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 THE NEW SYDENHAM 
 
 SOCIETY. 
 
 INSTITUTED MDCCCLVlll. 
 
 VOLUME CXII.
 
 1
 
 HANDBOOK 
 
 as 
 
 GEOGRAPHICAL AND HISTORICAL 
 
 PATHOLOGY. 
 
 BT 
 
 DR. AUGUST HIRSCH, 
 
 Professor of Medicine in the University of Berlin. 
 
 Vol. II.— Chronic Infective, Toxic, Parasitic, 
 Septic and Constitutional Diseases. 
 
 TRANSLATED FROM THE SECOND GERMAN EDITION 
 
 BT 
 
 CHARLES CREIGHTON, M.D. 
 
 LONDON^ 
 THE NEW SYDENHAM SOCIETY. 
 
 1885. 
 
 1\A .\-i.^
 
 U1 
 
 PBINTED BY J. E. ADLAED, BAETHOLOMEW CLOSE.
 
 n' 
 »* 
 
 CONTENTS. 
 
 Chronic Infective Diseases. 
 CHAPTER I. 
 
 Leprosy in Ancient and Mediasval Times— Present Distribution 
 
 PAGES 
 
 of Leprosy — The Etiology much obscured by Narrow Hypo- 
 theses—Influence of Climate— Question of a Special Relation 
 to the Sea Coast— Influence of Fish as the Staple Food- 
 Influence of Insanitary Conditions — The Doctrine of a 
 Specific Infective Yirus — Question of Contagiousness — The 
 Influence of Heredity— Special Liability of the Negro and 
 other Races — Acquired by Europeans who had resided in 
 Leprous Localities Abroad— The Anaesthetic and Tuber- 
 cular Varieties ..... 1—58 
 
 CHAPTER II. 
 
 SYFMILIS m 14-25). 
 
 Antiquity of all the forms of Venereal Disease — The Great Epi- 
 demic of Syphilis in the end of the Fifteenth Century — The 
 Characters of Syphilis in the Great Epidemic — Venereal 
 Disease in Former Times in other parts of the World — Pre- 
 sent Distribution of Syphilis — Has spread over the Globe 
 through the Conveyance of a Virus — Severity of Type not 
 specially affected by Climate— Alleged unfavorable Influ- 
 ence of Altitude — Immunity from Syphilis in certain 
 Countries and among certain Races — Influence of Police 
 Surveillance— Remarkable Epidemics and Endemics of 
 Syphilis— The Origin of the Great Fifteenth-Century 
 Epidemic . . . • • 59" 'oo
 
 Yl CONTENTS. 
 
 CHAPTER III. 
 
 TAWS (FIAN), BUTTON SCURVY, AND VERRUGA PERUVIANA 
 
 (§§ 26-37). 
 
 PAGES 
 
 Nosological Characters of Taws — History and Geography of 
 Yaws — Native Habitats of Taws — Taws a Disease of the 
 Tropics — Taws not accounted for by Defective Hygiene — 
 Contagiousness of Taws — Inherited and Racial Pi-edispo- 
 sition — One Attack usually gives Protection but not invari- 
 ably — Literature of Taws, 
 
 Button Scurvy of Ieeland. — Characters of Button Scurvy. 
 
 The Peruvian Wart (Verruga Peruviana). — History and 
 Characters of Verruga — Endemic Circumstances of Ver- 
 ruga — Verruga a Disease due to a Specific Cause — Etiology 
 of Verruga ..... loi — 120 
 
 CHAPTER IV. 
 
 ENDEMIC GOITRE AND CRETINISM (§§ 38—54). 
 
 Historical References — Geographical Distribution — Instances of 
 Decrease or Increase in Recent Times — Epidemic outbreaks 
 — Independent of Climate, Season, or Weather — Influence 
 of Locality — Influence of Altitude and Configuration — Rela- 
 tion to the Geology and Mineralogy of the Locality — In- 
 fiuence of Wet Soil — Connexion with Limestone, and with 
 Magnesian in particular — Difi^ei'ences of Liability according 
 to Race— Neglect of Hygiene a predisposing Cause — Theory 
 of Increased Vascular Pressure within the Thyroid — How 
 far caused by the Drinking- Water — Theory of Deficiency of 
 Iodine in the Air and Water — A pair of Infective Diseases 
 due to a Morbid Poison — Relation of Cretinism to Goitre of 
 the Parents ..... 121 — 202 
 
 Toxic Diseases. 
 
 CHAPTER V. 
 
 ERGOTISM (§§ 55-59)- 
 
 Historical Notices of Ergotism — Two Forms of Ergotism dis- 
 tinct in Time and Place — Geographical Distribution of 
 Ergotism — Conditions favorable to the Growth of Ergot on 
 Rye — Mostly a Disease of the Poorer Peasantiy and of 
 Children in particular . . . 203 — 216
 
 CONTENTS. vii 
 
 CHAPTER VI. 
 
