless is still very far from a settle- 
 ment. 
 
 I may take it as acknowledged that the view of the disease as 
 the product of a diffuse chronic meningitis and cortical mostly 
 interstitial encephalitis, resulting in atrophy of the cortex, has 
 been pretty unanimously accepted through the work of Mendel 
 and others. I shall leave it undecided how far this view of its 
 pathogenesis is generally justified, and restrict myself to the 
 consideration of its connection with syphilis. 
 
 It was natural enough that the initial irritant for the inter- 
 stitial degenerative inflammation of the pia and cortex should be 
 sought in the infection of syphilis ; and isolated statements were 
 made a long time ago which as a matter of fact seemed to speak 
 for the existence of such a causal relation. Of modern writers 
 Mendel especially has supported this view. His statistics, which , 
 embrace 146 cases of general paralysis, are really very convincing, 
 as they show that in 75 per cent, of all paralytics secondary 
 syphilis has preceded, and this does not take into account 8 cases 
 of chancre which were not followed by secondary symptoms, and 
 9 cases with merely cicatrix on the penis. Alongside these figures 
 referring to general paralysis Mendel places a set dealing with 
 101 cases of other forms of insanity. In only 18 per cent, of 
 these could secondary syphilis be proved to have been an 
 antecedent. The calculations of Eohmell, Snell, Reinhard-, and 
 others lead to similar conclusions. The opponents ot this view, 
 like Westphal, Fiirstner, Obersteiner, Goldstein, and others, give 
 a smaller percentage, but even with them syphilis has preceded 
 
218 ZIEMSSEN ON SYPHILIS OF THE NERVOUS SYSTEty. 
 
 in from 25 to 50 per cent, of the cases of general paralysis,- 
 while in other forms of mental disorder it plays a much smaller 
 part. 
 
 From these materials the conclusion may certainly be drawn 
 that general paralysis of the insane is very much more common in 
 those who have had syphilis than in those who have not. An 
 attempt has lately been made to explain the connection by the 
 hypothesis that the form of cerebral lesion depending on syphilis is 
 not general paralysis but an affection resembling paralysis. 
 Pournier, who was the first to express this view, has named the 
 form pseudo-paralysis of syphilitic origin, and gives a number of 
 differential symptoms by which such pseudo-paral\-sis according 
 to him may be distinguished from genuine dementia paralytica. 
 He notes specially the absence of the delusions of grandeur in 
 the syphilitic pseudo-paralysis. While the majority of the French 
 writers have supported Fournier, ' most of the Germans have 
 protested against the separation of the two forms as artificial. 
 Eumpf, in particular, has lately emphatically asserted that the 
 delusions of grandeur are not absent even in the syphilitic form, 
 so that the differential feature on which Fournier relies most 
 would fall away. 
 
 In this way, then, general paralysis is distinguished essentially 
 from all other mental disorders, that it is much commoner among 
 those who have had syphilis than among those who have not. 
 Now, the connection may be directly causal, or the syphilis niay 
 act in this case as alcoholic and venereal excesses do, as a 
 predisposing influence, lowering the constitution and weakening 
 especially the central nervous system. Which of these two 
 suppositions is the right one we cannot at present decide. 
 
 As to the effect of anti- syphilitic treatment on general 
 paralysis, it appears to have pretty nearly no effect at all. This 
 has been adduced by many as a proof against the dependence of 
 the paralysis on syphilis ; but it really proves very little. The 
 estimate of the results of treatment has to contend in this case 
 with the same difficulties as in the case of tabes. In the 
 beginning of the disease, when perhaps anti-syphilitic remedies 
 may do good, the diagnosis is not certain ; in the later stages, 
 when the diagnosis is reached, these remedies have either no 
 effect at all, or, at the most, we have the disease coming to a 
 standstill, a result which pretty often occurs in paralysis with 
 
ZIEMSSEN ON SYPHILIS OF THE NERVOUS SYSTEM. 219 
 
 no drug treatment whatever. Furthermore, even in undoubted 
 brain syphilis, especially in the later stages of extensive vascular 
 lesion, anti-syphilitic treatment only too often is of no use. 
 Coming to a definite conclusion, then, by the aid of therapeutic 
 experiment is not so easy. Further investigations, let us hope, 
 will bring light on these complicated questions. That they are 
 of the highest practical importance is very evident. 
 
 I come now to deal with the syphilitic diseases of the spinal 
 cord. These lesions are no doubt of much rarer occurrence 
 than those of the brain and its membranes, though recent times 
 have modified our views here also in more than one particular. 
 Lesions of the spinal column and its periosteum, to judge from 
 the small number of recorded cases, are among the greatest 
 rarities. Syphilis of the dura, the arachnoid, and the pia appears 
 to be somewhat more common. It occurs in the form of diffuse 
 gummatous meningitis, the circumscribed gumma of the spinal 
 membranes being rare. 
 
 The symptoms of syphilitic meningitis are those characteristic 
 of chronic meningitis — spinal rigidity and tenderness, with root- 
 symptoms, chiefly sensory, in the form of eccentric neuralgias 
 and paresthesias. When the anterior roots are affected, motor 
 paralysis is a prominent feature ; this possesses all the characters 
 of atrophic paralysis. The absence of other spinal symptoms is, 
 in a case like this, of great value, as shutting out disease of the 
 cord substance itself. Of further importance for the diagnosis 
 of syphilitic disease is the fact that, in accordance with their 
 nervous supply, any muscle or group of muscles in the body may 
 be attacked, the muscles of the trunk being affected as often as 
 those of the extremities. The bladder and rectum may not 
 escape. Anassthesia extending over a wide area may be accom- 
 panied or ushered in by severe neuralgia. 
 
 In short, a picture of disease is presented which, with its 
 combination of sensory disturbance with paralysis and a high 
 degree of atrophy of numerous muscles, can be recognised as 
 something quite" peculiar. Of course differences in the longi- 
 tudinal and transverse distribution of the morbid process can 
 give very great variety to the features of the disease in different 
 cases. Instead of any further description I will give an account 
 of a case that came under my own observation. It is instructive 
 in every respect, and especially in this, as proving that in even 
 
220 ZIEMSSEN ON SYPHILIS OF THE NERVOUS SYSTEM. 
 
 apparently desperate cases of the '-kind life may be saved by 
 
 timely and energetic specific treatment. 
 
 The case was one of a merchant, 37 years of age, in comfortable 
 circumstances. After I had examined him in his own house he 
 was admitted, on my direction, into a private room in the hospital 
 in February, 1881, with the diagnosis, " syphilitic cer.ebro-spinal 
 meningitis." 
 
 Patient had a, chancre in 1862 followed by buboes, and after- 
 wards a skin eruption. Treatment with sulphur baths got the 
 better of the latter after it had persisted for half a year. In 1872 
 he had a vesicular eruption in the neck, which he said disappeared 
 after eight days. In the last year or two rheumatic pains coming 
 and going in the shoulders and legs. In April, 1880, suddenly 
 seized with severe pains down the whole left side, worst in the 
 abdominal and lower thoracic region. In June a feeling of 
 numbness round the body. In August and September remission 
 of pains and onset of anaesthesia over the whole left half of the 
 trunk. In October severe headache, especially in the brow, and 
 pains in all the muscles of the body, worse at night. In December 
 a sudden sensation that his face was divided into two, then 
 diplopia and left-sided ptosis. Eight days later pains in the 
 left shoulder, followed by weakness of the left upper extremity, 
 which in a few days gave place to complete paralysis. . About this 
 time also loss of sensation in the right half of the mouth and 
 nose, so that patient was obliged to chew on the left side, and in 
 snuffing had no sensation in the right nostril. Soon after this the 
 right arm became weaker, and the hand on that side numb. 
 Towards new year weakness in legs to so marked an extent 
 that patient could no longer go without support. Further, he 
 noted complete loss of the sweat secretion on the left side of the 
 face, and distinct diminution of it over the whole left half of the 
 body. Bladder and rectum intact. Intellectual and mental 
 condition normal. 
 
 On his admission into the hospital he was very emaciated. 
 Skin loose and muscles extremely flabby, and everywhere wasted 
 to about the same extent. Upper eyelid drooping, left eyeball 
 almost quite immovable, only slight rotation outwards and down- 
 wards still possible. In right eyeball external rectus completely 
 paralysed. Left half of the forehead smooth, left naso-labial fold 
 partly obliterated, mouth drawn a little to the right, tongue 
 protruded towards the left. Symptoms in the muscles of the 
 trunk are very striking. The left half of the thorax is quite 
 immovable in respiration, the upper intercostal spaces exposed in 
 consequence of the atrophy of the pectorals, and deeply retracted. 
 Muscles in the left side of the abdomen also paralysed completely 
 in the upper half, incompletely below. Patient unable to raise 
 himself from the recumbent position. Over the lower intercostal 
 
ZIEMSSEN ON SYPHILIS OF THE NERVOUS SYSTEM. 221 
 
 spaces on both sides, but more markedly on the left, there is a 
 horizontal furrow moving downwards in inspiration, upwards in 
 expiration (visible diaphragmatic motion). In forced expiration 
 the muscles on the right side of the abdomen contract fairly well ; 
 on the left side below very weakly, and above not at all, so that at 
 each coughing impulse, the left mesogastrium and hypochondrium 
 bellies out to the size of a child's head, and at the same time the 
 lower opening of the thorax is very much dilated. Active and 
 passive movement of right upper extremity possible in all 
 directions ; strength, however, for coarse movements at a mini- 
 mum. Pressure of the hand scarcely perceptible. Left upper 
 extremity very much emaciated, equally so all over, and almost 
 completely paralysed. Resistance to passive movements in the 
 joints. Deltoid, supra- and infra- spinp.ti, latissimus dorsi, pectorals, 
 and serratus magnus paralysed and extremely wasted, muscular 
 substance scarcely to be felt. Points of the fingers can be inserted 
 between the acromion and head of the humerus. Head turned 
 to the right, cervical spine curved to the right, dorsal spine, by 
 way of compensation, to the left. Left scapula approximated to 
 the spine, and fixed in this position on account of contracture of 
 the rhomboids, trapezius (middle and lower portion), and latis- 
 simus dorsi. Legs paretic ; muscles very thin and soft, especially of 
 left leg. Patient can walk with the support of two persons ; feels 
 himself safer when on the left leg than when on the right. 
 Strength of muscles for coarse movements everywhere very much 
 diminished. Dorsi-flexion in the right foot very limited. Left 
 knee-jerk absent, right much exaggerated. Ankle-clonus absent. 
 Cremasteric reflex prompt. Skin reflexes exaggerated, tickling 
 plantar reflex very marked. Tactile conduction normal, pain 
 conduction prompt. Sense of space on the right side moderate, 
 on the left distinctly defective. On the left ' side of the abdomen 
 and thorax almost complete analgesia and anaesthesia, incomplete 
 in. the left lower extremity. Skin of the left inguinal region and 
 of the penis and scrotum rather hypersesthetic. On the right half 
 of the abdomen and thorax sensibility normal, normal also on the 
 left half of the face and tongue. No hyperesthesia in the skin of 
 the extremities on right side. Of trophic disturbances in the 
 skin all that could be seen was on the fingers of the left hand, and 
 on the left foot, where there was a marked hypertrophy and 
 desquamation of the epidermis ; none of this on the right side. 
 The sweat secretion, diminished in the left half of the body since 
 the end of December, has now for a short time been absent 
 altogether on that side ; normal or even exaggerated on the fight 
 side of the face and thorax. This observation was repeatedly 
 verified by means of pilocarpine injections, when the left half of 
 the face remained quite, of the body almost quite, free from 
 perspiration. Electrical examination of the paretic and paralysed 
 muscles gives simple diminution of irritability to both kinds of 
 
222 ZIEMSSEN ON SYPHILIS OF THE NERVOUS SYSTEM. 
 
 current, more evident on the left than on the right. In the 
 completely paralysed nerves and totally atrophied muscles of the 
 left arm and shoulder and left half of the abdomen this has gone 
 on to complete loss of reaction to either current. ~So trace of the 
 reaction of degeneration. K. CI. C. everywhere greater than 
 A. CI. C. Lightning-like contraction in the paretic muscles. Idio- 
 muscular contraction easily brought out in the atrophied muscles. 
 Of subjective sensations patient complains of a feeling of extreme 
 muscular weakness all over, a feeling of numbness around the 
 body and in the left thigh, at times cramps in the left lumbar 
 region, and on one occasion pain in the left shoulder. Otherwise 
 he was free of pain. Appetite good and bowels regular, always 
 free of fever, and in good spirits. 
 
 On the 10th March patient left the hospital essentially improved, 
 having used over If ounces of iodide of potash and nearly 2f 
 ounces of mercury ointment. In all the paralysed muscles traces 
 of contractility were showing themselves. Even the left upper 
 eyelid could be lifted a little, though always with the help of the 
 frontalis muscle. The unilateral sweating on the right side of the 
 face was still present. In the following weeks, under treatment 
 at his own house, he made tolerably rapid progress, and from the 
 middle of April onwards patient was engaged once more in his 
 business. 
 
 It is of the greatest value to keep striking cases like this 
 under observation over a long period. Unfortunately we know 
 from experience that severe cases of cerebro-spinal syphilis, 
 almost always in a longer or shorter time, and in spite of the 
 most skilful and energetic treatment, relapse, and ultimately 
 succumb to the malady. It was thus specially interesting to 
 follow up this instance of relative recovery from an unusually 
 severe attack of the kind. The patient, at my request, willingly 
 allowed himself to be visited again in April, 1888, eight years 
 after the illness. The result of my examination surprised me in 
 more than one particular. 
 
 His general condition is in every respect satisfactory. He is 
 engaged in his very extensive business from morning to night, 
 mounts stairs without difficulty, and walks for hours at a time. 
 He is in a restaurant for several hours every evening, eats largely, 
 and drinks freely both of beer and wine. But in spite of this 
 capacity for exertion, the examination brought to light many and 
 serious traces of the illness he had passed through. The head is 
 now held upright. The spinal column, however, with the whole 
 trunk, has a bend to the left, and on account of this he has worn 
 ior some years a corset with arm supports, which he finds very 
 
ZIEMSSEN ON SYPHILIS OF THE NERVOUS SYSTEM. 223 
 
 useful. The spine is not tender to touch, though this has been 
 the case only for a year past ; before that it was " sore " on 
 touching. In the legs the muscles are strong and the movements 
 normal. The lower margin of the costal framework is pushed a 
 little forwards on the left side. The whole left half of the thorax 
 is immovable both in ordinary and deep breathing. In coughing 
 the left lower thoracic and left upper abdominal regions are strongly 
 pushed forward. Abdominal and thoracic muscles in left side, 
 also muscles of arm, especially upper arm, on the same side are 
 thin. Left deltoid moderately atrophied, and shoulder joint 
 almost completely anchylosed. On this account arm -;an only be 
 raised to the horizontal position, and its muscles and those of the 
 hand are less capable of work than those on the right side. 
 Facial mobility on the left side is again quite normal, and the 
 play of features very lively. Paralysis of the left third still persists 
 in part, the movements of the eyeball upwards and downwards 
 being very limited, inwards rather better. The ptosis is gone. 
 Function of the right external rectus almost normal. The left 
 pupil is rather smaller than the right ; both react sluggishly. 
 Patient wears a dimmed glass in front of his left eye, as the 
 double images standing on different levels are a source of great 
 annoyance. When his spectacles are taken off these images are at 
 first scarcely noticeable, but gradually they separate, the separation 
 being produced by the image for the left eye moving upwards and 
 to the left. Apart, however, from the effect of the double vision, 
 patient walks unsteadily, easily stumbles on the level ground, and 
 has to be very cautious, especially in moving round. After over- 
 exertion in walking or stair climbing he easily gets cramps in the 
 muscles of the thighs and calves, very markedly in the peroneal 
 muscles, also in the quadratus lumborum and abdominal muscles. 
 These cramps are sometimes more on the one side, sometimes on the 
 other. Up to two years ago walking for any length of time brought 
 on sudden attacks of diarrhoea, or even involuntary motions of the 
 bowels, and under the same circumstances sudden desire to pass 
 water with involuntary action of the bladder if the desire could not 
 be given efiect to. Also passed water during sleep. During the last 
 year or two these vesical and rectal troubles have ceased. Some 
 ataxia ; standing with the eyes shut produces unsteadiness ; knee- 
 jerks quite gone; sensibility over the left foot nearly normal, 
 tactile distance in the toes being 12 millimetres. Complete 
 anaesthesia in the left thumb. Cutaneous sensibility in the 
 left arm and left side of the abdomen and thorax still markedly 
 deficient. Over the front of the left thigh distinct anaesthesia. 
 Over the left side of the face, where at first there was complete 
 anaesthesia, sensibility is now quite normal, but the secretion of 
 sweat is not restored. Sexual functions, which at first were 
 retained, have completely disappeared for almost seven years. 
 Urine normal in quantity and free from albumen and sugar ; can 
 
224 ZIEMSSEN ON SYPHILIS OF THE NERVOUS SYSTEM. 
 
 be kept for any length of time. Appetite and bowels always 
 normal. 
 
 This case — a typical picture of syphilitic cerebro-spinal men- 
 ingitis with multiple root-neuritis — showing in its features a 
 remarkable agreement with those of Buttersack (Archiv f. 
 Psyehiatrie, xvii. p. 603) and Kahler (Prag. Zeitschrift f. Heil- 
 kunde, 1887, 1), both of which ended fatally. Affection of the 
 substance of the pons and medulla was from the very first by 
 no means out of the question. But the chief element was the 
 atrophic paralysis arising from the lepto-meningitic root-neuritis. 
 In our case this had reached a greater degree and a more exten- 
 sive distribution than has ever previously been recorded, at any 
 rate in instances where recovery followed. This gives quite a 
 peculiar value to the observation, for it shows the extent to 
 which the lesion may go, and yet be capable of relative cure if 
 an energetic antisyphilitic treatment is commenced in time, and 
 further, it teaches that such cures may be permanent. That the 
 cure may fall short of being complete is merely the rule enforced 
 by all previous experience. 
 
 The subsequent development of a kind of atypical tabes is 
 particularly interesting. The symptoms were, some degree of 
 ataxia, absence of the knee-jerks, impotence, and partial immo- 
 bility of the pupils. 
 
 Such cases of syphilitic cerebro-spinal meningitis with multiple 
 root-neuritis are quite easy to diagnose. The flying pains at the 
 commencement, the rigidly upright position of the spine, the 
 symptoms indicating implication of the base of the cerebrum, 
 and the spinal roots, are all characteristic enough. More diffi- 
 culty arises in the differential diagnosis between a circumscribed 
 spinal meningitis, for example, meningeal gumma, and syphilis 
 of the vertebras, as in the latter case also we have local tender- 
 ness and rigidity of the spinal column. A swelling of one or 
 more vertebras with local tenderness probably always means 
 syphilis of the vertebras, but of course if the growth is in the 
 vertebral canal there may be no swelling. We must, besides, 
 not overlook the fact that gummatous periostitis in the vertebral 
 canal may set up a morbid process in the meninges, and 
 finally even in the substance of the cord itself. But these 
 syphilitic lesions in the spinal canal are under any circum- 
 stances not common, and of the various localisations here 
 
ZIEMSSEN ON SYPHILIS OF THE NERVOUS SYSTEM. 225 
 
 under review syphilis of the vertebrae themselves seems to be 
 the rarest. 
 
 Our knowledge of syphilis of the substance of the spinal cord 
 is little more than in its first beginnings. In the few cases that 
 have been accurately examined histologically we have the arteritis 
 with the thickening of the vessel wall going on to obliteration, 
 the multiplication of nuclei in the adventitia, and the cellular 
 infiltration in the perivascular lymph-spaces. Professor Bol- 
 linger recently demonstrated to us some very instructive pre- 
 parations showing these vascular changes from a case that had 
 died of somewhat acute corebro-spinal syphilis. 
 
 But such changes appear to be by no means so common in the 
 cord as in the brain ; and the discovery and proper estimate of 
 them during life is certainly often attended with great diffi- 
 culties. For the differential diagnosis Bumpf lays most stress 
 on this, that syphilitic myelitis has no tendency to produce puru- 
 lent breaking down or softening, as is the case with transverse 
 myelitis, and that accordingly the clinical, features of syphilis of 
 the cord correspond more to those of a tumour than to those of 
 a transverse myelitis. We have chiefly the symptoms of such 
 irritation as attends only partial destruction of the conducting 
 power of the cord, excentric neuralgias, spastic phenomena, 
 cramps, along with some degree of paralysis. But in each indi- 
 vidual case we must have present other late forms of syphilis, or 
 evidence that there have been such formerly, before the syphilitic 
 nature of the myelitis is regarded as proven. 
 
 Of surpassing importance appears to be the part which syphilis 
 plays among the causes of locomotor ataxia. Fournier in 1876 
 was the first to express the opinion that locomotor ataxia in the 
 majority of cases was due to syphilis. After him Berger and 
 Erb in Germany lent substantial support to the view by the 
 results of their extensive inquiries. Erb especially, in a series 
 of publications, has ' exhibited the causal relationship between 
 syphilis and locomotor ataxia as statistically proved. The state- 
 ments of these authorities have been confirmed by the experience 
 of a number of trustworthy observers, as Gowers, Benedikt, 
 Erlenmeyer, Beumont, Voigt, and Bumpf. The other side of 
 opinion is represented by Westphal, Leyden, Bemak, Lancereaux, 
 and Althaus, who have expressed themselves as for the present 
 against the connection. The differences between the figures of 
 
 Q 
 
226 ZIEMSSEN ON SYPHILIS OF THE NEKVOUS SYSTEM. 
 
 individual observers are very great and at present inexplicable. 
 Erb, whom we may certainly call a cautious and trustworthy 
 investigator, basing his statements on the carefully recorded 
 histories of 100 cases, gives 91 per cent, of them as preceded 
 by chancre and syphilis, secondary syphilis having certainly 
 occurred in 61 per cent., and chancre, without proof of constitu- 
 tional syphilis in 20 per cent. Only 9 of the 100 cases had no 
 specific history. Alongside these numbers Erb places those 
 giving the occurrence of chancre and syphilis in 1,200 indi- 
 viduals with no tabes. 10-25 per cent, of them had had syphilis 
 and 12'5 chancre alone. Fournier also gives the percentage in 
 ataxies as -91, Althaus as 86'5, Voigt as 81, Bernhardt and 
 Eisenlohr each as 60, Rumpf as 70. In all these numbers 
 syphilis and chancre are reckoned together. My own observa- 
 tions in hospital and private practice since I have paid precise 
 attention to this point in each individual case give 71 per cent, 
 of syphilis and chancre combined as preceding the ataxia. On 
 the other hand no doubt there are many authors who only make 
 out from 30 to 40 per cent. At the very least we can certainly 
 say, what even the opponents of Pournier's and Erb's theory 
 must grant, that there is a causal relationship between syphilis 
 and tabes. Whether the former is the direct or only the pre- 
 disposing and auxiliary cause of the latter must, as in the case 
 of general paralysis, remain for the present undetermined. 
 
 The anatomical changes in sclerosis of the posterior columns 
 so far as they are yet known give no handle for any estimate of 
 the causal relationship, nor do the effects of specific treatment. 
 The result of the use of both mercury and iodide of potash in 
 ataxia is in general very unsatisfactory, though cases of un- 
 doubted improvement and even recovery have been related by 
 such competent observers as Erb, Berger, and Bumpf. It must 
 be borne in mind, however, that most cases of locomotor ataxia 
 come under treatment at a relatively late period, and that while 
 they certainly as a rule not only do not improve but even get 
 worse with iodide of potash and mercury it is possible that good 
 results might have been obtained in the initial stages. 
 
 But any estimate of the results of treatment in tabes is ren- 
 dered uncommonly difficult on account of the spontaneous im- 
 provements or pauses as regards both the general progress of the 
 disease and the individual symptoms which occur under any 
 
ZIEMSSEN ON SYPHILIS OF THE NERVOUS SYSTEM. 227 
 
 treatment or none at all. Instances occur of suspension of the 
 progress of the affection for ten, fifteen, or thirty years, even of 
 its coming to a full stop. I have myself seen, and still have 
 under my eye, cases of the latter. 
 
 It is therefore impossible at present to be certain about the 
 causal relation between syphilis and locomotor ataxia, and we 
 can perhaps hardly expect the matter to be cleared up until both 
 our diagnosis and our treatment are under the guidance of 
 pathological histology, and a knowledge of the pathogenic micro- 
 organism of syphilis. At present we can only say this much, (1) 
 that there is a causal relationship between syphilis and locomotor 
 ataxia, and (2) that the treatment of a case of locomotor ataxia 
 on antisyphilitic lines is only indicated in the initial stage of 
 the case, and where there is no doubt about the syphilitic 
 infection. 
 
 We come finally to consider syphilitic disease of the peripheral 
 nerves. That there is such a thing is beyond doubt, and the 
 occurrence of a syphilitic neuritis seems to me to be even 
 commoner than we have hitherto assumed. The microscopic 
 examination of nerve trunks affected with this neuritis shows the 
 same changes as characterise the specific disease of the central 
 nervous system — the peculiar vascular changes, proliferation of 
 nuclei in the lymphatic sheaths, formation of swellings by means 
 of infiltration of granulation cells into the perivascular lymph 
 spaces, absence of the tendency to degenerate, breakdown, or 
 suppurate, rather a steady persistence of the condition of 
 irritation, eventually regression with hyperplasia of the connective 
 tissue and cicatricial shrinking. The clinical features may be 
 gathered from this description — an obstinate affection with 
 persistent symptoms of irritation and moderate disturbance of 
 function. 
 
 The most usual form is syphilitic neuralgia from neuritis of 
 sensory and mixed nerves. It may occur in any nerve, but the 
 trigeminal and the sciatic are the commonest seats. It occurs 
 along with other syphilitic processes, especially with specific 
 periostitis of the skull, or with disturbances in the ocular muscles, 
 pupil, &c. In this way it is of great importance in a case of 
 obstinate sciatica, in one who has had syphilis or is yet syphilitic, 
 to note the occurrence of ptosis, paralysis of ocular muscles, any 
 difference in the size of the pupils, or absence of the pupillary 
 
228 ZIEMSSEN ON SYPHILIS OF THE NERVOUS SYSTEM. 
 
 reaction to light, all phenomena which make it probable that the 
 neuralgia is of specific origin. Nocturnal exacerbation of the 
 pain also points to syphilis, especially when the coming on 
 of the pain at night and subsidence after midnight occur with a 
 certain regularity. The ineffectiveness of the usual antineuralgic 
 remedies, e.g., heat, blisters, and the galvanic current on the one 
 hand, with the success of iodide of potash on the other, is in 
 favour of syphilis ; so is marked and persistent thickening and 
 shortening of the affected nerve trunk, an appearance which can 
 be observed particularly in the sciatic with surprising distinct- 
 ness. Seeligmuller has described a peculiar distribution of 
 neuralgic pain in the head as characteristic of syphilis. The 
 region affected is a strip two or three finger breadths in width, 
 going from one ear to the other right across the vertex. The 
 pain is worse at night, interfering with sleep. It may be brought 
 out by pressure. It remain's yet to be ascertained whether this 
 neuralgia has its seat in the scalp, perhaps in the auriculo- 
 temporal nerve (the opinion of Seeligmiiller), or whether there 
 is some affection of the meninges (as Eumpf thinks probable 
 from the frequent association of other syphilitic cerebral 
 symptoms with it). Anyhow, antisyphilitic treatment in 
 Seeligmiiller's cases was attended with immediate success. One 
 circumstance more in this connection is worth mentioning. 
 Sometimes in the course of syphilitic skin eruptions and 
 syphilitic neuralgia other , anomalies of function occur in the 
 affected nerve districts, such as anaesthesia, hypersesthesia, 
 analgesia, and disturbances of reflex action. 
 
 Among the nerves of special sense, the optic is the favoured 
 seat of syphilitic disease, as the literature of ophthalmology 
 abundantly shows. The syphilis takes the form partly of re- 
 tro-bulbar neuritis, partly of syphilitic papillitis, partly, as I 
 previously mentioned, of retinal arteritis. In the two first forms 
 the prognosis, both in my experience and in that seemingly of 
 every one else, is bad. In regard to the last form, the syphilitic 
 disease of the artery, nothing very definite can be said about the 
 prognosis ; the favourable result in my above-mentioned case, in 
 which the infiltration in the arterial wall went back under 
 specific treatment, is an isolated observation and proves nothing. 
 
 The other nerves of special sense are so rarely affected in 
 syphilis as hardly to come into consideration. 
 
ZIEMSSEN ON SYPHILIS OF THE NERVOUS SYSTEM. 229 
 
 It remains for me to say a little about the treatment of syphilis 
 of the nervous system. After a pretty extensive personal expe- 
 rience, which agrees with that of other physicians who have paid 
 attention to this question, I advise you as follows : in those 
 affections of the nervous system I have mentioned, as well as in 
 several others running a severe course, if there is a syphilitic 
 history, and if the affection is not too far advanced, make at least 
 an attempt with antisyphilitic treatment, and if you have any 
 success go on with it most energetically. I can only repeat 
 what has been often said, the harm that can follow such an 
 attempt is in any case trifling, while the benefits may be the 
 greatest possible, namely, the preservation of life. Iodide of 
 potassium is generally sufficient in this kind of tentative course, 
 but if the experiment is attended with success it will not do 
 to remain content with that ; energetic treatment with mercury 
 must be added. You will also along with those two drugs 
 employ the other therapeutic methods which experience has 
 proved effectual in inveterate syphilis, in particular the use of 
 the hot springs of Aix-la-Ohapelle and Wiesbaden, hydropathy, 
 sarsaparilla, &c. In a case of this kind requiring specific 
 treatment to be continued over a long period, I agree with 
 Fournier, Neisser, and Eumpf, who advise alternate courses of 
 mercury and the iodide. Only in this way can we be certain of 
 guarding against a continuance or a return of the syphilis in the 
 brain or spinal cord. 
 
PROGRESSIVE 
 MUSCULAR DYSTROPHY. 
 
 BY 
 
 Phot. WILHELM ERB, 
 
 DIRECTOR OP THE MEDICAL ClINIQUE IN HEIDELBERG. 
 
 Translated by 
 A. M. STALKER, M.A., M.D. : 
 
 Physician to the Dundee J&oyal Infirmary 
 
PROGRESSIVE MUSCULAR DYSTROPHY. 
 
 Gentlemen, — 
 
 We owe the notion of progressive muscular atrophy to the 
 descriptions of Aran 1 and Cruveilhier 2 and above all to the 
 incomparable clinical powers of Duchenne 3 . The disease they 
 introduced us to under that name — a chronic, insidious, slow, 
 general muscular wasting — has in its various forms kept up its 
 interest for pathologists to this day. Nor has the conflict of opinion 
 about these forms come to a halt. In our own day, in the last 
 ten years, this interest has shown itself in the most lively way 
 in a series of recorded cases and publications. New ways of 
 looking at the facts have been proposed, new opinions have 
 been formulated and actively discussed. These discussions 
 appear to have essentially advanced our knowledge, clearing up, 
 and in part reconciling the various mutually hostile views. 
 
 To begin with, there were considerable differences of opinion 
 about the nature and proper seat of the disease. One party 
 (Aran, Duchenne, Friedberg) explained it as a primary muscular 
 lesion, while another (Cruveilhier, L. Clarke, R. Eemak, 
 Eulenburg and Guttmann, and others) held that it was a disease 
 taking origin in the nervous system — spinal cord or sympathetic. 
 Gradually, however, under the influence of the French school, 
 aided by a happy series of clinical and anatomical observations 
 (Luys, Hayem, Charcot and Joffroy, Duchenne and Joffroy, 
 Charcot and Gombault, &c), the theory of the spinal origin 
 gained ground. By Charcot* in particular the theory was 
 developed in an attractive and convincing way, and chronic 
 degeneration of the anterior horns of grey matter with dis- 
 appearance of the large multipolar nerve-cells was laid down as 
 its primary cause. 
 
 But this view did not remain uncontradicted. It was very 
 energetically opposed by Friedreich, who in his well known 
 
284 ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 
 
 monograph 5 (1874) defended the myopathic origin with great 
 learning and acuteness ; according to him the disease was a 
 chronic inflammation of the muscles, a chronic progressive poly- 
 myositis. But Friedreich's weapons were not sharp enough ; 
 he based on a series of cases that was sadly in need of proper 
 sifting and contained a good deal that was foreign to the 
 subject, and his microscopic work was not equal to the require- 
 ments even of that time. So the triumph of the neurotic 
 theory was temporarily assured, and the practical unanimity 
 with which it was accepted is evident from Kussmaul's essay 6 
 in the present collection (No. 54, 1873). Even the very 
 remarkable and now thoroughly understood case published by 
 Lichtheim 7 in 1878 made no change in public opinion. 
 
 During all this time, of course, " progressive muscular 
 atrophy " was accepted as a clinical unity, and though much 
 was taken from it as not belonging to it, yet there was a very 
 distinct tendency to extend its limits in various directions. 
 The pseudo-hypertrophic paralysis of children, which had been 
 first described by Griesinger and afterwards more exactly by 
 Duchenne, and which certainly at the first glance appeared to be 
 far enough removed from it, was even by Friedreich brought 
 into association and viewed as essentially identical with it. 
 Leyden 8 (1876), however, with true clinical instinct, in his 
 treatise on Diseases of the Spinal Cord, made a proposal to 
 separate from the rest under the term " hereditary ; ' certain 
 forms of progressive muscular atrophy which occur in families. 
 He gave, though with insufficient exactness, the clinical features of 
 the variety, and even then directed attention to a certain like- 
 ness which it bore to pseudo-hypertrophic paralysis. Moebius 9 
 (1879) went still further, and without any hesitation brought 
 the latter, the pseudo-hypertrophic form, which also frequently 
 occurs in families, into one group with Leyden's. But these 
 views failed at first to find general acceptance, evidently from 
 the fact that neither clinically nor anatomically were they laid 
 down with sufficient precision. 
 
 In the meantime the advance in the study of the nervous 
 system had succeeded in separating from progressive muscular 
 atrophy the following : the results of acute anterior poliomyelitis, 
 the chronic forms of poliomyelitis, chronic multiple neuritis, the 
 atrophies following joint affections, syringomyelia, and the various 
 
ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 235 
 
 secondary spinal amyotrophies. With all this curtailment, how- 
 ever, there was still a residuum of considerable importance included 
 under the apparently one and undivided progressive muscular 
 atrophy. At that time (1883), grounding on numerous cases of my 
 own I made an attempt 10 to show that this apparent unity contained 
 at least two clinically and probably anatomically different forms 
 of disease, and that these were clearly distinguishable throughout 
 in symptoms, development, localization, and actual condition of 
 the tissues. By the side of the well-defined spinal form, which 
 depends on lesion of the anterior horns of grey matter, I placed 
 another, which I called "juvenile " muscular atrophy, and I sought 
 then to show in detail that the pseudo-hypertrophic paralysis 
 and the hereditary form of Leyden both belong to the latter 
 type. Looking at the matter in this way, and with the light 
 thrown upon it by Lichtheim's case, it followed jbhat probably 
 we had in these latter forms not a spinal affection but a purely 
 muscular lesion, in which the nervous system, more particularly 
 the spinal cord and the peripheral nerves, appear to be quite 
 intact. Thus the view maintained with such obstinacy by 
 Friedreich was recognised as having at least partial justifi- 
 cation. 
 
 The separation of the two forms which I proposed, and which 
 I arrived at exclusively from the observation of living cases and 
 from carefully noting the differentiating features, met shortly 
 with almost universal acceptance. It was of especial value that 
 Charcot and his pupils at once and unreservedly closed with 
 my view and proceeded to give it greater breadth and its 
 foundations greater firmness. Shortly afterwards Duchenne's 
 " infantile " muscular atrophy, on which I had not touched 
 and whose essential criterion is commencement in the face, was 
 recognised by Landouzy and Dejerine n as a primary myopathy, 
 the central nervous system remaining normal ; after some little 
 reluctance they associated this also with my juvenile and with 
 the pseudo-hypertrophic form. The results of some more 
 autopsies in cases of juvenile muscular atrophy (Fr. Schultze, 12 
 Landouzy and Dejerine, P. Marie) contributed in no small 
 degree to the establishment of the, theory, and additional 
 progress has been made through the large number, partly of re- 
 corded cases and partly of careful anatomical and clinical studies, 
 which the last year or two have produced (Zimmerlin, Fr. 
 
236 ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 
 
 Sehultze, Marie-Guinon, Edgren, Frohmaier, Penzoldt, Hopmann, 
 Singer, Ladame, Hitzig, Sachs, Westphal, F. Raymond, and 
 many others). Through all these more recent works, with few 
 exceptions, there runs as a fundamental supposition the view that 
 the way in which I have put this matter is completely justified, 
 and, although many of the details are still subjects of dispute, 
 and many important questions still await solution, we are 
 now standing on clearer and firmer ground than we did fifteen 
 years ago. 
 
 Allow me now, gentlemen, to bring before you to-day some 
 cases by means of which you can form a judgment of your 
 own : 
 
 1. You have here a young man, twenty years of age, Theodor 
 Brandt. He works in a brewery, and has sought our help on 
 account of increasing weakness and emaciation in his arms and 
 legs. He is the youngest of twelve children, and an elder brother 
 suffers, it seems, from the same trouble. The affection com- 
 menced gradually, in his seventeenth year, with weakness in the 
 arms and legs, falling in over the region of the pectoral muscles, 
 and wasting of the upper arms. He has never had either pains 
 or parassthesise, and is otherwise perfectly well. 
 
 Tou see before you a strongly -built man, in whom at first the 
 only thing that strikes you is the great slenderness of the upper 
 arms as compared with the forearms and shoulders, and the 
 abnormal position of the shoulder blades. If you examine more 
 carefully, you will find very extensive, and in part extreme, atrophy 
 and weakness of a large number of the muscles in the trunk and 
 upper extremities. 
 
 These are as follows : the pectorals (especially in the middle, 
 and lower bundles, the clavicular portions being in parts un- 
 touched) ; the trapezii (almost completely disappeared) ; the 
 latissimi dorsi (on the right side almost completely gone, on the 
 left all but a slender bundle of fibres on the anterior edge) ; the 
 serrati magni (especially on the right side); rhomboids (only 
 partly, and in moderate degree); sacrolumbales and longissimi 
 dorsi with their continuation in the neck (largely disappeared) ; 
 bicipites and brachiales antici (on the right side extensive atrophy, 
 moderate on the left); supinatores longi (on both sides wholly 
 gone); and tricipites (on right side extreme atrophy, moderate 
 on left). 
 
 These atrophied muscles contrast strongly with the following, 
 which are well preserved, or even distinctly hypertrophied : sterno- 
 mastoids and splenii (normal and well developed); levatores 
 anguli scapulae (slightly hypertrophied); deltoids (in the lower 
 
ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 237 
 
 part on left side distinctly hypertrophied, firm and hard, in the 
 upper part rather atrophied; on right side throughout more 
 atrophied, but in the lower part still hard and firm) ; supraspinal 
 (strongly developed) ; infraspinati (on both sides distinctly hyper- 
 trophied, very hard and firm); teretes ma] ores (on both sides 
 rather thin) ; coracobrachiales (very powerful and well developed) ; 
 flexors and extensors in the forearm (on both sides normal 
 throughout and very strong) ; and the small muscles of the hand 
 (all of them normal and acting well). The facial muscles also are 
 perfectly normal. 
 
 The upper arms are from 2 to 4 cm. less in circumference than 
 the forearms. The forearms in the upper part are rather more 
 cylindrical in shape than usual. 
 
 In the lower extremities there are very few changes to be made 
 out; the thighs are almost quite normal, perhaps the tensor 
 fasciae is a little wasted. In the legs there is distinct weakness 
 of the peroneal region on both sides, especially in the tibialis 
 anticus muscle, which on the right side is also a little atrophied. 
 
 The recti abdominis are in good condition, and acting well, but 
 the flat abdominal muscles are distinctly weak, and when the 
 head is raised up from the lying position swellings of elastic 
 consistence make their appearance in the sides of the abdomen. 
 Muscles feel for the most part rather soft, but are nowhere 
 tender. No fibrillar twitchings. Mechanical irritability in the 
 affected muscles is everywhere distinctly lowered, especially in 
 the peroneal regioD (tibialis anticus). Electrical irritability 
 everywhere more or less lowered, especially to direct stimulation ; 
 no qualitative change, and nowhere even an approach to the 
 reaction of degeneration. 
 
 Sensibility perfectly normal. Skin reflexes normal, tendon 
 reflexes absent in the upper arm (triceps and biceps), present in 
 the forearm, active in lower extremity. 
 
 Head, cranial nerves, special senses, internal organs, all per- 
 fectly normal. 
 
 Here, gentlemen, you have a typical picture of the disease 
 which I have described under the name of juvenile muscular 
 atrophy. The case is in the medium stage of development. 
 
 Turn your attention now to this next patient. 
 
 2. Max Mudrak, a locksmith, twenty-two years of age, apparently 
 of a healthy family, among whom no affection of a similar nature 
 to his own has been observed. 
 
 Began his apprenticeship at fourteen years of age, and was 
 obliged to work very hard. Not long after this his shoulder- 
 blades were observed to stand out in a peculiar way, and by the 
 time that he was eighteen this was very noticeable. From his 
 
238 
 
 ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 
 
 twentieth year onwards felt his work harder on him, and observed 
 that his right upper arm was getting thinner. Now it is only 
 with some trouble that he can, "with a jerk," raise his arm to the 
 vertical position. Lately great exhaustion in his legs and some- 
 times in his back. Has never had pain. Has had frequently 
 migrainous headache ever since his schooldays. Otherwise quite 
 healthy. 
 
 If now, gentlemen, you will take a look at this man, you will 
 see that he is of middle height and well built. He strikes you at 
 
 once by the following peculiarities: the neck is very broad, thn 
 shoulders very sloping, and the shoulder-blades standing out ; in 
 contrast with the enlarged deltoids and sturdy forearms his upper 
 arms are remarkably thin ; there is slight lordosis of the lumbar 
 vertebrae, and his lower extremities are very large. 
 
 More careful examination brings out, as in the case of the last 
 patient, extensive wasting and loss of power in a large number of 
 the muscles in the trunk and upper extremities. 
 
ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 239 
 
 The details are as follows : pectorals gone on each side, all but 
 the clavicular portion ; trapezii all but disappeared ; latissimi on 
 the right side almost altogether, on left in great part gone ; 
 serrati magni the same ; rhomboids atrophied to a slight extent ; 
 biceps on right side greatly atrophied and weak, on the left in the 
 lower half as on the right, in the upper half contracting strongly 
 into a hard lump; brachialis anticus on the right side more 
 atrophied than on the left ; supinator longus almost quite absent 
 on both sides ; triceps greatly atrophied on both sides, more on the 
 left ; extensors in the forearm on right side partially gone, also 
 first and second interossei on right side somewhat weak and 
 wasted ; erector spinae a little weak on both sides, especially on 
 the right ; lateral abdominal muscles distinctly weak. 
 
 In marked contrast to these the following muscles are normal 
 or even enlarged and very powerful: sterno-mastoid distinctly 
 enlarged ; levator anguli scapulae, splenius, muscles of the neck 
 and supraspiuatus normal and very powerful; infraspinatus on 
 both sides hypertrophied and very hard ; teretes and subscapularis 
 normal; recti abdominis very powerful, distinctly hypertrophied ; 
 deltoid on both sides hypertrophied, very powerful ; extensors in 
 the forearm on right side only partly preserved, on left very 
 powerful, and for the most part hypertrophied; flexors in the fore- 
 arm very powerful, and in part distinctly hypertrophied, especially 
 on left side ; small muscles of the hand on left side quite, on right 
 for the most part, normal. 
 
 Dynamometer marks on the right side 30°, on the left 50° ; 
 upper arm is 2 to 3 cm. less in circumference than the forearm. 
 
 If you take hold of the patient by the armpits, as if you were 
 going to lift him into the air by the shoulders, the shoulders go 
 up at once to the ears, the patient having no power of fixing 
 them below (absence of the latissimi and pectorals). If the arm 
 raised to the horizontal level is brought down strongly against 
 powerful opposition, the scapula is strongly drawn towards the 
 upper arm and its angle is moved outwards (defective fixation by 
 the trapezius and rhomboids). These are two very characteristic 
 symptoms. The thorax is widened out at the sides with slight 
 eversion of the lower edges (weakness of the lateral abdominal 
 muscles). 
 
 In the lower extremities there is only enlargement of the 
 muscles. The glutasi are large, very powerful, and distinctly hyper- 
 trophied; the quadriceps, sartorius, tensor fascias, and adductors all 
 appear unquestionably hypertrophied, and display great strength- 
 the muscles of the legs are normal, powerful, perhaps hyper- 
 trophied (his riding-trousers have become too narrow for him). 
 
 The muscles feel in some parts very tough and firm, in others 
 softer and more flaccid. No fibrillar twitchings ; mechanical 
 irritability lowered when there is atrophy; where there is hyper- 
 
240 ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 
 
 trophy, normal or even increased. Electrical irritability behaves 
 in the same way; no reaction of degeneration. Skin reflexes 
 normal ; tendon reflexes present in lower extremities, absent in 
 upper. All kinds of sensibility, brain, special senses, internal 
 organs perfectly normal. 
 
