56

family in Park-street, Bristol, in which two children had beenaffected one after another with intestinal fever. At my sug-gestion, a third, a little girl eight years old, who had hithertoescaped, was sent into the country to a neighbourhood whereno fever was. Here she remained for three weeks in entireseparation from her friends, and with little or nothing amiss.At the end of the third week she began to droop, and in themiddle of the fourth she was brought home with all the cha- Iracteristic marks of the fever upon her.

(c) The third and last example is taken from the outbreak ofintestinal fever which occurred at the military school of LaFleche, in 1826. In this example, the peculiarity of the circum-stances gave a scientific clearness and precision to the facts butJ .: "ly met with in medical evidence. The fever first broke out.. ie school in the month of July, and did not cease until 109students had been attacked by it. Amongst those who sufferedwere 26 who had been sent to their own homes in distant partsof France, in the vain hope that they might thus escape thedisease which was spreading amongst their comrades. These26 young men were, to all appearance, perfectly well whenthey were sent away, and continued to be so for more than aweek afterwards. In the second week they began to droop,and before the week had ended they were all laid up with in-testinal fever. As it may be considered certain that these 26subjects contracted the fever at the school, it is plain that thepoison must have remained latent in their bodies at least aweek or ten days.Of the existence in this, as in all the other contagious fevers,

of the remarkable immunity which one attack confers againstany future attack of the same malady, the evidence, althoughrequiring more pains to collect, is not less conclasive. M.Bretonneau, who was the first to draw attention to this re-markable and all-important characteristic, avers that for a

period of thirty years he had never seen an instance of thisfever occurring twice to the same person. In regard tothe same point, Chomel expresses himself in the followingterms, which, precise and decided as they are, acquire addi-tional weight from the well-known scrupulous accuracy of thewriter :-" We have already said that typhoid fever, in ordinary cir-

cumstances, only affects the same individual once. This ap-pears from all the facts hitherto recorded. From the timewhen physicians began to make special and consecutive re-searches on this malady, no authentic instance to the contraryhas been observed, although the number of cases of typhoidfever annually studied is so considerable that examples of re-currence must have been met with, had the disease been sus-ceptible of occurring more than once in the same subject.Although in interrogating our patients we have always takencare to call their attention to this point, they have never an-swered in a manner to lead us to believe that they had alreadyhad the disorder; and, after all, even were some opposite facts Inow and then found in a disease of such great frequency, afew exceptions would have nothing extraordinary in them, andwould not destroy the kind of law which has just been enun-ciated; for small-pox, scarlet fever, and measles, which ordi-narily attack the same individual once only, recur sometimes,especially in great epidemics of these disorders. It would not,therefore, be astonishing if examples of the same kind werenow and then met with in the case of typhoid fever."

Louis, who on all points relating to the natural history ofthis fever is the greatest of authorities, living or dead-whosemonograph on it is unique in medicine as a model of elaborateresearch—and whose conscientious accuracy is only paralleledby his slowness of belief, declares himself to the same effect inlanguage which is the more striking from the contrast it pre-sents to the caution with which he expresses himself on mostother subjects.+Amongst many illustrations of the fact which he cites from

Gendron de 1’Eurp, especially remarkable is the case of the IItown of Caumont, which was swept twice by an epidemic of z,this fever, with an interval of eight years between, and inwhich all the persons who were attacked with the fever in thefirst visitation were spared in the second. §

I may add that my own experience is in entire accordancewith that of these distinguished writers. For seven years, Imade careful inquiries as to the point in question in every caseof this fever that fell under my charge ; and during the whole

* See Archives Generates de 1!6define, 1st series, vol. xxi., p. 62.t Ijeons de Clinique Medicate, p. 333.T See Recherches, &c., sur ]a Maiadie connue sous les r.oms de Fievre

Typhoide, &c. Vol. ii., pp. 371, 5]6. 1st Edition.