 PELLAGRA AND ALLIED DISEASES (§§ 60—74). 
 
 PAGES 
 
 Symptoms and Morbid Anatomy of Pellagra — History and Pre- 
 sent Distribution — A Recent Disease of the Peasantry, 
 limited to a few Regions— Not distinctively caused by Poor 
 Living — Evidence tbat it is due to Damaged Maize — Not 
 dependent on the Low Nutritive Value of a Maize Diet — 
 Due to Maize Cultivated and Harvested under Unfavorable 
 Circumstances — A Bad Maize Harvest is followed by an 
 Increase of Pellagra — The Pellagra-Poison : Experimental 
 Evidence — Affinities to Ergotism — Objections to the Maize- 
 Theory answered — Not Contagious ; doubtfully Hereditary 
 — List of Authorities on Pellagra. 
 
 ACRODYNIA (MAL DES PIEDS ET DES MAINS, ERYTHEME EPIDE- 
 
 mique). — Clinical Characters. Historical Outbreaks— Affi- 
 nities of Acrodynia with Ergotism and Pellagra : the Food 
 Suspected. 
 Pelade or the Colombian Maize-Disease. — Toxic Effects 
 
 of Ergot of Maize on Men and Animals . . 217 — 253 
 
 CHAPTER VII. 
 
 MILK-SICKNESS AND THE TREMBLES (§§ 75—82). 
 
 " The Trembles," an Enzootic Disease of Cattle in the United 
 States— Historical Notices of the Trembles— Nature of the 
 Localities where the Trembles break out— Poor or Fallow 
 Land favorable to the Trembles— The Trembles probably 
 due to a Toxic Substance in the Pasture—" Milk -Sickness" 
 in Man corresponding to the Trembles in Cattle — Evidence 
 of Poisoning by the Milk or Meat— Other Explanations of 
 Milk-Sickness. Similar Observations at Malta . 254—263 
 
 CHAPTER VIIL 
 
 ■ "ENDEMIC COLIC" (§§ 83—88). 
 
 Definition of the Subject— Historical Outbreaks mostly proved 
 to be Lead-Colic -The "Dry Bellyache " of the Tropics— 
 Always caused by Lead— The " Colique Seche" of Steamships 
 of the French Navy— Review of Objections to the Doctrine 
 of Lead-Colic on board Steamships . . 264—278
 
 viii CONTENTS. 
 
 Parasitic Diseases. 
 
 CHAPTER IX. 
 
 ANIMAL PARASITES (§§ 89—134). 
 
 I. Cestodes. — Tffinia Mediocanellata — Taenia Solium — Distribu- 
 
 tion of T. Mediocanellata and T. Solium corresponds with 
 a Popular Diet of Beef and Pork respectively — Botlirio- 
 cephalus Latus — Bothriocephalus associated with the Shores 
 of Seas or Lakes — Echinococcus — Echinococcus the Larva 
 of a Tasnia infesting the Dog. 
 
 II. Trematodes. — Distoma Hsematobium. Endemic Hsema- 
 
 turia of Egypt and South Africa — Mode of Access of Distoma 
 Hgematobium to the Human Body — D. Hasmatobium mostly 
 affects Males and principally Boys — D. Ha3matobium com- 
 monest in Summer. 
 
 III. Nematodes. — Ascaris Lumbricoides — Mode of Access of 
 A. Lumbricoides to the Human Body — Parasitism of Ascaris 
 probably favoui'ed by climatic Heat and Moisture — Oxyuris 
 Yermicularis and Trichocephalus Dispar — Trichina Spiralis : 
 its Discovery— Earlier Cases of Trichinosis. Present Dis- 
 tribution — Life-History of the Trichina Parasite. Anoma- 
 lous Distribution of Trichinosis. 
 
 Anchylostoma ditodbnale and the Anemia associated 
 WITH it. — Symptoms of the Cachesie aqueuse of West 
 Indian Negroes — Geographical Distribution of Cachexie 
 aqueuse — The Cachexia proved to be associated with Anchy- 
 lostoma duodenale — Circumstances favorable to the Intro- 
 duction of the Parasite — List of Writers on Anchylostoma 
 duodenale. 
 
 Anguillula steecoralis and the Endemic Diarrhoea 
 OF Cochin China. — Question of the Relation between the 
 Diarrhoea and the Parasite. 
 
 FiLARiA SANGUINIS HOMINIS. — Importance of Lewis's Dis- 
 covery — History of the Researches on Endemic Hsematuria 
 and Chyluria— Life-History of Filaria : the Mosquito its 
 Intermediate Host : Periodicity of the Phenomena — Geogra- 
 phical Distribution of Filaria sanguinis — List of Authorities 
 on Filaria sanguinis hominis. 
 