 But there is something else about this patient, gentlemen. 
 Look at his face. The lips are remarkably thick, while the chin 
 and lower parts of the cheeks appear fallen in, there being distinct 
 wasting of the left half of the chin. If we test the functional 
 activity of the muscles we find the frontals, orbiculares 
 palpebrarum, and zygomatics normal, but distinct weakness of 
 the left side of the mouth and of the left buccinator— brought out 
 in showing the teeth, in whistling, and in puffing out the cheeks. 
 Palpation shows undoubted wasting and softness of the left side 
 of the mouth and chin, It is not easy to say for certain 
 whether things on the right side are normal. The muscles of 
 mastication of the tongue and of the pharynx, the ocular muscles, 
 and the pupils all perfectly normal. The patient did not know 
 that there was anything wrong about his face, and can therefore 
 tell us nothing about when it began. 
 
 In this case then, gentlemen, which in other respects agrees 
 in all essential points with the first one (putting aside some 
 interesting details) we have a juvenile muscular atrophy with 
 affection of the face. 
 
 Let us take another case. 
 
 3. Look at this little Hercules we have here, and observe, 
 particularly, the enormous development of his limbs, especially 
 the legs and glutasal regions, his somewhat stupid expression, 
 and the peculiar attitude. 
 
 Philip Arnold, nine years of age. Family apparently quite 
 healthy, except that a younger brother is affected in the same 
 way ; the parents and the two older than himself are healthy. 
 The boy could run about at the usual time, but with some 
 difficulty, and he could never jump; in his second year had 
 convulsions. From his fourth and fifth year he is said to have 
 been getting thicker about the calves, and walking has become 
 difficult and the gait tottering. Intelligence very defective, and 
 has made no progress in school. The first thing that strikes one 
 in examining him is the immense development of the boy in flesh 
 and adipose tissue, especially in the lower extremities, which call 
 up lively recollections of statues of the "Infant Hercules." Note, 
 also, a generally distributed mottling of the skin. 
 
 More exact investigations reveal, however, under these deceitful 
 external appearances, not only extensive muscular wasting, but 
 everywhere distinct weakness, even in the apparently normal or 
 
EEB ON PROGRESSIVE MUSCULAR DYSTROPHY. 241 
 
 hypertrophied muscles. I should except the face : there is nothing 
 abnormal in respect either of function or of size in the muscles of 
 expression, the muscles of mastication, of the tongue, and of the 
 throat. On the other hand, in the trunk and in the upper 
 extremities the muscles affected are almost the same as in the two 
 previous cases, only that in this case a larger number of the 
 muscles appear to be hypertrophied while they nevertheless show 
 motor weakness. 
 
 Tou have then, as you see, atrophy and weakness in the pectorals 
 
 (all but small portions), the latissimi dorsi, the biceps and 
 brachialis anticns on both sides, the supinatores longi (almost 
 wholly gone), and the abdominal muscles. 
 
 On the other hand, you have enlargement and weakness in the 
 deltoids, rhomboids, inf raspinati, serrati magni (forming a large 
 swelling surrounding the scapula in front and below), tricipites, 
 and extensors and flexors in the forearm (which form nodular 
 swellings on active movement). 
 
 R 
 
242 ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 
 
 The extensors of the spine are very weak ; down to the level of 
 the first lumbar vertebra they are distinctly atrophied, from the 
 first lumbar to the sacrum they are enlarged, forming a thick soft 
 swelling on either side. 
 
 The following muscles are apparently quite normal: trapezn, 
 sterno-mastoids, supraspinati, teretes, subscapulars, and small 
 muscles of the hand. The small size, along with the maintenance 
 of their function in these muscles, stand in marked contrast with 
 the enlargement and weakness of most of the others. 
 
 The lower extremities, as you see, are very large in their whole 
 extent. The glutei are massive, though rather soft and weak. 
 The muscles of the thigh are of immense size and of firm elastic 
 consistence, forming hard nodular swellings on contraction ; they 
 are pretty powerful. The same description applies to the 
 gastrocnemii. The muscles in front of the legs, though no doubt 
 enlarged, seem rather weak. 
 
 The feet are to some extent in the position of pes equinus. The 
 gait is waddling and helpless. If you place the boy sitting on the 
 ground he can only get up by supporting himself against some 
 object, or, in the characteristic way, by climbing up his own legs ; 
 if the trunk is bent forward the work of raising it to the upright 
 position is performed only with great difficulty and with the help 
 of the arms supported in some way ; if you attempt to lift him up 
 by the shoulders they rise to the ears and you feel as if you had 
 no grip at all. 
 
 The muscles for the most part feel soft and flabby ; those of his 
 calf and thighs, however, liave more firmness and elasticity. 
 There are no fibrillar twitchings. Excitability of the muscles to 
 simple percussion is all over much diminished, so also his galvanic 
 and faradic irritability (in varying degrees) ; the contractions on 
 direct stimulation are rather sluggish, but there is no definite 
 reaction of degeneration. Sensibility and skin-reflexes everywhere 
 normal. Tendon-reflexes not made out in the upper extremities, 
 in the lower distinct and active. Sphincters, special senses, 
 internal organs, all normal. Mental development very defective. 
 
 Gentlemen, you have here a really classical case of the pseudo- 
 hypertrophic paralysis of children, as it is called. The next case 
 presents a somewhat different picture. 
 
 4. He is also a boy of nine years of age, Wilhelm Biicher, and 
 comes of a family in the Taunus, in which no trouble like his has 
 been previously known. He learned to run about at the usual 
 time, but he was slow in his movements, and " he couldn't jump " 
 or take part in the usual boys' games. During the last two 
 years he has been tumbling more frequently, has been unable to 
 get upstairs, and his attitude and mode of progression have bit 
 
ERB Otf PROGRESSIVE MUSCULAR DYSTROPHY. 
 
 243 
 
 by bit become what you will see presently. For the rest, he is in 
 good health, is well on in his education, and has never had either 
 pains or convulsions. 
 
 The boy is now undressed, and you will see first that the skin 
 is very mottled, next that he stands in a very peculiar way; there 
 is extreme lumbar lordosis, the abdomen is very prominent, the 
 shoulders are drawn well back, the arms hanging down far 
 
 behind, and the feet are planted a good way apart, giving a broad 
 base of support. There is not much fat on him ; the upper part 
 of the body is relatively spare, the upper arms especially are 
 surprisingly thin, and the shoulder-blades stand out ; on the other 
 hand, the legs and buttocks are relatively large, while the thighs 
 are relatively small. He walks in a peculiar waddling, high- 
 stepping, straddling fashion, with an approach to the talipes 
 eqninus position of the feet ; if you set him down he doesn't go 
 
M4 ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 
 
 down gradually, but suddenly and all of a heap ; if you take him 
 under the armpits and attempt to lift him you find yourself getting 
 no hold over his body but merely raising his shoulders to his ears ; 
 if he wishes to raise himself from a squatting position he first 
 gets on all fours and then clambers with his arms up his own legs, 
 bringing himself with a jerk at the last into his ordinary position 
 . of lumbar lordosis. 
 
 On closer inspection we recognise here also the presence both 
 of atrophy and hypertrophy of the muscles. In the upper half of 
 the body there are in a condition of atrophy and paresis — the 
 pectorals (all but the clavicular portion), the trapezii (in the lower 
 two-thirds), the latissimi dorsi (quite gone), the bicipites and 
 brachiales antici (moderately wasted), the tricipites (to a slight 
 degree), the supinatores longi (almost quite gone), and the 
 extensors of the trunk (very much wasted) ; in a condition of 
 hypertrophy — the infraspinati (in good condition functionally 
 also), deltoids (vigorous but rather soft and wasted posteriorly) ; 
 in normal condition — sterno-mastoids, rhomboids, serrati magni, 
 levatores scapulas, supraspinal, coracobrachiales, flexors and 
 extensors of the forearm, and small muscles of the hands. In the 
 lower half we have atrophy and weakness in the following : the 
 flexors of the hips, the quadriceps, and the lateral abdominal 
 muscles ; hypertrophy in the tensor f ascise, sartorius, perhaps the 
 adductors, the peronei (distinctly weak), gastrocnemii (very 
 strong). The glutaei and recti abdominis appear normal. The 
 muscles of the face and of mastication are quite normal. 
 
 The muscular substance is in part soft, in part firm and elastic. 
 No fibrillar twitchings. Mechanical and electrical irritability 
 lowered in the atrophied muscles, no trace of reaction of degenera- 
 tion, sensibility and skin reflexes normal. Tendon reflex absent 
 in the triceps, almost absent at the knee, active in the tendo 
 Achillis. Sphincters, organs of special sense, mental condition and 
 internal organs perfectly normal. Lower section of the thorax 
 much dilated and flattened out. 
 
 According to former usage, gentlemen, this case also would 
 have been termed pseudo-hypertrophic paralysis without more 
 ado, although, as you have satisfied yourselves, the muscles that 
 are enlarged and are acting well by no means give the impression 
 of pseudo-hypertrophy or lipomatosis. "We cannot properly call 
 it -an example of Leyden's hereditary atrophy, because, though 
 in other respects akin, it lacks the quality of heredity, on which 
 so much stress has been laid by Leyden. It would agree better 
 even with the features of the variety I have termed juvenile 
 atrophy, had it not taken origin in very early childhood. 
 
ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 245 
 
 That, however, need not give us any great concern in the 
 meantime. 
 
 I should next like to bring before you for a moment two of 
 the same family, in whom you can discern the earliest stages of 
 the disease. 
 
 5 and 6. These two cases are sisters. The parents are free from 
 the affection, and no similar case has occurred so far as they (the 
 parents) are aware in the families of either of them. Our little 
 patients, however, have a stepbrother (son of the same father by 
 a sister of their mother's) whom 1 saw in 1875 in the first stages 
 of the trouble, and who now has advanced atrophy over the whole 
 body, with contracture in several places. In him the face is 
 unaffected. 
 
 I saw the girls two years ago, and will tell you what I found 
 then, that you may compare the record with their condition 
 to-day. The elder of the two, Helene, is now fourteen years of 
 age. In April, 1888, the afEection had been gradually coming 
 upon her for several years, with weakness of the legs and back, 
 and latterly some difficulty in mounting stairs. The examination 
 at that date gave the following results: face quite unaffected;; 
 atrophy of the latissimi, trapezii (lower two-thirds), and rhom- 
 boids ; less marked but still distinct wasting of the pectorals, 
 flexors in the upper arm, and supinators; hypertrophy of the 
 infraspinati and serrati ; weakness and wasting of the lumbar 
 muscles ; distinct atrophy of the thigh, especially of the quadri- 
 ceps, knotty condition of the latter in contraction ; sartorius 
 normal ; moderate enlargement of the calves ; muscles generally 
 firm ; slight affection of the gait and characteristic climbing up 
 the legs in rising from the ground ; quite healthy otherwise. 
 
 Now, as you observe, the affection has advanced a bit. The 
 atrophy of the muscles I have named is distinctly greater; the 
 iatissimi, the flexors of the forearm, and the supinators, have in 
 particular distinctly grown weaker ; the lower hah of the pectorals 
 is almost gone ; the weakness in the thighs is increased. In addition 
 to the infraspinati the deltoids and tricipites are now manifestly 
 hypertrophied, and the calves are distinctly larger. There is 
 some weakness in the peroneal region ; the walk is high-stepping 
 (steigend). Face remains quite normal. No fibrillar twitchings, 
 no reaction of degeneration, knee jerk weak, and tendo Achillis 
 reflex active. 
 
 The younger sister, Auguste, is now ten years old. She was 
 only brought to me in April, 1888, by her anxious mother because, 
 as she said, " she cannot run upstairs like other children." The 
 mother did not at that time think of her otherwise than as quite 
 healthy. The only things I could then be certain of were that 
 the latissimi were distinctly atrophied, the trapezii rather weak, 
 
246 ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 
 
 the biceps on either side somewhat thin, and, on the other hand, 
 the serratus magnus on either side very strongly developed. The 
 face was quite intact, and there was no pseudo-hypertrophy 
 anywhere. 
 
 To-day you can see that the disease in this poor child has made 
 a distinct advance. The lower portions of the pectorals are 
 markedly atrophied, also the supinators and flexors of the fore- 
 arms. The angle of the scapula stands out somewhat (weakness 
 of the latissimus and trapezius) ; the child's shoulders are loose ; 
 if the arm held horizontally is brought down strongly against an 
 endeavour to keep it up, the angle of the scapula moves outwards. 
 Triceps and infraspinatus on each side distinctly hypertrophied. 
 Weakness of the extensors in the loins, and slight lordosis of the 
 lumbar vertebrae. Quadriceps weak and nodular on contraction. 
 Rising from the squatting position impossible without assistance. 
 Calves greatly enlarged. Face absolutely intact, no fibrillar 
 twitchings, tendon reflexes active. 
 
 What are we to call these two cases ? Assuredly not pseudo- 
 hypertrophic paralysis, or disputes would arise. Perhaps we 
 might reckon them cases of hereditary muscular atrophy, for we 
 have the heredity and the commencement in the legs and sacral 
 region. And yet the early affection of the shoulder girdle and 
 upper arm brings them nearer to my juvenile form. Here, 
 also, this question may remain undecided at present. 
 
 Unfortunately I cannot show you a case in which the disease 
 has begun, and is specially marked in the face. I have not, up 
 to the present, met with such. They appear, in Germany at 
 any rate, to be very rare. Striimpell has lately described and 
 given illustrations of a case in his " Spec. Pathologie " (vol. 2, 
 1 , 5th edit.) In France Duchenne 3 , and of late years Landouzy 
 and Dejerine 11 and Marie and Guinon 13 have recorded a number 
 of such cases, calling the form " infantile " muscular atrophy. 
 
 You have now, gentlemen, a fairly complete idea of the variety 
 of forms which this disease assumes. It will not have escaped 
 your notice in what respects these various forms agree (and in 
 some ways the agreement goes very far), and in what respects 
 they, to a certain extent, differ. 
 
 They all agree, in the slow and insidious development of the 
 disease, with very frequently hereditary or family influences at 
 
ERB ON PROGRESSIVE MDSCDLAR DYSTROPHY. 247 
 
 work ; in the general wasting of many of the muscles, combined 
 with increase in the size of others ; very notably in the localisation 
 of the affection, in that almost invariably they are exactly the 
 same muscles in the different cases that atrophy on the one hand, 
 and exactly the same that become hypertrophied in the other ; 
 in the way in which this localising takes place in the trunk, 
 shoulder girdle, and loins, and in the proximal ends of the limbs, 
 the distal ends remaining free for a long time ; and in the 
 peculiar changes which are then brought about in the form and 
 movements of the body, the attitude, and gait. They agree further 
 in the condition of the muscles, as ascertained by percussion and 
 palpation, in the effects of electrical stimulation, particularly in 
 the absence of the reaction of degeneration, in the fact that there 
 are no fibrillar twitchings, and in the gradual disappearance of 
 tendon reflexes. Finally, in all of them the various forms of 
 sensibility, the sphincters, the brain and organs of special sense, 
 and all the internal organs, are quite normal. 
 
 Thus in all the forms the outline of the features is the same, 
 ,and yet there are certain differences which cannot be overlooked. 
 These are as follows : Some of the cases appear to be independent 
 of hereditary influences ; sometimes the process begins in 
 earliest childhood, sometimes in youth or at puberty, some- 
 times even later. In some cases it makes its appearance first 
 in the loins and lower extremities ; in others in the shoulders 
 and upper extremities ; at times even in the face. The rules of 
 localisation are often set aside, the muscles of the forearm and 
 small muscles of the hand being sometimes attacked, and muscles 
 which, as a rule, are affected, being sometimes exempt. The 
 degree of muscular hypertrophy may vary extremely, at times 
 being quite unnoticeable, or limited to a few muscles, at times 
 extended over a wide area, and present in a very marked degree. 
 Further, this hypertrophy appears in some of the cases to be a 
 true hypertrophy, depending on actual increase in volume of the 
 muscle substance, and in others to be false, caused by a deposit 
 of fat or lipomatosis. Lastly, the rate at which the disease 
 advances, and the way in which, towards the close, all the 
 muscles of the body may be affected, are very different in the 
 individual cases. 
 
 Are those differences sufficiently great and sufficiently essential 
 to justify us in ranging the cases under different nosological 
 
248 ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 
 
 forms? You know that already we have quite a number of 
 them. Pseudo-hypertrophic paralysis has long had a position of 
 its own, and the enlargement of the lower extremities, the fatty 
 deposit on the muscles, and the peculiar attitude and gait might 
 seem distinctive enough. Then Leyden 8 brought forward his 
 hereditary muscular atrophy, and gave as its pathognomonic 
 characters heredity and commencement in the back and lower 
 extremities. I followed 10 with juvenile muscular atrophy, distin- 
 guished by its beginning in the upper half of the body, a peculiar 
 localisation, the presence of muscular hypertrophy, and the 
 absence both of fibrillar twitchings and the reaction of 
 degeneration. Lastly, we have had lately a form that Duchenne 
 had described as infantile muscular atrophy, but now brought 
 forward by Landouzy and Dejerine u under the name " myopathie 
 atrophique progressive," as an independent and, indeed, as the 
 most important form of the disease. Nor would it be difficult 
 to specialise still further, and extend this list, as you can see 
 from a perusal of Baymond's recent exhaustive work. 14 
 
 The longer I have occupied myself with the question, and the 
 wider my experience of these forms has grown, the more has the 
 conviction forced itself upon me that they all present one and 
 the same disease. I am satisfied that, while in subordinate 
 features such as the time and rate of development, the initial 
 localisation, quantitative differences in the individual symptoms, 
 particularly as regards the amount of hypertrophy, they may 
 differ from one another, yet in all essential points they 
 thoroughly agree. The proof of this clinical unity of those 
 forms must, in the first instance, of course, be deduced from 
 clinical material, but, from the number of my own cases and 
 from a record on the part of others which has gradually grown 
 to be very large, we have no difficulty about that. 
 
 First of all we must establish the fact that the separate forms 
 agree with one another in the following particulars : The 
 development and the localisation of both the atrophy and the 
 hypertrophy in the muscles ; the condition of the latter, as 
 ascertained by inspection and palpation, by their mechanical 
 and by their electrical reaction ; and, lastly, the absence of all 
 other symptoms. Now, that they do agree in these respects you 
 have already seen, even from the few cases I have shown you. 
 A- more extended series of observations would bring it out with 
 
ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 249 
 
 still greater certainty, and would easily show that the juvenile, 
 the pseudo-hypertrophic, the hereditary, and the infantile forms 
 agree in all the above-mentioned particulars to an extent that 
 is quite surprising. You must allow me on the present occasion 
 to forego the details of this proof, as it would take up too much 
 of our time. 
 
 But still more convincing evidence is given by the cases, and 
 they are not so very rare, which may be looked upon as transi- 
 tional varieties between those individual types^ — cases of one 
 form in which you meet with certain features which you have 
 learned to consider as properly belonging only to another form. 
 For example, there have been lately observed several cases, both 
 of the juvenile and of the pseudo-hypertrophic form, in which 
 the muscles of the face have become involved (as in the second 
 case which I showed you) ; or you may see the infantile form, 
 beginning with pronounced facial atrophy, developing, as regards 
 the rest of the body, at one time the juvenile type, at another 
 time the pseudo-hypertrophic type ; or you may observe the 
 lower half of the body take on the distinct pseudo-hypertrophic 
 type, while the upper half is an example of simple atrophy — the 
 juvenile type ; or you may have the exact appearances of pseudo- 
 hypertrophic paralysis, coming on in adult life, i.e., as a juvenile 
 form. 
 
 Further, we not infrequently see the different forms passing 
 into one another in the course of their development. A case 
 that began as pseudo-hypertrophy takes afterwards the juvenile 
 or infantile form ; a hereditary case turns into a pseudo- 
 hypertrophic or juvenile case, and so on. We frequently come 
 across cases, also, which I should like to call indeterminate or, 
 better, indeterminable forms, cases in which there may be doubt 
 as to which type they belong to. We have seen an example of 
 this in our fourth case, and to a certain extent in the two 
 sisters (cases 5 and 6). In a case of this kind one man sees 
 one type, another, another; or perhaps the case has been taken 
 for a certain type at one time and two years later the physician 
 finds himself inclined or obliged to call it an example of another. 
 And yet all these cases most certainly belong to the same 
 nosological group. 
 
 Different types occur in the same family, and this fact, it 
 appears to me, speaks with great force for the viBW we are 
 
250 ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 
 
 upholding. For in that case they occur in circumstances where 
 there is no room for doubt as to the unity of the disease. For 
 example, the infantile form may appear among children whose 
 father has the juvenile form (observed by Duchenne, Landouzy- 
 Dejerine, Troisier-Guinon 15 and others), or different types may 
 occur in a family in which the hereditary form has already 
 gained a footing. These are, I think, very convincing proofs. 
 
 I believe that the facts I have laid before you in the present 
 state of our knowledge, and disregarding just now the proof 
 from pathological anatomy, to which I shall return later, are 
 sufficient to allow you to recognise in all the different types one 
 nosological species. It is fitting that we should have for this 
 a short distinctive name, and I proposed as such Dystrophia 
 muscularis progressiva. I still think that it is the best, and that 
 it involves fewer assumptions than any of those that have been 
 proposed by others.* 
 
 Let us now sketch the clinical features of the disease as we 
 learn them from a study of a sufficient number of cases of the 
 various types. The picture thus formed will be a standard to 
 go by in the differential diagnosis between progressive muscular 
 dystrophy and other similar affections. 
 
 It always begins very slowly and insidiously, and in many 
 cases remains unnoticed for a long time, perhaps for years. It 
 begins sometimes at one age, sometimes at another, but most 
 commonly there is a preference (probably due to the influence 
 of heredity) for childhood and infancy, though commencement 
 about the time of puberty is not infrequent. Much more 
 rarely it develops in later years and towards the fifties. 
 
 It begins generally in the trunk and proximal parts of the 
 extremities ; sometimes the lower half of the body, including the 
 pelvic girdle and thighs, is the first and most severely affected, 
 sometimes the upper half with the shoulder girdle and upper 
 arms. The earliest symptoms are weakness and exhaustion in 
 the affected parts, with awkwardness in using them. Pain, 
 parassthesise, and other symptoms are absent. In a certain 
 
 * The name chosen by Fr. Schultze, 12 " Progressive muscular wasting asso- 
 ciated with hypertrophy," is too cumbrous, and scarcely suitable for others than 
 Germans. The "Myopathic atrophique progressive " of Landouzy and Dejerine 
 takes no account of the hypertrophy that is generally present. Charcot's 18 
 " Myopathic progessive primitive " would suit best of all if it were only certain 
 that the myopathy is primary. 
 
EBB ON PROGRESSIVE MUSCULAR DYSTROPHY. 251 
 
 number of the cases in children the lesion appears to commence 
 in the face. In this position it may remain unnoticed for a 
 particularly long time, and it is only when it has gone very far, 
 has given to the patient a peculiar expression, and gravely 
 affected the facial movements, that it attracts attention. As 
 the disease progresses, the growing weakness and defect in 
 the movements of the muscles always become associated with 
 distinct changes in their volume. These changes are of two 
 kinds : we may have atrophy, and this is generally manifested in 
 certain particular muscles, or we may have hypertrophy, most 
 prominent in certain other particular muscles ; the latter may 
 be true hypertrophy or, especially in the later stages, false or 
 fatty hypertrophy. It is not improbable that in the case of 
 most of the muscles there is a hypertrophic stage, which very 
 seldom comes under observation, as the patients in general only 
 seek medical aid when there is already atrophy. This is the 
 impression, at any rate, made by the study of the morbid 
 changes in some of the muscles. The dividing lines between 
 hypertrophy and atrophy in individual cases certainly shift 
 about in the most varied fashion, and the following list of the 
 muscles which are most commonly atrophied and of those which 
 are most commonly hypertrophied is only to be taken in a very 
 general way, and as admitting of many exceptions. 
 
 In moderately advanced cases the following muscles are found 
 for the most part more or less atrophied : The pectoralis 
 major and minor (except, generally, the clavicular portion), 
 trapezius, latissimus dorsi, serratus magnus, rhomboids, sacro- 
 lumbalis and longissimus dorsi. Further, and this is very 
 characteristic, the flexors in the upper arm (biceps and brachialis 
 anticus), including the supinator longus. In addition to these, 
 there may also be affected the lateral abdominal muscles, the 
 glutaei and quadriceps femoris, frequently, also, the adductors ; 
 in the leg the peroneal muscles, and particularly the tibialis 
 anticus. In all these muscles, along with the atrophy, there is 
 growingly distinct motor weakness. If the face is involved it is 
 especially the muscles around the mouth and chin which atrophy, 
 frequently also the orbiculares palpebrarum and frontales. 
 
 The following muscles are generally, though, as I have said, often 
 only for a time, hypertrophied : the deltoid, infraspinatus (more 
 rai-ely also the supraspinatus) and triceps in the upper half of the 
 
252 ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 
 
 body, the tensor fascias, sartorius and gastrocnemius, possibly the 
 whole calf in the lower half. In these muscles the motor power 
 may be very good, sometimes almost abnormally so, but you 
 often find them getting pretty weak, even in an early stage. 
 
 Lastly, the following are normal, and, in general, long remain 
 so : The sterno-mastoid, levator anguli scapulae, coracobrachialis, 
 teretes, flexors and extensors in the forearm, and the small 
 muscles in the hand ; the rectus abdominis, and in part the 
 muscles of the leg, especially of the calf, and the small muscles 
 of the foot. 
 
 Of course here, also, the boundary line between what is 
 affected and what is not often cannot be fixed with anything 
 like precision. Sooner or later, muscles that were previously 
 intact are involved. First, as a rule, come the extensors in the 
 forearm, then the small muscles in the hand and flexors in 
 the forearm, and, finally, the morbid process may extend over 
 the whole body, sparing not even the diaphragm or the muscles 
 of respiration. Extremely rarely it may happen that the 
 muscles of mastication and the ocular muscles are attacked. 
 The patients finally become wasted and helpless all over, or, 
 with equal helplessness, the atrophy may be masked by masses 
 of fatty tissue, giving an appearance of muscular volume. In 
 no case does the disease go on to bulbar paralysis. 
 
 In moderately advanced cases the peculiarities in the form, 
 attitude, and movements of the body affected by the 
 muscular lesion are extremely characteristic. There is 
 marked lumbar lordosis, the upper half of the body arching 
 well back and the abdomen being protruded in front ; the 
 shoulders are lowered and brought forward ; the line running 
 from the side of the neck to the apex of the shoulder is divided 
 into two by the prominent superior angle of the scapula ; the 
 shoulder blades may stand out like wings, and often possess a 
 very comical mobility, from not being fixed down in the usual 
 way by the trapeizii, latissimi, rhomboids, and serrati, while the 
 fair development of the infraspinati may give them at the same 
 time a singular appearance of deformity. If the arm is raised 
 to the horizontal level and brought down again against some 
 resisting force, the inferior angle of the scapula is turned very 
 much outwards and is approximated to the arm by the powerful 
 action of the teretes and infraspinatus. This is due to the 
 
EEB ON PROGRESSIVE MUSCULAR DYSTROPHY. 253 
 
 absence of the usual fixation by the rhomboids and, trapezius. 
 The thinness of the upper arm is , very striking, from the large 
 size of the deltoid above and the powerful forearm below. The, 
 latter has more of a cylindrical form than usual in its upper 
 portion from the absence of the supinator longus. The 
 infraclavicular fossa is hollowed out and there is an oblique 
 groove alongside the insertion of the deltoid, from the absence 
 of the pectorals. The wasted condition of the thigh is brought 
 out by contrast with the well-developed buttock and the huge 
 calf. The walk is peculiarly waddling and high stepping, 
 with pointing of the toes ; mounting stairs is difficult. The 
 way in which the patient sits down on the ground and rises up 
 again is highly characteristic ; in the latter movement he getsi 
 on all fours, with the legs extended, and then, with his hands, 
 climbs up his own legs, attaining the upright position at the last 
 with a jerk. The weakness of the quadriceps, erector spinse, 
 and glutaei is responsible for this. The shoulders are very 
 slack, and if the patient is lifted up by the armpits, the shoulders 
 rise at once to the ears (weakness of the latissimi, pectorals and 
 trapezii). Not uncommonly, especially in children, we 
 ^notice an anomalous condition of the lower part of the 
 thorax. It is flat and retracted in the middle from the action 
 of the powerful rectus abdominis and prominent at the sides, 
 the edges looking almost as if turne,d up. The latter appearance 
 is due to the weakness of the oblique and transverse abdominal 
 muscles ; at the attempt to raise the head in the lying position 
 these muscles appear as two soft tumours in the lateral aspect, 
 of the abdomen. 
 
 If the face is affected early and in a high degree, a 
 characteristic facial expression is produced (" facies myopathique " 
 of the French). The countenance is like a mask, smooth and 
 immovable, the lips thick and. prominent, " tapir lips," the 
 patient is unable to whistle, to close the lips firmly, or to 
 wrinkle the eyebrows ; the play of features is poor, and there is 
 a very peculiar alteration in the smile (griines Lachen, rire en 
 travers). 
 
 This picture, it is well-known, can be modified in a great 
 variety of ways. The distribution and intensity of the 
 process, the difference in the way it affects the upper and lower 
 half of the body, the absence or presence of hypertrophy, the 
 
254 ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 
 
 stage at which the disease has arrived, the individuality of the 
 patient, and the family type, all help to produce these modifica- 
 tions. To go into a description of the possible varieties on this 
 occasion is quite superfluous. 
 
 But there is still something more to ascertain to complete 
 the necessary precision and objectivity of the description. The 
 atrophied and hypertrophied muscles on palpation show changes 
 in their consistence which are often very marked. Sometimes 
 they are soft and flaccid, with the feeling- of a fatty growth, at 
 other times elastic and firm. On active contraction they may 
 form irregular nodular tumours, and easily pass into a condition 
 of tonic spasm or cramp, The mechanical irritability is mostly 
 lowered, often in a very marked degree. The faradic and 
 galvanic irritability is always lowered in the atrophied muscles 
 and frequently in the muscles which are enlarged ; but if there 
 is true hypertrophy the electrical irritability may remain normal. 
 There is no reaction of degeneration.* You will further find 
 that fibrillar contractions are as good as never present^ That is, 
 not reckoning as such the muscular tremors and twitchings 
 
 * I must stand by this statement, in spite of the fact that in my first paper 
 I spoke of the absence of the reaction of degeneration as by no means absolutely 
 certain, and although in one case (described by Fr. Sehultze) at an advanced 
 stage, I ascertained for myself that this reaction was quite distinctly present in 
 various muscles. Several observers have, indeed, asserted its occurrence ; bnt 
 even if I grant that what they saw was actually the reaction, and not something 
 like it, some slowness of contraction, or such like peculiarity erroneously taken 
 for it— my own experience has taught me that an error like this is quite possible — 
 nevertheless, from numerous careful observations I can only repeat that the 
 absence of degeneration in the dystrophic affection is almost without exception 
 the rule. I shall have more to say of this afterwards. 
 
 t In regard to this, statement, also, I have been criticised a good deal, and 
 accused of being in error. If in one case, for example, a muscle (the masseter) 
 that was not even for certain affected at all, showed fibrillar twitchings, while 
 in the rest of the body in which the disease had reached an advanced stage 
 nothing of the sort was seen, even with long observation, it has been thought 
 quite justifiable to say that the statement above is unwarranted. The same 
 criticism is made when, in another case, fibrillar twitchings had been noticed 
 (so it is said) on the first day, but never again in the course of several weeks' 
 observation. Such remarks correct themselves, the exception simply proving 
 the rule. In spinal muscular atrophy and amyotrophic lateral sclerosis, fibrillar 
 twitching is always present and widely distributed, but from a large experience 
 of progressive muscular dystrophy, I must hold to my assertion that the absence 
 of such twitching is in this disease the almost invariable rule. Even if here and 
 there it is observed, we must remember that its occasional or even constant 
 occurrence in neurasthenic, and, indeed, in healthy people, is not so very 
 uncommon. 
 
ERE ON PROGRESSIVE MUSCULAR DYSTROPHY. 255 
 
 which are so frequently seen in those exposed to cold or in a 
 state of excitement. These may occur in anyone, well or ill, 
 but are especially observed in " nervous " people. 
 
 The tendon-reflexes are diminished in all the muscular areas 
 where the disease has gained a firm footing, and finally they 
 disappear altogether ; the skin-reflexes generally persist for a 
 longer time. In many cases, and often in an early stage, 
 contracture occurs, or rather retraction of certain muscles, and 
 this may lead to abnormal positions of the limbs ; the commonest 
 are pes equinus and contracture in flexion at the knee and 
 elbow. It only remains to mention the peculiar mottling of the 
 skin, which is so especially marked in many children with 
 pseudo-hypertrophic paralysis. Everything else — sensory and 
 trophic functions of the skin, sphincters, sexual power, special 
 senses, brain, all other internal organs, and all vegetative 
 functions — are normal. 
 
 Turn now to the differential diagnosis. We require first of 
 all to distinguish it from spinal muscular atrophy, amyotrophia 
 spinalis progressiva, the pathological basis of which is believed 
 to be a disseminated degeneration of the anterior columns of 
 grey matter in the cord. This disease, also a form of slow 
 muscular wasting, is characterised by the following features : 
 There is rarely evidence of heredity, and it begins generally in 
 adult years ; the small muscles of the hand are almost always 
 the first to be attacked, with gradual atrophy of the individual 
 muscles, extending progressively to the forearm, upper arm and 
 trunk, affecting the lower extremities only at a later period ; 
 there is never either true or false hypertrophy of the muscles ; 
 fibrillar twitching in abundance is generally present ; electrical 
 irritability is long preserved, but at the last in the most of the 
 muscles, when the atrophy is advanced, there is always the 
 reaction of degeneration, either partial or complete, and 
 occurring with most regularity in the small muscles of the 
 hand ; tendon reflexes generally long maintained, very often 
 combined with chronic bulbar paralysis. Everything else — 
 sensory functions, special senses, sphincters, &c, — normal. In 
 this list I have given you the determining elements for the 
 differential diagnosis. The most important are the different 
 localities affected, the progress of the disease from the distal 
 ends of the limbs to the trunk, the absence of hypertrophy, the 
 
256 ERB ON. PROGRESSIVE MUSCULAR DYSTROPHY. 
 
 presence of fibrillar twitching and of the reaction of degeneration, 
 and the association with bulbar paralysis. As a rule the 
 distinction is easy. In difficult or doubtful cases when, for 
 example, the spinal form begins in the trunk or shoulders, or 
 the dystrophic form attacks the small muscles of the hand at an 
 early stage, careful examination of the other symptoms and the 
 further progress of the disease will generally guide to a right 
 conclusion. 
 
 The distinction from syringomyelia, a disease of which many 
 cases were formerly put down to progressive atrophy, is very 
 simple. The localisation of the affection is of the spinal type, 
 there is atrophic paralysis with the reaction of degeneration, 
 hypertrophy is absent, and, above all, there are sensory dis- 
 turbances — pain, parassthesias, anaesthesias, in particular partial 
 sensory paralysis for pain and temperature. 
 
 So, also, is the distinction from chronic multiple neuritis, 
 which frequently presents a certain similarity to progressive 
 muscular atrophy. But the pain and sensory disturbances, 
 paralysis and atrophy, with the reaction of degeneration, the 
 absence of hypertrophy, and the localisation, all these are suffi- 
 ciently characteristic to guard against any confusion. The same 
 holds good for another form of progressive muscular atrophy 
 which has lately received close attention. Eichhorst 17 , F. 
 Schultze 18 , Charcot and Marie 19 , Herringham 20 and 
 others have described cases, and J. Hoffman 21 has recently 
 given a careful study of them under the name " progressive 
 neurotic atrophy " (type Oharcot-Marie or " peroneal " type of 
 the English). The place of this affection in a systemic 
 arrangement is not yet quite clear. Its features, however, are 
 atrophic paralysis, especially in the feet and legs, later on in the 
 hands and forearms, with deformities, reaction of degeneration, 
 fibrillar and fascicular twitching, frequently, also, with sensory 
 disturbances, &c. Thus, although the disease has a distinctly 
 hereditary character, and begins for the most part in early 
 childhood, it is very easily distinguished from our dystrophy. 
 
 Diagnostic difficulties may, perhaps, arise in rare cases, such 
 as out of the way localisations of focal disease in the cervical or 
 lumbar cord, or peculiar combined peripheral paralyses (plexus- 
 paralyses). For example, I have seen a bilateral birth paralysis 
 affecting the shoulder and arm which at first closely imitated 
 
ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 257 
 
 the features of progressive muscular dystrophy, and another 
 similar case in which the deformity was caused by bilateral 
 operations in the supraclavicular fossas. Certain surgical 
 affections, for example, bilateral dislocation of the hip joint, 
 flail joints, &c, may, on account of the secondary muscular 
 lesions, imitate the disease, but as a rule a careful history and 
 examination will clear up such cases. 
 
 And now, gentlemen, that we have got so far, let us see what 
 we can learn from pathological anatomy, and inquire whether 
 this is favourable or not to our view of the clinical unity of the 
 various forms of dystrophy. In this region we are no doubt 
 still moving on uncertain ground and amid much discussion, 
 but gradually matters are clearing up, and that, as far as 
 I can see, favourably for our views. I shall, however, be as 
 brief as possible in what I have to say. 
 
 I have • myself examined excised pieces of muscle from a 
 whole series of cases of the most varied types. Other observers 
 have done the same, and quite recently several autopsies have 
 been made in juvenile, infantile, and pseudo-hypertrophic forms ; 
 we have at our command, therefore, a fair quantity of material. 
 
 Taking first of all the changes in the muscles themselves, 
 I may begin by saying that the results of the examination of 
 muscle obtained post-mortem thoroughly agree with the results 
 of the examination of portions excised during life. Further, so 
 far as I can at present judge, the condition of the muscles in 
 all the various forms of dystrophy is in all essential points 
 almost precisely alike ; apparent differences are brought about 
 only through quantitative distinctions in the various histological 
 changes, and through varying combinations of these changes 
 at different stages of the disease in different muscles and in 
 different individuals. The differences between individual muscles 
 in the same patient are not less than those between muscles 
 from different forms of dystrophy, and it is thus quite legitimate 
 to represent all these forms as varieties of one disease. On the 
 present occasion, however, we are not going beyond a brief out- 
 line of the features of the disease. 
 
 Formerly the greatest stress was laid on the changes in the 
 interstitial connective tissue. These were looked upon as the 
 
 S 
 
258 ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 
 
 primary lesion, and the essence of the disease was conceived to 
 be the overgrowth of the interstitial tissue, and especially the 
 formation of fat. The affection of the muscular fibres, according 
 to this view, was secondary. They had atrophied, been, so to 
 speak, surrounded and suffocated through the overgrowth of the 
 connective and fatty tissue. But our investigations have led us 
 to quite other views. We find that the most important and 
 most essential changes are in the muscle fibres themselves, 
 and look upon the alterations in the connective tissue rather as 
 accompanying accessories, perhaps as secondary. 
 
 These muscle changes are the following : First of all there is 
 very considerable hypertrophy of the fibres, to as much as three 
 or four times the normal.* Then there are all possible degrees 
 of atrophy ; rounding of the fibres till they are circular in form ; 
 increase of the nuclei both at the edge and in the interior ; the 
 formation of slits and the division of the fibres into two or 
 more]finger-like processes ; vacuolation, sometimes only here and 
 there, sometimes to a greater extent ; faint transverse and pro- 
 nounced longitudinal striation, with a tendency to splitting of 
 the fibres into longitudinal fibrils. On the other hand, there is 
 no fatty or wax-like degeneration of the fibres. . 
 
 The changes in the connective tissue are increase and over- 
 growth, slight to begin with, more abundant later on. There 
 are firm broad strands lying between the muscle-fibres, with 
 abundant nuclei and thickened multinucleated vessel-walls. 
 Besides these changes there is sooner or later more or less of 
 a deposit of fat, which may go on to distinct lipomatosis. 
 
 These alterations show themselves in very different degree 
 in the different muscles, and may be combined in the most 
 varied way. Between muscles which give the impression of 
 being quite normal and possess only hypertrophied or normal 
 fibres, with a small quantity of connective tissue, and muscles 
 
 * I know very well that, according to the observations of Auerbach and of 
 Oppenheim and Siemerling M , the existence of this hypertrophy intra vilam, 
 at least in the fragments of muscle excised from the living subject, has been 
 called in question. But as it is present in exactly the same way in muscles 
 taken from the dead body, and as we can decidedly infer from the marked 
 proliferation of nuclei and division of the fibres that there is some process of 
 overgrowth going on in the muscle, I should like in the meantime to hold by the 
 real existence of this hypertrophy, though its exact degree may possibly be 
 modified and conditioned by the method of preparation. ^Knoll's work 21 has 
 thrown some direct light on this point, and leads to the same conclusion. 
 
ERB ON PROGRESSIVE MDSCOLXR DYSTROPHY. 259 
 
 which are instances of pure fibrous or fatty degeneration, in 
 which there are only the scattered remnants of hypertrophied or 
 atrophied muscle-fibres, there is every conceivable stage, com- 
 bination, and transition. Not uncommonly in one individual, 
 nay, in different parts of one and the same muscle, every stage 
 and degree of the morbid process can be studied. I show you 
 here a drawing, itself diagrammatic certainly, but copied from 
 different actual preparations, and true in its details, which will 
 bring before you these different stages and forms (see 
 fig. 4). 
 
 If you study now the state of the different muscles, and 
 attend to the degree of morbid change and the duration of the 
 disease in each, which can be brought out by looking at the 
 condition of the tissue elements in the various preparations, 
 you will recognise that the most important and the earliest 
 changes are those in the muscle-fibres. The alteration in the 
 connective tissue may at the utmost begin in a small measure 
 at the same time, but more probably follows the changes in the 
 muscle. The lipomatosis, last of all, makes its appearance in 
 the overgrown connective tissue. 
 
 According to our present knowledge the cause of the morbid 
 changes in the muscles is somewhat as follows : First, there 
 are alterations in the muscular substance itself. These hyper- 
 trophy and their nuclei proliferate ; they swell up, taking more 
 of a rounded form, and slitting and subdivision goes on ; pcvri 
 passu there is slight increase and proliferation of nuclei 
 in the connective tissue. At an early period, however, muscle- 
 fibrss here and there atrophy, and this process quickly extends 
 more or less, gradually gaining the upper hand, and finally 
 leading to complete disappearance of the muscle-substance. 
 • Along with it goes on a very great increase in the amount of the 
 connective tissue, with proliferation of the nuclei, thickening of 
 the vessels, and so fqrth. In this tissue, sooner or later, fat 
 cells make their appearance, leading, it may be, to the most 
 extreme forms of fatty degeneration. The muscular fibre has 
 now wholly, or about wholly, disappeared, and the final result of 
 the whole process is one of two forms. It may be an atrophic 
 and sclerosing lipomatosis, in which there is a good deal of 
 pure connective tissue without much fat, and the original volume 
 is very much reduced, or it may be a hypertrophic lipomatosis 
 
260 EKB ON PROGRESSIVE MUSCULAR DYSTROPHY. 
 
 Fig. 4. 
 
 Ilade by combining four different sections from as many different 
 
 cases. 
 
 A. From the hypertrophied deltoid of a typical juvenile case ; showing almost 
 everywhere very much enlarged fibres with increase in the nuclei, 
 slitting (s), and vacuolation (u); slight increase in connective tissue with 
 abundant nuclei. 
 
 B. Prom the atrophied biceps of an indeterminate case (juvenile ? pseudo- 
 
 hypertrophic ?) showing muscle-fibres of very different sizes, with great 
 proliferation of the nuclei, abundant slitting (s), and here and there 
 vacuolation («) ; connective tissue very much overgrown and with nume- 
 rous nuclei ; no fat deposit. 
 
 C. From the enlarged serratus magnus of a psendo-hypertrophic case (our third 
 
 case). Muscle-fibres mostly atrophied, here and there enlarged and 
 slit (s) ; abundant firm connective tissue ; large deposits of fat cells. 
 
 D. From the very atrophied biceps of a juvenile case, showing little else than 
 
 adipose tissue lying among stout bands of connective tissue, the 
 vessels of the latter very much thickened (g) ; small insulated patches 
 of muscle-fibre in some places still very much enlarged (A) with numerous 
 nuclei. 
 
ERB ON PKOGKESSIVE MUSCULAR DYSTROPHY. 261 
 
 in which there is little else than fat, while the original volume is 
 either maintained or exceeded. 
 
 On the other hand, the results of the examination of the 
 nervous system have, up to the present, been almost wholly 
 negative. Leaving out of account Lichtheim's case and the 
 older cases of pseudo-hypertrophy, we have had recently a series 
 of exact records from Fr. Schultze, Landouzy, Dejerine, P. 
 Marie, Dreschfeld, Westphal, and Singer, and neither in the 
 spinal cord nor in the peripheral nerves have any noticeable 
 changes been observed. In accordance with these records, we 
 should be entitled to view this dystrophy as a disease limited to 
 the muscle-substance, and as a truly primary myopathy, were 
 it not that some facts have come out which warn us to exercise 
 great caution in this direction. Heubner's case 22 deserves 
 special mention. Though an undoubted case of dystrophy, he 
 found there was extensive atrophy of the large cells in the 
 anterior horns of grey matter. Frohmaier 30 has a similar 
 case with the changes in it less marked. In this new light the 
 more trifling alterations observed by Singer and the older 
 observations in pseudo-hypertrophic cases of L. Clarke, Gowers, 
 Kesteven, Bramwell, and J. Boss, gain a certain significance. 
 But in the meantime we must say this, that in progressive 
 muscular dystrophy in its various forms, the nervous system 
 must be considered to be, as a rule, and for our present methods 
 of investigation, normal. 
 