§ see Archives Géllérales de la Medecine. 1st Series. Yol. E., p. G’2.’fl", pmpmis tpferrcd to occurred in 1820 and 182s.

of that period, although my range of observation included twogreat epidemics, in addition to a large average of fever patients,I only met with three subjects in whom there was reason tobelieve that the disease had ever occurred before. To thesethree I added a fourth in my own person shortly after.

During the same period, I was constantly meeting withpersons who, having once had the fever, remained perfectlywell under prolonged and intense exposure to its specific poison,while all around them were falling victims to it. Of suchpersons, I have many still vividly in my mind who, by thi-very accident of having acquired in this way an exemptiorwhich none around them possessed, continued to perform, forweeks, and sometimes for months together, the exhaustingand dangerous office of nurse to the other members of an in-fected household, and who, nevertheless, came out harmless.

In reference to the four who were not so fortunate, it is onlynecessary to remark, that in no one of the contagious fevers isthe protecting power of a first attack absolute. In the spaceof the same seven years, indeed, in which these cases camebefore me, I met with’five others in which small-pox happenedtwice to the same person. And yet that, as a rule, small-poxoccurs only once in life, is a fact established on a larger basisthan any other fact in medicine. The occurrence of exceptionsin the case of small-pox is, therefore, the best possible proofthat the occurrence of similar exceptions in the case of intes-tinal fever does not invalidate the remarkable law in whichboth participate.

I shall have to recur to all these points in another place. Ihave already said that their real significance cannot be doubt-ful. They define at once, indeed, the position and naturalaffinities, as well as the true pathology, of the disease to whichthey belong. For had we no other light than that which isafforded by them, we should see clearly enough that in thespecific cause of this fever we have to deal with one of thatremarkable group of poisons which, in order to produce theirspecific effects, require in the human body not only a subjectfor their action, but conditions for their growth and develop-ment. This is a conclusion of immeasurable importance to theinquiry in which we are engaged. That the operation of allthe poisons belonging to this group is entirely dependent ontheir own reproduction in the living body, may, I repeat, beinferred with great certainty from the relations on which wehave just been dwelling. But* the fact stands on even stiirsurer ground. Demonstrable in all as a matter of inference,it has actually been demonstrated in one of the number as theresult of experiment.

(To be continued.)

CASES OF PARALYSIS AS A SEQUELA OFDIPHTHERIA.

BY PETER EADE, M.D.,PHYSICIAN TO THE NORFOLK AND NORWICH HOSPITAL, TO THE

NORWICH DISPENSARY, ETC.

IT is well known to all who have had to deal with cases ofdiphtheria, that severe as is often the affection of the throatand windpipe, and dangerous and difficult to treat as this maybe, yet that this local affection is by no means the whole ofthe malady, and that the constitutional symptoms form a verylarge and important part of the morbid manifestations which itis necessary to combat. Moreover, these constitutional pheno-mena have this peculiarity, that not only do they manifesttheir presence at the outset of the disease,-often, indeed, withsuch severity as to destroy life before the local and special epi-phenomena have had time to develop themselves,-but theyalso tend to show themselves at a very advanced period, whenthe local disorder has passed away, and when, in many re-spects, the patient might otherwise be considered to haverecovered from his malady, and to have reached that periodwhen serious results were no longer to be dreaded.The influence which the diphtheric poison exerts upon the

constitutional powers appears essentially to be of a depressingcharacter, both in the earlier and later stages of the disease,

! and its effects bear a strong analogy to those of some diseases

which all allow to be produced by the introduction into thesystem of a specific morbid poison, such as scarlatina, low

fevers, and especially some of the more malignant forms of; erysipelas; but in none of these-except, perhaps, in some