 Guinea-Worm (Filaria medinensis, Dracunculus medi- 
 NENSis). — History of the Pathology of Dracontiasis — 
 Geographical Distribution of the Guinea- Worm — Relation 
 of Dracontiasis to Heat and Moisture — Alleged Preference 
 of Dracunculus for Certain Soils — No Racial, Social, or 
 
 PAGES
 
 CONTENTS. ix: 
 
 FAQE3 
 
 other Immunity from Dracontiasis— Larval "Worms in 
 . Water corresponding to Guinea- Worm— Evidence for and 
 against the Entrance of Dracunculus with the Drinking- 
 Water and through the Skin respectively — Guinea- Worm has 
 followed the African Negro to America and elsewhere— 
 List of Writers on Guinea- Worm. 
 IV. Insects.— Geographical Distribution of Sarcoptes Scabiei, 
 the Itch Insect — Want of Cleanliness the Single Favouring 
 Condition for the Itch. 
 
 Sandflea (Pulex, Rhynchoprion penetkans). — Geogra- 
 phical Distribution of Sandflea— Instances of the Sandflea 
 in Europe— Sandflea acquired in Filthy Huts and Piggeries 
 in the Tropics— Sandflea enters Houses in the Rainy Season 
 — Persons most liable to Sandflea. 
 
 DiPTERA. — Larva3 of Flies in the Nasal Passages — Larvaj 
 found in the Nasal Passages belong mostly to Tropical Species 
 — Bots in the Human Subject . • . 279 — 371 
 
 CHAPTER X. 
 
 PARASITIC fItNGI (§§ 135—146). 
 
 Pityriasis Versicolor and Favus — Herpes Tonsurans or Ring- 
 worm — Gune, Tokelau Ringworm (Lafa Tokelau), and 
 Cascadoe — Relation of these Local Varieties of Ringworm 
 to Herpes Tonsurans. 
 
 Mal de LOS PINTOS. — Clinical Characters of the Pinta Disease 
 — History of the Piuta Defective — Present Geographical 
 Distribution of the Pinta — Predisposing Causes — Due to a 
 Fungus in the Rete Mucosum — A Communicable Disease — 
 Other Tropical Discolorations of the Skin — Dubious In- 
 stances of Spotted Skin . . • 372 — ^^^ 
 
 Infective Traumatic Diseases. 
 CHAPTER XI. 
 
 ERYSIPELAS (§§ 147—158). 
 
 History of the Term " Erysipelas." Definition of the Disease- 
 Mostly a Disease of the Temperate Zone — Endemics and 
 Epidemics, mostly in Hospitals^Epidemics complicated-, 
 with Throat- Affection— Remarkable Series of Epidemics in 
 North America— Influence of Climate— Influence of Season 
 
 VOL. 11. ^
 
 CONTENTS. 
 
 PAGES 
 
 and Weather — Alleged Influence of Damp Soil — No Racial 
 Immunities — Breaks out both in Insanitary and Clean 
 Hospitals — The Morbid Poison — a Micrococcus — Point of 
 Origin — Mode of Transmission . . . 389 — 415 
 
 CHAPTER XII. 
 
 PUERPERAL FEVER (§§ 159—171). 
 
 The Modern Doctrine started by Semmelweiss and continued by 
 Hirsch — Puerperal Fever in former Times — Present Distri- 
 bution — Epidemic Outbreaks — Epidemics most frequent in 
 Cold and Wet Weather — The Influence of Cold Weather an 
 indirect one — Kind of Soil of no Account — Specially a 
 Disease of Lying-in Hospitals — Relation to over- crowding 
 in Lying-in Hospitals — Evidence against the theory of a 
 Miasmatic Origin — Evidence of the Transmission of Infec- 
 tion — Relation to Micro-organisms — Causal Connexion with 
 Erysipelas — List of Writers on Puerperal Fever . 416 — 475 
 
 CHAPTER XIII. 
 
 HOSPITAL GANGRENE {^^ 172—176). 
 
 Historical Outbreaks. Present Geographical Range — Depend- 
 ence on Climate and Weather — Often associated with an 
 Overcrowded and Unwholesome State of the Hospitals, but 
 not always so — A Communicable Disease due to a Morbid 
 Poison — Relation to Erysipelas, Puerperal Fever, and Diph- 
 theria ..... 476 — 491 
 
 Chronic Disorders of Nutrition. 
 
 CHAPTER XIV. 
 
 CHLOROSIS AND AN.EMIA (^^ i 'J 'J— iSs). 
 