 This is the place in which to say a little about the proper 
 nature, pathogenesis, and exact seat of the lesion. It is not 
 necessary to prove further that it is neither a simple atrophy of 
 the muscles nor an inflammatory affection with its consequences ; 
 there is unquestionably a more complicated disturbance of 
 nutrition, regarding the nature of which, for the present, I 
 would rather not express a definite opinion. 
 
 Pathological anatomy has led many to consider it simply as a 
 local muscular affection, quite independent of the central nervous 
 system, a pure myopathy. But a good deal of doubt has been 
 expressed (for example, by Knoll 24 ) regarding this view, 
 and I myself, in my earlier work, brought forward some 
 reasons which prevented me from accepting it without more 
 inquiry. A much larger experience, a good deal of con- 
 sideration given to the subject, and most of all the results 
 
262 EKB ON PROGRESSIVE MUSCULAR DYSTROPHY. 
 
 of the previously mentioned autopsies have confirmed me in my 
 scruples. 
 
 The considerations which weigh with me are various. • The 
 muscles depend for their nutrition to a very large extent on 
 trophic nerve centres ; the localisation of this atrophy frequently 
 follows in a noticeable way the exact course of the nerves in a 
 plexus, or the disposition of the centres in the central organ, and 
 occasionally we find a case of spinal amyotrophy (Strumpell's 
 case 25 ) presenting an almost exactly similar arrangement. 
 Hereditary influence is of great importance; mental aberra- 
 tions are common among the patients, and other neuroses 
 frequently occur in their families. Further, even in the 
 undoubtedly spinal cases, such as acute anterior poliomyelitis, 
 similar morbid changes (hypertrophy, proliferation of nuclei, 
 division of the fibres) both in the muscles and connective 
 tissue have been pointed out by W. Miiller 26 , Dejerine- 
 Huet 27 , Joffroy-Achard 28 , and Hitzig 29 . In pseudo-hyper- 
 trophic cases malformations and changes of a minor kind 
 in the spinal cord have been met with. When I consider these 
 facts, and bear in mind further the results of Heubner's 22 and 
 Frohmaier's 30 observations, I cannot avoid the suspicion that 
 after all the affection may be dependent on the nervous system. 
 It is tempting to suppose, as I formerly expressed it, that we 
 have to do with a kind of trophoneurosis, having its origin in 
 the trophic centres of the cord — a disturbance of the function of 
 these centres which finds its expression in the very complicated 
 muscle changes of the disease. While on this supposition there 
 are, as a rule, no coarse nerve changes, now and then, and after 
 the affection has lasted a long time or been very intense, such 
 a change does become visible. 
 
 The idea is inevitable that if something like this is the case 
 the relations between dystrophy and spinal amyotrophy will 
 turn out again in the end to be close and intimate. The latter 
 would represent an affection of the trophic centres that from the 
 very first is a distinct coarse anatomical lesion taking effect in a 
 degenerative atrophy of the muscles with fibrillar twitchings, 
 reaction of degeneration, &c. ; the former at the outset would be 
 merely a functional disturbance of these centres, conditioned 
 probably by different causes, and expressing itself as muscular 
 dystrophy with all its characteristic symptoms, At the same 
 
ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 263 
 
 time, there would remain the possibility that even this merely • 
 functional disturbance might in the long run become associated 
 with a coarse lesion of the centres. Many things about these 
 affections would agree very well with such a supposition, among 
 them the occasional occurrence of the reaction of degeneration 
 in dystrophic cases and the occasional initial localisation of 
 spinal amyotrophy in the shoulder and trunk. But I will not 
 spin out this discussion to any greater length ; the whole question 
 is by no means yet ready for decision, and the future alone can 
 lift the veil and reveal the finer processes that as yet lie hid 
 from us. 
 
 Coming back from this digression to the clinical aspects of 
 the disease, we have yet to say something about etiology. "We 
 know very little of its causes. The most certain thing about it 
 in this connection appears to be its hereditary character ; at any 
 rate, this holds good for a majority (about three-fourths) of the 
 cases. It not unfrequently occurs as a family disease, and can 
 be traced through several generations ; in cases of this kind 
 there can scarcely be a doubt as to the hereditary trans- 
 mission of the affection, or at least of the predisposition. But it 
 often happens that two, three, or more cases occur in one 
 generation only, and here we may probably assume some 
 influence proceeding from the parents, though it is not necessary 
 to suppose this in every case. Marriage between blood-relations 
 sometimes seems to act as a factor, and in one of my cases the 
 parents are cousins, the children of twin brothers, thus standing 
 in the closest conceivable relationship in which a legal marriage 
 is permissible. In another, the father had suffered from a severe 
 injury. What I found to be of most frequent occurrence was 
 the existence of neuropathic and psychopathic tendencies, but 
 even this was present only in 8 out of 18 families. Many cases 
 occur, however, quite in an isolated way ; in certain of these no 
 doubt the history may be defective, but the disease must always 
 make a beginning with someone, and it remains to be seen 
 whether in these instances it is transmitted to the posterity. 
 All the other causes which have been blamed — overstrain, 
 injury, influences affecting the mother in pregnancy (injury, 
 mental agitation), acute infectious diseases, &c. — are of so 
 little relative importance and so rarely present that they hardly 
 deserve mention. 
 
264 ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 
 
 The course is generally a progressive one, though not nearly 
 so much so as in spinal amyotrophy. It is always very slow 
 and insidious, extending over 20 or 30 years, and sometimes 
 coming to a standstill altogether, so that the patients live to a 
 good old age. I have seen individuals between 50 and 60 years 
 of age who had been affected with it when young. 
 
 The end comes not unfrequently in this way, that the lesion 
 makes continual progress, spreading to one muscle after another, 
 until the patient becomes at last quite helpless, and with 
 affection of the respiratory muscles and diaphragm death is 
 finally produced by asphyxia or intercurrent disease. The 
 younger the patient when first attacked, the more rapid and 
 destructive is the course of the disease. Other unfavourable 
 elements for the prognosis are the spreading quickly from one 
 part of the body to another and a marked tendency to 
 lipomatosis. But children with the pseudo-hypertrophic form 
 in general attain to a considerable age, though there are 
 exceptions to this. 
 
 About the prognosis I have already said all that can be said. 
 Actual recovery does not appear to occur, but I have repeatedly 
 seen the condition improve and the disease even coming to a 
 halt. This occurs especially in cases beginning first in youth 
 or adult life. 
 
 In regard to treatment, the outlook is far from encouraging, 
 and the results attained hitherto are extremely meagre. Should 
 the attempt not be made to try some kind of prophylaxis against 
 this disease in the actual presence of which we are so helpless ? 
 Should not we subject to some treatment parents, who, without 
 being affected themselves, have already had dystrophic children 
 or who have come of dystrophic families ? The object aimed 
 at would be of course to endow any children they might have 
 afterwards with greater strength and power of resistance. It is 
 rational enough to argue in this way, but I cannot see what 
 more we can do beyond following the ordinary laws of health 
 and employing the usual " tonic " remedies. The same holds 
 good of the prophylaxis in the case of children of dystrophic 
 families, whether their parents or brothers or sisters are affected 
 or not ; we cannot get further than laying down some general 
 rules about healthy modes of life and good food, general 
 hardening up, fresh air, baths, avoidance of undue muscular 
 
ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 265 
 
 strain, tonics, perhaps the use of arsenic ; these exhaust the 
 means we have at our command. 
 
 For the disease itself we merely possess the old remedies 
 which have so often failed of their purpose. My own opinion is 
 that the application of electricity is still the most trustworthy 
 thing we have. In particular, I would have you use the galvanic 
 current along the back and over the cervical and lumbar 
 swellings of the cord with a regard for the trophic centres 
 lying about these regions, whether you consider them the 
 proper seat of the disease or not. You may, besides, employ 
 peripherally the faradic, galvanic, or farado-galvanic currents to 
 the nerves and muscles, although I must warn you against 
 using too strong currents or having too long sittings. Massage 
 of the affected muscles deserves a trial, but it must not be too 
 energetic. So do gymnastics, but they must be carefully 
 adapted to the condition of the individual muscles as regards 
 nutrition and strength, and, above all, must not be carried too 
 far. In addition, you may employ any of the means which 
 give tone and resisting power to the whole organism. Such 
 are cold baths, sea-bathing, warm salt baths, chalybeate 
 and peat baths, pure air, good food, tonics, arsenic, 
 strychnia, &c, 
 
 Gentlemen, I am coming to an end. I have endeavoured to 
 bring before you progressive muscular dystrophy as a perfectly 
 well-defined disease, though it assumes various forms. It is 
 certainly by far the most common of all the progressive muscular 
 atrophies, and the number of the cases that have come under 
 my own notice, reckoning all the forms together, is many times 
 the number of my cases of spinal amyotrophy. I trust, at any 
 rate, I have convinced you of the clinical unity of our 
 " dystrophies," and I am now satisfied to leave it to yourselves, 
 if you choose to distinguish individual forms or subspecies (types) 
 in that unity — a course which is not without its advantages. The 
 division into the pseudo-hypertrophic, the juvenile, and the 
 infantile forms is recommended by its simplicity, and the 
 characters of these forms I do not need to repeat again. It is 
 possible, however, that with advancing knowledge we may 
 arrive at a division still more suitable for our purposes. 
 
266 ERB ON PROGRESSIVE MUSCULAR DYSTBOPHY. 
 
 LITERATURE. 
 
 1. Aran, Kecherches sur une maladie non encore decrite du syst. musculaire 
 
 (Atrophie museul. progress.). — Arch, gener. de M(5d. 4. Ser. T. XXIV. 
 1850. 
 
 2. Cruveilhier, Sur la paralysie museul. progr. atrophique. Arch, gener. de 
 
 Me"d. 1853. 
 
 3. Duchenne (de Boulogne), Stance de l'Acad. de Mdd. 21. Mai. 1849.— Union 
 
 m<5d. 1852.— Bullet, de Therap. 1853.— De l'electrisat. loealise'e etc. 1855. 
 (2nd Ed., 1861— 3rd Ed., 1872.) 
 
 4. Charcot, Klinische Vortrage ttber die Krankheiten des Nervensystems. I. 
 
 Deutsch von Fetzer. 1874. 
 
 5. N. Friedreich, Ueber progressive Muskelatrophie, iiber wahre und falsche 
 
 Muskelhypertrophie. Berlin 1873. 
 
 6. Kussmaul, Ueber die fortschreitende Bulbarparalyse und ihr Verhaltniss zur 
 
 progressiven Muskelatrophie. Volkmann's Sammlung klin. Vortrage. 
 Nr. 54. 1873. 
 
 7. Lichtheim, Progressive Muskelatrophie ohne Erkrankrung der Vorderhorner 
 
 des BUckenmarks. Arch, f . Psych, u Nervenkr. VIII. 1878. 
 
 8. E. Leyden, Klinik der Bttckenroarkskrankheiten. II. 1876. 
 
 9. Moebius, Ueber die hereditaren Nervenkrankheiten. Volkmann's Sammlung 
 
 klin. Vortrage. Nr. 171. 1879. 
 
 10. W. Erb, Vortrag " Uber die juvenile Form der progressiven Muskelatrophie.'' 
 
 Tagebl. d. Naturforscherversamml. in Freiburg i/B. 1883 (Mendel's Neurol. 
 Centr. Bl. 1883. 1. Okt.).— Ueber die juvenile Form der progressiven 
 Muskelatrophie und ihre Beziehungen zur sog. Pseudohypertrophic der 
 Muskeln. Deutsch. Arch. f. klin. Medic. Bd. 34. 1884 (Marz). 
 
 11. Landouzy et Dejerine, De la myopathie atroph. progressive. Acad, des 
 
 Sciences (Sitzung vom 17. Jan. 1884).— Bev. de M6dee. Fevr.-Avril 1885.— 
 Nouvelles recherches cliniques, etc. Bev. de med. Dec. 1886. 
 
 12. Fr. Schultze, Ueber den mit Hypertrophic verbundenen progressiven Muskel- 
 
 schwund und ahnliche Krankheitsformen. Wiesbaden 1886. 
 
 13. P. Marie et G. Guinon, De la myopathie progressive primitive. Bev. de m£d. 
 
 Oct. 1885. 
 
 14. F. Baymond, Atrophies mnseulaires et maladies amyotrophiques. Paris 1889. 
 
 15. E. Troisier et G. Guinon, Deux nouv. cas de myopath. progr. primit. chez le 
 
 pere et lafille. Bev. de mid. 1889. 
 
 16. Charcot, Bevision nosographique des atrophies muse, progres. Progres me'd. 
 
 1885. Nr. 10. 
 
 17. EichhorBt, Ueber Hereditat der progressiven Muskelatrophie. Berl. klin. 
 
 Woch. 1873. S. 497. 
 
 18. Fr. Schultze, Ueber eine eigenth. progress, atroph. Paralyse bei mehreren 
 
 Kindern derselben Familie. Berl. klin. Woch. 1884. Nr. 41. 
 
 19. Charcot et Marie, Sur une forme particul. d'atrophie muse. etc. Bev. de 
 
 med. 1886. p. 96. 
 
ERB ON PROGRESSIVE MUSCULAR DYSTROPHY. 267 
 
 20. Herringham, Muscnl. atrophy of the peroneal type, affecting many members 
 
 of a family. Brain 1888. June. 
 
 21. J. Hoffmann, Ueber progress, nenrot. Muskelatrophie. Arch. f. Psych, u. 
 
 Nerv. Bd. XX. 1889. 
 
 22. BZeubner, Ein paradoxer Pall von infantiler progress. Mnskelatrophie. 
 
 Wagner-Festschrift. Leipzig 1887. 
 
 23. Oppenheim n. Siemerling, Ueber das Vorkommen von Hypertroph. d. Primitiv- 
 
 fasern in Muskelpartikeln, welche d. leb. Menschen excidirt wurden. 
 Centr. Bl. f . med. Wiss. 1889. Nr. 39 u. 41. 
 
 24. Ph. Knoll, Ueber Paralysis pseudohypertrophica. Wien. Med. Jahrbiicher. 
 
 1872. 
 
 25. Strilmpell, Ueber spinale progr. Muskelatrophie etc. Zenker-Festschrift. 
 
 Leipzig 1887. 
 
 26. W. Miiller, Beitr. zur pathol. Anatomie u. Physiol, des menschl. Riickon- 
 
 marks. Leipzig 1871. 
 
 27. Dejerine et Huet, Arch, de physiol. 1888. p. 386. 
 
 28. Joffroy et Achard, Arch, de Med. experiment. I. 1882. p. 64. 
 
 29. E. Hitzig, Ueber spinale Dystrophien. Berl. klin. Woch. 1889. Nr. 28. 
 
 30. Frohmaier, Ueber progr. Mnskelatrophie. Dentsch. med. Woch. 1886. Nr. 
 
 23,24. 
 
ASTHMA AND DISEASES OF THE 
 GENERATIVE ORGANS. 
 
 BY 
 
 De, ALEXANDER PEYER. 
 
 Translated by 
 
 PRANK H. BARENDT, M.D., Lond., F.R.C.S. Eng. 
 
U', 
 
ASTHMA AND DISEASES OP THE 
 GENEBATIVE OEGANS. 
 
 '(Asthma sexuale.) 
 
 As we all know, the pathology of asthma has already undergone 
 various modifications. For some time past two forms have been 
 recognised: Bronchial Asthma and Nervous Asthma. 
 Under the first we comprehend those cases where an excess of 
 bronchial secretion is present. This forms the well-known three 
 layers of expectoration in the spit-jar : purulent, ropy, and frothy 
 mucus. Examination of the lungs reveals the signs of chronic 
 bronchial catarrh, which is constantly kept up by acute attacks. 
 According to Boeker (German medical weekly journal, No 26 
 and 27, 1888), asthma is generally caused by the state of the 
 bronchial mucosa. No proper anatomical idea was connected 
 with the expression "nervous asthma"; there was only a 
 vague impression that nervous processes had something to do 
 with its causation. 
 
 This view was often questioned by the representatives of the 
 anatomical school of this century. It was held that asthma was 
 no nervous affection at all, but always connected with emphysema 
 and bronchitis, and even Laennec was of the opinion that the 
 chief cause of asthma was catarrhe sec and emphysema. 
 
 On the other hand, several authorities on asthma, asRamadge, 
 Bergson, &c, maintained that asthma cannot be explained 
 without assuming a nervous element. 
 
 In later times, however, we know definitely that asthma is a 
 pure neurosis which has just as much a substantive existence 
 as many other nervous affections^ e.g., megrim, epilepsy, &c. 
 
 Hence, in the light of this knowledge we must regard every 
 case as a symptom of some underlying disease, and must direct 
 our attention, as regards aetiology, to the nervous processes, 
 however obscure. 
 
 The onset of an attack of asthma is explained by irritation 
 of the central nervous system, wherever the path lies the 
 
272 PEYER ON ASTHMA AND 
 
 origin is the same: the nerve endings are morbidly 
 irritated and transfer the irritation to the central 
 organs. 
 
 This irritation may be produced either through catarrh 
 developing in the vicinity of the nerve endings, or through 
 hyperplasia of the surrounding tissue, or through dry 
 atrophic catarrh, which destroys the respiratory 
 mucosa in places, thus rendering the nerve endings more 
 sensitive, or through derangement and obstinate catarrh 
 of the stomach affecting its nerve supply, or through 
 emphysema, bronchial catarrh, caseous bronchial 
 glands, &c, any of which cause chronic irritation of the 
 bronchial nerves, or through diseases of the ovaries, 
 uterus, vagina, prostate, bladder, penis, (at times the 
 glans,) any of which may establish nerve irritation. All these 
 various affections may produce asthma. (Asthma : its nature 
 and treatment. Brugelmann.) 
 
 Asthma may occur as a neurosis pure and simple, but it is 
 much more frequently observed in connection with congestion 
 and catarrh of the respiratory mucosa. The nerve which is 
 generally assumed to be implicated in the production of spasm 
 is the vagus. However, the sympathetic appears to me to be 
 more likely, for although we may not have sufficient grounds for 
 this, still from analogous distribution of the sympathetic to un- 
 striated muscle there is nothing strange in inferring the bronchial 
 muscular fibres to be similarly supplied. 
 
 It might, therefore, be held that there is but one form of 
 asthma, namely, that which arises through nerve influence. But 
 for practical reasons it is better to classify the various forms 
 of asthma according to the seat of irritation. Brugel- 
 mann makes the following division : — 
 (a) Nasal asthma. 
 (£) Pharyngo-laryngeal asthma. 
 
 (c) Bronchial asthma. 
 
 (d) Toxic asthma. 
 
 («) Neurasthenic asthma. 
 
 Under neurasthenic asthma all those forms are included that 
 do not fall under the other divisions. He would therefore include 
 those cases about which I intend to say a few words, namely, 
 asthma dependent upon sexual affections. These are not 
 
DISEASES OF THE GENERATIVE ORGANS. 273 
 
 by any means so seldom as has hitherto been assumed, as 
 will be seen in the course of .my remarks. I might almost main- 
 tain that the generative system is one of the chief seats of irrita- 
 tion producing asthma, and divide asthma into six classes, of 
 which sexual asthma forms one. 
 
 This division has a further practical bearing as plainly in- 
 dicating the chief exciting cause of asthma, which is generally 
 overlooked in the examination of the patient, either from 
 ignorance or false modesty on the part of the physician or 
 of the patient. 
 
 In not a small number of cases, we find, in males 
 as well as in females, disorders of the generative 
 organs, which produce attacks of asthma through the 
 medium of the sympathetic nervous system. 
 
 But in the male sex, particularly, these disorders are much 
 more frequent than has hitherto been thought. They are chiefly 
 affections of the posterior portion of the urethra which cause 
 reflex nerve troubles, e.g., urethritis posterior in consequence of 
 sexual excess, masturbation, gleet, &c, and spermatorrhoea, 
 though affections of the penis, especially of the glans, may also 
 play an important part. 
 
 If we, then, admit a sexual asthma, we must carefully 
 enquire into the generative functions in the presence of negative 
 results from other causes, otherwise we are liable to errors of 
 omission. 
 
 This examination is very troublesome and tedious, as only 
 an exact and painstaking history of the case and repeated 
 microscopic examination of the urine yields safe conclusions as 
 to the pathological condition of the generative tract. Even 
 endoscopy may be necessary to be quite certain of the 
 diagnosis. 
 
 My object is now to bring forward a number of 
 important cases illustrating the significance and 
 influence of sexual derangements, especially in the 
 male, in the causation of asthma. 
 
 Various views are entertained as regards the immediate 
 mechanism of a paroxysm of asthma. Biermer's explanation 
 is the most probable, according to which a spasm of spastic 
 narrowing of the bronchioles takes place. Inspiration and 
 expiration are in consequence interfered with, but especially 
 
 T 
 
274 PEYER ON ASTHMA AND 
 
 the latter, as the effect of the bronchial spasm is considerably 
 increased by the expiratory pressure. 
 
 There is, however, another variety of asthma where inspira- 
 tion is impeded or rendered impossible for a time through 
 clonic spasm of the diaphragm (phrenic asthma). 
 
 The thorax remains some seconds fixed in the position of 
 inspiration, the epigastrium is arched forward, the heart 
 depressed, and the spasmodically-contracted diaphragm can be 
 felt. Patients suffer frequently from great oppression on the 
 chest and pain in the diaphragmatic region. These cases are, as 
 a rule, less numerous than those of bronchial asthma, and seem 
 to me to occur more often in women. 
 
 However, bronchial and phrenic asthma can be very easily 
 distinguished, and no one who has seen a typical case of either 
 will have any difficulty in diagnosis. Both kinds may be caused 
 by sexual affections. 
 
 Case I. — Severe Asthma in consequence of Masturbation in Youth, 
 and later on Spermatorrhoea — Cure. 
 
 In 1871, as family medical attendant, I was called in to 
 see Mr. A., inn-keeper and farmer. He was 26 years old, 
 married, and had two children. Bodily strength well developed, 
 temperament lively, and habits very regular. For a year past 
 he frequently suffered from slight bronchial catarrh and from 
 several severe attacks of asthma. 
 
 History : Patient's father suffered in later years from chronic 
 bronchial catarrh and emphysema ; his brothers and sisters, four 
 altogether, were quite healthy, and, with the exception of measles, 
 Mr. A. had never had any other illness. When 18, he became 
 steward to a farmer, and it was then he first had an attack 
 of asthma, which recurred some four times in the 
 course of the next two years. On this account he was 
 exempted from military service. During the following four years 
 he actively pursued his farming duties and enjoyed excellent 
 health. He then married, and also undertook the management of 
 an inn. He ascribed his no longer feeling so well, and his sallow 
 muddy complexion, to the want of his former outdoor occupa- 
 tion, and attributed his susceptibility to catarrh, which, as above 
 mentioned, was accompanied by attacks of asthma, to being fre- 
 quently in his vaults. These attacks became more frequent, 
 
DISEASES OF THE GENERATIVE ORGANS. 275 
 
 patient lost flesh, and was sent by his medical advisers to Davos, 
 under a strong suspicion of tuberculosis. During a two months' 
 residence there, he gained twenty-five pounds (27f lbs. Eng.) in 
 weight, his appearance became normal again, he lost the catarrh, 
 and no more asthmatic attacks occurred. He was able to do 
 plenty of mountaineering without the least fatigue. He had 
 scarcely returned home, when the attacks came on again. In 
 the summer of 1872 he went back to Davos for a longer course 
 of treatment, in spite of which he again experienced several 
 attacks at the beginning of winter, and consequently spent the 
 whole of that winter (from 1872 to 1878) at Davos. The follow- 
 ing summer he remained quite free. In the autumn, however, 
 they reappeared, and so severely and frequently that he had to 
 give up his inn and retire. Notwithstanding these steps, there 
 was no improvement, and on my advice he consulted my former 
 teacher, Professor Biermer, of Zurich, who reported as follows 
 on the case : — 
 
 " Mr. A. suffers from chronic dry bronchitis and consequent 
 emphysema. The cardiac dulness is much diminished owing to 
 encroachment of the lungs ; vesicular breathing cannot be heard 
 in several area?, or is replaced by dry rales. The asthmatic 
 attacks are produced by spastic narrowing and catarrhal swelling 
 of the bronchioles. I recommend potassium iodide as a well- 
 tried empiric remedy." 
 
 At first he obtained some relief from the medicine, and had it 
 made up some sixty times in the course of a year. Unfortunately 
 he was worse than ever in the autumn of 1874. The asthmatic 
 attacks increased terribly, and he did not venture to go out 
 without respirator, or without being muffled up to the ears in 
 woollen wraps. 
 
 The thought occurred to me now, for the first time, that these 
 attacks might have some connection with the sexual functions, 
 from what the patient casually told me when called to see him 
 one night in an attack. He remarked that he thought sexual 
 connection was harmful to him, and that he would have to give 
 it up, as he was almost certain that it always brought on an 
 attack. 
 
 From this communication, I carefully inquired into the sexual 
 functions of the patient from his youth, and obtained the following 
 statement : From boyhood he was much addicted to masturbation, 
 
276 PEYER ON ASTHMA AND 
 
 and practised it continuously up to manhood. At school, when 
 greatly excited {e.g., when he had quickly to work out a difficult 
 sum before the teacher) seminal emissions would occur with the 
 penis quite flaccid. Later on these took place when simply 
 coming into contact with women. Nocturnal emissions occurred 
 without erection or awaking 'him. Several attempts at sexual 
 intercourse completely broke down, either from defective erection 
 or from precipitate ejaculation. In his marital relations it was 
 just the same; even if penetration was effected, ejaculation 
 immediately occurred; and his wife stated she had never ex- 
 perienced the sexual orgasm, and therefore was very much 
 surprised at conceiving. 
 
 The penis was small and flabby, and the glans was completely 
 covered by the long prepuce. The meatus was greatly reddened, 
 the mucosa tumid, and the introduction of a bougie caused 
 unusual pain. Frequent examination, of the urine, which 
 chemically was normal, revealed almost invariably traces of 
 semen. Biermer, like the preceding medical men, diagnosed 
 pulmonary catarrh and emphysema. 
 
 " The asthmatic attacks are produced by catarrhal swelling 
 and spastic contraction of the bronchioles," so Biermer 
 states. 
 
 At that time I certainly and quite naturally thought so 
 too. But what is the origin of this spastic contraction (i.e., the 
 paroxysm, which determines the nature of asthma) ? What is 
 its cause ? Along which nerve path does it travel ? And last, 
 but not least, to the practical physician, will it yield to treatment ? 
 
 At that time, about 1870, asthma was not regarded as a 
 nervous disorder, and still less was the idea ever entertained that 
 it could be brought about reflexly by affections of the generative 
 organs. Yet, for an observing practitioner, the probability of 
 this causal connection in the above case lay quite close at hand. 
 For we have here defective sexual power, typical sperma- 
 torrhoea, and asthmatic attacks following and brought on by 
 sexual connection. At any rate I resolved upon local treatment 
 of the spermatorrhoea. This consisted in the prolonged use of a 
 metallic bougie for some minutes at a time, and of astringent 
 injections. As regards the ultimate result I can only state that the 
 patient since then, some 15 years now, has remained quite free 
 from asthma. 
 
DISEASES OF THE GENERATIVE ORGANS. 277 
 
 Case II. — Temporary Aspermatismus, followed by impotence. 
 Spermatorrhoea. Neurasthenia. Severe Asthma. 
 In July, 1880, Mr. E., a miller, consulted me on account of 
 severe asthma and a distressing feeling of depression. Patient 
 was 48, medium height, well built, muscles well developed, 
 and body well covered. He had five children, the youngest 
 being ten years old ; no symptoms of hereditary disease. He 
 was accompanied by his' wife, a very intelligent woman, who 
 volunteered the following statement : " Doctor, I shall just tell 
 you the cause of his illness ; my husband has been completely 
 impotent since he was 88 years old, and even before he 
 was never quite right in this respect." Following up this 
 remark, I inquired into his past history and obtained further 
 particulars about his sexual habits. Ever since the age of six 
 he was addicted to masturbation ; ejaculatio seminis took place 
 first when he was 15, and from then up to 20 he gener- 
 ally masturbated some four or five times daily. When 18^ 
 shyness and attacks of depression appeared, but usually passed 
 off" quickly. He himself referred them to his vicious habits, 
 which lie nevertheless continued, although not quite so frequently, 
 up to 26, when he married. Erection did not always occur at 
 the time of coitus and then the patient had to resort to manual 
 friction. From the very first, ejaculation had absolutely never 
 taken place during natural coitus. After repeated intra-vaginal 
 friction the penis lost erectile power without ejaculation occurring. 
 In fact, under no conditions did ejaculation follow connection. 
 He, therefore, aided the process by withdrawing the penis after 
 more or less vaginal friction and then manually excited it until 
 ejaculation was imminent, whereupon he quickly reintroduced 
 the organ. In this way Mr. E. begat five exceptionally vigor- 
 ous and mentally and bodily healthy children. When 38, 
 in spite of great bodily strength, he completely lost sexual 
 power, and from that time his present illness first began to 
 assume a definite character. His wife mentioned this when he 
 first consulted a doctor, and added she drew the attention 
 of the different medical men he saw to this circumstance, 
 none of whom, however, attached any importance to it. The 
 above-mentioned attacks of dread and depression, which- had 
 never quite left him since his 18th year, became frequenter 
 
278 PEYER ON ASTHMA AND 
 
 and lasted longer. Periodic attacks of profuse perspiration, 
 commencing when he was 20, which exempted him from 
 military service, increased in spite of a naturally cheerful dis- 
 position. Strange fixed ideas took hold of him, which he could 
 not get rid of, although quite convinced of their absurdity. For 
 instance, the idea oppressed him that his inside was not formed 
 like other people's, and his first thought on seeing a stranger was 
 what his inside might be like. Then he gradually got to believe, 
 without the slightest reason, that he squinted with the left eye. 
 He kept constantly looking in the glass, and, notwithstanding 
 the evidence of his own senses and the assurances of the ophthal- 
 mic surgeon he consulted that there was nothing wrong with 
 his eyes, he could not get rid of this impression. Another idea 
 was that he had a cough, and no arguments of his friends were 
 sufficient to disabuse his mind. However, it was only within 
 the last year that his symptoms attained a serious degree. His 
 despondency became so intense that he did not trust himself to 
 be alone ; even when taking a short walk he would have his wife 
 and daughter accompany him. If asked how he was, his eyes 
 filled with tears, and he cried before strangers just like a child. 
 Sleep, which had formerly been good, had been disturbed during 
 the last few years ; now it was wretched, and he scarcely slept 
 more than two or three hours, and then was troubled by oppressive 
 dreams. He used to be an untiring worker ; he was now always 
 languid. Perspiration was so profuse that when he only stooped 
 he became literally bathed in sweat. His fancied cough was 
 now a reality, and pretty severe asthma was present. He 
 could only go up a short flight of stairs with difficulty, and then 
 had to rest for some moments before he could speak a word. At 
 night he spent hours sitting on a chair in order to obtain breath, 
 and was consequently terribly afraid of going to bed at night. 
 The attacks became severer and more prolonged. They came on 
 without the slightest provocation, and were at times so intense 
 that the patient, with body bent forward, cyanosed features, and 
 thick swollen veins of the neck, clutched hold of the table, 
 struggling for breath. This was his condition when he came 
 under my care. Up to that time he had been treated by several 
 medical men for the lung affection and all his sufferings were 
 referred to asthma. Shortly before a professor of medicine had 
 recommended him to go to Corsica, but, not feeling strong enough 
 
DISEASES OF THE GENERATIVE ORGANS. 279 
 
 to do so, he spent two months in Gersau (Lake of Lucerne), 
 where he obtained no relief. On examination I found moderate 
 bronchial catarrh and well-marked gmphysema. The somewhat 
 scanty frothy expectoration revealed under the microscope asthma 
 crystals, like the spines of a hedgehog. 
 
 The urine contained neither albumen nor sugar, but almost 
 every time a varying amount of semen could be detecbed, along 
 with urethral mucus, although the patient never had gonorrhoea. 
 
 I diagnosed severe neurasthenia, reflex asthma depending 
 upon chronic posterior urethritis, and spermatorrhoea. Treat- 
 ment, which was chiefly directed to the primary affection, 
 confirmed the diagnosis. The patient completely recovered and 
 has since remained well. 
 
 Case III. — At the end of February, 1883, Mr. F., teacher in 
 Z., in the Black Forest, Baden, came under my care. He was 
 26 years old, very tall, broad shouldered, big-boned, with well- 
 developed muscles (Mr. F. served in the Guards), but looked pale 
 and anaemic. 
 
 He complained chiefly of a peculiar form of coryza and 
 periodic attacks of asthma. The former, for the last five 
 years had regularly occurred twice a week and on definite days, 
 Wednesdays and Saturdays. On each preceding evening 
 prodromata manifested themselves, consisting in general malaise, 
 a feeling of heaviness in the head and of oppression on the chest ; 
 frequent sneezing ensued and a tenacious mucus was secreted 
 from the nose. 
 
 The same night the patient was restless, had troubled dreams, 
 and awaked in the morning unrefreshed. The nasal mucosa 
 began now to secrete a watery fluid, the eyes kept on filling, and 
 violent sneezing occurred incessantly. 
 
 The sneezing at the nose was so copious that Mr. F. often used 
 ten pocket-handkerchiefs a day, which became dripping wet. 
 
 Towards evening the nasal discharge abated considerably, but 
 the sneezing was still frequent. The night was passed undis- 
 turbed, the next morning on waking he felt refreshed, and the 
 attack was over. 
 
 This recurred in an exactly similar manner in the same week. 
 
 In the interval between the attacks there was no nasal 
 secretion, and the patient did not use a handkerchief at all. 
 
280 PEYER ON ASTHMA AND 
 
 It must, however, be mentioned that on the coryza days the 
 feet were markedly dry and hot, and gave rise to a burning 
 Sensation ; otherwise the patient's feet perspired normally. 
 
 . The sense of smell was completely lost during an attack, 
 but in the interval was quite normal. 
 
 About a year after the commencement of the coryza, i.e., about 
 four years ago, the above-mentioned asthmatic attacks 
 supervened, but only in connection with certain events. 
 
 Mr. P. was a heavy beer drinker. One evening, in company, 
 he had taken his 10 to 14 glasses of beer, which he could 
 always very easily stand, when the next day, on the slightest 
 exertion, he suffered from difficulty of breathing, which 
 considerably increased during the next six months. For 
 instance, if he wanted to do a little gardening, or quicken his 
 steps on level ground, an attack would come on, which finally 
 reached such an intensity that he was obliged to remain bent 
 forward, seizing hold of any fixed object to get his breath. 
 
 As above stated, asthma at first only appeared at times after 
 excessive drinking. If he avoided excess he could walk as usual 
 and even climb a hill without any difficulty. 
 
 As this affection was first manifest during the hay-harvest, his 
 medical advisers regarded it as " hay-fever." The diagnosis 
 really seemed to be correct, for in the next winter the attacks 
 were much less frequent, and only occurred after heavy 
 drinking. 
 
 The following summer, however, they grew severer, and at 
 times were so severe that owing to difficulty in breathing the 
 patient could scarcely walk 50 paces on level ground without 
 having to rest. Consequently he gave up beer drinking, the 
 immediate cause, as much as possible. His usual amount for a 
 few years past had been two bottles a day, and as a rule he took 
 no spirits. He also became more moderate in smoking, having 
 previously been a very heavy smoker. 
 
 He also had noticed latterly that slight excess in drinking and 
 smoking completely knocked him up, and he suffered considerably 
 from after-effects, as he had never done before. 
 
 Furthermore, he had lately lost appetite, which was formerly 
 excellent, and instead, had a sensation of sinking and depression. 
 He felt the need of taking food, but had no inclination for it 
 when placed before him. 
 
DISEASES OF THE GENERATIVE ORGANS. 281 
 
 Formerly the bowels had acted regularly, but during the last 
 two years their action became noticeably frequent. At first 
 twice, then four to five times a day, with regular intermissions. 
 Then periods occurred when he had severe diarrhoea — 12 to 15 
 evacuations daily — lasting from one to two weeks without any 
 apparent cause. Treatment had but a temporary effect and it 
 usually ceased of itself. 
 
 On various occasions Mr. F. had been troubled with worms, 
 and he vomited a large one a short time ago. 
 
 He had been married a year, and recently his wife was 
 confined of a healthy child. 
 
 Physical examination revealed tolerably marked anaemia, 
 faucial catarrh, slight chronic enlargement of the tonsils, a 
 swollen, bluish red, pendulous uvula, and moderate pulmonary 
 emphysema. On rising the patient always hawked up a scanty 
 phlegm ; he seldom coughed. Heart and abdominal organs 
 normal. Chemical examination of the urine revealed nothing 
 abnormal ; at the bottom of the urine glass a slight cloudy sedi- 
 ment settled, which I unfortunately did not examine micro- 
 scopically, as, from the history of the case, I thought there was 
 no indication for it. 
 
 Diagnosis. First and foremost I sought a connection between 
 all the symptoms which would present a complete picture of the 
 disease, and proceeded thus. Here we had for several years past 
 chronic gastric and enteric catarrh, as shown by loss of appetite 
 and constant diarrhoea, caused, by immoderate drinking and 
 smoking. The enteric catarrh was probably kept up by the 
 presence of worms, which had been noticed several times. The 
 chronic faucial catarrh, hypertrophy of the uvula, and chronic 
 tonsillitis were likewise referable to his smoking and drinking. 
 The almost periodic attacks of nasal catarrh I could not account 
 for; I had never seen anything similar before. In any case, 
 however, I regarded it as connected with the chronic faucial 
 catarrh. 
 
 There was in all probability a causal relationship between the 
 gastric catarrh and the asthma; the latter I regarded as a 
 reflex nervous affection. This view was corroborated by 
 the attacks coming on after excessive drinking, and also perhaps, 
 as I thought, by the presence of worms in the alimentary canal. 
 From the very first the presence of pulmonary emphysema and of 
 
282 PEYER ON ASTHMA AND 
 
 the chronic inflammatory condition of the fauces predisposed 
 the patient to them. 
 
 On this diagnosis I based my treatment. At the outset, diet 
 was strictly regulated and the amount of drink taken was limited 
 to two glasses of light good beer daily. Smoking was forbidden 
 and an energetic course of santonin was carried out. 
 
 Fifty-four days after I saw the patient again ; his condition 
 was about the same, appetite slightly better, no worms had been 
 found. 
 
 Local treatment of the nose and throat, and various internal 
 remedies were used, but without any result, and during the two 
 months he was under me the patient received no benefit worth 
 mentioning. 
 
 In the course of conversation one day Mr. F. told me, inciden- 
 ally, that he was still obliged to pass water very frequently, and 
 at times experienced a slight burning sensation. 
 
 He had already mentioned this fact at the first examination, 
 but, as I regarded it as a result of his heavy drinking, I did not 
 pay any attention to it. But now, as he had given up drinking, 
 I concluded that Mr. F. was suffering, from irritable bladder (on 
 idiopathic irritability of the bladder by Peyer, Enke Stuttgart, 
 1888), _ and therefore determined to examine the urine again. 
 He passed water in my presence and I again observed the 
 deposit of a slight cloud similar to what I had previously noticed, 
 but unfortunately not examined microscopically. 
 
 The chemical examination gave, as on the first occasion, a 
 negative result. On the other hand, a microscopic examination 
 of the sediment, after a little trouble, revealed a fair number 
 of spermatozoa, mucus-filaments, and a few hyaline 
 casts. 
 
 In consequence of this discovery, I filled in that part of the 
 history of the case which, unfortunately, from motives of delicacy, 
 is generally neglected by medical men, and questioned him as to 
 the condition of the sexual system. The patient then told 
 me that from very early youth, about the 10th year, he was 
 led to masturbate, and constantly practised this vice till he was 
 18. About this time he obtained a post as teacher, and 
 also became acquainted with a woman with whom he had inter- 
 course very frequently, until his marriage some 15 months 
 ago. 
 
DISEASES OF THE GENERATIVE ORGANS. 283 
 
 For a long time lie did not notice any injurious effect from 
 excessive sexual indulgence, until some four years ago, when he 
 had nocturnal emissions in spite of frequent sexual intercourse. 
 At first they occurred about once a week, then more often, until 
 in the same night he had connection and later on seminal 
 emissions. In the morning he was dreadfully tired and played 
 out, and suffered slightly from shortness of breath. In the last 
 two and a-half years intervals- occur red — and recently more fre- 
 quently — when regularly, for a week at a time, he had nocturnal 
 emissions, in spite of frequent sexual connection. 
 
 Sexual desire had considerably decreased. Erection took 
 place readily enough, followed almost by immediate ejaculation ; 
 and it was only when the patient had drunk freely of beer, in 
 spite of long-continued friction, that no discharge of semen took 
 place, and the erection passed off — in other words temporary 
 aspermatismus. The sexual orgasm accompanying ej aculation 
 had almost completely disappeared. 
 
 Several specimens of urine the patient sent me always showed 
 the same characters — -more or less traces of semen, at times 
 hyaline casts (testicle casts) as above mentioned, and a few 
 lymph corpuscles. 
 
 I altered my diagnosis, and considered the case to be n euro tic 
 in nature, one of nervous erethism or neurasthenia, brought 
 about by early-commenced and long-continued sexual abuse. 
 The periodic nasal catarrh, asthma and chronic diarrhoea were 
 nervous or reflex in nature, and depended upon the sexual disorder. 
 The frequent micturition represented the so-called irritable 
 bladder, and was due to an inflammatory condition of the neck of 
 the bladder, which had extended from the prostatic portion of the 
 urethra. 
 
 The correctness of the diagnosis was proved by the result of 
 the local treatment of the uro-genital tract. 
 
 The nervous coryza, asthma, and chronic diarrhoea disappeared 
 completely in the course of half a year, and no return occurred. 
 
 Case IV. — Spermatorrhoea. Severe Spinal Irritation. Asthma. 
 
 Mr. H., farmer, well-to-do, 85 years old, exceedingly robust, 
 who served with me in the same regiment, consulted me in May, 
 1883, on account of pain in the back and asthma. 
 
 His habits were very regular and industrious ; parents healthy 
 
284 PEYER ON ASTHMA AND 
 
 and strong. He had never had any real illness, had been seven 
 years married, with three children, the youngest being three 
 years old. About four years ago he noticed for the first time 
 a certain oppression and stiffness in the back, especially after 
 hard work. Gradually the pain became at times so severe that 
 he could neither move his body nor stir from his position, not 
 only after hard work and heavy muscular exertion, but even whilst 
 quietly walking or sitting. He even felt his back when lying 
 down. At that time also severe asthmatic attacks appeared 
 without any apparent external cause. They seized 
 him in bed, at work, or when walking quietly along 
 the road ; he was then obliged to remain standing. Later on 
 asthma came on almost daily, at one time lasting from 
 five minutes to a quarter of an hour, at another lasting 
 half a day. No cough and no expectoration. When I saw 
 the patient,, his digestion was disturbed, appetite variable, 
 never good; frequently a sense of fulness and distension after 
 meals ; bowels sluggish ; no emphysema ; frequent desire to 
 micturate, withal difficulty in starting the stream, which was not 
 forked. Since his illness began he suffered a good deal from 
 headache ; during the morning his head was heavy and he felt 
 giddy. Memory good as a rule, no depression of spirits ; con- 
 stant lassitude, sleep heavy, dreams rare but oppressive. For 
 some time past he had felt remarkably little inclination for 
 sexual intercourse ; in fact, after coitus- he felt quite exhausted, 
 could not speak, and fell into a heavy sleep, only to awake with 
 a severe headache in the morning. Examination of the urine 
 revealed nothing abnormal, except now and then the presence of 
 semen. 
 
 Local treatment of the sexual affection cured the asthma and 
 spinal irritation. 
 
 Case V.- — Impotence. Spermatorrhoea. Asthma. 
 
 In October, 1877, Mr. L., merchant, setat. 30, consulted me 
 for general debility, heaviness of the head, persistent loss of 
 appetite, nausea, frequent vomiting, -weakness of memory, and 
 periodic severe attacks of asthma. 
 
 History. No hereditary taint; two years ago he was quite 
 .well, and, in fact, had never had any serious illness. When 
 15, through bad example, he began to masturbate, and con- 
 
DISEASES OF THE GENERATIVE ORGANS. 285 
 
 tinned to do so more or less up to the present time. When 
 21 the patient for the first time endeavoured to have con- 
 nection, but, in spite of all efforts, did not succeed in obtaining 
 an erection. Half a year later he succeeded, but ejaculation 
 took place immediately on introduction. This occurred with 
 every subsequent coitus, whenever the attempt was thus 
 far successful. He noticed that when he was about 26, 
 during his attempts at connection he sometimes 
 suffered from slight asthma, which, however, soon passed 
 off, although he was never troubled with any difficulty of breath- 
 ing, even during heavy walking. About two years ago he 
 awoke in the night, greatly alarmed, and unable to get 
 his breath. He sprang out of bed, rushed to the window in 
 order to get air. His medical attendant, who was hastily sum- 
 moned, prescribed him a full dose of morphine, which relieved 
 the paroxysms, only to recur in the same night. Mr. L. 
 was consequently so weak that he was obliged to remain in bed 
 for a week, and suffered a good deal from palpitation. For 
 some weeks afterwards he felt very weak on his legs. For a 
 whole year he remained quite free from an attack ; in the course 
 of the last year, however, four serious paroxysms occurred. 
 He began to lose flesh, was always languid, especially in the 
 morning, his head felt heavy, and he was much depressed in 
 spirits. His memory became much weaker, appetite was com- 
 pletely wanting, nausea and frequent vomiting occurred, the 
 bowels were sluggish, and his gait was peculiarly unsteady. About 
 half a year ago, he felt while walking a dull heavy pain in the 
 left testicle, which was present later on, even when sitting. He 
 fancied he must have unconsciously squeezed the organ. 
 Physical examination of the thin, slender built, ansemic looking 
 patient revealed nothing abnormal beyond slight emphysema. 
 There was nothing noticeable about the painful testicle, the 
 scrotum was lax and the penis flabby. Chemical examination 
 of the urine showed nothing abnormal, although microscopically 
 numerous spermatozoa could be detected in almost every 
 specimen. 
 