57

virulent cases of scarlet fever-.do we find the nervous system pale, clear, specific gravity 1009, and free from albumen orshowing more than its due share of the depressing influence, microscopic deposit. The throat appeared to be quite well;and in none do we find that the effect upon it is sufficiently bowels regular; tongue clean, and protruded straight; appetitespecial to produce at a later period an interruption to the exer- moderately good. He was free from pain, in the head or else-cise of its peculiar functions, as shown by a more or less com- where, and had never suffered from fits ; denied spermator-plete suspension of its motor or sensory, or special cerebral rhoea or masturbation. Ordered, futi diet and a pint of porter,functions. and to take thrice daily the following draught :-Sulphate ofThe special action of the diphtheric poison upon the nervous iron, two grains; sulphate of zinc, one grain; disulphate of

system, even from the very first, appears to me to be shown in quinine, one grain; dilute sulphuric acid, five minims; water,the rapidity with which its life-destroying agency is manifested one ounce.

- an agency capable, as I have myself witnessed, in the case Dec. 10th.-Feels slightly stronger and better; can walkof an apparently healthy child, of terminating existence in rather more steadily, and has a little more power of graspingless than twenty-four hours, not from pharyngeal inflammation with the hands, but the numbness is not much diminished.and exudation, and not from laryngeal strangulation (though He is still very pale and anaemic looking. Ordered a draught,both pharynx and windpipe were found, on dissection, to be cons ng of ten grains of citrate of iron to an ounce of water,covered with an incipient false membrane), but apparently from to be taken three times a day, with the following pill; sulphatesimple vital nervous depression-a depression which has seemed of zinc, one grain; disulphate of quinine, one grain; and suffi-to me to be in many respects peculiar, and to approach nearer cient quantity of extract of gentian.to pure asthenia than anything I have witnessed in other cases 14th.—Rapidly improving; can walk much better and graspof acute disease, more strongly; sensibility is returning in both arms and legs;That this depressing influence of the poison upon the central appetite very good; urine less pale, specific gravity 1018.

sources of life continues beyond the period of the first invasion 27th.—Steadily improving; looks better, and feels muchof the disease is, I think, manifested in the sudden and appa- stronger; power of grasping with hands much greater. Reflexrently causeless sinking and death which have occasicually actions as well as sensibility in legs returning.supervened in the course of what appeared to be rapid con- Jan. 4th.-Going on well; some numbness of both handsvalescence from the acute attack; and that :L is active at a and feet still remains.still later period is shown by the occurrence of various forms of 29th.-Complains only of a very slight numbness of theparalysis at a period of some weeks from the date of the first right foot; in other respects he is quite well Dischargedseizure with the disease. cured.These observations have been induced by a consideration of CASE 2.-William N—, aged seventeen, by occupation a

the following cases (as well as of others), which have lately groom, was admitted by me as a patient of the Norfolk andoccurred in my own practice, and which tend, I think, to show, Norwich Hospital on April 2nd, 1859. He states that atthat the later nervous phenomena there recorded are not due Christmas last he was seized with sore-throat, which he wasto mere poverty of blood-to spaneemia induced by the pre- told was diphtheria ; that he recovered from this in about three,ceding disease-but that they are due rather to the presence in weeks, and returned to his work, but that after a fortnight hethe system throughout all its stages of a peculiar morbid poison, was obliged to give it up again by reason of weakness of hiswhose special affinity is for the nervous tissues, its action upon limbs. His legs (he says) were first affected, becoming gra-which is shown, in the first instance, by the general vital de- dually numb, and incompetent to any exertion without greatpression, and subsequently by a more or less complete suspension and rapidly supervening fatigue. At this time he had a littleof the function of particular nerves or systems of nerves. pain at the back of the neck, but in no other part. About aWe do not find that similar forms of paralysis result from fortnight afterwards the legs and hands also began to feel numb

extreme anemia, however induced, whether by haemorrhage, and weak, so that soon he could hardly feel anything he touched,by the presence of disease of the kidney, or by chlorosis, or that and was unable to hold even a cup without using both hands.it occurs in convalescence from other exhausting or depressing Now also the face (cheeks and nose) began to feel numb. Be-