 Vague Statements on the Connexion of Anajmia with CiviUsa- 
 
 tion. 
 I. Chlorosis. — References in Ancient and Mediaeval Writings 
 
 -^Present Distribution : Remarkable Extension in Sweden 
 
 of late — Independent of Climate, Soil, and Race — Mostly a 
 
 Malady of Women leading an Indoor Life.
 
 CONTENTS. Xi 
 
 PAGES 
 
 II. Anemia Intkrteopica..— The General Ansemia of the 
 
 Tropics. 
 
 III. Anemia Montana (Mal des Montagnes).— Symptoms of 
 Mountain Sickness — Localities where Mountain Sickness 
 has Occurred — Theories of the Cause of Mountain Sickness 
 
 492—506 
 
 CHAPTER XV. 
 
 SCURVY {^^ £86—199). 
 
 Neglect of Historical Research on Scurvy — Criticism of the 
 supposed references to Scurvy in ancient writings — Histo- 
 rical Epidemics. The " Scorbutic Constitution " of Former 
 Times a Myth — Present Area of Prevalence — Outbreaks at 
 Sea — Question of the Influence of Cold and Wet — The Kind 
 of Soil of no Account — Influence of Overcrowding and of 
 Impure Air— Caused by want of Fresh Vegetables — Scurvy 
 under Exceptional Circumstances — Attempts to prove a 
 Miasmatic, Infective or Contagious Origin for Scurvy. 
 
 The Ponos (or " Pain ") of the Islands op Spezza and 
 Hydra. — Clinical Characters and Morbid Anatomy of 
 '■ Ponos " — a Constitutional Disease of Infancy — History of 
 "Ponos" — Circumstances under which "Ponos" occurs — 
 List of Writers on Scurvy . . . 507—568 
 
 CHAPTER XVI. 
 
 BERIBERI {^ 200—211). 
 
 Clinical Characters. The Paralytic and the Dropsical Form — 
 Historical References — Present Area of Distribution — In- 
 fluence of Climate and Season — Intimate Association with 
 the Sea Coast— Occurs mostly in Adult Males, Native 
 and Acclimatised, and in those of Good Physique — Seden- 
 tary Occupations predispose to it — Influence of Over- 
 crowding and Want of Ventilation— Evidence of a Dietetic 
 Causation — Various Theories of the Nature of Beriberi — 
 The Cause of it a Specific one— Leading Indications for the 
 Etiology — No Evidence of Communicability— List of Writers 
 on Beriberi ..... 569—603
 
 ^11 CONTENTS. 
 
 CHAPTER XVII. 
 
 SCROFULA (,^%.2\2—2i&). 
 
 PAGES 
 
 Historical References to Scrofula — Present Geographical Distri- 
 bution — Influence of Climate and Change of Residence — 
 Question of the influence of a Wet Soil — Evidence that it is 
 due to Dietetic and Hygienic Errors — To a great extent 
 inherited, but not necessarily from Scrofula in the Parents 
 — No Evidence that it is Inoculable along with Vaccinia or 
 otherwise . . . . . 604 — 641 
 
 CHAPTER XVIII. 
 
 'diabetes (§§ 219—222). 
 
 Defective Historical Record — Earliest References to Diabetes — 
 Area of Prevalence mostly within the Tempei-ate Zone — 
 Etiological Questions .... 642—647 
 
 CHAPTER XIX. 
 
 OOUT (§§ 223—228). 
 
 Copious i-eferences to Gout in Ancient Literature — Present Geo- 
 graphical Distribution. Rare in the Tropics — High Degree 
 of Heredity — Connexion with Luxurious Living ; exceptions 
 both Positive and Negative — Influence of Season and 
 Climate — Doubtful Influence of Race . . 648—665 
 
 INDEX . . . . .667
 
 GEOGEAPHICAL 
 
 AND 
 
 HISTOEICAL PATHOLOGY 
 
 T 
 
 CHAPTER I. 
 LEPROSY. 
 
 § I. Leprosy in Ancient and Medieval Times. 
 
 TuE word " leprosy," with its colloquial equivalents^ 
 among tlie various nationalities of antiquity and the middle 
 ages, was used during those periods in a collective souse, 
 in the same way as the word ^' plague " was used ; just as 
 the latter included the most various diseases that occurred 
 in epidemics and ran an acute course, so, under leprosy 
 were embraced a number of chronic morbid processes, which 
 had this much in common, that their most conspicuous 
 symptoms were affections of the skin. And just as we are 
 nowadays hardly able, with any certainty, to resolve into its 
 elements the " plague " of antiquity and the middle ages, as 
 described for us in the contemporary writings, and to decide 
 
 1 Elephantiasis (of Llic Greeks), Lepra (of the Arabians), Morpha-a (of the 
 physicians of mediajval Christendom), Maalzey (the oUlcst German nninc). 
 Of later designations in various countries, which are still current in part, 
 I mention the following: Ladrerie (France), Aussatz ((Jermany), Melaatscheid 
 (the Netherlands), Gafedad (Spain, where there is also the provincial name of 
 Rosa Asturiensis), Gafeira (Portugal), Lilithra (Iceland), Spcdalskhcd (Norway), 
 Spetelska (Sweden), Kushta (India), Ngerengere (New Zealand), Morfea (Mexico), 
 Mai rouge de Cayenne, Kakobc and Boasi (Surinam). 
 