 Under treatment, which from the nature of the circumstances 
 was purely local, the symptoms completely vanished. Nausea, 
 vomiting, and loss of appetite disappeared first, normal appetite 
 and regular action of the bowels returned, and in quite a short time 
 
286 PEYER ON ASTHMA AND 
 
 the patient gained 7 kilograms (15 lbs.)- Spermatorrhoea ceased, 
 nocturnal emissions occurred normally, and his gait became 
 steady again. About two years after the end of treatment I 
 heard from Mr. L. that he was quite well, the sexual functions 
 quite normal, and he had no trace of asthma. 
 
 Case VI. — Long-continued Sexual Abuse. Asthmatic Attacks, 
 especially after Coitus. 
 
 In September, 1883, Mr. M., commercial traveller, consulted 
 me for very troublesome attacks of asthma, which came on 
 once or twice a week. He was 28 years of age, of medium 
 height, well developed, and looked healthy. He was a heavy 
 smoker, and, from the nature of his occupation, drank more 
 than was good for him. Frequent matutinal sickness, appetite 
 and digestion otherwise normal, sleep good. About two 
 years ago he had the first attack of asthma, although 
 during the whole of his military service as foot soldier he bore the 
 greatest fatigue without any discomfort. 
 
 The first attack came on after sexual connection, 
 and up to the time of observation he almost regularly 
 suffered in this manner. 
 
 As regards sexual intercourse the patient stated he had but 
 little desire, in fact ejaculatio seminis occurred almost immedi- 
 ately on attempt at coitus, and moreover an asthmatic attack 
 would follow so regularly that coitus almost became impossible. 
 He gave a history of long-continued sexual abuse, and, in con- 
 sequence, frequent nocturnal emissions. 
 
 Physical examination revealed slight faucial catarrh with 
 moderate emphysema. Urine,, which was only examined once, 
 was normal. I did not see the patient again, who only happened 
 to consult me whilst on his travels. 
 
 Case VII. — Temporary Aspermatismus. Asthma. 
 
 Mr. K., farmer, a3tat. 59, a tall, somewhat thin and anaemic 
 man, suffered for some years past from periodic asthma, which 
 occasionally was followed by slight feeling of " oppression." 
 Generally these attacks came on after sexual inter- 
 course, which had undergone a peculiar modification. 
 
 When 40, he married quite a young lady, who bore him four 
 children in quick succession. 
 
DISEASES OF THE GENERATIVE ORGANS. 287 
 
 The first stage of coitus was normal, but he no doubt indulged 
 too freely, and ascribed to this circumstance the fact that at 
 times no ejaculatio seminis took place. After such an occurrence, 
 in the course of 24 hours, he experienced a burning sensation 
 in the urethra, which was particularly severe when passing 
 water. 
 
 On the first occasion of this sexual anomaly, asthma appeared. 
 There was slight pulmonary catarrh and emphysema present. 
 The relation of the two complaints in this case was very apparent, 
 and I at once examined the genital system. The organs were 
 normal in shape and showed no external sign of weakness or 
 inflammatory irritability. No history of sexual infection. 
 Examination of the urine revealed slight urethral irritation and 
 at times spermatozoa. 
 
 Local treatment very soon improved the sexual powers. 
 Ejaculation accompanied connection, and the result was a healthy 
 boy. 
 
 At the same time the asthma completely disappeared. 
 . At the end of 1885 I saw Mr. K. again ; his wife had recently 
 been confined. He said he had noticed latterly premonitory 
 symptoms of his former trouble, ejaculatio seminis failed to occur 
 during coitus, and now and then an attack of asthma came on. 
 
 Resort again -to local treatment improved his condition, 
 and cure now was permanent. 
 
 Case VIII. — Masturbation during Youth ; later on frequent 
 
 Nocturnal Emissions and Coitus Beservatus. Frequent and 
 
 Severe Attacks of Asthma. 
 
 Mr. P., lawyer, aetat. 38, a tall, well-built man, pallid 
 complexion, was up. to 14 years of age a healthy-looking lad. 
 He was an only child; his father, a strong man, died, aBtat. 52, 
 from kidney disease; his mother, an extremely delicate and 
 nervous woman, succumbed to lung disease, astat. 50. 
 
 As far as his memory went, he said he was always of an 
 imaginative turn of mind, especially in sexual matters. When 
 14 he accidentally became addicted to masturbation, which 
 he practised continuously for the following six months. His 
 parents admonished him to give up the pernicious habit, which 
 he did, whereupon frequent seminal emissions occurred, often 
 three or four nights in succession, and almost always towards 
 
288 PEYER ON ASTHMA AND 
 
 morning. With the object of combating this state, the patient 
 used an alarum. If he set it for five in the morning, this was 
 effectual once or twice, but afterwards seminal emission would 
 take place at a quarter to five. If he set it still earlier, e.g., at 
 four, his waking did anticipate matters for a few days, but 
 subsequently seminal discharge would occur from a quarter to 
 half an hour before. At times the alaTum and the seminal 
 emission coincided. 
 
 Internal medicine, milk diet, change of air, sea bathing, 
 abstinence from highly-seasoned dishes, from alcohol, tea and 
 coffee, had no influence over his condition, and just as little 
 had regular intercourse, to which he later on resorted, on medical 
 advice, as a last resource. After leaving school, Mr. F. entered 
 the army in order to have as much out-door exercise as possible. 
 When 22, at the close of the great autumn manoeuvres, 
 which he had gone through without any great trouble, he was 
 suddenly attacked, during the night, by asthma. He sprang out 
 of bed, flung open the window and gasped for breath; it was 
 not till after some hours that the dreadful state yielded ; hence- 
 forward the paroxysms happened more frequently. 
 
 Several medical men noticed slight emphysema, and attributed 
 the asthma to this condition as well as to the strain of 
 campaigning. He consequently resigned his commission in the 
 army, and carried out his primary intention of studying law. 
 As Mr. P. was well-to-do, and engaged, he married soon, and 
 then, in order to prevent children, practised coitus reservatus. 
 His marital life had no influence on his general health, nocturnal 
 emissions still persisted, asthmatic attacks were in fact very 
 troublesome during the next six years, which he spent partly in 
 Carlsruhe and partly in Rastatt. At the former place they were 
 so severe that he often thought he would suffocate. 
 
 As a rule they came on during sleep and at night ; if they were 
 but slight, or if he only felt prodromata, burning nitrated paper 
 or hot application always brought relief. When they were at all 
 severe he had to be propped up in bed with five or six pillows, or 
 was obliged to get up and sit bending over a chair. " He had 
 passed many such terrible nights thus, coughing, wheezing, 
 spitting, and gasping for breath, half suffocated." Chloral alone 
 relieved this condition ; morphine was less beneficial. 
 
 He had not noticed any direct relation between sexual con- 
 
DISEASES OF THE GENERATIVE ORGANS. 289 
 
 nection and his sufferings. Local treatment which the patient 
 underwent, when 28, for nocturnal emissions had not the 
 slightest influence upon them or the asthmatic attacks. 
 
 Now, however, that I recognise the evil consequences of 
 frequently-practised coitus reservatus, I ascribe the failure of my 
 treatment to this factor, and although the patient told me of it, 
 I did not forbid it. 
 
 Later on the patient gave up this practice for various reasons, 
 and treated himself for the nocturnal emissions by administering 
 a cold water enema just before retiring. Gradually his sexual 
 troubles disappeared, and his asthma got well, after having lasted 
 some 16 years. 
 
 Case IX. — Severe Asthma in a Young Lady brought on during 
 
 Goitus. 
 
 In the summer of 1884 I was called during the night to attend 
 the young wife of a French officer, who was staying at the well- 
 known Schweizerhof Hotel, at Ehinefalls, on her wedding tour. 
 
 On arrival, I found the patient, setat. 20, who was fair, some- 
 what delicate and anasmic looking, out of bed, sitting in an 
 arm chair,, and suffering terribly from want of exspiratory power. 
 Her husband informed me that they only arrived at Ehinefalls 
 two days ago, and that in the latter part of the same night asthma 
 appeared. - Four days ago the young couple had been married at 
 Brussels, the home of the bride, and had left immediately for 
 Cologne, where, on -consummation of the marriage, his 
 wife, who had no idea that she was asthmatic, had a paroxysm 
 for the first time. It was not, however, serious, and did not 
 last long. The following night a severe attack occurred 
 again during sexual connection, which lasted in 
 varying intensity some two days. Then, on arrival at 
 Rhinefalls, during the third intercourse, the severest 
 attack of all came on, in which I found the patient, and 
 which lasted, varying in degree, some eight days. In fact, it was 
 so serious that I was obliged to spend three whole nights with 
 the patient. 
 
 In the course of conversation, Captain 0. told me that his 
 wife had suffered a good deal from chlorosis, nervousness, and 
 leucorrhcea. During sexual intercourse she is exceedingly ex- 
 citable; sexual orgasm, very soon occurred with her, whereas he 
 
 u 
 
290 PEYER ON ASTHMA AND 
 
 was of a remarkably sluggish. nature, and a considerable interval 
 elapsed before ejaculation. Afterwards she was completely done 
 up, whereupon the breathing at once became laboured; the 
 genuine attack did not come on until some hours after. 
 
 When she was able to undertake the return journey she passed 
 from under my care, but I impressed upon her very strongly the 
 advisability of consulting a specialist for diseases of women, and 
 submitting to a thorough examination of the sexual organs, which 
 • were in all probability in a condition of inflammatory irritability. 
 
 Case X. — Masturbation. Hyperaesthesia oftlis Orificium Vaginae. 
 
 Vaginal and Uterine Catarrh. Hysterical and Asthmatic 
 
 Attacks. 
 
 One of my acquaintances consulted me shortly after marriage 
 about his being unable to have connection with his wife. No 
 sooner did he touch the genitals when she became greatly ex- 
 cited, hysterically convulsed, and swooned away. She was 
 24 years old, very intelligent, delicate, nervous, and yet 
 excelled in certain forms of exercise,' e.g., riding. From time 
 to time she suffered from hysteria and fits, as above mentioned, 
 followed by dead faints, and at times from asthmatic attacks, 
 lasting some hours. There was no pulmonary emphysema present. 
 Digital examination brought on attacks similar to those on attempt 
 at connection. Consequently, this could only be satisfactorily 
 carried out under anaesthesia. It was found that inflammatory 
 irritability of the ostium (orificium) vaginee was present, hymen 
 absent, vagina dilated and inflamed, and catarrh of the cervix 
 uteri. 
 
 Diagnosis : Inflammatory condition and hyperaesthesia of the 
 whole genital tract, due to long-continued masturbation ; hence 
 the hysteria and asthma. 
 
 Therapeutics : Local treatment, and prohibition of any attempt 
 at sexual intercourse. Complete cure. 
 
 Case XI. — Fibroid of the Uterus. Severe Asthma. Operation. 
 
 Cure. 
 The patient, setat. 49, had been suffering for years from severe 
 asthma, which occurred more frequently during summer. She 
 •had had five children, and formerly never suffered from any dis- 
 turbance of the menses. For some time past the periods had 
 
DISEASES OF THE GENERATIVE ORGANS. 291 
 
 •been persistently profuse, which she attributed to the change of 
 life. As she had been undergoing treatment for a considerable 
 period. without any result, and the lungs were quite healthy, with 
 the exception of slight emphysema, I proposed a vaginal exami- 
 nation, which, however, was declined. 
 
 A year later, one of my colleagues informed me that she con- 
 sulted him, and was then vaginally examined. A fibroid about 
 the size of the fist was found protruding into the vagina. This 
 was removed ; the menorrhagia and the asthma ceased. 
 
 Other writers have reported cases where displacement and 
 catarrh of 'the uterus, leucorrhcea, &c, were at the bottom of the 
 attacks of asthma they suffered from. 
 
 That form of asthma, due to spasm of the diaphragm, seems to 
 me to be particularly frequent in women. 
 
 I have observed a number of such cases, more or less marked, 
 two only of which I shall briefly mention as typical in every 
 . respect. 
 
 Case XII. — Phrenic Asthma. Uterine Catarrh. 
 
 A. M., astat. 17, native of the Black Forest, Baden, good com- 
 plexion, and in , comfortable circumstances, had been suffering 
 from depression of spirits, shortly after the appearance of the 
 menses, between 15. and 16. Her mother and brother were also 
 liable to fits of depression (slight melancholia). She was given to 
 weeping, apparently at nothing, and was always moody. When 
 she was about 17, slight attacks of asthma came on at varying 
 intervals during the day and night. She said she felt great 
 oppression on the chest, and wanted to take a deep breath ; the 
 attempt did not succeed, and inspiration became impossible, 
 causing her great fear and alarm. When in bed she had to sit 
 up, kneel forward, and then recline. All at once she managed 
 to , draw in a breath, and immediately she felt all right again. 
 However, by degrees these attacks became more frequent and 
 intense. For quite half the day and night she suffered dreadfully 
 for want of breath. Unable to breathe properly she became 
 almost maniacal, springing out of bed and knocking everything 
 about her. In the intervals she was confused and melancholy. 
 No remedies did her any good. 
 
 About this time. she became pregnant by her lover, and her 
 symptoms completely disappeared. She married and bore a 
 
292 PEYEK OX ASTHMA AND 
 
 healthy child. During the whole of pregnancy she remained 
 perfectly free from any distress of breathing. Shortly after, 
 however, it returned, gradually increasing in severity. The 
 presence of leucorrhoea necessitated a vaginal examination, which 
 revealed chronic uterine catarrh. The patient also stated that 
 she suffered, when single, a good deal from "whites." Local 
 treatment of the uterine affection also cured the asthma. 
 Mrs. 6. has since remained quite well. 
 
 Case XIII. — Chronic Metritis. Phrenic Asthma. 
 
 The second case is that of a peasant woman, setat. 52, widowed 
 for about 10 years. She had had four children ; ceased to men- 
 struate some five years ago without any troubles worth mentioning. 
 About the same time difficulty of breathing commenced. Whilst 
 working, or during animated conversation, or in bed — in fact, at 
 any time or anywhere — the patient, who was robust, well-nourished, 
 but slightly anaemic, would feel at times a weight on the chest 
 which compelled her to take a deep breath. To her terror she 
 noticed she could no longer breathe in deeply; she became 
 alarmed ; blood rushed to the head and she was greatly agitated. 
 Suddenly she succeeded in inspiring deeply, the oppression 
 vanished, and the patient was quite well again. These attacks 
 would come on some five or ten times a day, but sometimes not 
 for several days together. There was, moreover, well-marked 
 globus hystericus. Different medical men and the patient herself 
 attributed the main cause of her troubles to a fall down-stairs 
 which happened some years before. 
 
 My personal experience and the presence of the globus 
 hystericus rather induced me to refer her illness to some uterine 
 trouble. 
 
 Examination revealed a somewhat enlarged uterus, and 
 leucorrhoea. Local treatment, systematically carried out, of the 
 uterine affection alleviated, and finally cured, the asthma. 
 
 Case XIV. — Masturbation. Gonorrhoea passing into Gleet. 
 Seminal Emissions. Phrenic Asthma. 
 Parents healthy, as also two brothers and a sister. When a 
 boy, from 8 to 14 years, the patient suffered from earache and 
 poverty of blood ; the latter was the cause of languor and palpi- 
 tation. When 17 he went to business; there, through bad 
 
DISEASES OF THE GENERATIVE ORGANS. 293 
 
 example, he learnt masturbation. A year after he began to suffer, 
 as a consequence of this vicious habit, from headache, which was 
 chiefly frontal and worse in the morning on rising. Although 
 he gave up the practice after a few years, nocturnal emissions 
 kept on frequently occurring, and at last were, towards his 20th 
 year, of almost nightly occurrence. Headache became more 
 troublesome, general lassitude and weakness were noticeable. 
 Shortly after 20, he went to Marseilles, and there he had sexual 
 intercourse about once a week on the average. Nocturnal 
 emissions in consequence almost ceased, headache also became 
 much less troublesome. On the other hand, other symptoms 
 gradually appeared, the bowels became sluggish, and he suffered 
 almost daily more or less from heartburn and asthma. The 
 latter chiefly occurred during the day whilst sitting at the desk. 
 He felt an oppression on the chest, which gradually became 
 severer and prevented him from drawing his breath. He was 
 then obliged to get up and pace the room, in great anxiety, when 
 all of a sudden he succeeded in inspiring, whereupon the asthma 
 and anxiety disappeared, only however to recur after a time. 
 During the night he was, as a rule, perfectly free. In the course 
 of a year the affection grew considerably worse, and headache 
 reappeared ; failing memory and general debility induced 
 Mr. G. to return to Switzerland. It should also be mentioned 
 that, towards the close of his stay in Marseilles, he got gonorrhoea, 
 which however disappeared fairly quickly, leaving behind a 
 tendency to nocturnal emissions. In addition, diurnal emissions 
 — without erection of the penis — occurred, brought on by mere 
 stimulation of fancy. There was a constant desire to pass water, 
 with a burning sensation along the urethra, and later on headache 
 was often accompanied by giddiness. 
 
 This was the condition I saw the patient in when he was about 
 22-J- years old. He was a big-boned, thin, and anasmic looking 
 man. Physical examination revealed nothing abnormal in the 
 chest or elsewhere ; the urine showed traces of urethritis, not 
 quite cured. At times, especially in the urine passed in the 
 morning and during a difficult stool, a fairly large number of 
 spermatozoa were detected. 
 
 The treatment was purely local. In the course of three months 
 Mr. G. felt quite well, and obtained a post in Italy. After 
 having remained perfectly well for two years, he got another 
 
294 PEYER ON ASTHMA AND 
 
 attack of gonorrhoea. Seminal emissions again became frequent, 
 and difficulty of breathing returned, especially at night, just before 
 falling to sleep. In 1885 he returned to Switzerland and placed 
 himself again under my care. At present he is married and 
 enjoys perfect health. 
 
 Case XV. — Sexual Anomalies. Phrenic Asthma. 
 
 In the middle of July, 1885, I was called to see Mr. Th., aetat. 
 85, painter, who was suffering severely from some lung trouble. 
 I found him in bed, thin and anajmic. There was no fever, but 
 he complained of great difficulty in breathing, and gave 
 the following history: About three months ago, whilst at .his 
 work, he felt a peculiar constriction in the neighbourhood of 
 diaphragm. He could no longer draw his breath properly, and 
 felt as if his chest were in a screw-press. At the same time he 
 had intense pain in the region of the stomach. It lasted half an 
 hour, only to return, however, on the following day. This 
 happened almost every day, and even several times on the same 
 day. The duration of an attack was sometimes two or three 
 hours, and the pain was intense. Latterly he suffered so much 
 that he was scarcely able to follow his occupation. His former 
 medical attendant told him that it was " spasm of the midriff," 
 and I quite agreed with the diagnosis. Mr. Th.'s family history 
 was as follows : His father was a robust and strong man ; his 
 mother, on the other hand, was nervous, and suffered greatly 
 from headache, as also his only sister. As a boy he was vigorous 
 and healthy ; had a distaste for beer and wine, which always 
 gave him a headache. When 15 he became apprenticed, and in 
 the course of a month he lost flesh considerably, and suffered 
 alternately from constipation and diarrhoea. Constant borborygmi 
 and frequent nocturnal emissions. 
 
 When 1 8 he went to America, where he was constantly work- 
 ing in the open air, and felt relatively better than during his 
 apprenticeship. 
 
 When 19, after prolonged constipation, he had severe headache, 
 which lasted from morning to night, disappearing with vomiting. 
 Henceforth, these- attacks of megrim constantly recurred, obliging 
 him to remain in bed, and even on the next day he was scarcely 
 fit for work, feeling quite exhausted and stupid. He especially 
 noticed that' sexual intercourse produced megrim the next day. 
 
DISEASES OF THE GENERATIVE ORGANS. 295 
 
 When 25 he returned to Switzerland, where he had hoped to 
 get rid of his headache, which in the meantime had become nigh 
 unbearable. However, his hopes were doomed to disappointment. 
 When 27 he was compelled, from external circumstances, to marry. 
 Although he was very moderate in sexual intercourse, he always 
 felt unwell after it. Ejaculation occurred prematurely, and 
 sexual desire was very slight.. After some time, owing to his 
 losing flesh and the frequency of headache, he was advised to give 
 up work. A two years' rest, however, brought no improvement, 
 and Mr. Th. consequently resumed his occupation. When 80 
 he suffered severely from sciatica on the left side, which lasted 
 some nine months. Morphine had to be frequently administered 
 hypodermically. Headache had somewhat decreased during that 
 time, but returned as. severe as ever, accompanied by frequent 
 giddiness. He remembered one night to have awaked with a 
 dreadful feeling of giddiness, headache, and oppression on the 
 chest. When .32 he suffered for a time from a peculiar form of 
 mental aberration whilst executing some work, which was so 
 great a strain on his mind that for a week he was quite unable 
 to . sleep. As a result he became affected with ideas of exaltation, 
 which lasted some 14 days. He thought that he was called upon 
 to reform his trade by delivering addresses and by writing upon 
 the subject, and that he was endowed with great ability and 
 strength. A few days after he discovered he was unfitted for 
 his supposed vocation,, and thought he was despised on all sides ; 
 took gloomy views of everything, and despaired of the future. 
 During the day he was restless, never sitting still ; at night he 
 either did not sleep or, which was worse, suffered from nightmare. 
 His medical attendant wished to send him to an asylum. 
 Suddenly he quite recovered mentally. He felt as if a great 
 change had come over him. For nearly a year after he was' 
 much better, and no longer troubled with headache. Then by 
 degrees obstinate constipation reappeared, accompanied by 
 headache and the above-mentioned spasm of the diaphragm. He 
 was! much depressed in spirits,' and the amount of work he was 
 able to do was much less, which greatly distressed him, as he had 
 now four children to support. 
 
 Examination of. the lungs revealed nothing abnormal — no 
 catarrh and no emphysema, and the other organs of the body 
 were apparently healthy. The urine was free from albumen and 
 
296 PEYER ON ASTHMA AND 
 
 sugar; on several occasions, however, semen could be easily 
 detected. 
 
 Local treatment of the affection brought about complete cure 
 of the asthma and other nerve symptoms. 
 
 This case is particularly interesting, as it shows that the 
 asthma appeared as a neurasthenic symptom alternating with 
 headache and giddiness, sciatica and mental disturbance, and, 
 further, that all these troubles disappeared on local treatment 
 being systematically carried out. 
 
 Case XVI. — Nasal Asthma Combined with Sexual Asthma. 
 
 Mr. P., astat. 86, merchant, gave the following history : Up to 
 his 16th year he enjoyed excellent health. When 14 he began 
 to masturbate, and continued this vicious habit for several years 
 (five to six times a day). When 17 he had a severe cold, which 
 lasted some weeks. 
 
 Up to that time he had not noticed any evil results from 
 masturbation. Now his health began to give way, he became 
 pale, anaemic, monosyllabic, and morose, and tried to overcome 
 his bad habit. He took no interest in female society, and up to 
 22 had only had sexual intercourse four times. The first two 
 occasions virile power was quite normal, on the last it was 
 distinctly weakened. When 24 he obtained the mastery to some 
 extent over his passion, and thereupon nocturnal emissions began 
 to occur. When 25 he had a severe attack of gonorrhoea, 
 accompanied by swelled testicle, which laid him up for a month. 
 When 29 he had the first attack of asthma, which at 
 first happened monthly, then every three weeks, later 
 on every fortnight, and at last every week, and at 
 times more frequently still. Cold beer, wine, &c.,in fact, 
 any exposure to cold, had a particularly pernicious influence over 
 these attacks. They, in turn, were usually followed by oft- 
 recurring seminal emissions, which produced great nervousness. 
 
 Compressed air and hydropathic treatment in Schonegg 
 brought about some alleviation, which, however, did not last 
 long. 
 
 When 32, Mr. F. was under the care of Dr. Hack of 
 Freiberg, who cauterised the thickened nasal mucosa. A marked 
 improvement followed, which lasted some months, and no asthma 
 occurred. His general health also greatly improved. Neverthe- 
 
DISEASES OF THE GENERATIVE ORGANS. 297 
 
 less, towards evening he suffered somewhat from oppression on 
 the chest, and had again recourse to the pneumatic apparatus. 
 Seminal emissions likewise became less frequent. In the 
 course of time a relapse occurred. Nocturnal emissions frequently 
 occurred, even after sexual connection on the preceding night. 
 Sleep was disturbed, and towards morning he would have a severe 
 attack of asthma. He now consulted Dr. Miiller, who found 
 marked pulmonary emphysema, depression of the diaphragm 
 and complete obliteration of the cardiac dulness. Auscultation 
 revealed everywhere purring and cooing rhonchi. As regards the 
 sexual functions, in addition to very defective virile power and 
 frequent nocturnal emissions, slight spermatorrhosa was present. 
 
 His general health was at the time rather bad, besides neuras- 
 thenia he was greatly depressed. 
 
 Dr. H. Miiller treated the sexual troubles locally. 
 
 In quite a short time marked improvement in the general 
 health took place. Asthma did not recur, and Mr. F. married. 
 
 A year after Dr. H. Miiller heard from the patient that he 
 was quite well. 
 
 Causes of Sexual Asthma. 
 
 If we once more pass in review the various histories of these 
 cases, which have told us the causes of the attacks of asthma, we 
 find that in eleven cases occurring in males spermatorrhosa 
 was present in nine. On two occasions I did not make a thorough 
 microscopic examination of the urine, although no doubt from 
 the condition of the genital system I would have obtained 
 corresponding results. Spermatorrhoea was accompanied by 
 some functional anomaly, the most frequent being nocturnal 
 emissions and impotence, or at any rate great loss of virile 
 power. Twice I observed temporary aspermatismus. 
 
 In the five cases occurring in women, uterine fibroid 
 occurred once; vaginal and cervical catarrh and hyperassthesia of 
 the ostium vaginas, due to masturbation, once ; leucorrhcea once, 
 cause unknown, as no vaginal examination took place ; enlarge- 
 ment, induration and catarrh of the uterus after the menopause, 
 once ; and chronic metritis onee. 
 
 Case XVI. shows that there may be several causes at work in 
 such patients in the production of asthma ; in this patient two 
 chief causes were present. 
 
2,98 PEYER ON ASTHMA AND 
 
 Constitution and nervous taint. Out of eleven men,^ seven 
 were very strong and well developed, and four rather slim and 
 delicate looking. In two cases only was there an inherited 
 taint of nervousness on the maternal side. 
 
 With almost all the males, in addition to asthma, there were 
 other nerve symptoms present ; in fact, that condition which we 
 understand by the phrase sexual neurasthenia. 
 
 This is almost without exception the result of sexual abuse in 
 its various forms. As regards the women, a hereditary nervous 
 taint could only be ascertained in two. On the other hand,- all 
 suffered, in a more or less pronounced form, from hysteria .and 
 other nerve symptoms, which, like the asthma, depended upon 
 some uterine affection, and therefore belong to the same category. 
 
 Condition of the lungs. In ten there was more or less, severe 
 emphysema, which, as a rule, did not give rise to any complaint. 
 They could walk, go up hill, and take part in the manoeuvres. 
 A few only suffered from frequent catarrh of the respiratory, 
 tract. 
 
 Manifestation of the asthmatic attacks. It is well known that 
 congestion plays an important part in asthma, for not only in 
 the idiopathic form but also in the rest it is frequently ushered 
 in by nasal and bronchial catarrh. There are individuals in 
 whom any slight catarrhal irritation is accompanied by asthma 
 (Bronchial asthma — Biermer, Berlin clinical transactions). 
 What the exact connection between catarrhal hypersemia and 
 bronchial spasm is we cannot say. We may, a priori, suppose 
 that either bronchial congestion produces bronchial spasm, a 
 causal relation thus subsisting between the two, or that both' 
 are the result of a disturbance of the nerve paths, in other words 
 result of reflex action. 
 
 On the other hand, cases of bronchial asthma are met with — 
 and Tronsseau drew attention to these — where no symptoms 
 of catarrh are present at ■ the outset, but which terminate with 
 such, so that it would seem that bronchial hyperaemia may be a 
 sequela of asthma (Biermer). 
 
 The congestive element likewise plays a part in sexual 
 asthma, for some cases commence with nasal and bronchial 
 catarrh. On the whole this is not so frequent. 
 
 In one case only I observed that sexual' asthma was brought on: 
 sometimes by heavy drinking. 
 
DISEASES OF THE GENERATIVE ORGANS. 299: 
 
 In a few, the attacks were, so to say, spontaneous, i.e., no 
 exciting cause could be ascertained. 
 
 The majority, however, were brought on by mere sexual 
 excitement, or by the simple act of coitus, or even by 
 nocturnal emissions. 
 
 In a few cases the patient was convinced that there was a 
 connection between the sexual malady and asthma ; in the rest, 
 I suspected that it might be a cause of the attacks. • 
 
 In some the sexual act was so regularly followed by asthmatic 
 attacks that the relation was at once patent. 
 
 Diagnosis. The chief point is that we should know and always 
 bear in mind that disturbance of the generative system is one of 
 the chief exciting causes of asthma in males as well as in females. 
 
 We must thoroughly inquire into the history and condition of 
 the sexual functions. We shall then learn whether the patient 
 has suffered from congenital weakness of the uro-genital system 
 (wetting the bed), whether he has either during youth or later ; 
 on been addicted to sexual abuse of any form, whether he has 
 ever had any venereal trouble (gonorrhoea, &c), whether 
 nocturnal seminal emissions are morbidly frequent, or, lastly, 
 whether any anomaly of the sexual function occurs. Examina- 
 tion of the urine — frequently made — and endoscopy, if necessary, 
 should iriform us as to the present condition of the uro-genital 
 system, especially whether chronic urethritis or spermatorrhoea 
 exists. 
 
 Similarly,' in the case of women, we must inquire into the 
 history of the sexual functions, the amount and duration of the 
 menses, the character of the molimina, the presence of fluor albus 
 or of lumbar symptoms (back-ache, &c). If the history indicates 
 its necessity, a vaginal examination should be resorted to. 
 
 Having then carefully informed ourselves upon these points, 
 we find, for instance, that in an asthmatic patient, after long 
 continued masturbation during youth or after excessive sexual 
 indulgence, especially in coitus imperfectus, - or with partial 
 impotence, by microscopic examination of the urine, spermator- 
 rhoea exists and other nerve symptoms are present, then, by 
 careful exclusion of other causes, the diagnosis of sexual 
 asthma may be made. Our diagnosis is likely to be more 
 certain if we find that any sexual event precedes the attack 
 of asthma. 
 
300 PEYER ON ASTHMA AND DISEASES OF GENERATIVE ORGANS. 
 
 Of course we must not forget that even in the same patient 
 other exciting causes may be present as is seen in Case XVI. 
 
 We can only be quite certain of our diagnosis when, along 
 with the sexual affection, asthma also ceases. 
 
 Prognosis wholly depends upon the cause. 
 
 As a rule, however, we can say that it is favourable in sexual 
 asthma, as a fair number in the course of time recover completely. 
 I have observed severe cases where for 13 years no attack of 
 asthma has recurred. 
 
 The treatment of sexual asthma is naturally that of the primary 
 cause and will vary accordingly. 
 
 In women this, of course, belongs to the province of the 
 gynaecologist. I should, however, like to mention that the 
 medical attendant should not overlook, from false prudery, the 
 evil consequences of onanism and coitus imperfectus. In 
 men great importance must be attached to the latter point. For, 
 as a rule, the patient is ignorant of the pernicious results of this 
 practice, for it is but true that, in persons of nervous disposition, 
 neurasthenia sexualis is thus brought on and kept up. In Case 
 VIII. I found that the seminal emissions and asthma were not 
 benefited in the slightest degree as long as coitus reservatus was 
 continued. After this was stopped, they both ceased under the 
 administration of cold water enemata before retiring. 
 
 The urethritis posterior, on which sexual asthma depends — be 
 it specific in nature or otherwise — as well as spermatorrhoea, 
 impotence, or temporary aspermatismus, must as a rule be treated 
 locally. General treatment is, of course, of material value, but as 
 a rule is not sufficient to cure the affection. 
 
 It is not within the limits of this paper to consider the treat- 
 ment of chronic affections of the male generative organs that 
 may be the cause of sexual asthma. 
 
 I shall here only mention that the treatment usually is some- 
 what difficult and troublesome, and requires great perseverance, 
 both on the part of the doctor and patient, in order to arrive at a 
 happy result. 
 
TRAUMATIC NEUROSES. 
 
 Professor ADOLF STRUMPELL, 
 
 DIRECTOR OF THE MEDICAL CLINIC IX THE UNIVERSITY OF ERLANGEN. 
 
 Translated hj 
 
 A. M. STALKEE, M.A., M.D., 
 
 Physician to the Dundee Soyal Infirmary. 
 
TRAUMATIC NEUROSES. 
 
 Gentlemen, — The subject I have chosen for this address* will, 
 I trust, have no little interest for you. For what I am going to 
 speak about ia certain morbid conditions in regard to which the 
 physician at the present day, and in consequence of modern 
 legislation, is frequently obliged to giye a decisive opinion, and 
 an opinion the formation and precise expression of which are often 
 attended with no small difficulty. I believe, however, that these 
 difficulties exist, not merely in the nature of the things themselves, 
 but also, and perhaps even more, in the circumstance that in our 
 appreciation of the morbid conditions in question we are not 
 uncommonly too one-sided in our views, and leave out of account 
 considerations of great importance. 
 
 Although the cases I am about to speak of are of very common 
 occurrence and, as you can understand, must necessarily have 
 been known to the older physicians, yet the exact study of them 
 has gone on only for the last twenty or thirty years. At all 
 events, it was their frequent occurrence after collisions and such- 
 like accidents that first drew the attention of railway companies' 
 surgeons to them, especially as practical questions of damages 
 were first raised 'in the case of railway servants. It is well- 
 known that a particular clinical picture has been formed by 
 English surgeons especially (Erichsen and others), which even 
 in Germany we frequently call by its English name of " railway 
 spine," the origin of which is commonly said to be the severe 
 shock to the spinal cord which occurs in a railway accident. 
 
 This name "railway spine," however, was plainly not very 
 happily chosen. On the one hand, it must be at once noted that 
 there, evidently does not exist a certain kind of injury peculiar 
 to railway accidents, and experience shows that precisely the 
 same symptoms frequently result from other accidents of every 
 description. On the other hand, a more careful consideration 
 
 * An Address delivered to the Niirnberg Medical Society, on March 1st, 1883. 
 
804 STBUMPELL ON TRAUMATIC NEUROSES. 
 
 and analysis of the symptoms brought out that it was quite 
 impossible that they could be dependent merely on a disturbance 
 of the functions of the spinal cord. Numerous phenomena of 
 undoubtedly cerebral character pointed distinctly to concomitant 
 affection of the brain; even symptoms which had previously 
 passed as spinal came more and more to be looked upon as 
 of cerebral origin. For these reasons American neurologists, 
 Walton and others, proposed instead of " railway spine " the 
 name "railway brain" as more suitable. This was certainly an 
 important forward step for the proper pathological understanding 
 of these affections, especially as the observers drew attention to 
 the affinity which these cases of "railway brain" had with 
 neurasthenia and hysteria. It may be even asserted that it was 
 the exact systematic study of the two last-named diseases which 
 first made it possible at all to arrive at a proper understanding 
 of the nature of the " traumatic neuroses." 
 
 This expression, "traumatic neuroses," appears to me at 
 present at any rate to be the best we have. It implies first of 
 all nervous affections, the origin of which must be immediately 
 referred to some injury or other. Further, there is implied in 
 the word " neuroses " the supposition that the nervous symptoms 
 in question are not dependent on coarse injuries of any part of 
 the nervous system. ' Traumatic paralysis through crushed or 
 torn nerves, lesions of the cord or brain from fractures or dis- 
 locations of the vertebrae or fractures of the skull, traumatic 
 haemorrhages, secondary inflammatory conditions — all of common 
 occurrence, and important as they are — do not belong to the 
 traumatic neuroses. But we must note — and this is the first 
 point of importance — that after certain injuries attended by no 
 coarse lesion of any part of the nervous system, peculiar and 
 serious nervous disturbances may be produced, which may last a 
 long time, and are not infrequently incurable ; and, further, that 
 we cannot understand these if we seek their causes in any one 
 of the above-mentioned coarse anatomical changes. 
 
 Before we go into the question as to how these conditions may 
 be explained, it is proper to treat of their symptoms a little more 
 fully. We shall do this first from the purely clinical and 
 empirical side, and see what practical experience has to teach 
 us. 
 
 As advantageous in a general survey, it appears to me 
 
STRUMPELL ON TRAUMATIC NEUROSES. 305 
 
 advisable to distinguish two chief groups of the traumatic 
 neuroses, and to describe these separately. In one set of cases, 
 occurring generally after some local injury, there are merely 
 local nervous disturbances, e.g., in one leg, in one arm, or such 
 like. We may name these cases "local" traumatic neuroses. 
 In other patients we have, mostly as a result of some severe 
 shake to the whole body, a much more complicated set of 
 symptoms, and among them, in particular^ certain general 
 nervous phenomena appear in the foreground. This group we 
 call " general " traumatic neuroses. Let us first examine more 
 closely the latter. 
 
 I shall suppose a particular case, in order to bring the features 
 of the affection as clearly as possible before your eyes. A work- 
 man — let us say a carpenter — previously in perfectly good health 
 and strength, falls from a scaffolding a distance of twelve or 
 fifteen feet. In consequence of the shock he is rendered 
 unconscious, or at least very much stunned, and his fellow- 
 workmen have to carry him home. After some hours he comes 
 to himself, but feels so languid that he "can't move a muscle." 
 The medical man who is called finds no evidence of severe injury 
 — perhaps only a fractured rib or even only some skin-wounds 
 with ecchymoses. The patient recovers but very slowly, and can 
 only leave his bed after the lapse of some weeks. The relatively 
 trifling bodily injuries which he received at first have long ago 
 healed. Nevertheless he feels very weak, complains of various 
 pains, and says that he is as yet quite unfit for work. His 
 medical attendant thinks there may be some internal injury or 
 its effects; and repeatedly and carefully examines the limbs, 
 spine, lungs, &c, but can "find absolutely nothing abnormal in 
 any of the organs." The authorities wish a medical report in 
 regard to his condition. A second doctor is called in, and he 
 also can " find nothing," so the suspicion readily gets up that the 
 patient is shamming, and intentionally exaggerating his com- 
 plaints, in order to avoid working for some time longer. 
 
 And yet, gentlemen, in cases of this kind there is generally 
 a very great deal to be observed. We have only to know what 
 the proper symptoms are, and to seek after them in particular. 
 I do not mean by the proper symptoms dislocations or fractures, 
 displacements of the vertebrae or pleural exudations, but rather 
 certain peculiar nervous disturbances which meet us in all these 
 
 x 
 
306 STRUMPELL ON TRAUMATIC NEUROSES. 
 
 cases in so constant a fashion as to give us in their totality a 
 thoroughly characteristic set of symptoms, forming the clinical 
 picture of general traumatic neurosis. 
 
 We must have regard first of all to the psychical condition of 
 the patients. I cannot refrain here from remarking that, un- 
 fortunately, in the case of a large number of patients the requisite 
 attention is not paid to the mental symptoms. And yet there 
 are a number of morbid conditions which the physician will 
 never rightly comprehend, without paying attention to these 
 symptoms. We must accustom ourselves to take account even 
 of the more trifling psychical alterations. These are undoubtedly 
 much commoner, and therefore practically much more important, 
 than the more severe, just as coughs and catarrhs are commoner 
 than' pneumonia or tuberculosis. The more severe kinds of 
 mental disturbance, indeed, are quite recognisable, even by the 
 laity. Of course the practitioner in private practice often meets 
 with great difficulties in the way of rightly judging of the mental 
 condition, which he would not have to contend with in a hospital 
 or similar institution. 
 
 The mental disturbance in traumatic neurosis exhibits chiefly 
 the features of melancholia, mostly of the hypochondriacal type. 
 Many of the patients are fully conscious of the change in them- 
 selves. They tell us that previously they were of a cheerful and 
 contented disposition, but that now they take no pleasure in 
 anything. They sit silent in the midst of their families, and 
 keep out of the way of the company of old friends ; nothing 
 apparently interests them. Their thoughts are continually 
 playing about the incidents of the accident and its results, and 
 the only occasions on which they talk freely are when they are 
 speaking of these. At such times, however, we can note how 
 thoroughly they are convinced of the serious consequences which 
 the accident has had for them, and how deeply they are 
 persuaded that they will never enjoy health again, never be 
 able to attain to their old strength and energy. These dismal 
 convictions often bring on a state of excitement, and -the patients 
 in the course of conversation will begin to weep. In such 
 conditions we may even have hallucinations and delirium coming 
 on, although these are very much rarer than the above-mentioned 
 states of slight melancholia. With the latter is closely associated 
 a peculiar weakness of will and lack of energy, with anxious 
 
STRUMPELL ON TRAUMATIC NEUROSES. 307 
 
 fears of various kinds. The patients cannot brace themselves 
 to any kind of regular employment. Everything irritates and 
 distresses them. They avoid meeting other people, and are 
 alarmed at any loud noise or slight commotion, or such like. 
 Their agitation rises to a high pitch on the occasion of every 
 fresh medical examination or inquiry. This is also the case 
 when their recollections of the accident become unusually lively ; 
 for example, when they revisit the place where it occurred. • i 
 
 The patients frequently complain that their memory is weak, 
 and that they are incapable of fixing their mind steadily on any 
 subject. For example, they are unable to read for any length 
 of time ; after a few minutes their thoughts get confused, arid 
 they cannot understand what they have read. It is the same 
 with every other kind of mental activity. They can no longer 
 calculate figures as they used to do, or follow a story or a sermon. 
 In many instances these symptoms, especially when they ..aye 
 present only to a slight extent, seem to me to depend, properly 
 speaking, on a disturbance of the intelligence. It is merely that 
 the patients are taken up almost exclusively with themselves' and 
 their troubles, and that they have no attention to spare for any- 
 thing outside, nothing else making a deep or lasting impression 
 on them. But in severe cases, as I have seen again and again, 
 distinct mental weakness comes on at last, with failure of memory 
 and incapacity for any continuous mental exertion. . •> 
 
 The sleeplessness, also, of which most of them complain must 
 be for the most part referred to the persistent mental unre$t 
 which I have described. The constant anxiety hardly ever 
 permits of the quiet state of mind which is the first condition 
 of falling asleep, or not infrequently the thoughts of the waking 
 state are carried on into dreams, which then associate themselves 
 more or less closely with the events of the accident. A ,sleep. ,of 
 this kind, of course, is restless and unrefreshing. , ; 
 
 All these mental symptoms are so characteristic of general 
 traumatic neurosis that there is scarcely a single case in which 
 they are quite absent. Their occurrence was not altogether 
 unknown to the older observers, but their importance and pro- 
 found; significance for the comprehension of this morbid condition, 
 as a whole, has only recently been shown, in particular by Moeli 
 and Oppenheim. They vary very much in intensity, being 
 present sometimes in a slighter, sometimes in a severer, form,, anjd 
 
808 STRUMPELL ON TRAUMATIC NEUROSES. 
 
 may occasionally constitute the only evidence of the affection. We 
 may then, in fact, speak of a pure traumatic psychosis. 
 
 Next to the psychical symptoms come a second group of 
 disturbances, also of uncommonly frequent occurrence, and there- 
 fore of the greatest diagnostic and practical importance— the 
 sensory abnormalities, especially the ansesthesiae. The merit of 
 having drawn attention to the occurrence of this class of 
 symptoms belongs among the German physicians chiefly to 
 Thomsen and Oppenheim. Their practical importance consists 
 in this, that their objective existence can generally be easily 
 established, and statements regarding them formulated, making 
 them very valuable as a basis for a professional opinion and 
 report. 
 