maladies, the result of animal poisons; and therefore it follows sides this he has felt very weak, but has always had a goodthat something is required to explain these effects beyond the appetite, and has not suffered from dyspepsia, lowness ofordinary impediments to the blood-making powers which such spirits, want of sleep, or irregularity of bowels or bladder. Hasdisorders create, which something is theoretically explained never been laid up with rheumatism or other severe illness.by supposing the specific poison to be of such a nature as to He adds that three of his brothers and sisters suffered fromhave a peculiar and special as well as destructive affinity for sore-throat before he was attacked, and that one, a brother.nervous tissue. aged twenty-three, suffered afterwards for about a week fromThe attention of the profession has already been called to the slight numbness of both legs and hands, but that he soon re-

occurrence of paralysis, either local or more or less general, as covered. The patient has been under medical treatment, butan occasional sequela to diphtheria, during its present outbreak the numbness and muscular weakness have continued to in-in this country, by Drs. Gull, Kingsford, Sanderson, Mr. Dixon, crease up to the present time.and others; but as everything relating to, or illustrative of, the His present condition is as follows :-He is by no meansnature of this scourge is at the present moment of the greatest thin ; countenance fresh and cheerful ; pupils not dilated ;interest and importance, I make no apology for laying before tongue protruded straight. He complains of numbness of thethe readers of THE LANCET a brief report of the annexed four whole of both the lower extremities, and of the arms s high ascases, in which a more or less complete state of general paralysis the middle of the forearms; there is also, in a less degree.was present, and in all of which this lesion had supervened numbness of both cheeks and of the nose. The power of grasp-.during convalescence, or even after apparent recovery. ing with the hands is much diminished, the loss of volition

CASE 1.—James G-, aged seventeen, husbandman, ad- being equal on the two sides. He straddles in his walk, movesmitted a patient of the Norfolk and Norwich Hospital, under slowly, and is evidently unable to gnide his legs correctly.my care, November 27th, 1858. He states that about ten Reflex actions are lively when the soles are pricked with aweeks ago, and shortly after being discharged from the county sharp pen, but can scarcely be excited by any stimulation ofprison, he was attacked with diphtheric sore-throat, which was the skin with a blunt instrument. The trunk appears to bethen prevailing in the district in which he lived. On recover- unaffected. He says he is quite free from pain. and, but foring from this, at the end of about a month (being then merely this weakness of the limbs, would feel quite well. Pulse 88.suffering from some remaining debility), he began to complain soft and weak; heart’s sounds sharp and clear; a moderately-of numbness and weakness of the arms and legs, and, to a rough systolic bruit is audible over the base of the heart; 3slighter extent, of the whole trunk. For these symptoms he throat slightly relaxed, but not sore; appetite good; bowelshas been under medical treatment, but without benetit, to the regular; urine free, sherry-coloured, specific gravity 1025,present time. acid, and free from albumen. Ordered full diet with beer-On admission, he was found to be well and robustly formed, Sulphate of zinc, one grain ; water, one ounce: make into a

but pale and weak. He complained chiefly of debility, and of draught, to be taken three times a day.numbness and want of muscular power in all the limbs. His April 8th.—Rather better; has more power of grasping withpower of grasping with the hands was very slight, but rather the hands, and walks rather stronger; numbness much thegreater in the right than in the left hand. He waddled in his same. The zinc to be increased to two grains for a dose.walk, but did not drag either leg. Reflex actions almost 19th.-Says he has rather more feeling in the hands, andabsent; sensibility very slight in both lower limbs, as well as rather more power over the muscles of both arms and legs, butin both hands and arms; the skin of the whole trunk felt sensation in the feet is not much greater than on admission.slightly numb; pupils dilated; pulse soft and weak; a soft Citrate of iron, ten grains ; water, one ounce: make into asystolic murmur wa :heard over the base of the heart; urine I draught. to be taken three times daily, with the following pill:

58

Sulphate of zinc, two grains; sulphate of quinine, one grain ; the bands; numbness of face gone, and diminished in left handwith sufficient quantity of extract of gentian. and arm; bowels still very obstinate; pulse has again fallen toMay 13th.-Has been steadily and rapidly improving since 60, and is very weak. To have a pint of porter daily.