 VOL. II. 1
 
 2 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 in eacli particular case whether it is really with bubo-plague 
 that we have to do, or some other ej^idemic disease, and, if 
 so, what other ; we have a similar difficulty in extracting 
 from the notices and sketches of " leprosy " that have come 
 down to us from ancient and mediaeval times any safe con- 
 clusion as to what is implied in each case under that very 
 comprehensive term. This much, at least, we may infer 
 from them, that venereal, scrofulous, and other skin troubles 
 due to constitutional illness, had a place beside leprosy 
 proper, as well as lupus, scabies, eczema, psoriasis, and other 
 local cutaneous diseases. Keeping, then, that point of 
 criticism in view, the history of leprosy in antiquity and the 
 middle ages may be represented somewhat as follows. ^ 
 
 The earliest accounts, that are at all reliable, of the occur- 
 rence of the disease on extra-European soil date from the 
 time of the Exodus of the Israelites from Egypt, the 
 wanderings in the Desert and the establishment of their 
 power in Palestine. The inference that leprosy had been 
 endemic in Egypt from the I'emotest times, would appear to 
 be all the more warranted, inasmuch as all subsequent 
 chroniclers speak of Egypt as the home of the disease, or, 
 at any rate, as its headquarters. ~ An antiquity hardly 
 inferior to this appears to belong to the leprosy of India and 
 perhaps also to that of China ; and, if we may discover no 
 indication of it in the statements by Herodotus ^ and Pau- 
 sanias* as to the XevKi] of Persia in the sixth and fifth cen- 
 turies B.C., yet, in Japan, according to the unanimous accounts 
 of the chroniclers, it must have appeared as early as the 
 thirteenth century B.C. (between 1234 and 1250).^ 
 
 ^ For the history of leprosy, see the following : Raymond, ' Histoire de 
 I'Elephantiasis,' &c., Lausanne, 1767; Hensler, ' Vom abendliindischen Aussatze 
 im Mittelalter,' Hamb., 1790 (1794) ; Danielssen et Boeck, ' Traite de la spedal- 
 skhed,' Paris, 1848 ; Munro, ' Edin. Med. Journ.,' Sept., Nov., 1876, and March, 
 1877 J Haser, 'Lehrb. der Geschichte der Med. u. cpid. Krankheiten,' 3rd. ed., 
 Jena, 1876-82, iii, 70, 
 
 - See the remarks, in the sequel, on the history of leprosy as given by the 
 Greek and Roman writei's. Brugsch ('Histoire d'Egypt,' Leipzig, 1875, p. 42) 
 has fouixl, in the papyrus discovered by him, that "leprosy" is mentioned as 
 early as the reign of Husapti, the 5th King of Egypt, having been prevalent, 
 therefore, 2400 years before the Christian era. 
 
 3 Iffropiuiv,], 38, ed. Stein, Berl., 1856, i, 115. 
 
 * Bi'oi TrapdXXijXot, ed. Reiske, v, 490. 
 
 5 Schmid, ' New York Med. Rec.,' 1869, July, p. 194.
 
 LEPROSY. 3 
 
 In several passages of tlie Bible/ mention is made^ under 
 the name '' Saraat/^ of a disease whicli was pre-eminently 
 a skin disease, as appears from the minute account of the 
 symptoms in Lev. xiii. In this passage it comes out in the 
 clearest manner that the word " saraat " is used to describe 
 morbid states of the skin of various kinds, inasmuch as 
 those affected with it were designated " clean '^ or " un- 
 clean " according to the type of the disease and the pheno- 
 mena accompanying it. But that the word was used in a 
 quite general sense is still more obvious from the fact that, 
 in other passages/ " saraat in the garment " is spoken of, 
 and " saraat in the walls of the house, '^ The word " saraat " 
 means originally ''^ stroke ^^ {Schlag, Ger.), and in the passive 
 sense also, " stricken,^^ or " felled '' (in Arabic the word for 
 epilepsy or the " falling sickness " comes from the same root 
 " saraa '^ = to throw to the ground). In its application in the 
 passages above quoted, it corresponds clearly, therefore, to 
 the German term Ausschlag, and the rendering of "saraat'^ by 
 Jnssatz is justified only in the sense in which the latter name 
 was given in former times to all kinds of " deposits " [Nieder- 
 schlage), spots, and the like on the skin, the word Aussatz, 
 in the sense of an eruption, surviving in the vernacular 
 speech even to the present day in many parts of Lower 
 Germany. That leprosy, in our sense of the word, is con- 
 tained in this " saraat," along with other diseases, is highly 
 probable ; but there can be even less doubt that the term 
 comprehends many other skin diseases, such as psoriasis, 
 scabies, and eczema, and perhaps also syphilitic affections.^ 
 
 Reliable information as to the antiquity of leprosy in 
 
 1 Lev. xiii, Numb, xii, lo, IL Kiugs, v, IL Chron. xxvi, 19. 
 
 ^ Lev. xiii, 47, aucT xiv, 39. 
 