 The examination of the sensory functions in every case of 
 traumatic neurosis must extend to all the special senses. The 
 patients' own statements do not generally assist us much. They 
 certainly sometimes remark, of their own accord, that their eyes 
 get dim or that all their food has an insipid taste. They also 
 complain of too great susceptibility to all the more violent kinds 
 of sense-impressions— strong lights, loud noises, &c. But the 
 actual extent of the sensory lesions can only be determined by a 
 Careful objective examination. If certain parts of the body, for 
 example, one side of the thorax or a portion of the spinal column, 
 have been specially affected by the injury there is, as a rule, at 
 this part a remarkable tenderness on deep pressure. The skin 
 here, also, is sometimes hyperaesthetic, and a slight prick with a 
 needle. is felt as acutely painful. Not infrequently, however, the 
 skin over the part in question is anaesthetic, and pricking deeply 
 with the needle produces no sensation at all, or at least none that 
 is painful. But, in general, the cases where the chief disturb- 
 ances are found just at the seat of the injury belong more to 
 the local traumatic neuroses of which I shall speak later. Yet 
 we must particularly note that profound disturbances of sensi- 
 bility may be present in parts of the skin far removed from the 
 seat of injury, and in cases where there has been a general shock 
 to the whole body such disturbances may be found in a number 
 of different places. The distribution of these anomalies follows 
 no rule. Sometimes we find large anassthetic patches on the 
 breast, on the back, in the face, or on the scalp, sometimes 
 anaesthesia of one or more extremities in their whole extent or 
 
STRUMPELL ON TRAUMATIC NEUROSES. 309 
 
 merely in certain portions of them, surrounding, it may be, the 
 extremity as a zone-like band. These areas never coincide with 
 the distribution of particular nerves, nor are they marked off in 
 the same way as in the case of lesions of the brain or cord. 
 Like Oppenheim, I have only occasionally observed genuine 
 hemi-anaesthesia, and only in cases which had otherwise more 
 of the character of local traumatic neurosis or of traumatic 
 hysteria (see below). 
 
 If the anaesthesia is very marked in particular parts of the 
 skin all the forms of sensation are affected. But partial paralyses 
 also sometimes occur, there being special affection in some cases 
 for touch, in others for heat, and in others for pain. The last 
 appears to me the commonest. The patients feel slight cuta- 
 neous irritation fairly well, but over large portions or even over 
 almost the whole surface of the body exhibit an astonishing 
 indifference to very deep pricking with needles or very strong 
 faradic currents. 
 
 The anaesthetic areas are marked off, as we have said, according 
 to no definite rule. Sometimes an anaesthetic area borders upon 
 a particularly sensitive portion of the skin, while in other cases 
 they are more ill-defined and vary at different times. The 
 occurrence of the latter peculiarity must be borne in mind, and 
 we must not, without close inquiry, come to the conclusion that 
 there is simulation in such cases. 
 
 The sensory disturbances are by no means limited to cutaneous 
 sensations, but are present even more distinctly in the special 
 sensory surfaces. Here, also, we must seek for them, otherwise 
 they may only too easily remain unnoticed. If a careful objec-. 
 tive examination, however, is made, the most surprising symp-^ 
 toms come to light. In the sense of sight there may be simple 
 diminution of acuteness of vision, or the eyes may be easily 
 wearied, or there may be weakness of the colour-sense, or 
 narrowing of the field of vision. In hearing, we often find con- 
 siderable diminution of the auditory acuteness on both sides, or 
 more on one side than on the other, while examination with 
 the speculum fails to reveal the slightest evidence of organic 
 disease. Examination of smell, and particularly of taste, should 
 never be omitted, as it is often in these sensory areas that the 
 greatest disturbances show themselves. Taste may be wholly 
 abolished or retained in respect of only some qualities. Many 
 
olO STEUMPELL ON TEAUMATIC NEUROSES. 
 
 patients, for example, can feel the taste of salt or sugar and not 
 of quinine. 
 
 All these sensory lesions are so common in traumatic neurosis, 
 and present in so characteristic a way, that they are of the utmost 
 value in the diagnosis and proper estimation of cases of the 
 affection. 
 
 Among subjective pains we have already mentioned the 
 hyperaesthesia at the seat of injury. Pains in the back and 
 headaches also are common, though not, for the most part, 
 , specially severe. In many cases the remarkable tenderness of 
 the head to percussion is characteristic. 
 
 Motor symptoms are present in almost all the more developed 
 cases. In neurotic cases, without special local manifestations, 
 the commonest symptom is general muscular weakness, or, to 
 express it more exactly, general weakness of voluntary innervation. 
 With good muscular development and an appearance of strength 
 they are unable to grasp firmly with the hand or to lift any heavy 
 Weight, and exertion exhausts them easily. Their walk is 
 generally slow and laboured, but varies very much when local 
 disturbances are added to the general weakness. Very often 
 when the original injury has affected the haunch or back, these 
 parts continue to be painful, and the pain is increased by any 
 movement or shaking of the body. Patients suffering in this 
 way, in going about, avoid all the more pronounced flexions of the 
 spine, keep the back somewhat bent, but at the same time as 
 rigid as possible, and endeavour to support the haunch with the 
 hand. A good while ago I had under observation an officer who 
 was affected with severe traumatic neurosis in consequence of a 
 fall from his horse. He was so afraid of any great movement of 
 the spinal column, especially of the slightest turning of the head, 
 that he could not directly turn round to look at any object near 
 him, but with timid steps described the arc of a great circle 
 through the room. 
 
 Besides the general muscular weakness, there are very fre- 
 quently certain symptoms indicating motor irritation. These 
 are chiefly tremors and rigidity and stiffness of the muscles. We 
 shall devote more attention to these in describing the local 
 traumatic neuroses, but even in the general form they are some- 
 times very marked in certain limbs. We have trembling of the 
 arms, especially when the patients stretch them out unsupported, 
 
STRUMPELL ON TRAUMATIC NEUROSES. 311 
 
 or still more evidently when from this position they bring the index 
 fingers near one another. Any mental emotion, any increased 
 attention to the affected limb, increases the tremor, while, on the 
 other hand, it may temporarily disappear if the thoughts of the 
 patient are led away from it. The muscular rigidity in the back, 
 legs, and elsewhere, is brought out by passive movements. It is 
 not either a direct or reflex contracture, but probably originates, 
 in most cases, from an unconscious voluntary innervation (see 
 below). 
 
 The examination of the reflexes often reveals noteworthy 
 conditions. In anaesthetic or analgesic parts, pricking with a 
 needle produces no skin reflex whatever, or only a very weak 
 one. On the other hand, extremely active cutaneous reflexes are 
 elicited from hypereesthetic areas in the skin. The plantar 
 reflexes especially are very often increased, though in other 
 cases they may be quite absent. The superficial reflexes over 
 the abdomen also vary very much, while the cremaster-reflex is 
 almost always within its normal limits. The tendon reflexes are, 
 it would seem, generally increased. It is only in the cases 
 where there is great muscular straining in the legs when an 
 examination is made that it can be difficult to elicit the tendon 
 reflexes. I have never seen actual absence of the knee-jerk. In 
 those patients in whom the knee-jerk is very active it is not 
 uncommon to observe after the proper reflex in the quadriceps 
 two or three pretty strong jerks of the whole limb. This 
 symptom, which is observed also in nervous persons, doubtless 
 depends on unconscious voluntary movement. It is obtained if 
 one merely makes a feint of bringing down the stroke with the 
 percussion hammer while not even touching the ligamentum 
 patellae. 
 
 Local trophic symptoms, especially muscular atrophies, are 
 sometimes seen in the local form of the neurosis. In the general 
 form we see in many cases a distinct alteration for the worse in 
 the whole nutrition ; this probably results, for the most part, 
 from the insufficiency in the amount of food consequent on 
 the want of appetite, from the disturbed character of the sleep, 
 and from other such like causes. The fact that has been re- 
 peatedly observed, that in some bad cases of traumatic neurosis 
 the hair very quickly turns grey or falls out largely, must be due 
 to a more directly nervous cause. It is natural that we should 
 
312 STRUMPELL ON TRAUMATIC NEUROSES. 
 
 associate such disturbances with the well-known facts in regard 
 to the influence of mental emotion, especially of those of a 
 depressing kind, on the nutrition of the hair. 
 
 Organic changes in the internal organs are, as might be 
 understood, absent in pure traumatic neuroses. Functional 
 disturbances, however, are frequently present, especially in the 
 organs on whose activity mental states have most influence. For 
 example, many patients complain particularly of want of appetite, 
 oppressive feelings about the stomach, nausea — in short, of the 
 symptoms of nervous dyspepsia. If, in consequence, an insuffi- 
 cient amount of food is taken, then, in addition to the general 
 emaciation previously referred to, there is, of course, irregularity 
 in the action of the bowels. The action of the heart, as in almost 
 all nervous persons, is generally quickened and very easily 
 affected by external circumstances. Any mental emotion, and 
 especially any medical examination, is apt to bring on great 
 palpitation and acceleration of the pulse. Pronounced derange- 
 ment of the bladder-functions is in purely neurotic conditions 
 absent ; and the inability to empty the bladder completely, 
 which many patients complain of, is, as a rule, only one mani- 
 festation of the general want of muscular energy. The lowered 
 condition of sexual desire which is often present may also be 
 associated with the mental depression. Where there are sexual or 
 vesical disturbances of a graver kind they indicate, probably, 
 coarse lesion of the nervous system, and do not come under 
 consideration in traumatic neurosis proper. 
 
 After this endeavour to bring before you the clinical details of 
 so well-defined a disease, we shall now pass to the question of 
 what we are to think of the nature and origin of the condition. 
 The answer is not very easy, and neurologists differ very much 
 from one another in their views, If we glance over the whole 
 complex of symptoms we notice an undeniable similarity to a great 
 number of cases of what is called general neurasthenia. In both 
 conditions there is a large number of subjective complaints, and 
 abundant proof that both the mental and bodily activity are 
 interfered with, and yet in neither is there anything present 
 pointing to a definite localised anatomical lesion. It has been, 
 therefore, proposed to call traumatic neurosis simply " traumatic 
 neurasthenia." But, on the other hand, in traumatic neurosis 
 there is, as a rule, a whole set of symptoms which are not 
 
strDmpell on traumatic neuroses, 818 
 
 generally met with in ordinary neurasthenia, namely, the above- 
 described sensory disturbances. These recall distinctly the 
 analogous phenomena which are so common in hysteria, and 
 have given rise to the conception- of traumatic neurosis as a form 
 of hysteria — traumatic hysteria, — a view which is represented 
 especially by Charcot. German neurologists, on the other hand, 
 especially Oppenheim and Thomsen, while they recognise to the 
 full the close relationship between traumatic neurosis and these 
 other two diseases, have claimed for the former a position of its 
 own. They point to the setiological factor — the distinct bodily 
 injury — and also to certain peculiarities in the further course of 
 traumatic neurosis as distinguishing it from hysteria, especially 
 the fact that it is frequently incurable. 
 
 It appears to me that these differences are largely disputes 
 about words. For neurasthenia and hysteria are notions of so 
 changeable a character that we are unable to set up definite and 
 generally accepted criteria for the precise recognition of each 
 case of disease. Further, also, I believe that we cannot put all 
 cases of traumatic neurosis on the same level, and that we must 
 employ varying considerations in judging of the individual 
 cases. 
 
 In one section of the cases all the symptoms, it seems to me, 
 are of purely psychical origin. Let us first realise closely the 
 circumstances in which the disease originates. Undoubtedly, 
 along with the bodily accident on each occasion there is asso- 
 ciated violent mental emotion — "mental traumatism." And, 
 apart from any concussion of the brain, which may confuse the 
 consciousness for a longer or shorter time, the accident in itself 
 is always the cause of great fright. A multitude of anxieties 
 presses in upon the thoughts of the injured person. What is to 
 become of me now ? Can I ever again be well and fit for work ? 
 Who is to provide for my wife and children ? These, and 
 thoughts like these, the more active in proportion to the sudden- 
 ness with which they have acquired meaning, occupy the patient's 
 attention continually. The bodily injuries which, though not 
 severe in themselves, do generally exist, and the immediate 
 results of the great shock to the whole system, seriously affect 
 his' capacity for doing anything, and the doubts whether it will 
 ever be better with him are started afresh. The question arises, 
 Who is to recompense me for these injuries, which I have 
 
814 STRUMPELL 05T TRAUMATIC NEUROSES. 
 
 suffered in the service of other people ? Then come the nego- 
 tiations and examinations in connection with accident insurance. 
 One requires to have seen for one's self how these people have 
 been put off time after time, and how repeated examinations 
 have to be made and new certificates drawn out. It is then 
 possible to understand the hurtful influence which all this period 
 of doubt and hope and fear, of disappointment and mistrust must 
 exercise. It is not to be wondered at if, in order to establish 
 their just claims, they sometimes attempt to embellish and 
 magnify the story of their sufferings. 
 
 In this way the depression and lack of energy and irritability 
 with which they are affected, to begin with, and which all through 
 are characteristic of the condition, are but strengthened and 
 confirmed. The great attention they pay to all their sensations 
 is sufficient to develop a variety of morbid feelings which in 
 their excited condition take a very vivid form. On the other 
 hand, their mental state reacts on a number of their bodily func- 
 tions. We thus have headaches, palpitation, indigestion, profuse 
 sweating, or great coldness of the skin, tremors, &c. — all familiar 
 symptoms in conditions of great mental excitement. Uncon- 
 scious attention also interferes with the normal motor innervation. 
 Not from design, but from the action of "unconscious will," if 
 one may so phrase it, the movements lose their natural simplicity 
 and ease, and become stiff, trembling, and awkward. 
 
 But though I rate very highly all these purely mental factors 
 in accounting for the origin of traumatic neuroses, they will not 
 explain directly the whole body of the phenomena. Even the 
 clinical differences which mark them off from ordinary hypochon- 
 driasis and neurasthenia suggest the question whether the purely 
 material shock has not a certain importance for the production 
 of the symptoms. It is generally acknowledged that a sudden 
 violent shock to the nervous system, especially to the brain, even 
 though no coarse anatomical lesions are produced, may be the 
 cause of very serious nervous disturbances. It scarcely admits 
 of doubt that these disturbances, such as unconsciousness, slowing 
 of the pulse and respiration, &c, have an organic cause of some 
 kind or another, although of the finer changes in concussion of 
 the brain, as it is called, we know as good as nothing. And it 
 is quite conceivable that the morbid changes produced by sudden 
 violent concussion in the brain, and probably also in the spinal 
 
STRUMPELL ON TRAUMATIC NEUROSES. 315 
 
 cord, do not in all cases completely retrogress,' and that there is 
 sometimes left behind a certain material, though subtle, disturb- 
 ance, the nature of which is still unknown to us. The conse- 
 quences of a disturbance of this kind are naturally not the same 
 as those which follow a coarse localised lesion, but they show 
 themselves probably in the muscular weakness, the mental 
 change, the diminution of sensory activity, &c, which we have 
 detailed above. It is perfectly impossible to decide at present 
 which of all these symptoms are organic in origin and which are 
 psychical, i.e., produced by mental ideas ; and, in addition, there 
 is the uncertainty as to how far the mental disturbance, as such, 
 may have an organic origin, and how far in its turn it may give 
 rise to fresh bodily disturbances. 
 
 The view of traumatic neuroses we have here taken is of 
 practical importance in this way, that it lets us understand many 
 cases where there are no mental elements among the causes, and 
 others where the influence of such elements has been over- 
 come while the symptoms continue practically unchanged. The 
 disease occurs not only among the working classes where, naturally 
 enough, the mental factor must play a great part, but among 
 other ranks, for example, among ofEcers in the army who have 
 been thrown from horseback. And all observers further have 
 noted the fact that, even after the patients have been made quite 
 at ease in regard to their external circumstances, very often no 
 essential improvement follows. In the case of the injured work- 
 man, if he has at last got a favourable settlement of his accident 
 insurance claims, and has been made definitely certain of full 
 compensation, the symptoms do not, as a rule, come to an end. 
 He remains moody and spiritless, his morbid feelings continue 
 to be as before, and the sensory and motor disturbances are 
 unchanged. As a matter of fact many cases appear to be 
 incurable. It is of the greatest practical moment to be aware 
 that there is this very unfavourable prognosis in severe cases of 
 general traumatic neurosis. I have often seen medical certi- 
 ficates in which the opinion was expressed that, with sufficient 
 care and proper treatment, an improvement in the condition 
 might in time be looked for. The supposed trifling character of 
 the symptoms, and the absence of everything of a grave or 
 critical nature among them, certainly seem in many cases to 
 justify such a view ; and yet experience almost always teaches 
 
316 STKtfMPELL ON TRAUMATIC NEUROSES, 
 
 the opposite. In severe cases, and my experience is that of 
 others, I have only rarely seen essential improvement, and 
 never actual recovery, and this in spite of every care and 
 persistent electrical and hydro-therapeutic treatment. In some 
 cases, in fact, we find the initial symptoms — more especially 
 the indications of mental weakness — getting distinctly more 
 marked in the course of years. This circumstance marks an 
 essential difference from ordinary neurasthenia, in which 
 also permanent recovery only rarely occurs, but in which 
 temporary improvement can be often attained by the . proper 
 bodily, and more especially by suitable mental, treatment. 
 Among cases of traumatic neurosis mental treatment is often 
 just as ineffective as in genuine melancholia. 
 
 We require, then, if we would understand traumatic neurosis, 
 to take account of both its possible causes. These are ; (1), the 
 psychical injury, which gives rise to the hypochondriasis, and all 
 the nervous disturbances arising from this ; and (2), the material 
 injury so often present from which originate the subtle organic 
 changes in the nerve substance, and the marked functional 
 derangements which follow. Cases of the former kind are always 
 the less serious, and are susceptible of mental treatment. In 
 the latter the prognosis, so far as complete recovery goes, is very 
 unfavourable. Of course both kinds of causes often co-exist, 
 and when this is the case it may be impossible to make a strict 
 distinction between them. 
 
 I must here mention another circumstance which is not without 
 importance for the understanding of this subject. General trau- 
 matic neurosis may be associated in its origin with actual coarse 
 traumatic lesions of the brain or cord. I have seen some very 
 characteristic instances of this. Along with symptoms which 
 could only have been caused by a coarse lesion, such as circum- 
 scribed paralysis of cranial nerves, severe vesical disturbances, 
 &c, there were other symptoms which could have had nothing 
 to do with ordinary organic disease, and which perfectly agreed 
 with those of traumatic neurosis, as I have above described it. 
 Indeed, it is perfectly intelligible that, in certain circumstances, 
 an injury should produce not only a coarse lesion, but also the 
 psychical commotion or the unknown finer changes of concussion 
 which form the basis of the general neurotic symptoms, . ' 
 
 These cases are important in a diagnostic"- regard,- because if 
 
STRUMPELL ON TRAUMATIC NEUROSES. 817 
 
 we were not aware of their existence we should easily meet with, 
 great difficulties and confusion in our estimate of the seat of the 
 coarse lesion. They are important, furthermore, in respect of 
 the question of simulation, which, for obvious reasons, plays a 
 large part here. In cases where coarse lesions are most unques- 
 tionably present it is impossible that the patients can have any 
 object in complaining, besides, about a number of pretended 
 subjective troubles. As, however, the nature of these troubles, 
 the mental depression, the feelings of pain, the lack of energy, 
 &c, are quite the same as in pure traumatic neurosis, the com- 
 
 ■ plaints in the latter disease gain in objective credibility. 
 
 In agreement with most other neurologists who have seriously 
 
 . considered the subject, I must express my conviction that 
 simulation in this disease is by no means so common as many 
 physicians appear to believe. The symptoms of a well-developed 
 case are so peculiar and characteristic that I can scarcely under- 
 stand how it could be simulated, It would be astonishing, indeed, 
 if patients in Berlin, Leipzig, Erlangen, and everywhere else, 
 were to falsify the story of their complaints in exactly the same 
 way. It is easy to understand that there is such a thing as 
 simulation after bodily injury, also that it may be often very 
 difficult to distinguish the simulated from the real morbid 
 condition ; but that this difficulty arises with anything like 
 frequency is, in my experience, not the case. I believe it is 
 almost always easy, especially if you have had the patient under 
 observation for some time in hospital, to give a quite positive 
 opinion. 
 
 I have endeavoured in the foregoing to lay before you a brief 
 outline of the features of general traumatic neurosis, and of its 
 meaning and importance. Let us now turn to another group of 
 nervous disorders, also associated with injuries, to which we may 
 give the name local traumatic neuroses. The cases I am thinking 
 of are, to begin with, cases hot of severe injury causing general 
 shock, but of injuries that in themselves are often of very little 
 importance, mostly bruises of some limited area, generally in 
 one of the extremities. The patients get a fall on the knee or a 
 blow on the arm, get a finger crushed, or some such similar 
 accident, and as a result of the hurt, which is often to all appear- 
 ance very trifling, there follow a number of distinct nervous 
 
318 STEUMfrELL ON TEAUMATIC NEUEOSES. 
 
 symptoms limited, or all but limited, to the part of the body- 
 injured. 
 
 In these cases, also, we must make the distinction between 
 those in which there is actual organic injury to the peripheral 
 nerves and those which we should call, as before, pure neuroses. 
 It is often very easy to draw this distinction, but sometimes we 
 meet with difficulties. I should particularly like • here to say 
 that I suspect that after contusions of small peripheral nerve- 
 twigs minute neuromata develop, which are not perceptible to 
 the touch, but which give rise to acute pains, reflex muscular 
 spasms, and other symptoms. Of course these pains and spasms 
 could also originate from such a lesion as circumscribed thicken- 
 ings of the neurilemma. I have repeatedly seen such symptoms, 
 and others like them, especially after bruises of the fingers, 
 proving extremely obstinate, and resisting treatment for a long 
 time. But, as I have indicated, we cannot reckon this class of 
 cases among the traumatic neuroses proper, seeing that coarse 
 changes in the peripheral nerves are the causes of the symptoms ; 
 I shall not dwell upon them, therefore, any further. 
 ■ Other cases . that must be set aside are those which Charcot 
 has done a good deal to make known, where after an apparently 
 trifling injury to a joint, considerable atrophy makes its appear- 
 ance in' the muscles in the neighbourhood. Charcot believes 
 this may be explained as the result of a reflex inhibition of the 
 activity of the trophic cells in the anterior, horns of the cord, an 
 explanation which, to my mind,* can. hardly be looked upon as 
 satisfactory. 
 
 Genuine examples of the local form are those conditions where 
 complicated nervous symptoms follow injuries, which for the 
 most part have been of no great importance, in such a way as to 
 exclude the presence of a lesion of any particular peripheral 
 nerve. These -are, to begin with, as we have said, mostly cases 
 of simple contusion in one of the .extremities, or of a blow, or fall, 
 or some. sueh hurt. There is usually no general concussion of 
 the brain or . spinal cord, but naturally enough there is often a 
 good deal of fright;, especially in the case of nervous persons or 
 children. In .children the condition is of relatively common 
 occurrence. The.-, pain and difficulty of movement experienced 
 immediately after the accident are, of course, almost always 
 
 * Cf. Muncheher Medicinisohe Woohensehrift, 1888, No. 13. ■ • 
 
STRUMPELL ON TRAUMATIC NEUROSES. 819 
 
 considered to be the simple results of tlie bruise, and only after 
 some time has passed, and the symptoms in question are still 
 persisting, does the thought arise that there are other conditions 
 to be reckoned with. 
 
 One of the commonest symptoms is a hyperaesthesia of the 
 affected extremity, which sometimes goes to an extreme degree. 
 It is felt on passive movement, or with deep pressure, or even 
 with the slightest touch on the skin. The limb, even in the 
 cases where there is no great contracture (see below) is held in a 
 peculiarly stiff and constrained position. If it is quite at rest 
 there are, as a rule, no special sensations of pain. On every 
 attempt at passive movement, and on the occasion of any careful 
 examination by the medical attendant, the patient makes active 
 efforts with the sound parts of the body for the defence of the 
 injured part. If we attempt, nevertheless, to move the limb, 
 loud cries of pain follow. Sometimes, as we have said, the 
 hyperaesthesia is limited to the deeper parts, while in other cases 
 even the skin shows uncommon tenderness. I treated for a 
 long time a girl of 12 years of age who had suffered from a 
 fall on the right arm, and in whom the skin over that part 
 (without there being any definite nervous area involved) was so 
 hyperaesthetic that not even the gentlest touch could be borne 
 without loud complaint. The condition lasted almost a year. 
 All treatment was without effect, but she gradually recovered 
 completely. 
 
 Besides hyperaesthesia, aneesthesia not infrequently occurs. 
 In particular the association of hyperaesthesia on passive move- 
 ment with anaesthesia of the skin is pretty common. The latter 
 may be present in a very high degree, and a fold of the skin 
 may be transfixed with a needle without the patient having the 
 slightest sensation. The anaesthesia probably always extends a 
 good way beyond the seat of the injury, but in genuine cases of 
 local neurosis is always limited to the affected limb. I have 
 seen, for example, among other cases total anaesthesia of the 
 whole arm tip to the shoulder after a bruise of the elbow-joint. 
 No doubt the anaesthesia may extend still more widely, and in 
 particular sometimes over the whole corresponding side of the 
 body. This, however, is the ordinary hysterical hemianeesthesia 
 of traumatic origin (see below). Besides local anaesthesia we 
 may have, of course, different degrees of mere blunting of the 
 
820 STKUMPELL ON TRAUMATIC NEUROSES. 
 
 sensibility, or (rarely) partial sensory paralysis (for pain, 
 temperature, or touch). 
 
 Motor symptoms may occur, either associated with those 
 described above or in other cases alone. In their more trifling 
 forms they appear as stiffness and awkwardness, which may 
 reveal themselves in the peculiar position of the limb at rest, as 
 mentioned previously, or more naturally in the voluntary move- 
 ments. These symptoms must partly be looked upon as the 
 result of the pain attending all movement, but chiefly as the 
 result of the disturbance of voluntary innervation ; this, instead 
 of taking place in an easy and unforced manner, is carried out 
 slowly and cautiously. Here also, as in the analogous symptoms 
 in the general form of the affection, unconscious voluntary 
 spasms play an important part in the production of the phe- 
 nomena. 
 
 In severe cases the stiffness becomes rigidity and complete 
 contracture, so that almost all motion — active or passive — 
 becomes impossible. This is most evident in the lower ex- 
 tremities. The patients can, of course, neither stand nor walk, 
 and are generally confined to bed. The affected leg is kept, as a 
 rule, slightly flexed and rotated inwards. Every attempt at 
 passive movement is apparently extremely painful. Sometimes 
 the reflexes are much exaggerated ; at other times, in consequence 
 of the contracture, they are only indistinctly made out. 
 
 It is evident that these symptoms might easily produce the 
 impression of an afl'ection of the knee or hip-joint, and, indeed, 
 some physicians who do not know of this common form of local 
 traumatic neurosis have often allowed themselves to be deceived 
 in this respect. But the diagnosis is hardly ever difficult. The 
 general impression which the affection makes, the absence of all 
 organic change in the joint, occasionally the association with 
 anaesthesia, in doubtful cases, lastly, the results of examination 
 under chloroform, make the distinction from organic joint- 
 disease easy. The names, " neurosis of the joint," or " neuralgia 
 of the joint," which surgeons especially often use, appear to me 
 to be improper in this respect, that they contain the presuppo- 
 sition that there is an affection of the nerves of the joint. This 
 is certainly not the case. We have to do here, as we shall see 
 presently, with purely central disturbances. 
 
 Flaccid paralytic conditions are much less common than the 
 
STRUMPELL ON TRAUMATIC NEUROSES. 321 
 
 contractures. They occur, it seems to me, much more frequently 
 in the upper than in the lower extremities, and are often 
 associated with marked cutaneous hyperesthesia. In such cases 
 the patients say that the arm immediately after the injury — 
 which does not need to be a very severe one — dropped as if 
 paralysed, and has remained immovable since. Passive mobility 
 is often fully retained, but in some cases the movements are felt 
 to be painful in the deeper parts, especially at the seat of' the 
 injury. 
 
 Trophic disturbances in the skin and muscles, as a rule, are 
 absent. In some cases, where the paralyses have lasted a long 
 time, we can observe slight wasting of the affected limb, but the 
 electrical irritability of the muscles and nerves remains perfectly 
 normal. 
 
 Other nervous symptoms in cases of pure local traumatic 
 neurosis are absent. In particular, the mental alteration so 
 characteristic of the general form is hardly ever observed. No' 
 doubt the patients show considerable anxiety under examination, 
 and children are often wilful and unmannerly, but we see nothing 
 of that melancholic hypochondriasis which so dominates over the 
 whole mental life of those affected with the general form. 
 
 The question of the essential nature of local traumatic neurosis 
 is a much simpler one than the analogous inquiry in the general 
 form. As from the way in which the injury was received there 
 could be usually no possibility of concussion of the central 
 nervous system, we get rid at once of all the difficulties we met 
 with in our discussion of the general form about the interpreta- 
 tion of possible delicate changes in the nervous structures. We 
 have to do with purely functional disturbances alone, and in 
 this we observe the complete agreement between local traumatic 
 neurosis and hysterical affections ; it is, therefore, not incorrect to 
 call the former traumatic hysteria, that is, hysteria of traumatic 
 origin. 
 
 In order to make this clearer I must briefly explain what I 
 hold to be the right conception of hysteria. Fuller discussion 
 of the subject must be reserved for another occasion. 
 
 I call those affections " hysterical " which originate through a 
 disturbance of the normal connections and relations between the 
 nervous processes which are concerned with the bodily functions, 
 and which, for the most part, are situated centrally, and those 
 
 Y 
 
322 STRUMPELL ON TRAUMATIC NEUROSES. 
 
 processes which we must call psychical. In regard to the nature 
 of these latter each one may think' as it pleases him ; but every 
 one must allow the fundamental distinction that exists between 
 the processes which play a part in consciousness, the psychical 
 processes, and those which are purely concerned with the bodily 
 innervation, and, further, that the normal course of all voluntary 
 motion and all conscious sensation is only possible with per- 
 fectly normal associations between these two spheres. If the 
 mutual relationships are disturbed in any way motor and sensory 
 disturbances of the most varied kind follow. If the passage from 
 the will to execute a movement to the motor centres (probably 
 the well-known cortical motor centres) is interfered with we 
 have a hysterical paralysis. On the other hand, if abnormal and 
 morbid volitions act on the motor centres we have hysterical 
 contractures, spasms, &c. These are examples of morbid stimuli 
 which take origin in the sphere of voluntary action, and which 
 may, therefore, be immediately associated with other psychical 
 elements, such as ideas, passions, and the like. 
 
 Again, if the transmission of centripetal sensory stimuli, 
 whieh, in a normal way passing to the sensory centres of the 
 cortex, become conscious sensations,- is interfered with we have 
 hysterical anaesthesia. This anaesthesia is, however, by no 
 means arranged according to the plan of the sensory conducting 
 paths ; hence, for example, we have complete unilateral amaurosis 
 and not hemianopsia. If, on the other hand, the sensory stimuli 
 pursue a normal path, but produce sensations of abnormal 
 strength, we have hysterical hyperaesthesia. The spontaneous 
 hysterical pains (hysterical neuralgias and the like) I look upon 
 as excitations produced in consciousness itself, therefore, in 
 some measure, as hallucinations of pain. 
 
 Of the exact nature of this disassociation between the psy- 
 chical and tbe somatic spheres which forms the groundwork of 
 hysterical symptoms we know, of course, nothing, seeing that 
 the nature of the association itself is a perfect riddle to us. But 
 the disturbance for the most part does not consist in a complete 
 separation, but merely in a displacement, to use a figure of 
 speech, a kind of luxation; on that account any hysterical disorder, 
 as is well known, can disappear in a moment, giving place to 
 the normal condition. 
 
 The causes of this disturbance of the union between the 
 
STRUMPELL ON TRAUMATIC NEUROSES. 323 
 
 physical and the psychical may probably work from both sides. 
 In very many cases they take rise in the psychical sphere. 
 Among these come the large group of hysterical symptoms 
 produced by suggestion, when ideas, rising with great vividness 
 into consciousness, and referring themselves to the body proper, 
 result in the corresponding somatic condition. All morbid 
 symptoms originating in this way may be called "psycho- 
 genous." 
 
 In other cases, certainly of rarer occurrence, the derangement 
 appears to originate in the somatic sphere, although I readily 
 grant that it is difficult to say, in estimating the effect of the 
 bodily disturbances, how far it is aided by the mental conceptions 
 they give; rise to in the first instance. This latter consideration 
 comes in when we apply these views of the nature of hysteria to 
 the subject of local traumatic neurosis. Whether, with a special 
 predisposition on the part of the nervous system, a sudden violent 
 shock to the body is of itself sufficient to loosen the union 
 between the affected nerve channels and the mental processes, or 
 whether the profound psychical disturbance is in every case (it 
 frequently is) the direct and immediate agent in producing the 
 damage, must remain for the present undetermined. This much, 
 however, appears to me to be beyond doubt, that cases of genuine 
 local traumatic neurosis, as we have described it, must be con- 
 sidered hysterical affections. The affected limb loses through 
 the injury a portion of its normal relation to consciousness. 
 This derangement is the result of the commotion of mind 
 and body, both of which, as can be understood, are largely 
 affected by the injury to the limb ; the special nature of the 
 disassociation determines the production in the individual cases 
 of hystero-traumatic paralysis, hystero-traumatic contracture, 
 anassthesia, &c. 
 
 The prognosis of local traumatic neurosis, in harmony with its 
 almost purely hysterical character, is very much more>favourable 
 than that of the general form: But there are great differences, 
 especially in regard to the duration of the affection. According 
 to my experience, the contractures in the lower extremities, and 
 the peculiarities they cause in the gait, especially in children, 
 give the' best prognosis. As soon as 'the children are removed 
 from unsuitable surroundings, and are : taught by methodic 
 exercise of the will the proper way of directing, their voluntary 
 
824 STRUMPELL ON TRAUMATIC NEUROSES. 
 
 action into the motor paths, the symptoms generally disappear 
 in a very short time. All other kinds of treatment (electricity, 
 massage, hydrotherapeutics, &c.) must he looked upon merely as 
 mental aids to this — though no doubt often very valuable aids. 
 In other cases, however, local traumatic neurosis proves itself to 
 be a very obstinate trouble, and may last for months, or longer. 
 But even in these we must not give up hopes of ultimate 
 recovery. 
 
 With your permission I shall conclude with a brief resume : — 
 
 1. After a severe general concussion of the central nervous 
 system there is often produced a complicated but very 
 characteristic set of nervous symptoms, the best name 
 for which is "general traumatic neurosis." In its 
 features this affection has a strong resemblance partly 
 to neurasthenia, partly to hysteria, and partly to 
 certain of the psychoses (melancholia and hypo- 
 chondriasis). In its causation purely psychical elements 
 predominate, but very probably we should also allow 
 for a continued influence of the psychical shock, though 
 this does not take the form of coarse anatomical changes. 
 In the individual cases we must pay attention some- 
 times more to the one set of influences, sometimes 
 more to the other, so that we cannot analyse all of 
 them in the same way. 
 
 2. In certain cases where the injury acts locally — and 
 generally, though not exclusively, in these cases it 
 affects one of the limbs — we may have severe nervous 
 disturbances in the affected part. These are produced, 
 in all probability, through the influence of the mental 
 ■emotions associated with the receipt of the injury, and 
 may be looked upon as " hysterical " in their nature. 
 Every nervous affection may be called " hysterical " 
 (the name is certainly not a suitable one, but is in 
 common use) which depends on a derangement of 
 the normal connection between the psychical and 
 the, in the narrower sense of the word, physical 
 processes. 
 
STRUMPELL ON TRAUMATIC NEUROSES. 325 
 
 3. The separation between the general and the local forms 
 of traumatic neurosis must not, of course, be pushed 
 too far. Transitions and combinations are by no 
 means rare. In every case we must weigh the signi- 
 ficance of each individual symptom. 
 
 4; Cases occur of traumatic lesions of true organic character 
 associated with traumato-neurotic symptoms, a fact 
 that is of no small importance from a diagnostic point 
 of view. 
 
 5. Finally, general traumatic neurosis seems sometimes to 
 prepare the ground for the development of organic 
 lesions, such as paralysis or tumour. 
 
THE CAUSES AND TREATMENT OF SEVERE 
 AND OBSTINATE CASES OF 
 
 ENURESIS NOCTUMA IN MALES. 
 
 BY 
 
 ALEXANDER PEYER. 
 
 Translated by 
 
 FRANK H. BARENDT, M.D., Lond, F.R.C.S., Eng. 
 
329 
 
 THE CAUSES AND TREATMENT OF SEVERE AND 
 OBSTINATE CASES OF 
 
 ENURESIS NOCTURNA IN MALES. 
 
 When Oberlahder in his "current communications on the etiology 
 and treatment of enuresis nocturna in boys " begins with the 
 following sentence, " the results which the present treatment of 
 enuresis nocturna have to show are certainly of not such a 
 nature that new and fuller views of the subject will not be 
 welcomed," every medical man who has had to deal with obstinate 
 cases of nocturnal incontinence will agree with him. From this 
 standpoint I should like to contribute something to our know- 
 ledge of the causes and treatment of this affection. I emphasise 
 the word cause, because this complaint, like the irritable bladder, 
 is not a disease in itself, but only a symptom which may 
 represent quite different pathological conditions. 
 
 Moreover, Leopold Casper states in his translation of Sir 
 H. Thompson's work on "Diseases of the Urinary Passages," 
 " nothing certain is known of the production and astiology of 
 enuresis nocturna — deep sleep, taking too much liquid, &c, can 
 no longer claim our assent " — and yet the majority of publica- 
 tions deal only with the treatment of the affection. A number 
 of different methods and drugs have been recommended, their 
 influence being extolled in one case or another. Very frequently, 
 however, the cause is not taken into consideration at all, i.e., 
 the pathological basis which lies at the bottom of the symptom 
 of incontinence. If we are ignorant of the cause every line of 
 treatment is haphazard in action, and its publication has but 
 little value in the eyes of another medical man, as it affords him 
 no guide as to how he should proceed in any other case where 
 the incontinence may depend on a diametrically opposite cause. 
 
 It is far from my object in maintaining that henceforth in all, 
 or even in- the majority of cases, it will be possible, even after the 
 
330 PEYER ON ENURESIS NOCTURNA IN MALES. 
 
 most careful inquiry, to explain the causation of nocturnal incon- 
 tinence. On the contrary, it is my purpose rather to indicate the 
 direction in which steps should be taken to arrive at the nature 
 of this burdensome affection which embitters the youth of so 
 many. Treatment would be more satisfactory in its results, 
 whereas at present Sir H. Thompson (" Diseases of the Urinary 
 Passages," 19th edition, translated by Dr. L. Casper) states all 
 kinds of remedies and methods of treatment have been tried with 
 these unfortunate patients, including even the periodical use of 
 the rod, a species of plant which is. not to be recommended as a 
 therapeutic agent. We can be convinced that punishing this 
 form of youthful failing is of no use, for whatever moral effect 
 may be attributed to the popular saying, "Do not spare the 
 rod/' this is quite inapposite for medical men. Frequently the 
 relations of the child lose all patience because of the constant 
 recurrence of this unpleasant weakness, and fancy that obstinacy 
 or inattention on his part is the cause of it. I have seen unfor- 
 tunate children cruelly treated by their nearest relations — we at 
 any rate should never countenance such treatment. 
 
 In infancy the emunctories act without any subjective sensa- 
 tion, the slightest contraction of the bladder and the rectum is 
 sufficient to void the contents, as the resistance of the sphincters 
 is wanting. It is not until after- teething that the power of 
 retaining the urine is established. Consequently children who 
 after this period pass water involuntarily with the urinary channel 
 intact, suffer from enuresis, which represents a persisting infantile 
 condition. 
 
 As the child grows up, as a rule about the time of puberty, 
 the affection disappears spontaneously, and therefore at a •period 
 when the genital system reaches its complete development. 
 
 Trousseau and Bretonneau, with whom Ultzmann agrees, sup- 
 pose some nervous derangement, a want of proportion between 
 the innervation of the detrusor and that of the sphincter, which 
 is lacking in power. During the hours of waking the compressor 
 urethras (sphincter vesicae) is sufficiently stimulated to con- 
 traction by the exercise of the will, but at night during sleep a 
 certain amount of insensibility overcomes the patient and refiex 
 contraction fails. 
 
 In a large number of cases this view is undoubtedly correct, 
 for a considerable percentage get well spontaneously with the 
 
PEYER ON ENURESIS NOCTURNA IN MALES. 331 
 
 advent of puberty, others become normal through treatment 
 by electricity, and Trousseau mentions cases where a single 
 application effected a complete cure. 
 
 We have incidentally touched upon the various causes of 
 enuresis, which we shall now consider more fully. 
 
 In a number of cases we are compelled to assume that con- 
 genital weakness of the posterior portion of the urethra lies at the 
 bottom of the enuresis. 
 
 Oberlander shares the same view : " It is well known," he says, 
 "that the sphincter and detrusor powers of the bladder vary 
 greatly in individuals. This variability bears no relation what- 
 ever either to the muscular power and general health, or to a 
 more or less powerfully developed nervous system. There are 
 just as many little weak men with powerful bladders as strong 
 men with weak ones." According to Oberlander there is no 
 doubt that congenital weakness of the bladder and of the posterior 
 portion of the urethra is sufficient in itself to account for the 
 origin as well as the persistence of this affection. In his expe- 
 rience men with powerful uro-genital musculature are less liable 
 to severe attacks of vesical catarrh or posterior urethritis than 
 those in whom the reverse obtains. 
 
 As further proof of this congenital muscular weakness I should 
 like to mention that those who have suffered from enuresis when 
 young, show traces of this weakness after sexual development. 
 From the outset there is as a rule less sexual desire, and their 
 generative organs are unable to bear as much strain as those 
 of other men. If they indulge in, relatively speaking, slight 
 excesses, for instance, moderate masturbation during youth or 
 coitus incompletus when adults, consequences out of all pro- 
 portion may appear, e.g., exhausting nocturnal emissions, 
 spermatorrhoea, irritable bladder, sexual neurasthenia, &c. 
 
 Prom my experience in this class of diseases I inquire, in 
 every case where the sexual disturbance is out of all proportion 
 to the exciting cause, whether the patient ever when young 
 suffered from nocturnal incontinence, and thus at once obtain 
 an index of the congenital strength and energy of the affected 
 organs. I was surprised when looking up the literature of the 
 subject to find that Lallemand held similar views. In his book 
 on " Involuntary Seminal Emissions," vol. ii., in the chapter 
 on " Urinary Troubles in Childhood," he says, " I have noticed 
 
332 PEYER ON ENURESIS NOCTURNA IN MALES. 
 
 all the patients who have suffered from nocturnal seminal emis- 
 sions have been subject to incontinence of urine, which has lasted 
 at least up to seven or eight years of age, and in several cases 
 up to" puberty. Even then such patients for the rest of their 
 life are frequently obliged to empty the bladder, and always 
 have difficulty in retaining water when the need of micturition 
 is pressing." 
 
 Further on this author alludes to the spontaneous cure of 
 enuresis in spite of all treatment at the period of puberty. 
 " This close relationship," says Lallemand, " is sufficient to show 
 that congenital incontinence of urine augurs ill for virility, and 
 facts leave no room for doubt on the subject. It is therefore 
 very, important to question patients upon this point who are 
 suffering from involuntary seminal emissions. They never 
 attach enough importance to what has taken place during 
 childhood ; however, the practitioner may derive most valuable 
 information from it." 
 
 In conclusion, I may quote from my work on "Irritable 
 Bladder" the following passage which bears upon this very 
 point : " It is not rare for congenital weakness of the uro-genital 
 tract, which is manifested in childhood by wetting the bed, to 
 be the foundation of irritability of the bladder. Such patients 
 often suffer in later years from frequent micturition brought on 
 by relatively insignificant indiscretion, e.g., slight venereal excess 
 ^coitus reservatus, &c), or over-indulgence in pleasures of the 
 table (drinking, smoking, &c.)." 
 
 Other writers view the aetiology of enuresis from a diametrically 
 opposite standpoint. They assume a reflex origin. Magenruder 
 (cf. Surgical Reports, 1887) maintains that nocturnal inconti- 
 nence in boys over eighteen months old is due to phimosis, or 
 adhesion between the glans and prepuce. In proof of this he 
 cites a number of cases where surgical measures resulted in a 
 complete cure. 
 
 Enuresis may also occur in children suffering from epilepsy, 
 night terrors, or other disorders of the central nervous system. 
 It is also seen in chronic nephritis, pyelitis, stone in the kidney 
 and in the bladder. Again, the character of the urine may be a 
 cause, e.g., uratic and phosphatic urine — the so-called scalding 
 urine; in such cases it is assumed that hyperesthesia of the 
 neck of the bladder or of the whole vesical mucosa is present. I 
 
PEYER ON ENURESIS NOCTURNA IN MALES. 333 
 
 myself have published notes of a case in my article on Phospha- 
 turia (v. Yolkmann's Collection, No. 336). 
 
 Lastly, incontinence of urine is often one of the first symptoms 
 of diabetes mellitus. 
 
 We seldom observe it as a reflex affection of the alimentary 
 canal, e.g., from the presence of worms. Another class includes 
 such children who are ill-nourished and strumous, or sluggish 
 and dull children, whose mental calibre is generally below the 
 average. At times children who are physically weak, but men- 
 tally active, suffer from this affection. Sir H. Thompson says 
 it is well known that a child of active and excitable temperament 
 often shows during sleep more muscular movement than adults 
 or children of quiet disposition. This may become so marked 
 as to approach somnambulism, and it is in connection with such 
 conditions that the bladder is often voided involuntarily. 
 
 There are, on the other hand, children who enjoy excellent 
 health, mentally and bodily, who suffer from this affliction. 
 According to the last mentioned authority, incontinence may 
 occur for the first time under the influence of some periodic 
 disturbance of the function of micturition, or of the nervous 
 system, and simply recurs through force of habit long after the 
 primary cause has disappeared. 
 