the change of medicine. He can walk well, has little or no 13th.—Much better; pulse fuller and stronger; numbnessnumbness, and complains of nothing but a slight feeling of and weakness fast disappearing.weakness in one ankle. There is no longer any murmur to be 23rd.—Numbness, &c., all gone, except from tips of fingersheard with the heart’s sounds. and toes; he is rapidly improving in all other respects; bowels

20th.-Discharged, cured, and quite well in all respects. still costive. Made an out-patient, and ordered to continue hisCASE 3.-Henry G---, aged twenty-seven, a farm labonrer,

medicines.CASE 3.-Henry G—, aged twenty-seven, a farm labourer August 18th.—Reports himself quite well, except that rarelyadmitted an out-patient of the Norwich Hospital on the 4th of he has a little numbness at the end of his toes; looks fat andJune 1859. States that four months ago, he suffered from florid and well; bowels now act regularly without medicine.sore-throat, which he was told was diphtheria, and for which Discharged cured

bowels now act regularly without medicine.

he took medicine, and had caustic applied locally. Several Discharged cured.he took medicine, and had caustic applied locally. Several The last case I have ventured to class with the others, be-other persons, his neighbours, were similarly affected at the cause although the man gave no history of sore-throat (indeedsame time. In about ten weeks, and just as he began to con- he was not questioned about it, as at that time I had no sus-sider himself well and able to go to work, he began to feel a picion of the possible connexion of paralysis with diphtheria),weakness, with numbness and tingling in his fingers and feet. yet the symptoms he presented are so similar to those observedThis continued to get worse, gradually extending as high as in the others, and are on any other supposition so anomalousthe knees and elbows, for about a month, since which time it and inexplicable, that, coupled with the fact that he came fromhas been stationary, and it is now his only complaint. In the same district, where even then diphtheria was prevailing,other respects he appears to be quite well, has a good com- there can, I think, be no reasonable doubt of their commonplexion, is well nourished, has a good appetite, &c.; pulse soft origin; the chief difference being that in his case the stress ofand weak. He states that he has suffered no privation, and the disease fell very slightly (or not at all) upon the throat-knows of no cause for the present symptoms; he has taken no just as is soon a many cases of scarlatina,-its efficient causemedicine since their accession. Ordered, liberal diet, with manifesting its presence in the first instance only in someporter; and the combination of citrate of iron with zinc and slight general disturbance of the system, though at a laterquinine, as in the former cases. period producing the extensive nervous lesions above described.July 7th.-Reports himself as nearly well. Has continued On looking more closely at the details of these cases, it willto take the same medicines, and has been gradually improving be seen that certain variations or points of difference exist inever since his admission. He states that the return or power all of them, but that these chiefly refer to the extent or amountin the arms and hands has all along been in advance of that in of the lesion, and in a less degree to its seat. They are no-.the lower extremities. greater than may be accounted for by the habits, circumstances,CASE 4.—James R—, aged sixty-three, husbandman, also or temperaments of the individuals; by the condition of health