 ^ Finaly ('Arch, fiir Dermatol.,' 1870, ii, 125) is of opinion that the passage in 
 Leviticus where the description of " saraat " occurs, is wrongly interpreted, inas- 
 much as the Avord " basar," which is used to siguify the part of the body allcctod 
 with " saraat," is rendered by " skin " or " flesh," whereas it is employed tlicre in a 
 derivative sense, being a euphemism for " membrum virile." Whatever is said, 
 accordingly, of the disease, has reference solely to " penis," and " saraat " is no 
 other than " syphilis." Scligmann, the historian of medicine, and a tliorough 
 master of the Semitic tongues, remarks on this conjecture (' Jahresber. iiber die 
 Fortschritte in der Medicin,' 1870,!, 169): "Whether the dermatologists take 
 Finaly for a Hebraist, or the Hebraists look on him as a dermatologist, we have 
 had no more remarkable piece of medico-biblical exegesis thau this."
 
 4 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 India is given in "Wise's ' Commentary/^ where tlie linea- 
 ments of tlie disease, although obscured by other skin 
 diseases, are still clearly recognisable. These commentaries 
 are based upon the writings of Charaka and Susruta ; 
 so that we can trace leprosy in India back to the 
 seventh century B.C. Indications of the disease, which 
 has been known in India from time immemorial under the 
 generic name of " kushta/' had been given previously by 
 Atreya, in whose Rig Veda Sanita of the fourteenth or 
 fifteenth century b.c, there is mention made of it.^ In Ghina 
 it was probably endemic, as Hobson ^ thinks, among the 
 original inhabitants of the country ; but more definite infor- 
 mation is wanting, and the case adduced by him, of a disciple 
 of Confucius who became affected with " lepi-osy " (lae) is 
 untrustworthy, inasmuch as the term " lae,'' as Hobson 
 himself tells us, is used in Southern China, where true 
 leprosy is most widely prevalent, in a quite general sense 
 for scab. It is a noteworthy fact that the above-mentioned 
 regions of the globe form one of the headquarters of leprosy 
 at the present day. 
 
 At what time, in what regions, and under what circum- 
 stances the disease appeared first on the soil of Europe, 
 cannot be made out with certainty from the scanty references 
 to it that we meet with in the Greek writers of the pre- 
 Christian era ; and with all the less certainty for the 
 reason that most of these accounts are already vitiated by 
 the error of confounding leprosy with elephantiasis — a laxity 
 of thought and speech which has obtained in all subsequent 
 times down almost to our own day. 
 
 In tlie writings of the Hippocratic^ collection, tliere is mention of 
 the " Phoenician disease" side by side with a malignant form of 'KtvKi} 
 (afterwards a term in general use for certain forms of leprosy), and 
 obviously in connexion with the latter. According to Galen's expla- 
 nation,^ this term corresponds to " elephantiasis ; " but we are unfortu- 
 nately again left in doubt whether by " elephantiasis " we are to under- 
 stand leprosy, or elephantiasis in our sense of the word, inasmuch as 
 
 ^ ' Commentary on the Hindu System of Medicine,' Lend., i860, p. 238. 
 
 2 Munro, ' Ed. Med. Journ.,' 1876, Sept., p. 248. 
 
 ^ ' Transact, of the China Branch of the Roy. Asiatic Soc.,' 1S52, iii, p. 17. 
 
 * ' Prorrhetikou,' lib. ii (at the end of the book), ed. Littrc ix, 74. 
 
 * Erotiani, ' Galeni et Herodoti Glossaria in Hippocratem,' ex rccensioue 
 Stephani, Lips., 1780.
 