 I should now like to add to these various views my own 
 experience about one cause, which in my opinion is by no means 
 rare, and which in fact is often the source of the most intractable 
 cases of enuresis noctu'rna. 
 
 •Case I. — In" the spring of 1885 I was consulted, as family 
 medical man, on account of an intelligent boy setat. 7 addicted 
 to wetting the bed for some time past, though previously he had 
 been free from this trouble. Examination of the boy revealed 
 nothing at all to account for it ; his pale and ansemic look rather 
 struck me. The mother informed me that for some time he had 
 been very irritable, could not bear his brothers and sisters, and 
 liked best to be alone. Further, his schoolmasters had been com- 
 plaining for a long time of distraction, and want of attention on 
 his part. I attributed the incontinence to an overwrought nervous 
 system and to anaemia, and this latter in turn to over-pressure at 
 school. After a long stay in the mountains during the summer, 
 he returned very much worse. He wetted the bed much more 
 
334 PEYER ON ENURESIS NOCTURNA IN MALES. 
 
 frequently, in addition often had diarrhoea and suffered a good deal 
 from flatulency. He was also exceedingly irritable, depressed 
 in spirits, and often burst out crying and sobbing without any 
 cause,' e.g., when at table, in spite of a really voracious appetite. 
 I could not at all explain the case, until one day the mother 
 told me that — she had just noticed it for the first time— her boy 
 masturbated dreadfully, and in fact, as he confessed to her, had 
 been doing so for some time past. Now I altered my diagnosis: 
 the primary cause is chronic inflammatory, irritability of the 
 mucosa of the prostatic portion of the urethra, due to masturbation. 
 The former acted reflexly in producing nocturnal incontinence, 
 and the latter the anaemia and neurasthenia. The remedial 
 measures consisted in preventing masturbation, which was 
 exceedingly difficult to carry into effect, and in the local applica- 
 tion of a solution of tannin twice a week to the prostatic urethra. 
 The little patient was in the end completely cured after a good 
 deal of trouble and patience. 
 
 Here we have a case where none of the previously mentioned 
 causes existed, but where the mischief lay in the prostatic urethra 
 itself. This is by no means rare ; on the contrary, it lies at the 
 bottom of quite a number of obstinate cases of nocturnal incon- 
 tinence. 
 
 If we examine the urethra of a young male subject, Oberlander 
 says the size of the caput gallinaginis strikes us as out of all 
 proportion, standing up like a buttress. It is evident that this 
 eminence when transiently or chronically irritated must be a 
 source of acute reflex irritability. Further, numerous glands 
 belonging to the genital tract open into the posterior portion, of 
 the urethra, e.g., Cowper's glands and the vesiculas seminales. For 
 although these glands do not become active as a rule until 
 puberty, still it is a mistake to assume that their functions are 
 quite dormant prior to this period. That this is physiologically 
 •so, is also borne out by the frequent erections of infants and boys. 
 If these erections be at all abnormal in frequency from any 
 particular cause, a chronic inflammatory state of irritability may 
 ensue, which' may give rise to enuresis even in boys with no 
 congenital weakness. 
 
 As an illustration of this point I may cite the following case. 
 
 Case II. — H. St., aetat. 18, a gardener's apprentice, consulted 
 
PEYER ON ENURESIS NOCTURNA IN MALES. ■ 335 
 
 me in the winter of 1882-83 about his periodically wetting the 
 bed. He did not look more than 15, was pale and aneemic, and 
 although he had a very good appetite, he was always tired, 
 sluggish in his movements, and dull of comprehension. He had 
 never wetted the bed in early childhood,- it first began when he 
 was about seven. No family history of this affliction. The penis 
 was very large, and the testicles well developed. He stated he 
 never had nocturnal emissions, and even professed not to know 
 what they were. He strenuously denied masturbation. Exami- 
 nation of the urine more than once revealed leucocytes and 
 urethral epithelium in varying amount, and his landlady on my 
 inquiry told me that the bed linen was very frequently stained. 
 The youth now confessed that ever since he was five he practised 
 masturbation, and kept on doing so to an excessive degree, 
 frequently four or six times a day. He soon felt the consequences ; 
 he was often ill in the morning, his head felt oppressed and 
 heavy, he could learn nothing, bodily development was retarded, 
 and he began wetting the bed. Seminal emissions occurred 
 shortly after 14, and when he consulted me, they even took 
 place during the day at erotic thoughts or with certain move- 
 ments of the body. Latterly nocturnal incontinence had 
 remained about the same. Treatment consisted in introducing 
 full-sized metallic bougies and leaving them in the urethra for 
 some time. As soon as the patient ceased wetting the bed he 
 passed away from under my care, and I have not heard anything 
 further from him. 
 
 In both cases I have shown that a chronic irritable state of the 
 prostatic portion of the urethra may be the sole cause of enuresis 
 even in boys whose uro-genital tract had hitherto been perfectly 
 healthy. Prom both histories we have seen what was' the cause 
 which had abnormally increased the number of erections which 
 naturally .take place in childhood, and thereby induced this in- 
 flammatory condition, viz., masturbation. Ultzmann (" Nervous 
 Affections of the Male Genito-urinary System ") states : "Mas- 
 turbation and venereal excess, "in which persistent unnatural 
 erection is kept up for a considerable time, are not infrequent 
 causes of the prostatic urethra, and especially of the caput 
 gallinaginis, becoming hyperaesthetid, hypersemic, arid catarrhal, 
 and consequently stimulating reflexly the contraction of the 
 detrusors." " "- 
 
836 PEYER ON ENURESIS NOCTURNA IN MALES. 
 
 What then happens when this cause is at work, not in boys 
 previously robust, but in those who are suffering from enuresis 
 nocturna, the result of arrest in the infantile stage, or of con- 
 genital muscular weakness of the genital organs ? 
 
 In such cases two causes are at work— the congenita^ and 
 acquired vesical weakness, and the results are those obstinate 
 and severe cases of enuresis which continue into manhood and 
 are most intractable. 
 
 As examples of this class I may adduce the following cases : — 
 
 Case III.— At the end of October, 1883, S. P., aetat. 17, 
 farming pupil, son of a professor of medicine, consulted me on 
 account of obstinate nocturnal incontinence. The young man 
 was fairly well-developed, and had suffered from infancy from 
 this misfortune ; two of his brothers were similarly afflicted, but 
 they outgrew it between the ages of twelve and fourteen. 
 
 It occurred in the patient's case once or twice in the night in 
 spite of every precaution and the careful regulation of his habits. 
 He always had light digestible food, extremely little fluid, and 
 never drank anything in the evening. In the course of the night 
 he would be repeatedly awaked by the steward by means of a 
 cord fastened to his foot. At one time it would occur imme- 
 diately after falling asleep, at another soon after he had been 
 awaked and passed water. Sleep was always remarkably heavy 
 and deep. In the morning he could scarcely be got out of bed, 
 and then he was half-confused, and had difficulty in remember- 
 ing things. Usually he had quite forgotten he had been awaked 
 in the night. During the whole morning his head was heavy and 
 oppressed. He was exceedingly dull of apprehension, and his 
 condition only began to improve in the afternoon. Almost con- 
 stant lassitude. Local examination of the genitals revealed nothing 
 abnormal, though they were rather large. Urine normal ; after 
 standing some time, a slight cloud appeared at the bottom of the 
 urine glass, consisting of mucus, round small epithelial cells, a few 
 leucocytes, and a fair number of beautiful rhombic prism crystals 
 (coffin-lid crystals *), as are met with at times in the mucus of 
 Cowper's glands. From this discovery I could with certainty 
 infer an irritable condition of the genital organs, and on my 
 
 * Prom the resemblance to the lid of a German coffin ; they are triple phos- 
 phates. — Translator. 
 
PEYER ON ENURESIS NOCTURNA IN MALES. 337 
 
 inquiry the patient confessed that he had been suffering from 
 seminal emissions at night in consequence of masturbation, and 
 that even during the day they often occurred at erotic thoughts, 
 or with mere friction of the trousers. He commenced masturba- 
 tion when eleven years of age, and since then nocturnal incon- 
 tinence had become much more frequent. Treatment consisted 
 in the application of the Psychrophor.* After the first introduc- 
 tion the following night was passed without wetting the bed. 
 Progress became quite marked, and up to Christmas relapses 
 were quite exceptional. Prom the 1st of January to the end of 
 March nocturnal incontinence occurred but once, and the patient 
 then ceased to be under my care. At the same time his general 
 health greatly improved, the heavy. leaden sleep disappeared, he 
 was able to rise at once in the morning and felt cheerful. His 
 intellectual powers improved, he learnt his lessons more easily 
 and willingly, and his shy and depressed manner completely 
 passed away. In the course of six months, having resumed the 
 ordinary habits of life, taking beer and wine, nocturnal incon- 
 tinence and seminal emissions returned. Local treatment was 
 again carried out, and now the patient is permanently cured! 
 
 Case IV. — B., setat. 18, in the book-binding trade, had been 
 addicted to wetting the bed every night, and suffered from fre- 
 quent micturition during the day. As he was obliged to earn 
 his , living amongst strangers, he would give anything to be 
 rid of his troublesome affection. Father and mother healthy. 
 Two brothers up to the age of eighteen were also troubled with 
 nocturnal incontinence, otherwise they were strong and healthy. 
 The patient was said to have been a strong child, but from the 
 very first suffered from enuresis, which considerably lessened 
 in frequency up to his twelfth year, so that he wetted the bed 
 not more than once or twice a week. About this time B. was 
 taught to masturbate, and practiced it for 'a year or so. As, 
 however, he noticed that nocturnal incontinence was getting 
 more frequent, he gave up the bad habit. In spite of this step, 
 seminal emissions began to occur when he was fourteen, and 
 later on even in the daytime, especially during any powerful 
 muscular exertion (circling the bar and other gymnastic exer- 
 
 * Psychrophor (^vxp'os cold, and <£ «p« I bear), an instrument for applying cold to 
 the urethra.— Tbanslatob. 
 
 Z 
 
338 PEYER ON ENURESIS NOCTURNA IN MALES. 
 
 cises). In consequence he became more and more languid ; in 
 the morning his head was heavy, at times ached severely, 
 and he often noticed a dull oppression on the chest. When I 
 saw him in April, 1878, he wetted the bed regularly every night, 
 headache occurred daily, and often incapacitated him from doing 
 any work. His expression was distinctly effeminate, his voice 
 was thin like a girl's ; the genital organs were almost infantile 
 in development. 
 
 Local treatment, consisting in introducing full-sized metallic 
 bougies, and in the use of astringent injections, lasted with long 
 periods of interruption nearly a year. In the end the patient 
 was completely cured. 
 
 Case V. — A. 0., setat. 16, blacksmith's apprentice, from the 
 canton of Thurgau, had been troubled with nocturnal incon- 
 tinence from birth. His father had also suffered from the same 
 trouble, whereas the patient's two brothers remained quite 
 free. For his age he was a very well-developed, strong lad, and 
 in every other respect quite healthy. When he was 12 he 
 almost outgrew the weakness, which occurred rarely. About 
 this time 0. began to masturbate, and nocturnal incontinence 
 became again frequent. He always wetted the -bed if he had 
 masturbated the previous evening, and very often incontinence 
 of urine would occur several nights following. This fact struck 
 the patient so much that he himself connected the wetting of the 
 bed with masturbation. Up to that time he had not had any 
 seminal emissions during sleep. The enuresis nocturna became 
 more and more marked. 
 
 The member was large and well-developed, the glans covered 
 by the prepuce, which was not too long, and no phimosis existed. 
 
 Urine pale colour, no albumen or sugar ; by transmitted 
 light, specks could be seen floating in the urine, which, under 
 the microscope, consisted of fragments of transparent pavement 
 epithelium, connected with mucus filaments here and there 
 nucleated, and enclosing spermatic filaments, and a fair number 
 of solitary and grouped leucocytes. 
 
 After the first application of the psychrophor, enuresis occurred 
 but once in the following week, and in the course of three months, 
 under repeated treatment, the troublesome affection disappeared. 
 
 Case VI.— Sch., setat. 20, peasant, native of the Black 
 
PEYER ON ENURESIS NOCTURNA IN MALES. 339 
 
 Forest, Baden, suffered from childhood from incontinence once 
 or twice every night. Of four brothers and three sisters, one 
 brother only suffered from enuresis up to his 18th year. 
 
 Patient himself had noticed a marked improvement at the 
 same age, without, however, his trouble completely subsiding. 
 About this time he began to masturbate, and continued the bad 
 habit for a year, when he gave it up, as he noticed his general 
 health suffered. What particularly struck him was that the 
 nocturnal incontinence became much more frequent, and that 
 he now suffered continuously from headache, which he only 
 occasionally had before. ' Sch. was always tired and languid, 
 and though he no longer masturbated, his condition remained 
 unaltered. It was then he came under my care. The genitals 
 were poorly developed, no phimosis ; urine normal ; after 
 standing some time a slight sediment was noticed consisting of 
 mucus and leucocytes. 
 
 After the introduction of a full-sized metallic bougie enuresis 
 occurred but three times in a period of 10 days. Oberlander's 
 dilator was then used ; two relapses only occurred during the 
 following 12 days, and after another application of this in- 
 strument the patient was cured. 
 
 Case VII. — This case is chiefly interesting because it shows 
 that the enuresis did not depend upon the inflamed long, narrow 
 prepuce, but that the reflex irritation which produced the trouble 
 had its seat in the urethra. 
 
 A. Sp., astat. 13, a thin, miserable-looking lad, had been 
 suffering ever since birth from severe enuresis. 
 
 He was always tired, and most difficult to awake in th& 
 morning. During the day his head felt heavy, his thoughts 
 were sluggish, and his apprehension dull. 
 
 Prepuce long, narrow, reddened, and inflamed, as also the 
 meatus urinarius. For some years he had indulged in mastur- 
 bation. 
 
 Treatment. —The prepuce was slit up, with no improvement, 
 however ; thereupon a metallic bougie was introduced daily for 
 some weeks. Cure. 
 
 All the cases, III., IV., V., VI., VII., have the following points 
 in common — 
 
340 PEYER ON ENURESIS NOCTURNA IN MALES. 
 
 1. The patient suffered from infancy from enuresis, i.e., it was 
 congenital. 
 
 2. The affection was a family oner-father or brother having 
 also suffered. 
 
 3. In alL (except case VII., which is excluded by reason of the 
 age) sexual weakness was present, showing itself by seminal 
 emissions with flaccid penis, brought on by comparatively 
 trivial causes. 
 
 4. Lastly, in addition to the congenital weakness, another cause 
 was present, namely, chronic inflammatory irritability of the 
 prostatic portion of the urethra, due to masturbation. 
 
 Cases are also observed where wetting the bed at first is a 
 congenital nocturnal affection — "enuresis nocturna"; in the 
 course of time, however, micturition may become frequent during 
 the day (Case IV.) — " enuresis diurna " ; and, finally, it may pass 
 into " enuresis continua," where the patient cannot retain the 
 urine at all. As an example of this condition I take the follow- 
 ing case from my book on "Irritable Bladder." 
 
 M. W., aetat. 10, small, thin, miserable, and cachectic-looking 
 boy, with red nose and prominent belly, suffered from continuous 
 incontinence of urine. His shirt and trousers after half a day 
 were quite wet, and emitted an evil-smelling urinous odour. 
 The bowels were sluggish. Appetite very good, in fact voracious. 
 Constant languor, heaviness of head, especially in the morning. 
 He could not be awaked out of his sleep, not even by shaking. 
 Intellect normal. 
 
 The boy had suffered from infancy from incontinence, which 
 had gradually increased in severity ; there was constant desire to 
 pass. water during the day, and the last two years it became so 
 troublesome as to almost abolish retention, and thus established 
 the condition for which he came under my care. 
 
 The lad had never suffered from worms or any other serious 
 illness. The penis is small, the prepuce very long, and the 
 meatus a vivid red. 
 
 The urine passed in my presence soon showed a cloudy 
 sediment, consisting of mucus containing rhombic prisms (coffin- 
 lid crystals) , and also a number of quite small crystals of oxalate 
 of lime. A few round and oval epithelial cells and mucus 
 corptfscles could also be recognised. The urine itself was free 
 from albumen and sugar, but markedly acid. 
 
PEYER ON ENURESIS NOCTURNA IN MALES. 341 
 
 The glassy, ropy mucus which had collected at the bottom of 
 the glass, together with rhombic prisms (coffin-lid crystals), &c, 
 showed a marked alkaline reaction. 
 
 Before examining the urine, I asked the little fellow whether 
 he ever played with his genitals, but he strenuously denied 
 doing so. 
 
 From the results of the microscopic examination I again 
 questioned him on this point, and then he admitted having 
 masturbated ever since he was six, i.e., for the last four years, 
 and exactly during this period oppression of urine was noticed 
 during the day, which, as we have seen, passed into complete 
 incontinence. 
 
 The treatment-— besides explaining to him the consequences 
 of his bad habit — consisted in passing metallic bougies. The 
 first application lasted a quarter of an hour, and the following 
 night was passed without wetting the bed. This treatment was 
 continued regularly for eight days, incontinence was completely 
 cured, and the desire to pass water considerably lessened in 
 . frequency. 
 
 In order to cure the patient of masturbation, the prepuce was 
 slit up, and a sound was passed at intervals for some time 
 afterwards. 
 
 He remained quite well, and exchanged his wretched 
 appearance for a healthy if not a robust one. 
 
 What is the explanation now of such a case ? 
 
 From the outset we must not confound it with that form of 
 enuresis "which at times occurs in nervous children, when cough- 
 ing, sneezing, laughing, when doing gymnastics or coming 
 down hill, &c. 
 
 In my book on " Irritable Bladder," I have shown that irritation 
 of the prostatic portion alone is not sufficient to produce vesical 
 irritability, but rather that the frequent and at times constant 
 oppression of urine characteristic of the affection is not established 
 until the neck of the bladder is implicated. The neck is by far 
 the most sensitive region of the bladder, and it is evident that 
 anything that irritates or frets this must heighten its sensitive- 
 ness to an unnatural extent, and give rise to frequent micturition, 
 "which is characteristic of the affection known as " Irritable 
 Bladder." 
 
 If this chronic inflammatory state of the prostatic portion of 
 
342 PEYER ON ENURESIS NOCTURNA IN MALES. 
 
 the urethra and of the neck of the bladder supervenes in a case 
 where there is already a congenital weakness of the uro-gemtal 
 tract, especially of the sphincter vesicae, we can easily under- 
 stand that the patient is no longer in a position to resist the 
 urinary tension under such circumstances, and thus enuresis 
 continua is brought about. 
 
 The diagnosis of the presence of chronic inflammation of the 
 prostatic portion is, as a rule, not difficult, and the history 
 generally furnishes evidence in support of it. We should 
 always inquire whether the affection was equally troublesome 
 from the very first, or whether it decreased at any particular 
 age — e.g., 12th to 14th year — and then gradually increased, or 
 whether it only appeared for the first time in late childhood (6th 
 to 8th year). 
 
 If the patient or the parents are unable to give information 
 upon this point from its very commencement, we must endeavour 
 to obtain it by proceeding along definite lines. For if we have 
 ascertained that the affection became worse at a certain period, 
 then we may assume that some fresh exciting factor has super- 
 vened, and we must find out what this is. The best 'means to 
 this end is frequent microscopic examination of tfie urine. 
 
 If we have an apparently normal urine to examine, we shall 
 find probably by transmitted light and careful scrutiny that it is 
 not quite clear owing to a slight haze. After standing some time 
 a cloud settles at the bottom of the urine glass, which reveals 
 under the microscope mucus and more or less numerous leuco- 
 cytes. At times we may discover spermatozoa in patients who 
 have passed puberty, or we may notice in the pipette a trans- 
 parent tenacious alkaline mucus in which epithelial cells or 
 rhombic prisms (coffin-lid crystals) are imbedded. These results 
 indicate chronic inflammation of the posterior portion of the 
 urethra, and relying on them we may now complete the history 
 by telling the patient that such a discovery in young persons 
 is the result of masturbation, and that he may as well speak the 
 truth. 
 
 I should here remark that I do not pursue this method without 
 good reasons, for it often happens that such young patients, if we 
 are not almost certain of it, deny masturbating most positively, 
 as is seen in the history of Case II. 
 
 We may thus draw our conclusions. 
 
PEYER ON ENURESIS NOCTURNA IN MALES. 843 
 
 For instance, a young man comes to us setat. 18, who has 
 been suffering from birth from enuresis, which with the growth of 
 the body has decreased without quite disappearing. Gradually, 
 without any apparent external cause, it becomes again frequent ; 
 other nervous symptoms are noticed, e.g., irritable disposition, 
 heavy leaden sleep, difficulty of waking in the morning, and 
 oppression of the head. Examination of the urine yields the> 
 above-mentioned results. We can be almost absolutely certain 
 of our conclusion without any admission on the part of the patient 
 — chronic inflammatory irritability of the prostatic urethra due 
 to masturbation, and as a result of the former, aggravation of 
 incontinence and manifestation of neurasthenia. 
 
 Treatment. — As regards the general treatment I shall not 
 enter into particulars, for these measures are well-known 
 (e.g., easily digestible nourishment, and avoidance of fluid as 
 much as possible, especially towards evening, prohibition of 
 feather bedding, and methodical bathing). 
 
 All these measures, including hypnotism, most recently recom- 
 mended, are of no influence in such severe and obstinate cases 
 as we have described. 
 
 Local treatment only is of service. 
 
 Sir Henry Thompson (" Diseases of the Urinary Passages ") 
 states, after having mentioned the various remedies and modes of 
 treatment, " if these have no effect, then in those patients who 
 are either approaching, or have passed, puberty, instillation of a 
 2 per cent, solution of nitrate of silver may be used to the pros- 
 tatic portion of the urethra. The strength of the solution may 
 be subsequently increased if necessary. In the case of boys, 
 the introduction of a soft bougie every second or third day, and 
 leaving it in the urethra for two or three minutes, as a rule is 
 sufficient." 
 
 Although Sir Henry Thompson does not mention in which 
 class of cases the above treatment is indicated, in my experience 
 it is just in such patients I have here described, where a chronic 
 inflammatory irritation of the prostatic portion of the urethra is 
 the cause of all the trouble. 
 
 My treatment of these cases consists as a rule in the use of 
 full-sized metallic bougies. These are introduced two or three 
 times a week, sometimes even daily, and allowed to remain in 
 the urethra from three to five or seven minutes. 
 
344 PEYER ON ENURESIS NOCTURNA IN MALES. 
 
 Instead of bougies, Winternitz's psyehrophor may be used, 
 especially when micturition is accompanied by slight smarting, 
 or seminal emissions occur with the penis flaccid. 
 
 The application of astringents, e.g., instillation of 1 per cent, 
 or more of a solution of tannin or alum is at times useful. 
 Nitrate of silver I. also use, but never stronger than 1 per mille. 
 
 Oberlander has obtained excellent results in several cases by 
 means of his dilator. In Case VII. I used this instrument twice 
 with a favourable issue. I have, however, not sufficient experience 
 as yet to enable me to judge whether it yields better results 
 than the treatment I have described above. 
 
 Under local treatment I include the application of electricity. 
 The cathode is introduced into the urethra or bladder, and the 
 anode placed over the lumbar spinal cord, or inserted into the 
 rectum. In such a case the cathode acts not only electrically 
 but also as a bougie, by the frequent application of which Sir 
 Henry Thompson has often effected a cure. 
 
EECENT ADVANCES 
 
 IN THE 
 
 TREATMENT OF CHRONIC DISEASE 
 OF THE SPINAL CORD. 
 
 BY 
 
 Dh. l. lowenfeld, 
 
 Munich. 
 
 Translated by 
 
 A. M. STALKEK, M.A., M.D., 
 
 Physician to the Dundee Royal Infirmary. 
 
347 
 
 RECENT ADVANCES IN THE TREATMENT 
 OF CHRONIC DISEASE OF THE SPINAL 
 CORD. 
 
 INTRODUCTION. 
 
 Up to the close of the first half of the present century the affec- 
 tions of the spinal cord form, as is well known, one of the saddest 
 chapters in the history of medicine. The scanty character of the 
 knowledge of this subject possessed by physicians was equalled by 
 the miserable success of their treatment, and we can understand 
 only too well how it was that, for the great mass of the public, 
 to say that one was suffering from affection of the spinal cord 
 was precisely the same as saying that he was sinking under a 
 chronic incurable disease. This state of matters has undoubtedly 
 changed for the better during the last twenty or thirty years. 
 The astonishing advance which has taken place in our knowledge 
 of these diseases during that time has been accompanied by 
 distinct progress in their therapeutics also, and though the latter 
 has not been quite so marked as in the case of the former, we 
 may nevertheless comfort ourselves to-day with the thought that 
 the prognosis in a number of these affections is distinctly more 
 favourable than it was wont to be. It would, however, be 
 wrong to suppose that this encouraging change for the better 
 is essentially or even mainly due to the acquirement of new 
 remedies (i.e., previously unknown or unappreciated) against 
 disease of the spinal cord. In the first place, progress in 
 diagnosis has proved of pregnant value. We are now, through 
 a more accurate knowledge of the various forms of spinal disease, 
 and through the improvement in our methods of examination, 
 placed in a position to recognise the most of these forms in a 
 comparatively early stage, and at a period in which they are very 
 much more amenable to treatment than they are later. Further, 
 large additions have been made to our knowledge of the effects 
 
^48 LOWENFELD ON KECENT ADVANCES IN THE 
 
 of the various remedies used in spinal disease, and these have 
 resulted in improvements in their mode of application, and m a 
 more careful estimate of the indications for their employment. 
 Lastly, a great deal that is of importance for treatment has been 
 brought to light by the more thorough study of the causes of 
 these diseases. I will only mention the connection, so much 
 discussed in recent years, between syphilis and locomotor ataxia, 
 Tuczek's 1 proof that disease of the posterior columns can be 
 caused by chronic ergot-poisoning, and the derivation of one 
 form of spastic spinal paralysis from the effects of poisoning by 
 lathyrus cicera. 2 
 
 We must not, however, conceal from ourselves the fact that 
 the advances made in the diagnosis and treatment of these 
 diseases do not benefit all those affected to the extent that their 
 outward circumstances might allow. This regretable state of 
 things is due. in my opinion, to two causes. The first of these 
 refers to the difficulties in the way of diagnosis. The recognition 
 of chronic affections of the spinal cord in the earliest stages, that 
 is, when they are most amenable to treatment, requires not only 
 an accurate acquaintance with the various forms of spinal 
 disease, but also such a familiarity with all the methods of 
 neuro-pathological examination as has not yet become common 
 property among all the members of the medical profession. The 
 second cause is that we are at present over-loaded with remedies 
 and therapeutic methods, and the practitioner who has had no 
 •great experience of his own finds his choice of a suitable line 
 of treatment for any particular case very difficult. Our arma- 
 mentarium against spinal diseases is continually being over- 
 furnished with remedies which are thrown into the market, to 
 begin with, without being sufficiently tested, and after a longer 
 or shorter period disappear again frojn view. 
 
 It lies in the nature of things that the former of these two 
 difficulties will not be set aside for some time. But it should 
 be now possible to remove, or at least to considerably diminish, 
 the effect of the latter, and to produce some degree of separation 
 of the chaff from the wheat. The following remarks are intended 
 to be a contribution to this end. 
 
 Before we proceed to pass these remedies under review, I 
 think it desirable to make ourselves briefly acquainted with the 
 limitations whioh are placed on our therapeutic efforts from the 
 
TREATMENT OF CHRONIC DISEASE OF THE SPINAL CORD. 349 
 
 physiological properties of the spinal cord, and the nature of the 
 morbid processes which we wish to influence. We must be as 
 clear in our views as possible in regard to what we really can 
 do before making our choice of the means of doing it. 
 
 The question as to how far pathological changes in the spinal 
 cord can regress is yet to a great extent unsolved. The diffi- 
 culties which the investigator has to contend with makes this 
 only too conceivable. I shall endeavour in what follows to 
 sketch the present position of the question as shortly as possible, 
 and in doing so will bring out plainly enough thje" scanty 
 character of our knowledge. 
 
 Morbid changes in the spinal cord are still divided into the 
 two classes of impalpable and palpable or structural. Impalpable 
 changes, that is, such as cannot be discovered by our present 
 means of investigation, must be assumed to be present in a 
 number of affections. Among these are, first of all, spinal 
 neurasthenia, then many cases of hysterical paralysis and 
 concussion of the spinal cord, cases of hysterical paraplegia, 
 probably also the cases of intermittent spinal paralysis, and 
 many cases of toxic paralysis. All these lesions', though likely 
 enough very different from one another, have this in common, 
 that in the great majority of cases complete recovery from them 
 may be attained, though no doubt, as in neurasthenia, they 
 sometimes prove very obstinate, and, as in concussion of the 
 cord, may change apparently into coarse structural lesions. 
 
 Several experimenters have worked at the question whether 
 we can have anatomical and functional compensation in such 
 lesions of the cord as incised wounds or loss of substance. 
 Heinrich Miiller 3 worked. with cold-blooded animals, Masius and 
 Vanlair 4 and Brown-Sequard 5 with pigeons and guinea-pigs, 
 Flourens 6 with rabbits, Eichhorst and Naunyn 7 , Dentan 8 , Schie- 
 ferdecker 9 , and Eichhorst 10 in a second series of experiments, 
 with dogs. Though these experiments by no means agree with 
 one another in all their details, yet their general result puts it 
 beyond a doubt that the spinal cord, both in cold- and warm- 
 blooded animals, possesses the power, within certain limits, of 
 producing both structural and functional compensation in the 
 case of incised wounds and loss of substance. They have further 
 shown, however, that the extent to which this power is possessed 
 varies very much, not only among different genera, but among 
 
850 LOWENFELD ON RECENT ADVANCES IN THE 
 
 the different species of the same genus, and that young animals, 
 as a rule, possess it in larger measure than old. 
 
 Among mammals the power attaches chiefly, if not exclusively, 
 to the nerve fibres, and up to the present time, at any rate, 
 restoration of ganglionic cells has not been observed. On the 
 other hand, Masius and Vanlair have observed such a new- 
 formation in frogs, and Brown-Sequard in pigeons.* 
 
 Observations on the human subject are in essential agreement 
 with these results. They show that both traumatic lesions of 
 the cord and alterations produced by disease may be recovered 
 from ; in the case of the latter, however, that the capacity for 
 recovery varies inversely as the extent of the disease, and that, 
 further, the individuality of the patient is of the greatest 
 consequence, affecting both the commencement of the healing 
 process and its ultimate amount. 
 
 It is of particular importance to observe that functional by 
 no means presupposes structural recovery. We have several 
 cases recorded showing the persistence of considerable anatomical 
 changes side by side with the disappearance of functional 
 disorders, that is to say, practical recovery, t Anatomically, all 
 that has been ascertained is merely in favour of regeneration of 
 nerve fibres. Narrow fibres with dark borders have been found 
 
 * These results refer, as I have remarked, only to the cicatricial tissue formed 
 in the cord after incisions and loss of substance, and not to the degeneration of 
 nerve-fibres. In regard to the latter, Kahler's " experiments on dogs gave nega- 
 tive results. By crushing a number of the posterior roots he produced degene- 
 ration of the posterior columns, the fibres of which, in the main, are formed of 
 direct continuations of the fibres of the posterior roots. In the animals killed a 
 considerable time after the operation there was certainly regeneration of the 
 extra-medullary part of the posterior roots, but on the other hand no sign 
 whatever of regeneration in the intra-medullary portion. Kahler thinks that he 
 is at liberty to conclude from these observations that in systemic diseases of 
 the cord the restoration of disordered functions can only follow from the opening 
 up of vicarious conducting paths, and not from recovery on the part of the 
 nervous elements. This scarcely appears to me a just inference. Kahler's facts 
 only permit us to say that there must certainly be a distinct difference between 
 the capacity for regeneration possessed by the peripheral nerves and that possessed 
 by the systemic fibres of the cord. But from the negative results of three 
 experiments on animals of one particular species to deny altogether that there is 
 any capacity for regeneration on the part of these cord fibres is hardly correct, 
 all the more so as we have observations on the human subject which distinctly 
 favour an opposite conclusion. As to the question how far systemic fibres which 
 are merely morbidly affected, and which have not yet disappeared, can be 
 restored, Kahler's facts teach nothing. 
 
 t Schultze, 12 Fox, 13 and Benedict," have recorded cases of this kind where 
 sclerosis of the posterior columns was the lesion. 
 
TREATMENT OF CHRONIC DISEASK OF THE SPINAL CORD. 351 
 
 in the cicatricial tissue that sometimes forms in cases of transverse 
 myelitis after resorption of the liquefied medullary substance.* 
 In a case of fracture of the spine, where the cord had been 
 crushed in the middle of the dorsal portion, Gowers 15 found at 
 the cervical level, besides the ordinary ascending degeneration, 
 a number of very minute nerve fibres, each consisting of a fine 
 axis-cylinder surrounded by myelin. The fibres were smaller 
 than any met with in the normal cord; the appearance was, 
 says Gowers, as if from the lower extremity of the normal fibres 
 there had occurred a growth of new fibres, such as affects the 
 regeneration of peripheral nerves. And Benedict 17 saw in a 
 teased-out preparation from a case of locomotor ataxia delicate 
 threads (newly-formed axis-cylinders ?) passing out from a mass 
 of degenerated nerve fibres. 
 
 Qur knowledge of- the behaviour of the ganglionic cells is 
 still more fragmentary. Nothing is known in the human 
 subject of a new formation of nerve cells in the cord out of the 
 remains of broken-down structures of a similar kind, or out of 
 , any other kind of material. And our present information leads 
 us to believe that any regeneration of this kind is improbable. 
 If it could happen at all it would be preferably in the first years 
 of life. Observations have been repeatedly made in cases that 
 have suffered in early life from infantile paralysis ■ and have 
 completely recovered — cases, therefore, where from the clinical 
 appearances we should expect to find the restitutio ad integrum 
 of the diseased tissue, and along with it of the diseased 
 ganglionic cells, complete. But in these post-mortem obser- 
 vations there still remained something of the disease recovered 
 from, and the ganglionic cells in circumscribed portions of the 
 anterior horns are found to have completely disappeared. How 
 far morbid changes in the nerve cells can go, and yet keep 
 possible the restitutio ad integrum, or at least the recovery of 
 function, we do not know. It is, however, a fact of great 
 importance that, like the fibres, the cells may suffer considerable 
 
 * Charcot 16 records a case of this kind. There had been compression -myelitis 
 from Potts' disease, and complete recovery from the paraplegia had taken place. 
 The cord at the seat of compression was about the thickness of a goose-quill and 
 apparently sclerosed. There were, however, a considerable number of nerve- 
 fibres, with axis-cylinders surrounded with myelin. Charcot leaves it undeter- 
 mined whether there was a reproduction of all the constituents of the fibre, or 
 whether there was merely a medullary sheath around a naked axis-cylinder 
 Compare Miohaud's case quoted in Leyden's Klinik, p. 134. 
 
352 LOWENFELD ON RECENT ADVANCES IN THE- 
 
 alteration without becoming useless or failing in their physio- 
 logical functions. As in the case of the fibres, the persistence 
 of the axis-cylinders is sufficient, so the cells also may be 
 reduced to but a fraction of their normal size and still be 
 perfectly equal to all their work. A case related by Adam- 
 kiewicz 18 ; for example, brings this out in a very striking manner. 
 By the pressure of a tumour on the left half of the lower portion 
 of the cervical enlargement, the cells were reduced to the one- 
 thirty-second part of the normal, and yet this caused no 
 symptoms whatever during life. 
 
 We are in the dark also as to how far changes in the neuroglia 
 are capable of retrogression. The neuroglia is involved certainly 
 in a large number of acute and .chronic inflammatory processes, 
 from which recovery frequently takes place, so that it may be 
 assumed that, up to a certain point, changes in this substance 
 may undergo retrogression. Several observations in patho- 
 logical anatomy are in favour of this view, such as the slight 
 changes in the neuroglia which have been found after recovery 
 from myelitic processes. This much, however, appears certain, 
 that if it has been transformed into a delicate fibrillar tissue, 
 consisting mostly of longitudinal bundles with a wavy course — 
 a transformation which we often come across in the later stages 
 of chronic myelitis— retrogression in this case is out of the 
 question.. Simple changes in the circulation, anaemia and 
 hyperaemia of the cord, may undoubtedly disappear again. But 
 as to whether, and how far, alterations in the vessel-walls, such 
 as proliferation of nuclei, fatty .degeneration, and sclerosis, can 
 undergo retrogression, we are still quite in the dark. 
 
 From the foregoing it may be perceived that structural 
 changes in the cord are capable of retrogression only to a very 
 limited extent, at any rate are not' susceptible of complete 
 recovery to nearly the same extent as molecular alterations. 
 We have to take into account here another circumstance which 
 is by no means favourable from a therapeutic point of view. As 
 not only, molecular but also anatomical changes can exist 
 without affecting the functional capacities of the nervous 
 elements, we cannot identify the clinical with the anatomical 
 commencement of the affection. 
 
 Changes in the cord may precede by a considerable time the 
 advent of distinct spinal symptoms. This fact gives us an 
 
TREATMENT OF CHRONIC DISEASE OF THE SPINAL CORD. 353 
 
 indication of great importance in practice. In the majority of 
 the chronic affections of the cord associated with structural 
 lesion there is probably, to begin with, a stage of merely 
 molecular alteration in the nerve elements. This, which may 
 proceed from disturbances in the circulation, or may be 
 established independent of such, forms the groundwork from 
 which develops the structural change. The earlier treatment is 
 begun, the more may we expect that we have to do, in part at 
 any rate, merely with molecular changes, in other words the 
 greater is the prospect of bringing back things to the normal. 
 Practical experience teaches us every day that these are not 
 merely theoretical considerations. It is a deplorable error to 
 suppose that if our half measures, or expectant treatment as it 
 is called, should turn out to be useless, there will yet be time for 
 some more energetic course. The attitude of waiting observation, 
 which is so often assumed in the case of diseases of other organs 
 with so much advantage, is out of place here, and the short time 
 during which there is still a chance of recovery, or at least 
 improvement, may very easily be wasted away by adopting it. 
 On the other hand, we must not omit to observe that in the 
 choice and management of remedies in the initial stages of 
 chronic disease of the spinal cord it is absolutely necessary to 
 exercise the utmost care. For just as suitable treatment may 
 assist in quieting down the disturbances complained of, and may 
 pave the way for the recovery of the patient, treatment that is 
 unsuitable may have an opposite effect; it may favour and 
 hasten the transition of molecular into structural changes — in 
 other words, may lessen, if it does not destroy altogether, the 
 possibility of recovery. But while I lay stress on the necessity 
 of treating chronic spinal affections as early and as carefully as 
 possible, I would by no means encourage the notion that in old 
 and advanced cases any serious treatment is useless. Even in 
 those cases we are frequently able to put a stop to the con- 
 tinuance of the morbid process, and to bring about improvement ; 
 sometimes, though, of course, not often, we may have recovery in 
 the clinical sense of the word, that is, complete subsidence of all 
 the functional disorders.* These results are probably chiefly to 
 be referred to the circumstance that in the affected portions of 
 
 * This is, perhaps, commonest in cases of myelitis from compression, syphilis 
 of the cord, and anterior poliomyelitis. 
 
 A A 
 
354 LOWENFELD ON RECENT ADVANCES IN THE 
 
 the cord, in addition to those nervous elements that are markedly- 
 diseased, there are others where the process has not gone so far, 
 and where the alterations are in part still merely molecular. 
 The latter are capable of recovery. Bringing them back into 
 sound working order and strengthening those which are still 
 intact give us the conditions in which the functions of those 
 elements that are destroyed or are hopelessly diseased can be 
 taken over by other nervous structures. In this way, to a 
 greater or less extent, we gain compensation. Even advanced 
 cases then present a fruitful field for therapeutic endeavour ; but 
 while this is so, a comparison of the results obtained on the 
 whole with those which we get in cases of recent standing, makes 
 it perfectly clear that "principiis obsta" must be our guiding 
 principle in chronic spinal disease. 
 
 This is not the place for a description of the common features 
 in the treatment of all the chronic spinal diseases. The treat- 
 ment of chronic structural disease is in several important respects 
 different from that of the so-called functional affections. I shall 
 therefore in what follows first take up the treatment of the 
 former group, and afterwards add the necessary observations in 
 regard to the functional affections. 
 
 A. Treatment of Chronic Structural Disease ok the 
 
 Spinal Cord. 
 I. — Hydro-therapeutic and bahieo-therapeutic treatment. 
 
 Among the remedies at our command for chronic organic 
 disease of the spinal cord the external application of water in its 
 various forms plays a very prominent part. Within the last 
 fifteen years this method has unquestionably made a great 
 advance. No doubt our knowledge of the effects of medicinal 
 waters, and of the various ways of employing water, is still very 
 fragmentary, and the indications for the use of these remedies 
 correspondingly uncertain. A great deal of careful observation, 
 however, has been expended on the methods, and we are in 
 possession of certain outlines which practically are of great 
 importance. 
 
 The first question which naturally arises is, What are the 
 kinds of baths in general which are suitable in these diseases ? 
 Practical experience has taught us something of value in answer 
 to this. The baths that are useful are, in the first place, 
 
TREATMENT OF CHRONIC DISEASE OF THE SPINAL CORD. 355 
 
 hydropathy (the so-called water cure), then artificial and natural 
 brine baths, thermal brine baths, simple thermal baths, thermal 
 sulphur baths, chalybeate and carbonic acid baths, mud and peat 
 baths. On the other hand, sea-bathing, bathing in lakes or 
 rivers, vapour baths, and hot air baths are all found to be of 
 no benefit. 
 
 If then hydropathy or baths are to be employed, we have first 
 to take into account the temperature of the water, for this 
 determines the intensity of the thermic stimulant. This state- 
 ment may appear incorrect in view of the fact that in these 
 affections both the cold water treatment and hot baths are 
 employed with effect. But careful consideration makes it 
 evident that these therapeutic methods are not really so different 
 from one another as their names might seem to indicate. What 
 were formerly commonly known as cold water cure establish- 
 ments (Kaltwasserheilanstalten) have now, if they are conducted 
 on rational principles, dropped the "cold "in their name and 
 become simply water cure establishments (Wasserheilanstalten), 
 in other words, they have dropped any pretensions to using cold 
 water exclusively, and employ baths with high temperatures if a 
 particular case seems to require them. In chronic disease of the 
 cord, physicians in these establishments, as well as specialists 
 and clinical teachers, have invariably found that really cold bathe 
 and douches, whether with or without rubbing down, must be 
 avoided in cases of structural lesion. Tepid and cold baths, 
 that is, baths at a temperature of from 90° to 70° Pahr., are the 
 only ones which are employed with success. This is in harmony 
 with our experience of what takes place at hot spas. At all the 
 most important spas of this class in Germany, the general 
 conviction is that these cases are best treated, not with hot 
 baths properly so-called, but only with the water of the hot 
 spring after it has been cooled down somewhat. Even prepared 
 in this way, the patient is kept in the bath as short a time as 
 possible, and some simple hydropathic application, such as 
 pouring colder water down the back, is frequently added. 
 Thus it has come about that there is now no great difference 
 between the treatment by baths as it is practised in hydropathic 
 establishments (Wasserheilanstalten), and as it is carried on by 
 the various experienced physicians at the hot spas. And 
 practically the principles which regulate the treatment in hydro- 
 
356 LOWENFELD ON RECENT ADVANCES IN THE 
 
 pathic establishments, and at the indifferent thermal spas, are the 
 same as we see put in force in almost all the other watering 
 places in Germany to which patients, of this class habitually 
 resort. 
 
 A rapid glance through recent literature will sufficiently confirm 
 what has been stated in the text. Benedict" remarks: "The 
 chronic progressive forms of inflammation with proliferation of 
 the connective tissue require as a rule«hydrotherapeutic treatment. 
 The statement admits of few exceptions, that in chronic neuritis, 
 as we have it in such affections as locomotor ataxia and progressive 
 muscular atrophy, warm baths have no retarding influence on the 
 morbid process and do more harm than good." In cases of 
 myelitis, Rosenthal 20 allows of the use of warm baths of from 82° 
 to 86° Pahr., and also half-baths, when the temperature is from 
 75° to 71° at entering, and from 68° to 64° at leaving the bath. 
 Erb 21 recommends in chronic organic disease of the cord tepid or 
 cool baths, gentle hydropathy, dilute chalybeate baths, and care- 
 fully regulated thermal brine baths. Richter 22 says that in 
 locomotor ataxia and chronic myelitis the temperature should 
 range between 90° and 68°, and that anything higher or lower 
 than these figures should be looked upon as involving risk or danger. 
 In another and later communication 23 he gives as the lowest 
 allowable bath-temperatures in organic spinal disease, with half- 
 baths and sitz baths 73° to 71°, with washing-down and the wet 
 sheet 68° to 66°. Winternitz 24 also warns against the use of very 
 cold or very warm baths, or powerful mechanical stimuli, and 
 hardly uses anything else than half-baths of from 86° to 73°. 
 A. Erlenmeyer 25 in cases of locomotor ataxia allows only baths at 
 about 82°. Heller 26 (Teplitz) remarks that in locomotor ataxia 
 the treatment should regularly begin with baths at 86°, following 
 up with simple half-baths, and that in comparatively rare cases a 
 ' rise of temperature to 90° or 91J° at the utmost may be indicated. 
 Reumont 27 (Aix-la-Chapelle) finds that syphilitic cases of ataxia 
 in the advanced states, and when the constitution is undermined, 
 take best with baths at 89° to 91°, or at the utmost 93°. Voight 28 
 (Rehme-Oeynhausen) uses in chronic inflammatory affections of 
 the cord, brine baths and thermal brine baths at 88° to 81°. 
 Miiller 29 (Rehme-Oeynhausen) recommends the same kind of 
 baths at 88° to 84° in tabes. Stifler 30 (Stahlbad Steben) uses in 
 tabes chalybeate baths at 89°, and Oaspari 31 (Meinberg), the 
 aerated baths of Meinberg at 78° to 88°, and never for over 
 ten minutes. Grodel 32 (Nanheim) in tabes to begin with, uses 
 brine baths at 91°, never going below 82°, and in chronic myelitis 
 with increased reflexes, brine baths at 89° to 78°. 
 