a patient of the hospital, admitted, under my care, June 12th, previous to the attack; the dose or intensity of the poison im.1858. States that he is a married man, of regular and tem- bibed, or the treatment which had been employed.perate habits, and alwavs enjoyed excellent health until In all the cases, the spinal system was the one which wasJanuary last, when he was laid up for a month with influenza. especially affected. In two, the fifth nerve appeared also toFrom this he speedily recovered, resumed his usual employ- be involved. In only one was the sensorium proper at all im-ment, and remained quite well until about two months ago, plicated. In none of them could the intellect be considered towhen he caught what he considered to be a bad cold. He now be impaired. In one case there were dilatation of pupils, pallortook a little medicine, but was not compelled to discontinue of countenance, and urine of low specific gravity; but thesework, and in about a fortnight got quite well again. He was were probably due to the fact that in this case the diseasethen seized with numbness in his hands and feet, preceded for attacked the patient just after his discharge from jail, wheretwo or three days, but not accompanied by, vague pains in the he had been subjected to the depressing influence of confine-back and elsewhere (which he attributed to extreme constipa- ment and prison discipline, as a result of which ordinarytion of the bowels). Since that time, the numbness has in- anemia was doubtless superadded to his other ailment. In allcreased in both arms and legs, and there has also been con- the other cases, pallor &c. were absent, the complexion of thesiderable and increasing loss of power in all the limbs. He has patients being fully as high as natural. All the patients werebeen under medical treatment, has been bled and galvanized, males.and has taken mercury, without any impression having been The affection appeared readily to yield to nervine tonics,made upon his disease. Knows of no special cause for the especially full doses of iron combined with other tonic medi-attack ; has not suffered from gout or rheumatism, nor been cines, and liberal diet.exposed to the action of lead; has neither been over-worked In conclusion, I would observe that the phenomena producednor starved, by the presence of the diphtheric poison in the system appear

Present state.—Complains of loss of feeling and strength in to be separable into two distinct classes: the one referable tothe forearms and hands, and in the feet and legs as high as the the throat and air-passages, and showing themselves in themiddle of the calf; at times he has slight snatching of both irritation and familiar membranous exudation upon these parts;arms and legs ; the reflex actions are nearly absent; gait stiff the other referable to some special chemical influence exertedand trembling; has but little power of grasping with either hand; upon the nervous matter, which shows itself in the first in-

slight numbness around the mouth; is drowsy; taste slightly stance (a) by depression of this system, in common with (anddiminished ; tongue protruded slightly to right side; intellect probably as the primary cause of that of) the other powers ofunaffected; has no pain of head or elsewhere; heart’s sounds life; (b) during the whole of the acute stage of the disease, byweak, but free from murmur; lefc radial pulse stronger than the relaxed and often perspiring skin, the feeble pulse, the list-right ; pulse 60, soft and full; bowels extremely costive, and less and often indifferent manner, &c. &c.; (c) at a later period:"acted upon with difficulty; sphincters unaffected; appetite by the occasional rapid and sudden sinking when the patientgood; sleeps well; has a good colour in his face, and looks well appears to be steadily progressing towards convalescence; (d)nourished; urine free from albumen, and otherwise normal at a still later date, by the occurrence of various degrees qfOrdered, a draught, consisting of one drachm of solution of palsy even after convalescence may have been fairly estab-bichloride of mercury, and one ounce of infusion of cinchona, lished.three times a day. Also, two pills, composed of eight grains And in reference to the light reflected upon the nature ofof compound extract of colocynth, and a quarter of a drop of the disease by the results of treatment, I would say, that as allcroton oil, every night. appear to be agreed that this, even in the early stages of theJune 18th.—Much the same. To have full diet. malady, should be tonic, and in every way such as to stimulate28th.-There is very little alteration since his admission. and support flagging nervous power, so the fact that these

The numbness and weakness of the limbs, and the absence of forms of palsy which occur during convalescence-after failingreflex actions, remain as on admission; pulse still very weak; to get well with alteratives or when left to the unaided powersbowels obstinate. Ordered, a draught, consisting of disulphate of nature-readily yield to the influence of the nervine tonics,of quinine, one grain; sulphate of zinc, one grain; sulphate of such as steel, zinc, and quinine, is a further proof of what Imagnesia, half a drachm; dilute sulphuric acid, ten minims; have endeavoured to illustrate: that the diphtheric poison iswater, one ounce,-to be taken three times a day. essentially a nerve poison, one of the effects of which-and

July 2nd.-Decidedly better; pulse firmer, 72; is no longer that not the least important-is its power of destroying ordrowsy, and has regained a little muscular power in the hands. preventing the evolution of nervous force.

6th.—Walks better, and has more power of grasping with Xorwich, July, 1859.