 LEPEOST. 5 
 
 Galen, in another passage, ^ uses the same word to denote pachydermia. 
 It is equally uncertain what is meant by the " satyria " mentioned by 
 Aristotle ;- Rufus {vide infra) states that this word had been already 
 used to designate leprosy, and Galen ^ expresses the same opinion; 
 ugain using, however, the ambiguous term " elephantiasis." Even if 
 we discover leprosy in both of the diseases here spoken of, it would 
 still remain a question whether the statements about them relate to 
 Greece or to Egypt and Phoenicia ; and the same doubt arises regarding 
 the remark with which Rufus ■* prefaces his own brief but unambiguous 
 description of leprosy, that the disease, although it is a great and 
 dangerous one and of frequent occurrence (jusya /cal xaXfTrov voaniia kuI 
 xoXXoTf yivofiivov), had been described hitherto only by Sti-ato the 
 Erisistratean (probably Strato of Lampsacus in the third century B.C.) ; 
 for here also it is an open question whether this account of Strato, as 
 well as the notice of the disease given by Rufus of Alexandria, does not 
 relate rather to Egypt than to Greece. 
 
 Amons' the clironiclers both of the eai-lier and the later 
 times of the Empire, there is complete agreement that the 
 endemic leprosy of Egypt was not known to the older Greek 
 physicians (('.e. to physicians practising in Greece), that the 
 disease did not show itself in the Roman Empire until the 
 last century B.C., and that it was a still longer time before 
 it attained a general diffusion therein or among the neigh- 
 bouring nationalities. 
 
 According to Lucretius,* 
 
 Est eleplias morbus, qui propter flumina Nili 
 Gignitur Aegypto in medio, neque praeterea usquam. 
 Gelsus, to whose trustworthiness no objection can be taken, says of 
 it :" " Ignotus paene in Italia ... is morbus est, quem 'tXetpavriairiv 
 Grasci vocant." Plutarch ^ makes the physician Artemidorus, a con- 
 temporary of Pompey, say that leprosy first became kno\vn in the 
 Roman Empire in the time of Asclepiades (or in the last century B.C.). 
 Cajlius Aurelianus » indicates Themison, the founder of the methodical 
 school and the contemporary of PJiny, as the first Roman physician to 
 describe the disease; and even in Galen^ we find the remark: "In 
 
 1 ' Introductio, cap. xiii, ed. Kiihn, xiv, 757, and, in the same sense, in 
 ' Dcfuiitiones,' § 296 e. c. xix, 428. 
 
 - ' Dc generatiouc animal.,' lib. iv, cap. iii, 0pp. cd. Casauboni, Genev., 1605, i, 
 852. 
 
 ^ ' De causis niorbor.,' cap. vii, e. c. vii, 29, and ' Lib. dc tumonbus praeter 
 naturam,' cap. xiv, c. c. vii, 727-28. 
 
 ■> Oribasius, 'Collect, med.,' xiv, cap. 28, ed. Daremberg, iv, 63. 
 
 * 'I)e rerum natura,' vi, 11 14. " Lib. iii, cap. 25. 
 
 ' In ' Symposion,' vii, qu. ix, 0pp. ed. Reiske, viii, 905. 
 
 s 'Morb. Chron.,' lib. iv, cap. i, ed. Amstelod., 1755, 493- 
 
 '■> ' Lib. ii, De method, med. ad Glauconem,' cap. xiii, e. c, xi, 142.
 
 6 GEOGEAPHICAL AND HISTOKIOAL rATHOLOGY. 
 
 Alexandria plm-imi elephantiasi .... laborant. In Gei'mania 
 vero et Mysia rarissime affectus is gi-assari visus est. Et apud lacti- 
 potas Scytbas nunquam fere apparet." 
 
 The period when leprosy began to bo more widely diffused 
 and more frequent in Europe may be inferred with a good 
 deal of probability from the date of the making of laws and 
 regulations by the authorities towards preventing and counter- 
 acting the disease, which was generally considered to be a 
 catching one ; these consisted in part of laws regulating the 
 marriage of leprous persons^ and in part were directed to 
 their segregation and reception into institutions for their 
 care or cure {leproseria, ladreria, mescUeria). 
 
 There exist legislative enactments on the marrying of lepers and on 
 their segregation, made by Rotbar, King of tbe Lombards in the seventh 
 century,^ by Pipin (757) and Cbarlemagne (789) for tbe empire of tbe 
 Franks in tbe eigbtb century," and for England in tbe year 950.^ Tbe 
 earliest account of tbe founding of leper-boiises comes from tbe Frankisb 
 kingdom in tbe eigbtb and nintb centuries,"* from Ireland (Innisf alien), 
 in tbe year 869,^ from Spain (Malaga in 1007,*"' and Valencia in 1067),'' 
 Italy and England (Cbatbam, Northampton, London, and otber pbices)'' 
 in tbe eleventh century, Sicily (Palermo),^ Scotland (Aldnestun, 11 70), 
 and tbe Netherlands (Ghent, ii47)'"intbe twelfth century, and from 
 Norway (Bergen, 1266)'' and Switzerland (Ziiricb)^" in tbe thirteenth 
 century. 
 