 Among recent German authorities, Leyden in his text-book 
 on diseases of the spinal cord expresses himself unreservedly in 
 
TKEATMENT OF CHRONIC DISEASE OF THE SPINAL COED. OO/ 
 
 favour of warm baths. His views, however, since then may have 
 changed. Schuster 33 (Aix-la-Chapelle) also has advocated their 
 use. According to him and other physicians in Aix, baths at 96° 
 are for the most part those which have been found of use, while any- 
 thing colder has acted unfavourably. This hardly agrees with 
 Reumont's experience, and we must furthermore bear in mind 
 that the spinal cases which find their way to Aix are almost 
 exclusively syphilitic cases, and that among them there is no 
 doubt a large number in whom the constitution has been under- 
 mined, and who are. extremely susceptible to temperature. In 
 France, however, the use of warm baths, especially those at 
 Bourbonne, Aix-le-Bains, Balaruc, La Maloii, and Neris, finds a 
 good deal more support. The springs of La Malou, in the depart- 
 ment of l'Herault, which are alkaline and gaseous, and contain; a 
 little iron and arsenic, are used in baths at a temperature of 
 86° to 104° They enjoy a great reputation, and are recommended 
 in locomotor ataxia by physicians of the highest standing, such as 
 Charcot, Combal, and Grasset 34 . But even among these western 
 neighbours of ours a reaction seems preparing. Glax 35 at least 
 warns against the use of either too high or too low temperatures in 
 the hydrotherapeutics of tabes. But it must be noted before con- 
 cluding that although in the great majority of instances, according 
 to our present information, bathing at a temperature of 91° to 72° 
 will be found most suitable, this is not an absolute rule for all 
 cases of organic spinal disease. Among the cases that have 
 fallen under my own observation there have been several for 
 whom baths at 91° were found to be too cold, and to exercise an 
 injurious influence. I have never hesitated in such cases to raise 
 the temperature to 93° or 95°, and in regard to these temperatures, 
 as in regard to all the other factors coming into consideration in 
 bathing, the effect of the treatment on the patient must be 
 accepted as our guiding line in each individual case. 
 
 When, we have come to know that for the majority of cases of 
 chronic structural disease of the cord neither cold nor very 
 warm baths are permissible, we have unquestionably made a very 
 important step in advance. But the knowledge must have been 
 purchased at the expense of a large number of bad results. 
 Formerly the same spinal cases were treated in the hydropathic 
 establishments with cold baths, cold washing down, or cold 
 douching, and at the thermal spas with warm or even hot baths. 
 Many patients came to grief in both places, but the results of 
 the spa treatment were particularly bad. Erb, 36 for example, 
 mentions that in more than a half of the cases of chronic myelitis 
 in which he was able to ascertain the . result of a course of 
 
358 LOWENFELD ON RECENT ADVANCES IN THE 
 
 thermal waters, the patients became worse either during the 
 treatment or immediately after.* A change was certainly called 
 for, and this necessarily led to a reconciliation of the opposition 
 between these two methods. 
 
 One form of hydro-therapeutic treatment that is widely used 
 at present, and that can be warmly recommended, is in the 
 form of the so-called half-baths, given at a temperature of 
 86° Fahr. and under. Friction of the skin is used at the same 
 time with great advantage, as it facilitates reaction while the 
 patient is in the bath ; in certain circumstances massage of the 
 limbs may also be used. At the end of the bath I have often, 
 with great benefit, employed the pail-douche over the back, with 
 water 3° to 4° lower in temperature than that of the bath. It 
 must be poured on slowly from no great height, and the 
 quantity must be exactly prescribed — one or two pailfuls at the 
 outside. In using the wash-down the temperature of the water 
 may be one or two degrees lower than the lowest permissible 
 limit in the bath; yet care must be taken that too great energy 
 is not employed in this procedure. Wet packs must not be kept 
 on after the patient is sufficiently heated up, and must be 
 followed by a wash-down at the same temperature as the pack, 
 or by a half-bath of short duration. For the class of diseases we 
 are now discussing the cold douche is inadmissible. 
 
 We have become almost all over much more cautious lately in 
 regard to the duration of baths, as well as in regard to their 
 temperature. Here again bad results have played the school- 
 master. Winternitz recommends for half-baths at 86° and under 
 a duration of 6 to 10 minutes. In the last year or two I have 
 been accustomed to order half-baths to be of never more than 
 6 minutes' duration — on an average, about 5. It is a good plan 
 to make the duration short in proportion as the temperature is 
 low. The wash-down should only take up a very short time, 
 half, one, or one and a half minutes. At the ''indifferent" 
 thermal spas also they have become converted to the use of baths 
 of very brief duration. V. Eenz" (Wildbad) speaks of a 
 
 * Among 22 eases of chronic myelitis treated by hot ba(;hs that Erb had under 
 observation, there were 12 in whom this treatment (at Wildbad, Teplitz, and 
 elsewhere) proved distinctly hurtful, and 7 in whom it had no effect at all. 
 Only 3 cases improved, and in 2 of these the water was cooled down for 
 the bath, the patients were kept in for only a short time, and only a limited 
 number of baths were given. Facta loqwwntur. 
 
TREATMENT OF CHRONIC DISEASE OF THE SPINAL CORD. 359 
 
 duration of 5 to 10 minutes. Heller (Teplitz) applies in tabes, 
 to begin with, baths of 5 to 8 minutes, and only rises gradually 
 to 10 to 12 minutes. Voigt (Rehme-Oeynhausen) prescribes 
 simple and thermal brine baths of 5 to 15 minutes. Grodel 
 (Nauheim), in tabes, brine baths of 10 minutes (rarely 15). 
 I myself, up to the present time, have used artificial brine baths 
 of never more than 10 minutes' duration. 
 
 I may here remark, by the way, that we require to pay some 
 attention to the proportion which the water in this latter kind of 
 bath bears to the salt or brine. A brine bath, it is well known, 
 should properly speaking contain at least 2 per cent, of salt 
 (many authorities say 3 per cent.) ; 60 gallons of water, which 
 would about fill an ordinary tub, would require in this way 12 lbs. 
 of salt. If any one is unwilling to begin with this proportion, it 
 is at any rate advisable to rise to it in the course of time. 
 
 When we come to consider the special indications for all these 
 different forms of bath, we must acknowledge that there is still 
 a good deal of obscurity here. But the choice of a bath, or the 
 choice of any particular kind of bath treatment, does not depend 
 simply on the form of disease from which the patient is suffering. 
 Other considerations that must be taken account of are : the 
 duration of the disease, the prominence of particular symptoms, 
 the constitution and general state of nutrition, the complications 
 that may be present, the season of the year, the place from which 
 the patient comes, and the patient's pecuniary circumstances. It 
 is certain, it appears to me, that, at any rate in a large number 
 of the cases that are capable of improvement, the end may be 
 attained in several ways, and not merely by one particular form 
 of bath treatment. The cold water cure, at any rate, admits of 
 very wide application. There is, according to my experience, 
 no form of spinal disease for which it is not suited. The number 
 of modifications which the various steps in the method admit of, 
 allow of its being adapted to a very great variety of affections. 
 And one great merit it has, is that it is applicable all the year 
 round, whereas the usefulness of most of the spas is limited to 
 one particular season. There are, however, often enough 
 individuals who are unable to bear even the very mildest parts 
 of the ' treatment, and who would come to harm if it were 
 persisted with. This, is most commonly the case with patients 
 who suffer from intense feelings of cold in the extremities, and 
 
860 LOWENFELD ON RECENT ADVANCES IN THE 
 
 who dress in the hottest summer months in flannel and felt 
 shoes to keep themselves properly warm ; also in wasted and 
 anaemic individuals, and in those who have been spoiled by too 
 much tender care. For these classes thermal baths and weak 
 brine baths are particularly suitable. The warmer thermal 
 baths are said to do especially good service in the various forms 
 of meningitis where the substance of the cord is not much 
 affected. But further trustworthy observations are desirable on 
 this point. The stronger brine baths and the thermal brine 
 baths are indicated in scrofulous constitutions, and the spinal 
 affections associated with diseases of the bones, and in the 
 exudative forms of meningitis, where we may look for absorption 
 of the exudation from any stimulus given to the tissue-metabolism. 
 The thermal brine baths (especially those of Rehme-Oeynhausen) 
 go very well along with hydropathy in various other spinal 
 affections, especially sclerosis of the posterior columns. Sulphur 
 baths do very well in the lesions which follow syphilis when 
 associated with other distinct evidences of the continuance of the 
 infection. Nobody now says that these baths have any specific 
 effect on syphilis; even the physicians themselves (Reumont, 
 &c.) at sulphur spas merely rely on their beneficial influence on 
 the skin as a valuable aid to an anti-syphilitic course. This 
 influence, however, undoubtedly belongs to other kinds of baths 
 also ; the fact that the physicians at these spas insist on particular 
 routine courses in their treatment of syphilis appears to me to 
 be much more important. Chalybeate baths are indicated in 
 anaemic and reduced conditions, but only when the morbid 
 process is rather a slow-going one, and in patients who are not 
 in a nervous condition. For patients who are, or who show 
 marked evidence of spinal irritation, the stimulating effect of the 
 carbonic acid in the chalybeate waters renders their use un- 
 desirable. We have at present no very precise indications for 
 the use of the carbonic acid waters in baths, and the same may 
 be said of mud and peat baths. 
 
 A number of other points have to be taken into consideration 
 in coming to a conclusion about a course of baths. Patients 
 with disease of the cord do not bear the exertions of a long 
 journey very well, and this is especially the case if the disease is 
 advanced. They should not therefore be sent to spas far from 
 their own homes, or the journey to which is difficult. Little 
 
TREATMENT OF CHKONIC DISEASE OF THE SPINAL COKD. 361 
 
 good is attained with the usual four weeks' residence and 18 to 
 20 baths, and the patients ought to make up their minds to a 
 stay of from two to three months, or even longer in some cases. 
 It is advisable to make this quite clear to begin with. When a 
 course of baths is indicated at all, the time of year should not 
 be suffered to stand in the way, as, at any rate, the water cure 
 and brine baths (the most important forms of treatment in spinal 
 cases) can always be put into operation. 
 
 We must say something about the local thermic applications 
 to the spinal column. Moist warmth in the form of fomentations 
 and poultices to the back is scarcely ever made use of now. I 
 certainly think the former could hardly be expected to exercise 
 much effect on the lesion under discussion ; hot poultices, hot 
 sand-bags, or hot water in Chapman's bags, offer hopes of better 
 results. According to Chapman, 38 warmth applied to the spinal 
 column produces hypereemia in the affected portion of the cord, 
 and at the same time removes the congestion and feeling of heat 
 from the peripheral parts which derive their nervous supply 
 from the portion in question. On the other hand, he holds that 
 cold lowers the circulation in the cord, and after some time 
 raises the temperature at the periphery. I must acknowledge 
 that I have not been able to verify this theory in my own 
 experience, nor am I convinced from published cases that the 
 successes of the method are arrived at in the way Chapman 
 thinks. But I have certainly seen benefit in a number of cases 
 from the application of cold by means of Chapman's bags. 
 There have been, particularly, affections of the cord where both 
 the meninges and the vertebrae have been involved, as in tumour 
 of the cord and myelo-meningitis. I have seen good also in 
 some cases of lightning pains in locomotor ataxia.* 
 
 The special advantage, apart from the ease of application, 
 which these bags offer is that they allow of the careful regulation 
 of the thermic effects; in this way the temperature which 
 exactly suits the patient can be obtained. 
 
 1 II. — Electro-therapeutics. 
 The most distinct step in advance in the treatment of diseases 
 of the spinal cord within the past twenty or thirty years was 
 achieved by the introduction of a rational system of electrical 
 
 * Instead of Chapman's bags, Leiter's coils may be used. 
 
362 LOWENFELD ON KECENT ADVANCES IN THE 
 
 therapeutics. Nothing else in Our whole armamentarium has 
 greateT successes to show, and no other remedy used in these 
 diseases has been so generally recognised in all civilised 
 countries.* 
 
 Of the forms of electricity at present used, the constant 
 current is undoubtedly the most valuable. With regard to the 
 method of its application, there is at present a distinct prepon- 
 derance of opinion that there should be a direct influence on the 
 diseased portion of the cord, and that the current should traverse 
 this as completely and equally as possible. 
 
 To get this done without using very strong and painful 
 currents, we must seek the help of all the physical appliances 
 adapted to facilitate the entrance of the current into the spinal 
 canal. We place one electrode over the spine at the affected 
 region of the cord, and the other as nearly as possible at the 
 same level on the anterior surface of the body, so that the 
 greatest density of the current passes through the diseased 
 portion ; or we can place both electrodes over the spine at some 
 distance from one another, so that a large portion of the current 
 must necessarily pass through the spinal canal. Further, we 
 use on well-known principles large flat electrodes, and moistening 
 these well with warm water apply them with as firm and equal a 
 pressure as possible. ' According to my experience the most 
 suitable for the majority of cases are rectangular plates of 50 
 square centimetres (5 by 10). In individual cases, now and then 
 larger plates may be required; W. Miiller recommends 70 
 square centimetres, and v. Ziemssen's giant plates are 100 
 square centimetres and over. These exceptional sizes are used 
 particularly in cases of circumscribed disease, and where the 
 body is well nourished, but as a rule they offer no particular 
 advantages. In the case of spare individuals especially, the 
 difficulty of applying them exactly makes the advantage of their 
 larger size often a very imaginary one. Seeligmiiller's spinal 
 electrode again appears to me of even less value on account of 
 its surface being too small. In the case of children of course 
 smaller plates are used ; 3 by 6 cm. is a good size. 
 
 At present, of the two methods mentioned above, the former 
 with the current passing horizontally is the favourite in the case 
 
 * On the other hand, the nse of balneo-therapeutics, which plays so large apart 
 among us in Germany, is in England almost a terra incognita. 
 
TREATMENT OF CHRONIC DISEASE OF THE SPINAL CORD. 863 
 
 of circumscribed lesions, while the latter with the current passing 
 longitudinally is chiefly used in the so-called systemic diseases, 
 in which the lesion is distributed in the longitudinal direction of 
 the cord. One pole is applied to the neck and the other to the 
 lumbar spine, and while the one is stationary the other is moved 
 slowly along and brought nearer the first. But even in circum- 
 scribed lesions it is advantageous to make use sometimes of the 
 longitudinal current, with one pole moving along the neck, and 
 the other stationary at the seat of disease; also a horizontal 
 current, or one that is approximately horizontal, may be used in 
 longitudinal lesions, one pole being stationary on the front of the 
 body and the other moved along the spine. The latter pole is 
 moved about the breadth of the electrode at a time, and is kept 
 at each spot for from twenty to forty seconds. The direction of 
 the current with this method is, according to many authorities 
 who speak with great confidence on the subject, a matter of no 
 consequence ; others speak with less assurance, and acknowledge 
 that in certain respects it might not be quite a matter of 
 indifference where the positive pole was applied, and where 
 the negative. It would take me too far if I were to go fully 
 into the whole matter, and I must content myself with stating 
 shortly my own views, which are based on experimental investi- 
 gation and clinical study. 
 
 The statement that the direction ' of the current is of no 
 consequence if meant to be of general application is correct 
 neither for the horizontal nor for the longitudinal current, though 
 it must be acknowledged that in many cases it is a matter of in- 
 difference in treatment. When the current is used longitudinally 
 with one electrode applied to the neck, the ascending current 
 should be first tried if the case is recent, and there is probably 
 hypereemia of the cord; that is, the negative pole should be 
 applied to the neck, and the positive pole below. In older cases, 
 and especially if there are no symptoms of irritation of the roots, 
 the descending current. With the horizontal current the anode 
 alone is to be applied to the back, especially if there is anything 
 pointing to a condition of irritation of the posterior roots, such 
 as pain or girdle-constriction.* 
 
 * Compare in this connection my " Investigations in the Electro-therapeutics o 
 the Spinal Cord," Munich, 3. A. Finsterlein, 1883, pp. 7, 28, and particularly 
 60—66. 
 
364 LOWENFELD ON REGENT ADVANCES IN THE 
 
 In many cases the galvanic current has been found very 
 useful in the treatment of painful or tender spots over the spine. 
 Although such spots are not very common, yet where they do 
 exist they require special looking after. The method employed 
 is to apply the anode stationary over the part affected. Some 
 observers endeavour to attain an effect on the cervical sympathetic 
 along with the galvanisation of the cord. A method strongly 
 recommended by M. Meyer, of Berlin, and Erb for this purpose 
 is to apply the kathode stationary at the angle of the lower jaw, 
 while the anode is gradually moved down on the opposite side of 
 the vertebral column, close beside the spinous processes. This 
 method has one disadvantage, that giddiness and stupor are 
 easily caused unless very gentle currents are made use of. 
 
 A combination of central with peripheral galvanisation has 
 been very much employed in paralytic and anassthetic conditions 
 in the extremities. The one pole is applied to the spinal 
 column, the other over a plexus, nerve trunk, muscle, or group 
 of muscles. I myself prefer in general to use peripheral and 
 central galvanisation separately ; at any rate, in making use of 
 the nerve currents through the spinal cord it is reasonable 
 enough to employ the latter by itself. If there are disorders of 
 the bladder, rectum, or sexual organs, these parts, as far as 
 possible, should be included in the circuit. In paralysis of the 
 bladder the one pole is placed over the lumbar spine, the other 
 alternately over the symphysis and perinseum, or separately over 
 the one or the other, according as we wish to affect principallv 
 the detrusor or the sphincter. Passing the current from the 
 lumbar region to the perinasum is a method which may also be 
 employed in paralysis of the sphincter ani or affection of the 
 sexual powers. Any internal electrical treatment of the bladder 
 or rectum is generally unnecessary. 
 
 In applying galvanic electricity in these various ways we must 
 take account not only of the strength of the current, but of the 
 transverse section of the electrodes, that is, of the current- 
 density. For the expression of this, C. W. Miiller 39 has pro- 
 posed the formula — 
 
 D (current-density)^ 1 ^ T^ !? milliam P &reS >- 
 y (section of electrode in square cm.). 
 
 Erb 40 was the first to lay stress on the necessity of paying 
 
TREATMENT OF CHRONIC DISEASE OF THE SPINAL CORD. 365 
 
 attention to the current-density as well as to the current 
 strength ; but this way of looking at the subject has only been 
 generally recognised during the last three years, and since the 
 publication of Miiller's investigations. If we compare the 
 current-densities used now-a-days in the treatment of spinal 
 disease with those which, so far as can be ascertained, were 
 customary in the first years of galvano-therapy, we find all over 
 a tendency to the use of much weaker currents. Nevertheless 
 there are still very great differences between the views of various 
 authorities. Lewandowsky 41 * allows in the direct treatment of 
 the cord a current-density of from 45 to 2V, at the utmost tV- 
 Miiller 42 with his method of passing the current horizontally and 
 shifting the electrode along the spine as has been described, 
 allows generally about tV — to put it more exactly -fs ; in cir- 
 cumscribed lesions he employs on an average -gj, but may go at 
 times as low as sV or less. Erlenmeyer 43 does not go beyond tst- 
 On the other hand, Remak 44 holds that it is not at any rate 
 indispensable to have currents so weak as these in order to get 
 good results ; he comes to this conclusion because " the early 
 successes which insured tlie adoption of the method were, so far 
 as we can estimate now the strength of the currents used by E. 
 Remak and his immediate successors, attained with very much 
 stronger current-densities " than those quoted above. And 
 Bernhardt 45 recommends in tabes current-densities of % 
 
 ou-oj square cui.t 
 
 while De Watteville, 46 in chronic myelitis, uses 20 — 40 elements 
 which certainly correspond to much greater densities than those 
 employed by C. W. Miiller and Lewandowsky. Erb 47 advises the 
 use of weak currents in the direct treatment of the cord, at the 
 same time speaking of densities of ii^liou«|Jurecm : as " sufficient." 
 In utilising actual experience for the purpose of estimating 
 the current densities we are to employ, there are two or three 
 conditions which I have long thought must be observed. First, 
 the cases on which we are to found must have been treated by 
 electricity alone. Second, both the immediate effect of single 
 sittings on the condition of the patient, and the ultimate general 
 result, must allow of no doubt of the beneficial results of the 
 
 * I must not omit here to notice Lewandowsky' s excellent work on " Electro- 
 diagnosis and Electro-therapeutics," which was published last year. His careful 
 treatment of the matter from the side of elementary physios is specially adipted 
 to the needs of the physician, and makes the book a capital introduction to the 
 subject. 
 
366 LOWENFELD ON RECENT ADVANCES IN THE 
 
 treatment. Third, caeteris paribus, old stationary cases give a 
 surer basis for an estimate of effects than recent cases. 
 
 With a careful regard for these conditions, my own experience 
 allows me to say that in organic spinal affections current- 
 densities of ^ should be employed ; a density of 6 i BQU a're cm. 
 is about the average. It is well always, however, to begin 
 with lower densities than these, and to rise gradually ; if there 
 are well-marked symptoms of irritation present we should keep 
 by the lower densities.* 
 
 The duration of the sitting also in recent years has been very 
 generally shortened. While formerly it extended frequently to 
 ten or even fifteen minutes, there are few physicians now who 
 let it last beyond five minutes, and many will not go beyond 
 three. I think that, as fair averages, from four to five minutes 
 for the whole cord, and one and a half to three minutes for any 
 portion, will be found satisfactory ; at the same time these 
 figures must only be worked up to gradually. 
 
 The necessity of being provided with a galvanometer does not 
 now-a-days stand in need of argument. We get no trustworthy 
 standard to go by, or almost none, from the patient's sensations. 
 Measuring the current by the number of elements used is just 
 of as little value, because the electrical conductivity over the 
 back varies very much, not only in different individuals, but also 
 in different parts of the back in the same individual ; besides, the 
 activity of most of the elements usually employed is anything 
 but a constant quantity. 
 
 The induced current also is extensively employed in these 
 spinal diseases. It is much less suitable for the direct treat- 
 ment of the cord than the continued current, and it is recom- 
 
 * There is still considerable difference of opinion about the current-densities 
 which may be used in disease of the cord. I should like to draw attention to the 
 fact which has been brought out by Stintzing's™ investigations, that the current- 
 density necessary to obtain a certain effect at some distance from the surface of 
 the body varies inversely as the transverse section of the electrode. The 
 current-density ifo is therefore not the same in its effects on the spinal cord as 
 j'g, as C. W. Milller and Lewandowsky assume ; it is greater than the latter, 
 though it does not admit of precise valuation. Nor can we assume that with a 
 given current-density, say -^, the current-density in the spinal cord will always 
 be the same. The vertebras and soft parts surrounding them, like the skin, may 
 be different in different persons in respect of electrical conductivity, and in one 
 case a current of ^ may give the same current-density in the cord as is given in 
 another case by a current of ^y. It is useful to keep ourselves familiar with 
 these faots in order not to fall into any great delusions about the precision with 
 which we measure our currents. 
 
TREATMENT OF CHRONIC DISEASE OF THE SPINAL CORD. 367 
 
 mended that when used it should be alternated with galvanic 
 currents of moderate strength. But its peripheral application 
 is a matter of greater importance, and is much commoner. The 
 faradisation of nerves and muscles in spinal paralysis of the 
 extremities is a method much used to counteract the nutritional 
 disorders in the neuro-muscular apparatus brought on by want 
 of exercise, or by the absence of trophic currents from the 
 centres. This procedure is often followed by very remarkable 
 success. It is not necessary to believe that we have here to do 
 merely with peripheral and local effects, and that the results in 
 question are produced by such. The unavoidable irritation of 
 the skin (perhaps also the stimulation of the sensory muscle 
 nerves) acts reflexly on the cord ; in this way it is possible, as I 
 have already pointed out in my investigations on the electro- 
 therapeutics of the spinal cord, that faradisation of one leg 
 might increase the motility of the other. The application of 
 the faradic current to nerves and muscles requires therefore 
 some caution ; with too strong currents and too long sittings 
 we may easily over-stimulate and thus injure the cord. 
 
 But while the reflex effect in this application of the current 
 is accessory and unimportant, there is another method used in 
 which we make it our only, or at any rate our chief, object to 
 gain this effect : I mean the faradic stroking of the skin, .parti- 
 cularly according to Rumpf s plan. The positive pole is placed 
 over the sternum, while the wire brush, representing the negative 
 pole, is moved up and down the back and the affected extremities, 
 touching all the parts several times, and producing distinct 
 redness of the skin. This is done twice over, beginning with 
 the back each time, and such a strength of current chosen that 
 the feeling is midway between mere sensation and pain. The 
 whole sitting should last about ten or twelve minutes. This 
 treatment in the hands of Rumpf 49 (Bonn) has given very good 
 results in a number of cases, especially in locomotor ataxia, 
 where he has generally used it along with antisyphilitic remedies. 
 Eisenlohr 50 also has had good results. I have been like Eemak 61 , 
 and have been less fortunate with it; in the hands even of 
 Rumpf himself it has miscarried sometimes.* 
 
 * It must be noted that if the method is to be carried out as Bumpf would have 
 it, and considerable redness produced in the skin, it cannot always be done 
 without causing pain, and on that account it does not admit of indiscriminate 
 application to every patient. 
 
368 LoWENFELD ON RECENT ADVANCES IN THE 
 
 The method seems to me generally more fitted to be an 
 adjunct to the galvanic treatment, and I found it a valuable 
 help when locally applied for anaesthesia of the skin and mucous 
 membranes, paresis of the bladder and rectum, prolapsus ani, 
 lightning pains, &c. For the last-named, and in anaesthesia of 
 the skin, the pencil is applied over the region of distribution of 
 the disturbance, but in anaesthesia of the rectal or vaginal 
 mucous membrane, or in paralysis of the bladder or rectum, it 
 is placed about the anus or perinseum.* 
 
 The value of Eumpf s method deserves to be very carefully 
 weighed, especially in locomotor ataxia. We require a more 
 extensive experience, however, in order to recognise in what 
 class of cases the method is particularly indicated, that is, in 
 what kind of cases it is of more value than the treatment with 
 the constant current. 
 
 Electric baths, both galvanic and faradic, have been recom- 
 mended in the last few years for a great variety of nervous 
 affections, but in diseases of the cord I have seen little or no 
 benefit follow from their use. 
 
 I must mention, lastly, statical electricity, which has recently 
 been again brought forward. It was tried in spinal diseases 
 twenty years ago by Fieber, 52 and Schwanda, 63 and was subse- 
 quently strongly advocated by Clemens 54 (Frankfurt). Lately, 
 Morton 55 , of New York, claims to have gained a brilliant result 
 by its means in a case of locomotor ataxia. But my own ex- 
 perience of it has been so very unsatisfactory, that I have given 
 it up altogether in organic spinal affections. I readily allow, 
 however, that we are not yet in a position to pass a decisive and 
 final judgment on its therapeutic value in these diseases. 
 
 The total duration of a course of electrical treatment is de- 
 pendent on several circumstances. The chief of these are the 
 amount of perceptible success, the nature of the disease, and 
 the possibility of the application of other methods of treatment. 
 There are but few cases in which weeks will be sufficient, 
 generally months will be required, and frequently enough even 
 
 * S. Lowenfeld, Investigation on the Electro-therapeutics of the Spinal Cord. 
 Part VII. : On the Therapeutic Effect of the Faradic 'Brush in Spinal Affections. 
 I must direct attention here to the necessity of carefully disinfecting the brush- 
 electrode after each use of it on account of the danger of communicating 
 syphilis by its means. I am in the habit myself of using the spirit lamp for this 
 purpose. 
 
TREATMENT OF CHRONIC DISEASE OF THE SPINAL COED. 369 
 
 longer periods. In some affections, especially in tabes, a course 
 of electricity should be repeated every year for some years. 
 
 Electrical treatment may very suitably be used along with 
 baths, and the other remedies of which we have yet to speak 
 (drugs, massage, &c). 
 
 Erb 56 makes a very just remark when he says that " it is well 
 not to take the matter of electrical treatment too lightly." Of 
 course here, just as in other departments, we must not expect 
 every physician to be an expert, and the mere possession of 
 more or less elaborate apparatus does not make him one. The 
 subject of diseases of the spinal cord is surrounded with difficul- 
 ties, and whoever wishes to gain success in it with electricity, 
 and to avoid doing harm, must be at least tolerably well 
 acquainted with the handling of all the usual apparatus, and 
 with their' effects on the human body. Cases of spinal disease 
 are, as a rule, not well adapted for apprentice efforts in electro- 
 therapeutics. 
 
 III. — Treatment by Derivatives. 
 
 Until the last fifteen or twenty years the treatment of chronic 
 affections of the cord by derivatives was universally one of the 
 principal methods adopted. We can recognise very weir the 
 extent to which it was trusted from a remark made by Marshall 
 Hall, 87 to whom the pathology of the nervous system owes so 
 much. For inflammation in the spinal canal he recommends in 
 acute cases cupping, and in chronic cases setons and issues as 
 the most effective treatment they possessed. In Germany this 
 derivative method has been forced quite into the background by 
 the advances of hydro-therapeutics and electricity, but in France 
 and England it still finds application, and apparently even 
 more extensively than ever; one eminent French physician, 
 Dujardin-Beaumetz, is even yet inclined to give it the very first 
 place in the therapeutics of these diseases.* 
 
 The general theory of counter-irritation is that it relieves the 
 congestion around the spinal cord, and in this way forms the 
 starting-point for, and facilitates the absorption of exudation. 
 This is only partially, however, in harmony with actual facts. 
 
 * Dujardin-Beaumetz. Lectures on Clinical Therapeutics, Vol. III., Part I. : 
 Treatment of Diseases of the Nervous System, Paris, 1883, p. 282 .... 
 the derivative method which clearly takes the first place in the treatment of 
 diseases of the cord. 
 
 B B 
 
370 LdWENFELD ON RECENT ADVANCES IN THE 
 
 There are, I think, two kinds of effects produced by the 
 application of derivatives to the back. 
 
 1. A direct effect on the nervous elements in the cord from 
 the stimulation of the nerves of the skin or subcutaneous 
 cellular tissue at the spot at which the counter-irritant is 
 applied. According to the locality and the particular condition 
 of the spinal elements affected this stimulation of the cells and 
 fibres of the cord may either produce or may inhibit reflexes, or 
 may modify to a certain extent the irritability of the cord 
 without this being indicated in any particular way.* Accordingly 
 we have diminution or disappearance of any symptoms of motor 
 or sensory irritation, such as spasm, contracture, pain, pares- 
 thesias, or increased reflexes. On the other hand, however, the 
 irritability of some of the nerve elements which have been 
 suffering from damage to their nutrition may be increased and 
 inhibitions removed. 
 
 2. An effect on the circulation and nutrition in the spinal 
 canal. This may happen in two ways : (a) Through a reflex 
 influence on the vascular nerves of the cord, transmitted from 
 the cutaneous nerves or nerves of the subcutaneous cellular 
 tissue, affected by the counter-irritants. The possibility of this 
 has been proved by Brown-Sequard's 59 and my own 60 experimental 
 observations. (6) Through changes produced in the nutrition 
 of the soft parts over the spine. The nutrition of those parts 
 has intimate mutual relations with that of the spinal cord, as 
 the blood vessels and lymphatics supplying both the soft parts 
 covering the vertebrae, and the vertebrae themselves, have 
 numerous communications with the vessels and lymphatics of 
 the cord and membranes. Any morbid processes, therefore, 
 which produce a considerable change in the nutrition and blood- 
 supply of the surrounding parts must exercise a certain influence 
 on the nutrition of the spinal membrane and the cord itself. 
 
 The ordinary derivatives may be divided into weaker kinds, 
 such as dry-cups, sinapisms, painting with iodine, and blisters ; 
 
 * The possibility of " latent " effects of this kind has been proved by the 
 observations of S. Mayer 58 (Prague). He noticed in the rabbit that, after 
 division of the sciatic nerve, indications of motor irritation in the spinal cord 
 presented themselves under certain conditions (exclusive of central influence) 
 which were not observed in animals under these conditions in whom the sciatic 
 had not been divided. The section of the sciatic must therefore have produced 
 some permanent change in the irritability of the cord, though this only came to 
 light in those certain circumstances. 
 
TREATMENT OF CHRONIC DISEASE OF THE SPINAL CORD. 371 
 
 and stronger, such as caustic pastes, moxas,* and the actual 
 cautery. Midway between these two classes are setons and 
 issues, and the repeated application of faradic electricity with 
 strong currents. Experience teaches that in the class of cases 
 we are at present discussing, not much is to be looked for from 
 the milder derivatives; they may be used at times, however, as 
 aids to other methods of treatment, or applied for particular 
 symptoms, especially pain in the back. Setons and issues have 
 fallen very much into discredit in Germany. Yet Dujardin- 
 Beaumetz 01 considers the seton to be one of the most powerful 
 revulsives, and holds that it is particularly indicated in lesions 
 of the brain and upper part of the cord. Stroking the back 
 with strong faradic currents is a very powerful cutaneous 
 stimulant, and can be applied as often as we like, as it produces 
 merely trifling and transitory changes in the skin. But whether 
 this method by itself is capable of producing permanent effect 
 seems to me to need proving, and while it is a very painful 
 proceeding, we can also hardly look upon it as under all 
 circumstances quite harmless. The best counter-irritants are 
 the stronger ones, especially the actual cautery, the beneficial 
 effects of which in some spinal affections are not to be denied. 
 Its application, however, is not without various difficulties and 
 even dangers. It is well known that spinal cases are very 
 subject to trophic disorders of the skin, and that wounds in 
 such cases heal with some difficulty. Especially where there is 
 anaesthesia, there is very great danger that any destruction of 
 tissue, whether intentionally produced for therapeutic reasons 
 or accidental, may extend further. Moreover, in the lower 
 parts of the back even very slight irritation of the skin may 
 lead to the so justly dreaded bed-sores. Finally, there may be 
 considerable pain caused, and the general well-being interfered 
 with on that account ; there may be disturbance of sleep in 
 consequence of the difficulty of lying on the back ; and in 
 certain circumstances there may be loss of strength from pro- 
 fuse suppuration. For all those reasons pustulants and caustic 
 pastes, and even the actual cautery, have been falling recently 
 more and more into disuse, and physicians are contenting them- 
 selves with employing Pacquelin's thermo-cautery to produce the 
 
 * The moia is a form of cautery which has Ion passed out of use in this 
 country. The most usual moxa was a pellet of cotton wool soaked in nitre. — Tr 
 
372 LOWENFELD ON RECENT ADVANCES IN THE 
 
 so-called pointes defeu. Dujardin-Beaumetz 62 would have these 
 jpointes de feu arranged in parallel rows on both sides of the 
 spine, and renewed every eight days. Ball 63 thinks it sufficient 
 to touch the skin very lightly at a few points with the actual 
 cautery, but he finds that this requires to be repeated every two 
 or three days. 
 
 . : Among the diseases in which counter-irritation is found suit- 
 able, the first place is taken by those aifections which originate 
 frpm disease of the vertebrse. Charcot himself reports five or 
 six cases of Pott's disease in which application of the cautery 
 on both sides of the spinous processes at bhe seat of the deformity 
 removed paralytic symptoms which had persisted for a long 
 time. Althaus 6 * recently adopted this plan in a case of 
 paraplegia from caries of the vertebrae after other remedies had 
 failed; the case completely recovered. Next in point of 
 suitability for this line of treatment come the various forms 
 of meningitis, especially chronic pachymeningitis. Last of 
 all, simple chronic transverse myelitis. Benedict 65 has recom- 
 mended pointes de feu in the lightning pains of locomotor ataxia, 
 applying them to the side of the spine about the level of origin 
 of the affected nerve roots. As we now possess some very 
 effective drugs, however, for these pains, there is not much 
 opportunity for making use of Benedict's suggestion. 
 
 IV. — Treatment by Drugs. 
 
 We cannot on the whole say very much at the present day in 
 favour of the treatment of these diseases by drugs, and yet we 
 cannot well do without them. Only a very small proportion 
 has survived of all the drugs formerly used. Among those 
 which have answered the tests of experience the preparation of 
 silver, mercury, and iodine are distinctly the most important. 
 At present, for organic lesions of non-syphilitic origin, nitrate 
 of silver enjoys the best reputation. Wunderlich, 66 as is well 
 known, was the first to recommend it, and, in addition to him, 
 a host of eminent observers have reported favourably of its 
 effects, especially when used in posterior sclerosis ; the latter 
 disease even at present forms the chief field for its use. The 
 dose varies in different authors, from a seventh of a grain to 
 half a grain three times a day. I generally order a seventh of 
 a grain three times a day in the form of pill to begin with, and 
 
TREATMENT OF CHRONIC DISEASE OF THE SPINAL CORD. 373 
 
 after some weeks gradually increase the dose to about a third 
 of a grain.* Friedreich has drawn attention to one danger 
 attending the use of silver — the possible production of nephritis. 
 This danger on the whole, however, appears to me to be a far 
 from imminent one, and can easily be avoided with a little 
 reasonable caution. A very singular thing about nitrate of 
 silver is the unequalness of its action : in some cases it exercises 
 a most distinct influence for the better on the morbid process', 
 while in others, and these the majority of the cases, it does no 
 good whatever. Some authors, therefore, have proposed lately 
 to substitute some other silver salts for the nitrate. Thus 
 Hamilton 68 of New York recommends the tribasic phosphate of 
 silver as better than the nitrate in posterior sclerosis. He give's 
 from three-tenths of a grain to three-fifths of a grain in the form 
 of pill for several months. Bulenburg 69 thinks that the failure 
 of silver in many cases arises from the fact that it arrives in 
 the bowels in a reduced condition, and does not circulate 
 as a soluble chemically active compound. He has attempted 
 accordingly to replace the silver nitrate taken through the 
 mouth by the hypodermic injection of the soluble salts, the 
 phosphate of silver, and particularly the hyposulphite of soda 
 and silver. Rosenthal 70 (Vienna) however was dissatisfied with 
 this, as these salts are uncommonly easily decomposed, and besides 
 produce local irritation. On the other hand he had noteworthy 
 results with the subcutaneous injection of a solution of acetate 
 of silver, using 5 to 8 minims of a - 5 per cent, solution. He 
 treated five cases in this way; in two the ataxic symptoms 
 improved very much, two were unaffected one way or another, 
 and in the case of the fifth, indurations made their appearance 
 in the skin, and along with these an increase in the lightning 
 pains. The great susceptibility of the skin to hypodermic 
 injections in cases of ataxia has always prevented me from 
 heartily adopting these methods. 
 
 Besides nitrate of silver, iodide of potash is the drug most 
 used at present. The special indications for its employment, 
 however, are rather uncertain. It seems to do good service, 
 
 * Bokai 6 " gives a very good method of preparing pills of nitrate of silver. In 
 order to avoid the reduction of the salt he uses only kaolin in making them, with 
 the addition of a few drops of water, and prescribes at a time only the number' 
 required for a day or two. The patient must take the pills fasting to avoid the 
 action of the hydrochloric acid of the stomach, and must drink milk afterwards. 
 
874 LoWENFELD ON RECENT ADVANCES IN THE 
 
 especially where the meninges are affected both in uncompli- 
 cated chronic meningitis and in meningo-myelitis. But it 
 is in lesions of the cord of syphilitic origin that most is 
 expected of it, and undoubtedly a large number of cases of this 
 kind have benefited from iodide of potash. Yet, in my ex- 
 perience, it is a very untrustworthy remedy in severe cases of 
 syphilis of the cord if used alone, and mercury, especially in the 
 form of inunction, is much more effective. Many physicians 
 give the iodide along with inunction ; others recommend alter- 
 nating courses of inunction and iodide. My own observations, 
 however, lead me to believe the former to be the more effective. 
 The important share which is now-a-days allotted by many 
 observers to syphilis in the causation of locomotor ataxia made 
 it inevitable that the attempt would be often made to arrest 
 this disease by specific treatment. The time has not yet 
 arrived when we can form a decisive opinion on the value of 
 this method. A large number of authorities have reported 
 favourably, among others, Rumpf 71 particularly, then Fournier, 72 
 Erb, 73 Eisenlohr, 74 Reumont, 75 Benedict, 76 Gowers, 77 Pribram, 78 
 Schulz, 79 Berger, 80 Hammond, 81 and Striimpell 82 . Only a few 
 cases, however, of complete recovery have been recorded (Rumpf, 
 Fournier, Schulz, Berger, Landesberg 83 ), and in these it is at 
 least questionable whether the symptoms depended on degener- 
 ation of the posterior columns, and not rather, as Berger thought 
 in his case, on other lesions, either meningitis or multiple 
 neuritis. They were almost all cases in which the symptoms of 
 tabes developed in a comparatively short time, and much more 
 quickly, at any rate, than is usual in typical instances. Distinct 
 improvement has been observed in a larger number of cases. 
 But alongside these facts we must not fail to notice that in 
 the great majority of cases of locomotor ataxia antisyphilitic 
 treatment has proved useless, and that, frequently enough, the 
 patients have even got worse under it. So far as my own ex- 
 perience goes, as a whole, it has not been particularly favourable 
 to the method. Tet in one syphilitic case in whom the symptoms 
 of tabes developed in a few weeks, the use of iodide of potash 
 along with hydro-therapeutics and electricity was followed in a 
 relatively short time by complete and permanent recovery. But 
 another similar case, in which, however, the existence of syphilis 
 was doubtful (patient had had a chancre, but no secondary 
 
TREATMENT OF CHRONIC DISEASE OF THE SPINAL CORD. 375 
 
 symptoms), recovered equally well without any specific treatment 
 whatever.* 
 
 The lesson taught by all these observations is this, that while 
 specific treatment in tabes is to a certain extent justified, we 
 must by no means look upon it when used alone as a panacea. 
 It gives the fairest prospect of success in those cases (1) in 
 which no great interval has elapsed between the infection and 
 the first tabetic symptoms ; (2) in which, apart from syphilis, 
 there has been no other cause of any importance ; and (3) in 
 which the disease is yet in the initial stages. The longer the 
 interval between infection and the appearance of spinal symp- 
 toms, the longer the latter have already existed, and the more 
 advanced the disease is, the less can we expect from anti- 
 syphilitic treatment; although it must be allowed that some- 
 times success has been attained even in cases where a 
 considerable interval has elapsed before the appearance of the 
 tabetic symptoms, and where they have already lasted for many 
 years (Rumpf 84 ). But this corresponds perfectly to what we 
 know of the effects of specific treatment on syphilitic affections 
 of the central nervous system generally. It is possible to 
 suppose that the virus still remaining in the body (the 
 syphilitic microbes) is destroyed or rendered innocuous by the 
 treatment, and that further deleterious working on the spinal 
 cord is checked. It is possible further to suppose that retro- 
 gression of the syphilitic changes in the vessels, neuroglia, and 
 meninges is initiated by the treatment. But it is not conceivable 
 that we can in this way start the re-formation of fibres that 
 have disappeared. On the other hand, it is not only conceivable, 
 but has been repeatedly proved by experience, that when a 
 degeneration of the posterior columns has become thoroughly 
 established, a vigorous course of mercury may do great harm. 
 By its weakening influence on the whole body it may favour 
 the progress of the degeneration, or at least it may hinder any 
 approach to functional compensation. In any case the adoption 
 of specific treatment in tabes as in other spinal lesions requires 
 great caution. Especially in the case of the administration of 
 mercury the patient must be carefully and constantly watched. 
 And our experience certainly does not justify us in neglecting 
 
 * LSwenfeld. TJeber Spinallahnrang mit ataxie. Archiv. f . Psychiatric, Vol. 
 XV., part 2, Case II. 
 
376 LoWENFELD ON RECENT ADVANCES IN THE 
 
 at the same time the other remedies which lie to our hand. Baths 
 and electrical treatment not only form most valuable adjuncts 
 to an antisyphilitic course, but often give very good results 
 where the latter used alone has failed or proved harmful.* 
 
 Among the other drugs that are employed, strychnine may 
 first be alluded to. In consideration of its distinctive effect on 
 the cord it was formerly very much used for spinal paralysis, 
 though generally without success. It is not difficult to explain 
 this. It has no resolvent effect on the inflammatory and de- 
 generative changes in the cord, and its physiological property 
 of increasing the reflex irritability permits of only a very 
 limited therapeutic application. Latterly, therefore, physicians 
 have been somewhat sparing in their use of it, and rightly so; 
 and though recently De Gerenville 87 claimed to have attained 
 extremely good results with it in myelitis, tabes, and bulbar 
 paralysis, and Petrone 88 in infantile paralysis, and though 
 Eulenburg 89 has been putting in a word for it, yet I suspect those 
 things will not alter the general opinion. Strychnine seems 
 mostly suited for those cases in which active morbid processes 
 have come to an end, and where we have still to overcome some 
 functional inhibition in the conducting paths. Examples of this 
 are found in conditions of old-standing motor weakness, pareses 
 of the bladder or rectum, sexual debility, and so forth.f 
 
 The therapeutic reputation of phosphorus in these diseases 
 has fared still worse. It was first applied by Delpech, in 1863, 
 
 * A case recorded by Pusinelli, 85 of Leipzig, is very interesting and instructive 
 in this connection. The case was one of locomotor ataxia with a history of two 
 attacks of syphilis. Besides the tabes there were various other lesions un- 
 doubtedly syphilitic — syphilitic lupus on the forehead, cutaneous gummata over 
 the back, swelling of the testicle, and indolent swellings of all the lymphatic 
 glands. With very energetic specific treatment — mercuric inunction, and 
 between 35 and 40 grains of the iodide daily — the lesions over the forehead and 
 back almost completely recovered, and the swelling of the testicle diminished 
 very much. At the same time, however, the disease of the cord got worse. 
 Warm baths were tried for the latter, but also with unfavourable result. 
 Improvement followed the use of nitrate of silver and the application of the 
 galvanic current to the back. Lehmann (Rehme-Oeynhausen) has recorded the 
 following : A man 31 years of age, with a history of syphilis years before, 
 was treated with large doses of iodide and steadily got worse; complete 
 recovery followed a four weeks' course of thermal baths in Rehme with 
 galvanisation of the back and small doses (12 grains daily) of iodide of sodium. 
 
 t Strychnine is still largely employed in optic atrophy of spinal origin, and in 
 these cases is generally given spontaneously. According to Michel 82 this treat- 
 ment has hitherto proved quite useless, and my own limited experience leads me 
 to the same conclusion. 
 
TREATMENT OF CHRONIC DISEASE OF THE SPINAL CORD. 37>7 
 
 for some forms of toxic paralysis, and later, in 1868, it was 
 recommended by Dujardin-Beaumetz in locomotor ataxia. But 
 the latter, in his most recent statement 90 on this subject, 
 acknowledges that he has never seen recovery from tabes under 
 the use of phosphorus, but only improvement, and even with 
 regard to this improvement, that it is anything but . certain 
 whether it is to be attributed to the phosphorus, When this is 
 the state of, matters, I think we had better leave so doubtful a 
 drug alone. 
 
 - Ergotin and atropin cause, according to Brown-Sequard, 
 narrowing of the vessels of the cord; they should, therefore,' very 
 suitably be employed in hypersemic conditions. I confess I have 
 never been able to note any remarkable' result from the use of 
 either of them. Ergotin has recently been particularly recom- 
 mended in several quarters (Hammond, Benedict, Striimpell) 
 for posterior sclerosis. Grasset, 91 however, has drawn attention 
 to. .the, fact that this treatment is .not unattended with dangers. 
 He had under observation one case of tabes in which paralysis 
 of all the four extremities and of the voice occurred under the 
 use of ergot ;> these disappeared when the drug was omitted. 
 
 . All the other agents which have been recommended here and 
 there for affections of the cord — quinine, iron; arsenic, conium, 
 veratria, curara, calabar bean, chloride of gold, and sodium — 
 call for very little remark. Quinine and iron may now and then 
 be used for symptoms. Arsenic is recommended by Gowers 98 in 
 tabes. The value of the rest is more than problematical. In 
 cases where there are indications of spinal irritation, pain, 
 spastic symptoms, increased sexual excitability, the bromides are 
 frequently used with success. The same holds good of narcotics ; 
 their continued use was formerly often an unavoidable evil, but 
 happily we can now replace them largely by antifebrin and anti- 
 pyrin. These two last-named drugs have been unquestionably 
 a distinct addition to our armamentarium. No doubt they have 
 never proved to be of lasting service for the structural lesions in ■ 
 any case of organic disease, but they are extremely valuable 
 from a symptomatic point of view. In the treatment of the 
 lightning pains which are often so excruciating, of severe girdle 
 pains, of such spastic symptoms as cramp of the bladder, and of 
 the various forms of crises, rectal, laryngeal, &c., they surpass 
 every remedy we at present possess with the exception of the 
 
378 LoWENFELD ON RECENT ADVANCES IN THE 
 
 narcotics. Their usefulness in eccentric pains is particularly- 
 evident when these occur in regular attacks. From my own 
 observations I should say that, practically, both drugs are the 
 same in their effects, though in some cases antipyrin may do 
 better, in others antifebrin. I generally order the two together, 
 giving a powder containing twelve grains of antipyrin and four 
 of antifebrin three or four times a day. By the introduction of 
 these two remedies salicylate of soda has been superseded, and 
 the ether spray, which has been employed in France for the 
 relief of lightning pains, might now also be considered super- 
 fluous. 
 
 The external application of liniments is a mode of treatment 
 in which at present there is very little faith in many quarters. 
 But the scepticism has been carried rather far. I believe from 
 the results of my own experience, both clinical and experimental, 
 that we may beneficially employ friction with spirituous and 
 aromatic substances in spinal disease. Through the gentle 
 stimulating effect on the cutaneous nerves we can influence the 
 nutrition and irritability of the cord, and in certain circum- 
 stances favourably modify its morbid conditions. Of course we 
 are not to hope for any speedy or brilliant results from this 
 procedure. On the other hand, I am very much more distrustful 
 of the value of sedative and narcotic liniments. We are con- 
 stantly inclined to take refuge in them when dealing with spinal 
 pains ; but these pains recur again and again, and usually — not 
 to say regularly — the narcotics leave us in the lurch at the time 
 when they are most urgently needed. 
 
 V. — Orthopcedics, Gymnastics, Massage, and the application of 
 Rarefied Air. 
 
 The art of orthopaedics has not been turned to account in the 
 treatment of spinal disease as far as it might be. Most use 
 has been made of it in the paralytic conditions of the lower 
 extremities in children from anterior poliomyelitis; apparatus 
 have also been successfully applied for the vertebral and joint 
 lesions in locomotor ataxia. And recently the endeavour has 
 been made in the latter disease by means of suitable supports to 
 improve, or, it may be, to restore the power of walking when 
 the ataxia has become very bad. These attempts are worthy 
 of note, and no doubt in many cases of old-standing spinal 
 
TREATMENT OF CHRONIC DISEASE OF THE SPINAL CORD. 379 
 
 paralysis in adults the walking could be improved in a similar 
 way. 
 
 Gymnastics — both, the simple German chamber-gymnastics 
 and the so-called Swedish gymnastics — may be advantageously 
 used in conditions of motor weakness with or without atrophy. 
 They are mainly useful, of course, when the active morbid 
 process which is the cause of the condition has practically come 
 to an end. I have lately employed them in a case of hereditary 
 ataxia for the disturbance of co-ordination in the lower ex- 
 tremities ; the patient's gait was improved thereby. 
 
 Massage supplements gymnastics in certain respects, as it 
 may be used in those cases where there is not sufficient power 
 of movement to render possible a course of active gymnastics. 
 When properly carried out it can no doubt exercise a marked 
 influence on the nutrition and functional capacity of the muscles. 
 The amyotrophies form the most favourable field for its appli- 
 cation, but it has been tried with success even for the anaesthesia 
 in tabes (Schreiber 9 *).* 
 
 Lastly I must here mention the application of rarefied air 
 by means of Junod's boot (Lyman 95 ), which has been used 
 during the last few years for the treatment of the motor dis- 
 orders in tabes. The success of the method, the improvement 
 in the nutrition and function of the muscles, the diminution of 
 the sensory disorders, &c, make it extremely desirable that we 
 should have a further trial of it, particularly in amyotrophies. 
 
 VI. — Stretching Procedures, Nerve-Vibration, and Hypnotism. 
 
 One of the methods next to be described has been the subject 
 of a great deal of writing, almost of a whole literature — I mean 
 nerve-stretching. We know the enthusiasm with which this 
 operation was taken up after the wonderful reports which 
 Langenbuch gave of it, and the hopes that were cherished for 
 
 * Rossbach says (Lekrtrach d. physikalischen Heilmethoden, 2 Halfte, 1882, p. 
 495), "Only those diseases of the nervous system that are of peripheral origin 
 can be treated by massage," but this opinion, as is evident from what has been 
 said above, is quite untenable. In cases of atrophic spinal paralysis I have 
 repeatedly seen massage prove useful in the stage of convalescence. And 
 Berglind (Petersburg. Med. Zeitsch., 1874, N. F. 5, Heft.) has had good results 
 from it in some cases of progressive muscular atrophy where the disease was not 
 far advanced. In tabes, I have observed, it sometimes improves distinctly, though 
 only for a time, the power of walking. 
 
380' ■" LoWENFELD ON KECENT ADVANCES IN THE 
 
 the multitude of spinal cases that had, up to that time, been 
 without a remedy. But a short time seemed to elapse, and the 
 treatment of organic disease of the cord passed wholly over into 
 the hands of the surgeon. Yet our expectations, as we know 
 now from an abundant experience, were bitterly disappointed. 
 Of the huge number of cases operated on, not one was cured. 
 It cannot be denied that a certain number improved, and in 
 respect of some of the symptoms improved considerably, but in 
 many of these cases the ground that had been gained was once 
 more lost. And in a far larger number the operation had either 
 a negative result or was followed by more or less distinct 
 deterioration in the condition of the patient. Lastly, there were 
 not a few cases in which the operation caused death, either 
 through something going wrong with the wound, or through 
 lesion of the spinal cord. 
 
 From these facts it will be sufficiently understood that nerve- 
 stretching as a remedy for chronic disease of the cord has 
 latterly been generally rejected. In a small number of instances 
 the so-called "bloodless'' nerve-stretching has been tried. But 
 again experience teaches that, even in the most favourable case, 
 we can expect from this nothing but some improvement in 
 individual symptoms. And it is by no means so certain, it 
 appears to me, that it is so devoid of danger as some represent 
 — we must remember that the other operation to begin with 
 was represented as quite a harmless proceeding. I believe, 
 however, that a warning is here scarcely necessary : I rather 
 suspect that both kinds of nerve-stretching — it may be without 
 sufficient ground — are, in the treatment of diseases of the cord, 
 among the things we have done with.* 
 
 Two other stretching methods have been suggested. The 
 stretching of the spinal cord was proposed by A. Hegar, 97 of 
 Freiburg, as a substitute for nerve-stretching. The occasion 
 was the observation by this well-known gynecologist — though 
 it had been frequently observed before — that certain disorders 
 which he thought originated in the lumbar cord, but which are 
 frequently associated with sexual troubles, are produced by 
 marked bending of the spine forwards. To the observation 
 
 * Benedict 90 is the only physician of any importance who has latterly continued 
 to express himself in its favour as a remedy for tabes. It looks as if in this 
 matter Benedict would remain the voice of one crying in the wilderness. 
 
TREATMENT OF CHRONIC DISEASE OF THE SPINAL CORD. 381 
 
 Hegar added the reflection that what could do harm might in 
 certain circumstances do good. And starting from some 
 anatomical investigations of his own, he contrived a method for 
 producing extension of the cord in the living subject, which 
 consists essentially in this, that either the head and thorax are 
 passively flexed towards the lower extremities, or the latter, 
 kept extended, are flexed towards the head and thorax. This is 
 to be done without an ansBsthetic, and the exercise of undue 
 force is to be avoided. I cannot call Hegar's idea a happy one. 
 From several observations of my own in the matter, I believe 
 that all that is allowable and of any use in his " spinal extension 
 in the living subject " can be attained by the use of chamber 
 gymnastics. And in consideration of the very great differences 
 in different individuals in the elasticity of the inter-vertebral 
 connections,* we can by no means exclude with Hegar's 
 method the danger of injuring the spinal column, or even — 
 through tearing of vessels particularly — of injuring the cord 
 and its membranes.f We are still quite in the dark as to what 
 the method has specially accomplished. Motschutkowsky, 98 a 
 Russian physician, tried stretching the body by suspending the 
 patient. Among fifteen cases of tabes thirteen are said to have 
 improved in respect of pains, paresthesias, ataxia, and muscular 
 strength, while the remaining two became worse under the 
 treatment. In some other cases of disease of the cord — diffuse 
 myelitis, insular sclerosis, &c. — Motschutkowsky gained no 
 result. In tabes he recommends suspension for ten minutes 
 three or four times a week. He thinks the therapeutic effect 
 is to be referred to the stretching of the nerves and arterial 
 trunks ; this produces a rise of blood pressure in the cord, and a 
 consequent acceleration of the circulation. In spite of these 
 physiological arguments there are probably few physicians who 
 will be found ready to continue Motschutkowsky 's trials, f 
 Some physicians have seen good done in several forms of 
 
 * Let ns call to mind, for example, the performances of aome circus clowns and 
 contortionists, and compare with these the mobility of the spinal column in one 
 who has had no athletic training. 
 
 t Hegar himself remarks : " The proceeding is not so harmless as it may appear 
 at first sight. At any rate, my experience of it, both in the healthy and in those 
 affected by disease, though not yet of course very large, has convinced me that 
 it has a very distinct effect." 
 
 J This was written in 1888— TV. 
 
3S2 LoWENFELD ON RECENT ADVANCES IN THE 
 
 neuralgia from the effects of weak mechanical vibrations,* and 
 this may have induced Mortimer Granville" to try "nerve- 
 vibration," and to recommend it as a special mode of treatment 
 in some diseases of the spinal cord, especially locomotor ataxia. 
 He obtains this vibration by means of an instrument called a 
 " percuteur," which is set in motion by clockwork or electricity. 
 It is quite impossible to come to any conclusion at present on 
 the value of this method. 
 
 It can excite no surprise that in our time hypnotism also has 
 been tried. The only thing that deserves notice in this con- 
 nection is Bernheim's 100 (Nancy) account of the results of the 
 application of his suggestion method. In one case, which he 
 calls " sub-acute diffuse myelitis of the anterior columns " (the 
 diagnosis, to my mind, is not certain), he had considerable 
 improvement under its repeated application. In several cases 
 of ataxia he succeeded in overcoming for a time the lightning 
 pains, gastric crises, and tenesmus of the bladder. In one of 
 the patients the walking was for some time very much better, 
 and the man who previously had been unable to stand upright 
 was able to go without a stick.f In a number of cases of 
 spastic paralysis and multiple sclerosis, he obtained a diminution, 
 lasting for a longer or shorter time, of the exaggerated tendon 
 reflexes and the contractures. But in all the success was merely 
 temporary. He acknowledges himself, quite plainly, that the 
 course of lesions like locomotor ataxia and multiple sclerosis is 
 not to be stayed by hypnotic suggestion. From such indications 
 we can hardly assume that hypnotism has any particular part to 
 play in the treatment of organic disease of the cord. The 
 temporary results which are obtained may probably be, for the 
 most part, got at in another way. The so-called functional 
 diseases, however, form a rich soil for this method, and it seems 
 particularly suited for certain very troublesome symptoms, such 
 as back-ache, seminal emissions, &c. 
 
 * For example, Dr. Boudet, of Paris, has treated neuralgia with great success 
 by the transference of the vibrations of a tuning-fork to the painful spots in the 
 course of the nerve. 
 
 t The fact is not without interest that I have obtained a like result in several 
 patients by applying the faradic wire brush to the outer border of the foot. There 
 could be no question in these cases of any " suggestive " influence, as this result 
 was quite unlooked-for, both on the part of the patient and on my own. The 
 patients themselves drew my attention to the circumstance. Lowenfeld, 
 Investigations in Electrotherapeutics, p. 69. 
 
TREATMENT OF CHRONIC DISEASE OF THE SPINAL CORD. 383 
 
 VII. — Regulation of the Mode of Life. 
 
 No organic disease of the cord can be cured by dieting, yet 
 the regulation of the daily life plays a very important part in 
 the treatment. 
 
 The food should be, on the whole, nourishing and easily 
 digested, though we must avoid anything like fattening-np, 
 especially in cases where the ability to move about has already 
 suffered ; with any increase in the bodily weight these patients 
 would become still more helpless. The consumption of alcohol 
 must always be moderate. In the matter of clothing the chief 
 object is to guard against getting cold or wet ; looking after the 
 skin and regular washing with tepid or cold water can also do a 
 good deal in this direction. But the most important matter of 
 all is as large an allowance as possible of fresh air. The benefits 
 which even old cases frequently gain by a residence during the 
 summer months at some spa or climatic resort are very largely 
 to be referred to this particular influence.* This is the reason 
 why many patients who do not require much looking after 
 or nursing find it so much to their advantage to spend the winter 
 in the South ; and there is nothing yet known of any specially 
 favourable effect otherwise of one or other of these southern 
 resorts. The going about requires to be attended to. As bodily 
 movement alone can keep the muscles in good condition, a 
 certain amount of it must be secured according to the ability of 
 the patient. On the other hand, we must not hesitate to forbid 
 walking altogether if we find that it is carried on only with an 
 effort, and that there is danger of falling. 
 
 Some physicians speak favourably of the influence of complete 
 rest in bed for a long time in some forms of spinal disease. 
 Donkin, 101 for example, reports undoubted success in some cases 
 of spastic paralysis, whom he kept in bed for several months. 
 Brower 102 recommends for the initial stages of tabes that the 
 patient should be kept in bed for a long time lying on his back. 
 In hospitals particularly it has been noticed that cases of tabes 
 coming in in a state of exhaustion do very well with lying in bed 
 for a while. Donkin's cases just referred to were those of persons 
 in whom the disease had been brought on by muscular strain. 
 But, on the whole, in the case of individuals who are capable 
 
 * Sea-voyages are also recommended by English physicians. 
 
384 LOWENFELD ON RECENT ADVANCES IN THE 
 
 of going about, a moderate amount of movement out of doors is 
 preferable on account of the benefits both of the fresh air and of 
 the muscular exercise. 
 
 The mental occupations must be looked after, and any intel- 
 lectual strain avoided. 
 
 Sexual intercourse must always be restricted, and in many 
 cases forbidden altogether. The regulation of the bowels requires 
 attention ; most spinal cases are inclined to constipation. This 
 is best treated by suitable dietetic methods, and where these are 
 not sufficient, by drugs, enemata, or massage of the abdomen. 
 
 APPENDIX. 
 
 Treatment of Cystitis and of Bedsore. 
 
 The occurrence of cystitis or bedsores in the course of chronic 
 disease of the spinal cord is justly regarded with great dread. 
 Many patients suffer all the year round from these complications 
 and their consequences, and they immensely increase the suffer- 
 ing in a class of cases where there is generally quite enough of 
 it already. It must therefore be one of our first objects to guard 
 against their occurrence, or at any rate to put it off as long as 
 possible. 
 
 As the cause of cystitis is generally stagnation of urine in the 
 bladder, our first business is to see to the regular and complete 
 evacuation of the latter. Vesical weakness, accordingly, when 
 present must be treated as early and as thoroughly as possible ; 
 and the most effective means of doing this is undoubtedly a 
 suitable application of electricity. If this does not succeed in 
 removing the weakness, or if it succeeds but imperfectly, we 
 must try mechanical means, such as pressing on the bladder, 
 kneading the abdomen, placing the patient in the upright 
 position, or causing him to sit on the night-stool. Should these 
 measures fail, we must resort to regular daily catheterisation. 
 The instrument must be disinfected as carefully as possible on 
 each occasion of using, otherwise the cystitis which it is 
 intended to ward off will be produced in its very worst form. 
 If there is catarrh of the bladder internal remedies are not much 
 to be trusted to. The most of them, such as salicylic acid, 
 benzoic acid, boric acid, chlorate of potash, tannin, uva ursi, 
 
TREATMENT OF CHRONIC DISEASE OF THE SPINAL CORD. 385 
 
 but especially the balsams, cannot be continued for any length of 
 time : they disagree with the stomach, and disorder both the appe- 
 tite and digestion. Mineral waters such as those of Wildungen, 
 Vichy, Ems, &c, are more harmless in this respect, and in the 
 milder class of cases may be continued for a long time. If the 
 urine contains mucus and pus in abundance, in other words if 
 the cystitis is severe, the only way of making a distinct and 
 permanent impression upon it is by regular washing out ; that 
 is best done by means of the double catheter, with a three or 
 four per cent, solution of boracic acid.* Under this treatment I 
 have seen severe purulent catarrh reduced to a minimum. At 
 the same time of course any imprudence in diet, such as indul- 
 gence in beer, new wine, or highly-spiced dishes must be guarded 
 against. 
 
 As regards bedsores in these diseases, v. Gudden's well-known 
 view was that they were the results of defective nursing alone, 
 and that they had nothing to do with trophic nervous disorders. 
 Although this goes rather far,t yet there is no doubt that by 
 proper care we can do a very great deal to avert the complication. 
 
 The parts most exposed to the risk must be carefully watched 
 and protected from continuous pressure by means of air or water 
 cushions, and frequent changes of positions ; scrupulous cleanness 
 must be adhered to, and the skin regularly washed with a solution 
 of spirit to strengthen the tone of the cutaneous vessels ; dis- 
 infecting solutions followed by the application of powder should 
 also be used. If there is a slight bedsore it is sufficient to dress 
 it with zinc or boracic ointment ; if there is furuncular action 
 mercurial carbolic plaister should be used, and of course the 
 measures enumerated for prevention should now be enforced 
 with increased rigour. When there is extensive gangrenous 
 bedsore the treatment must be carried out strictly according to 
 modern antiseptic principles ; these principles have many a 
 triumph to record even on ground so unfavourable as this is, 
 and I have repeatedly seen cases of bedsores with undermining 
 and extensive sloughing where healing was finally attained by 
 careful and persistent antisepsis. 
 
 * Rosenthal 10s recommends for washing ont, on account of its antiseptic 
 property, a solution of four drops of nitrite of amyl in about a pint of water, 
 
 f Charcot's decubitus acutus is unfortunately no fable ; I haye repeatedly seen 
 it arise in circumstances where there could be no question of any continuous 
 pressure on the skin. 
 
 C C 
 
386 LOWENFELD ON RECENT ADVANCES IN THE 
 
 B. — Treatment of Functional Diseases of the Cord — Spinal 
 
 Irritation. 
 
 In addition to the organic lesions of the cord, the functional 
 affections as they are called are of no small importance. The 
 commonest and practically the most serious is spinal neurasthenia 
 (spinal irritation, myelasthenia), and I shall content myself in this 
 section with dealing with the treatment of this alone ; that of the 
 rest in so far as it is not determined by these causes (as in the 
 case of intermittent spinal paralysis) is essentially the same as in 
 neurasthenia. 
 
 In the slighter forms of this affection, in those forms especially 
 which are so frequently seen in young people as a consequence 
 of sexual error, all that is required in addition to removal of the 
 cause, regulation of the mode of life, and the avoidance of mental 
 and bodily strain, is the application of the galvanic current to the 
 back for a few weeks, either with or without some mild 
 hydropathy. Eesidence in the country or among the hills at the 
 proper time of the year, bathing in lakes or rivers when the water 
 is not too cold, and in the sea in the case of those in fairly 
 vigorous condition — all these also are very serviceable measures. 
 
 The more severe forms are not so easily dealt with.- These 
 are the instances when, with an inherited neuropathic tendency 
 to found upon, we have super-added the influence of some severe 
 strain, prolonged over several years, as, for example, from mental 
 or bodily exertion, or from sexual excesses. They call for very 
 careful observation on the part of the physician ; for, though life 
 is not endangered, the capacity of the individual for work is 
 very seriously interfered with, and may be destroyed altogether, 
 while in many ways his existence is made a burden to him. The 
 treatment of such cases not infrequently requires tact and 
 patience of the highest order. The removal of the cause, so far 
 as this is possible, is of course the first object. The importance 
 of attaining this, however, may be over-estimated. I have 
 explained elsewhere 104 that if the condition lasts long enough, 
 the morbid changes in the nervous system display a tendency ;to 
 disassociate themselves from their causes, so that the removal of 
 the latter may not check the continuance of the affection. This 
 particularly requires to be borne in mind where we have disease 
 of the genital organs as one of the causes, e.g., chronic urethritis 
 
TREATMENT OB' CHRONIC DISEASE OF THE SPINAL CORD. 387 
 
 in men, or change in the form and position of the womb in 
 women. If we do nothing else than attend to these, it is quite 
 possible that our endeavours may not only prove ineffectual 
 to cure the neurosis, but may even leave it ^ worse than they 
 found it. 
 
 Drugs take a subordinate position among the remedies at our 
 command, though some physicians, especially in America, lay 
 great stress on them, and have hit upon some very complicated 
 formulae. Those mostly used are nux vomica and its preparations, 
 arsenic, tonics like iron and quinine, and the bromides. With 
 none of them can we count on anything like astonishing success, 
 to say nothing of recovery. From my own experience I should 
 say that nux vomica and arsenic were the least trustworthy of 
 the whole of them. Tonics are useful as adjuncts to other 
 modes of treatment, but by themselves they hardly deserve 
 mention. Bromides are relatively the most effective. They 
 only suit those cases in which there is a markedly irritable 
 condition, indicated by pain, very troublesome parsesthesias, 
 sexual excitement, &c, and must be given in rather larger 
 doses than usual — 60 to 90 grains daily. Derivatives are of no 
 particular use for the general condition : they are best employed 
 to combat symptoms, especially the backache which is so much 
 complained of, but very commonly they only give ease for a 
 time. The most valuable remedies we at present possess are 
 undoubtedly electricity and hydro-therapeutics, and in Germany, 
 at any rate, we are coming more and more to recognise this. 
 Of the various ways in which electricity may be applied, 
 galvanisation of the back is perhaps the best. Applied with the 
 necessary care and persistence, it unquestionably gives very 
 good results in a great number of cases. Current densities of 
 moderate strength, such as 5 ,7s q uare cm .» should be used, the 
 duration of the sitting should be gradually lengthened, and the 
 part of the cord most affected (generally the lumbar portion) 
 should receive special attention. On the other hand, it is often 
 good practice to treat the periphery in this way, such as the 
 lower extremities and the sexual organs. In many cases we 
 get equal success from general faradisation, applied according to 
 the method of Beard and Bockwell ; indeed, now and then this 
 gives distinctly better results. A number of years ago I 
 explained in a little publication 108 the special excellencies of this 
 
388 LOWENFELD ON RECENT ADVANCES IN THE 
 
 method, and I content myself on the present occasion with 
 pointing out that it is particularly useful in those cases of 
 myelasthenia in which the motor activity is very seriously 
 affected. Faradic baths have been recently recommended in 
 various quarters (Ischewsky, 106 Stein, 107 Eulenburg, 108 Lehr, 1M &c.) 
 as a very convenient way in which to apply general faradisation. 
 I do not doubt in the slightest that the reports of the beneficial 
 effect of these baths are correct, but from my own experience I 
 can hardly think it the case that we may look to them for all 
 the good that we get from general faradisation, according to the 
 method of Beard and Rockwell. Statical electricity has been 
 tried both by myself and others within the last few years ; there 
 is nothing particular to say about it, and further observations 
 are necessary before we can form any conclusion as to its value. 
 Of hydro-therapeutic methods, half -baths, at a temperature of 
 77° — 86° Fahr., followed by a pail douche with the water at a 
 somewhat lower temperature, or the rapid wash-down, or the 
 wet sheet, followed by a wash-down — all these may be employed 
 with advantage. With the two latter methods the water can 
 — as the treatment goes on — be used some degrees lower than 
 the lowest limit permissible in organic disease. Individuals in 
 fairly vigorous health can bathe in lakes or rivers provided the 
 temperature is at least 72°. Those who are in a weakly 
 condition, and who are very susceptible to temperature, should 
 be recommended to use brine baths of from 89° to 93°, or 
 indifferent thermal baths ; and, if there is distinct anaemia, 
 chalybeate baths. Sea bathing, as a rule, is only to be used 
 afterwards ; the same holds good of mountain air, so far, at any 
 rate, as the enjoyment of this is to interfere with the continuance, 
 of the hydro-therapy. In spite of the fact that mountain resi- 
 dence usually exerts a very beneficial influence on the general 
 condition of the patient, it does not suffice by itself, as a rule, 
 to effect a permanent cure. In certain cases massage may be 
 used in support of other methods of treatment ; it is particularly 
 serviceable in weakness of the legs and back, and in some kinds 
 of backache. The massage may be performed in the ordinary 
 way, or it may be associated with general faradisation — faradic 
 massage ; in the latter case we use a particular instrument, e.g., 
 the " massirrolle," contrived by Dr. Stein of Frankfurt. .The 
 one pole of an induction battery is brought into connection with 
 
TREATMENT OF CHRONIC DISEASE OF THE SPINAL COED. 389 
 
 the instrument which is used for the massage of the various 
 parts affected, while the other pole is connected with some 
 indifferent spot on the body. Massage also, as is well-known, 
 plays an important part in the Weir-Mitchell treatment, and in 
 cases where the body is very much reduced we often get results 
 by the help of this latter method which we can attain to in no 
 other way. Whatever kind of treatment we may choose, it js 
 absolutely necessary to regulate the whole m'ode of life. The 
 diet must be simple but nutritious; alcoholic liquor must be 
 taken in great moderation, the patient must be a good deal in 
 the open air, and moving about as much as his strength will 
 permit, and he must have only moderate mental occupation. 
 Sexual intercourse must be limited, and even for a time 
 forbidden in some cases, and all causes of sexual excitement 
 must be avoided. 
 
 There are one or two remarks I should like to make in 
 concluding. Not much more than twenty years have passed 
 away since our master, Romberg, was ready to stand by his 
 famous saying in regard to the fate of those affected with tabes : 
 " There is no prospect of recovery for patients with this disease ; 
 the staff has been broken over each." The saying was no doubt 
 a perfectly just one at that time, but fortunately has ceased to 
 be true for a number of years. Recoveries from locomotor 
 ataxia have been recorded by thoroughly trustworthy physicians, 
 and I know of several cases myself, even in those who have not 
 had syphilis. And, in a similar way, in a great variety of 
 organic affections of the cord, treatment has been attended by 
 distinct success, improvement, and even recovery. But these 
 facts must not lead us to over-estimate our abilities. Encourage 
 ing as the advance is which has taken place in the treatment of 
 these diseases in the last twenty years, we must yet allow that 
 we are only just setting out, and that almost all the way still 
 lies before us. But just on that account it is of the utmost 
 importance that, in our anxiety to press forward, we should not 
 get into any false track. There was a time when every affection 
 of the spinal cord was attributed to excesses, and the poor 
 sufferer, in addition to his disease, had to contend with this 
 odious prejudice. At the present day, again, many are inclined 
 to refer the majority of them to microbes and toxines, and 
 
390 lo-wenfeld ox recent ADVANCES IX the 
 
 consequently they expect that any future advances in our 
 therapeutic resources will depend largely on the results of 
 setiological investigation. It may not be superfluous to remark 
 that the progress of the last twenty years has been made not 
 through increase in our knowledge of the causes of these diseases, 
 and, in particular, not through bacteriological investigations. It 
 is owing to the immensely increased precision and care in the 
 application of hydro- and balneo-therapeutics, and even more 
 to the advances in electro-therapeutics. But neither of these 
 two classes of remedies can exercise any direct influence on 
 bacteria or toxines. Again we must observe that an advance 
 in our knowledge of causes by no means coincides with an 
 advance in our treatment. The discovery of the tubercle and 
 cholera bacilli has not been attended by the discovery of any 
 remedy which can destroy these bacilli in the living body^ 
 This appears to me to show distinctly enough that, however 
 large our expectations may be in regard to what we are yet to 
 gain from a study of causes, we should keep our attention 
 constantly fixed on the development of our present empirical 
 treatment ; at the same time we must be always on the watch 
 for some general principles to guide us outside these setiological 
 ones of which I have spoken. 
 
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TREATMENT OF CHRONIC DISEASE OF THE SPINAL CORD. 391 
 
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392 LOWENFELD ON KECENT ADVANCES IN THE 
 
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TREATMENT OF CHRONIC DISEASE OF THE SPINAL CORD. 393 
 
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INDEX. 
 
 Abscesses, cold, 37 
 
 Acetone, tests for, 181 
 
 Agoraphobia, 64 
 
 Air, rarefied in disease of cord, 378 
 
 Ammonia, test for, 181 
 
 Arteries, syphilitic diseasc.of, 207, 209 
 
 cases of, 211, 213, 215 
 
 Albuminuria in diabetes, 185 
 Alcohol, 58 
 
 • in hernia operations, 142 
 
 Asthma, nasal, 296 
 
 pathology of, 271 
 
 phrenic, 292, 294 
 
 Sexual, 271 et seq. 
 
 cases of, 274 
 
 • causes of, 297 
 
 ■ constitutional taint in, 298 
 
 diagnosis of, 299 
 
 lungs in, 298 
 
 manifestations of, 293 
 
 prognosis of, 300 
 
 treatment of, 300 
 
 Atrophy, from joint injury, 318 
 infantile muscular of Duchenne, 
 
 235, 248 
 
 juvenile muscular, 235, 248 
 
 — . cases of, 236, 237 
 
 hereditary muscular of Leyden, 
 
 234, 248 
 
 progressive muscular, 233 
 
 spinal muscular, 255 
 
 Bacteria, specific pathogenic, 10 
 Baths, in disease of spinal cord, 354, 
 
 388 
 Bedsores, treatment of, 384 
 Billroth, on the mutual action of 
 living vegetable and animal cells, 5 
 Birds, infectious epithelioma of, 50 
 Bones of skull, syphilis of, 207 
 
 operations on, 141 
 
 Brain, foreign bodies in, 111, 112, 115 
 
 gumma of, 207, 208 
 
 — ■ — syphilitic disease of, 207 
 Bullets, as foreign bodies, 112, 132 
 
 Catgut, in hernia operations, 145 
 
 Carbuncles in diabetes, 168, 185 
 Carcinoma microbe, 51 
 Cecidia, 42 
 Cells, animal, 5 
 
 action of, on vegetables, 41 
 
 giant — see Giant cells 
 
 living vegetable, 5 
 
 as formative stimuli, 32 
 
 — — of spinal cord, regeneration of, 
 
 351 
 Cerebral disturbance in neurasthenia, 
 
 62 
 Climate, in neurasthenia, 75 
 Cocci, kinds of, 13 
 Coitus, a cause of asthma, 289 
 Coma diabeticorum, 186 
 
 treatment of, 187 
 
 Condyloma, 40 
 
 Constipation in neurasthenia, 72 
 
 Continuity, solution of, 23 
 
 Cord, syphilitic disease of the, 219 
 
 Cornea, inoculation of, 9 
 
 Cystitis, in spinal cord disease, 384 
 
 Dead tissue as foreign body, 117 
 Derivatives in cord disease, 369, 387 
 Diabetes insipidus, 186 
 Diabetes mellitus, 153 et seq. 
 
 a cause of enuresis, 333 
 
 aetiology of, 162 
 
 course of, 182 
 
 definition of, 153 
 
 — diagnosis of, 172 
 
 diet in, 190 
 
 drugs in, 198 
 
 history of, 155 
 
 hygiene in, 196 
 
 — — pathological anatomy of, 162 
 
 prognosis of, 182J 
 
 symptoms of, 165 
 
 theories of, 155 
 
 treatment of, 188 
 
 urine in, 172, 177 
 
 Diacetic acid, tests for, 181 
 Disintegration, 7 
 Drugs in diabetes mellitus, 198 
 in disease of the cord, 372, 387 
 
INDEX. 
 
 39c 
 
 Drugs in neurasthenia, 83 
 Dystrophy, progressive muscular, 233 
 
 setiology of, 263 
 
 — clinical features of, 250 
 
 course of, 264 
 
 diagnosis of, 255 
 
 face in, 253 
 
 • literature of, 266 
 
 — • muscles in, 250, 257 
 
 nervous system in, 261 
 
 pathogenesis of, 261 
 
 — pathological anatomy of, 257 
 
 prognosis of, 264 
 
 ■ reflexes in, 255 
 
 treatment of, 264 
 
 tremors in, 254 
 
 unity of forms of, 248 
 
 Electricity, in disease of the cord, 361, 
 368, 387 
 
 in neurasthenia, 81 
 
 Enuresis nocturna in males, 329 
 
 cases of, 333, 340 
 
 analysis of cases, 339 
 
 causes of, 329 
 
 treatment of, 343 
 
 Epilepsy, a cause of enuresis, 332 
 Erb, on progressive muscular dys- 
 trophy, 233 
 
 Fears, in neurasthenia, 63 
 
 Fibroids, uterine, a cause of Asthma, 
 
 290 
 Fluid, nutritive, accumulation of, 31 
 Foreign bodies, actions of, 25 
 
 clean, 109 
 
 ■ healinginof,conclusionsfrom,120 
 
 deductions, 139 
 
 literature of, 147 
 
 older observations, 110 — 120 
 
 personal observations, 122 — 
 
 139 
 
 microscopic alterations round, 135 
 
 unclean, 109 
 
 " Frost-gangrene," 41 
 Function, increased, 31 
 
 Galls, 42—49 
 
 Generative organs and asthma, 271 
 
 Genital anomalies in neurasthenia, 72 
 
 Giant cells, 33, 135 
 
 Glanders, 38 
 
 Glass, as a foreign body, 132 
 
 Glass-wool, as a foreign body, 143 
 
 in hernia operations, 122, 129 
 
 Glycosuria, 154 
 Gonococcus, 39 
 
 Gonorrhoea, a cause of asthma, 292 
 Growth, cessation of, 22 
 Gymnastics, in disease of spinal cord, 
 379 
 
 Hematoma, 26 
 
 Heart, foreign bodies in, 111, 112, 113 
 
 in neurasthenia, 69 
 
 Heredity, in tuberculosis, 90 
 Hernia, alcohol in operations for, 142 
 — • — catgut in operations for, 145 
 
 glass-wool in operations for, 143 
 
 Czerny's operation for, 143 
 
 History, in neurasthenia, 77 
 Hofmeister on diabetes mellitus, 153 
 Hydro-therapeutics, in neurasthenia, 
 
 79 
 Hypnotism, in disease of spinal cord, 
 
 379 
 Hysteria, nature of, 321 
 
 Incapacity for mental work, in neuras- 
 thenia, 62 
 
 Incapsulatiou of foreign bodies, 26 
 
 Inflammation, causes of, 5 
 
 varieties of, 13 
 
 Insane, general paralysis of and 
 syphilis, 217 
 
 Intestines, in neurasthenia, 71 
 
 Irritability, formative, 17, 18 
 
 Irritation, spinal, in neurasthenia, 68 
 
 Knife-blades, as foreign bodies, 114 
 Koch's discovery of tubercle bacillus, 
 
 Lead, as foreign body, 112, 127, 132 
 Life, mode of, in diseases of the cord, 
 
 383, 386, 389 
 Ligatures, as foreign bodies, 1 1 6 
 Locomotor ataxia and syphilis, 225 
 Lbwenfeld on recent advances in 
 
 treatment of chronic diseases of the 
 
 spinal cord, 347 
 Lung, infection in tuberculosis, 99 
 Lungs, apices of, in tuberculosis, 102 
 
 Massage, in disease of spinal cord, 379, 
 
 388 
 
 in neurasthenia, 82 
 
 Masturbation, a cause of asthma, 274 
 
 et scq. 
 
 a cause of enuresis, 331 
 
 Medicinal substances as formative 
 
 stimuli. 29 
 Meningitis, syphilitic, of brain, 207 
 
 of cord, 219 
 
 Metritis, a cause of asthma, 292 
 
 Microbes, 5 
 
 — — classification of, 8 
 
 — — formative action of, 12, 17 
 
 history of knowledge of, 6 
 
 relation of to tissues of body, 11 
 
 Microbic proliferation, termination of, 
 
 15 
 Milk, a cause of tuberculosis, 91 
 
396 
 
 INDEX. 
 
 Molluscum oontagiosum, 49 
 
 Morphia, 58 
 
 Motor disturbances in neurasthenia, 
 
 69 
 Multiplication, modes of, 19 
 Myelitis, syphilitic, 225 
 
 Needles, as foreign bodies, 111, 125 
 Nerve fibres, regeneration of, 351 
 Nerve-irritation, in disease of spinal 
 
 cord, 379 
 Nerves, injuries to, 318 
 
 syphilitic disease of, 227 
 
 Nervous system, pathology of, 205 
 
 ; syphilis of, 205 
 
 Neuralgia, syphilitic, 227 
 Neurasthenia, cases of, 57 
 
 definition of, 61 
 
 diagnosis of, 61 
 
 etiology of, 55, 58 
 
 forms of, 61 
 
 in United States, 56 
 
 - — symptoms of, 61 
 
 traumatic, 312 
 
 ■ ■ treatment of, 73 
 
 Neuritis, chronic multiple, 256 
 Neuroglia, of cord, repair of, 352 
 Neuroses, traumatic, 303 et segr. 
 
 — ; causes of, 316 
 
 • definition of, 304 
 
 general, 304 
 
 internal organs in, 312 
 
 local, 317 
 
 motor symptoms in, 310, 
 
 320 
 
 nature of, 312, 321 
 
 ■ origin of, 312 
 
 psychical condition in, 306 
 
 prognosis of, 3,15, 323 
 
 reflexes in, 311 
 
 resume of paper on, 324 
 
 sensory symptoms of, 308, 
 
 319 
 
 simulation of, 317 
 
 trophic symptoms of, 311, 
 
 321 
 
 Occupation, in neurasthenia, 77 
 Orthopoedics, in disease of the cord, 
 
 378 
 Ovule cells, 20 
 
 Pancreas, in diabetes, 1'55, 161, 185 
 
 Paralysis, pseudo-hypertrophic, 234, 
 248 
 
 case of, 240 
 
 Parthenogenesis, 48 
 
 Peyer, on asthma in disease of genera- 
 tive organs, 271 
 
 on enuresis nocturna in males, 
 
 329 
 
 Phagocytes, 15 
 
 in tuberculosis, 104 
 
 Phimosis, a cause of enuresis, 332 
 Phthisical habit, 94 
 Phthisis, in diabetes, 185 
 
 laryngeal, 106 
 
 Pneumonia, in diabetes, 185 
 Predisposition, hereditary neuropathic, 
 
 59 ' 
 Products of an organism, action of the, 
 
 15 ' 
 Pseudo-arthroses, formation of, 140 
 Ptomaines, 12 
 
 Purgatives, in neurasthenia, 85 
 Putrefaction, 7 
 
 Racial peculiarities, 59 
 Railway, brain, 304 
 
 spine, 303 
 
 Rhinoscleroma, 32 
 
 Baize', on healing in of foreign bodies, 
 
 109 
 Sensory disturbances in neurasthenia, 
 
 63,68 
 " Sepsin," 7 
 
 Sequestrum, effects of a, 27 
 Sexes, separation of, 20 
 Sexual excesses, 58 
 Skin, in diabetes, 168 
 
 ■ loss of, results, 28 
 
 Slate pencil, as foreign body, 115 
 Sleeplessness, in neurasthenia, 67 
 Solution of continuity in plants, 41 
 Spermatosoids, 20 
 
 Spinal cord, in fracture of spine, 
 351 
 
 morbid changes in, 349 
 
 ■ repair in, 349 
 
 treatment of disease of, 347 
 
 balneo-therapeutics in, 354 
 
 derivatives in, 369, 387 
 
 drugs in, 372, 387 
 
 electro-therapeutics in, 361, 386, 
 
 387 
 
 gymnastics in, 378 
 
 hydro-therapeutics in, 354, 388 
 
 hypnotism in, 379 
 
 literature of, 390 
 
 massage in, 378, 388 
 
 ■ nerve vibration in, 379 
 
 — — orthopoedics in, 378 
 
 rarefied air in, 378 
 
 regulation of mode of life in, 383, 
 
 386, 389 
 
 Btretching procedures in, 379 
 
 Spinal irritation, treatment of, 386 
 Spinal symptoms, in neurasthenia, 67 
 Stimulus, formative, 17 
 
 varieties of, 25 
 
 Stomach, in neurasthenia, 70 
 
INDEX. 
 
 397 
 
 Stretching procedures in disease of the 
 
 cord, 379 
 Striimpell, on traumatic neuroses, 303 
 Sugar, tests for, chemical, 176 
 
 fermentation, 179 
 
 polariscope, 180 
 
 Swarm spores, 20 
 Syphilis, 38 
 
 ■ congenita tarda, 92 
 
 of nervous system, 205 et seq. 
 
 history of, 206 
 
 treatment of, 220 
 
 Syphilitic disease of brain, 207 
 
 — — of cord, 219 
 
 of nerves, 227 
 
 Syringomyelia, 256 
 
 Tabes and syphilis, 225 
 Tendency, hereditary, 25 
 Thorns, as foreign bodies, 115 
 Tubercle, 33 
 
 bacilli, 33 
 
 forms of, 37 
 
 ■ modes of entry into body, 
 
 100 
 
 Tubercle, bacilli, stages of, 37 
 
 fibrous, 34 
 
 detritus, 36 
 
 Tuberculosis, causes of, 89 
 
 high altitudes in, 96 
 
 mortality in prisons from, 94 
 
 predisposition to, 93 
 
 social influences and, 97 
 
 Urethra, weak, a cause of enuresis, 
 
 331 
 Urine, character of, a cause of enuresis, 
 
 332 
 
 chemical examination of, 176 
 
 in diabetes, 172 
 
 irritation of, 40 
 
 Weir- Mitchell's treatment, 74, 389 
 Wood, as a foreign body, 133 
 Worms, a cause of enuresis, 333 
 
 Ziemssen, on neurasthenia, 55 
 
 on syphilis of the nervous system, 
 
 205 
 on tuberculosis, 89