 There is no doubt that the founding of the first houses 
 for the reception of lepers did not take place until a period 
 when the disease had already become spread to a considcr- 
 
 ^ Lindeubrog, 'Codex leguin autiquar.,' 1613, p. 609. 
 
 - Lobineaii, ' Histoire de Uretagne,' Paris, 1 707, i, 204. 
 
 3 Wharton, ' Anglia sacra,' ii, Praef. 32. 
 
 ■* Virchow (' Arcbiv,' xviii (i860), pp. 138, 273, xix, p. 43, xx, pp. 166, 459), 
 has published a very detailed and thorough investigation on the lepcr-houscs in 
 the Prankish kingdom and in Germany. 
 
 « Belcher, ' Dubl. Quart. Journ. of Med. Sc.,' 186S, Aug., p. 38. 
 
 ^ Martinez y Montes, ' Topogr. med. de la ciudad de Malaga,' Malaga, 1852, 
 p. 504. 
 
 7 Morejon, ' Hist, bibliogr. de la med. Espafiola,' i, 354. 
 
 * For the history of leper-houses in Britain, see the admirable pajiers of 
 Simpson, in the ' Edin. Med. and Surg. .Journ.,' 1841, Oct., p. 301, 1842, Jan., 
 p. 121, April, p. 394. 
 
 ^ Prof eta, ' La Sperimeutale,' 1875, Sept., p. 294. 
 
 '" See the excellent account of the history of leprosy in the Netherlands by 
 Israels, in ' Nederl. Tijdschr. voor Geneesk.,' 1857, i, 161. 
 
 '1 Bidenkap, ' Norsk. Mag. for Laegevidensk,' i860, xiv, 550. 
 
 '2 Meyer-AhrenSj ' Sweiz. Ztschr. fiir Natur- uud Heilkundc,' 1841, vi, 302.
 
 LEPEOSY. 7 
 
 able extent. The majority of sucli liouses appear to have 
 been establisliod between the eleventh and the thirteenth 
 centnries ; and they were founded in such numbers that, by 
 the beginning of the thirteenth century, there appear to have 
 been 2000 of them in France alone, and ig,ooo in the whole 
 of Christendom.^ It would be a mistake, in my view, to 
 infer from the multiplication of leper-houses, that there was 
 a corresponding increase in the number of cases, or to take 
 the number of the former as a measure of the extent to 
 which leprosy was prevalent, or to conclude, as many have 
 done, that the coincidence of the Crusades with that increased 
 diifusion of the disease implies any intimate connexion 
 between the two things, or that the rise in the number of 
 cases was chiefly due to importation of leprosy into Europe 
 from the East. In judging of all these matters, we must 
 not leave out of sight the fact, already adverted to more 
 than once, that the notion of " lepr-osy " was a very compre- 
 hensive one in the middle ages, not only among the laity but 
 also among physicians, that syphilis was included therein as 
 well as leprosy and a variety of chronic skin diseases, and 
 that the diagnosis with a view to segregation of '' lepers,"' or 
 to their admission into leper-houses, was not made by the 
 practitioners of medicine but mostly by the laity. One can 
 readily understand that many a soldier from Europe, who set 
 out for the East in good health, became leprous in a country 
 where want and hardships and a free kind of life all afforded 
 opportunities for his acquiring the malady. But here again 
 we shall have to take " leprosy " in its comprehensive sense ; 
 and, if the crusaders returning from the East brought back 
 with them some disease which they communicated to people 
 in Europe, it is much more reasonable to think of syphilis 
 than of leprosy, inasmuch as the communicability of leprosy 
 has not been proved hitherto by a single unambiguous fact. 
 One thing of especial importance in the judging of these 
 questions is that, when physicians came to be better acquainted 
 
 ' Raymond, 1. c, p. 106. Mezeray CHistoiro dc France,' ii, 168) says of 
 France in the 12th century: "II y avait nl viUe ni honrgadc. que ne fust 
 obligee de batir un hopital pour les (lepreux) retirer ; " and, for Italy, Mura- 
 tori's statement (' Antiq. Ital. med. acvi,' iii, 53) 'S to the sam ■ cff.-ct : '• A ix 
 ulla er;\t civitas, quae non ali(iuem locum leprosis dcstinatum haberet.
 
 8 GEOGRAPniOAL AND HISTORICAL Tx^THOLOGY. 
 
 with tlic distinctive cliaracters of syphilis at the time of its 
 wide diffusion in Europe in the end of the fifteenth and 
 beginning of the sixteenth century, the number of the 
 leprous diminished considerably within a very short period ; 
 that fact is explained, not by any such sudden extinction of 
 the disease, nor, as some have concluded, by the transfor- 
 mation of leprosy into syphilis, but according to the more 
 natural assumption that a correct diagnosis of each disease 
 had taught men to restrict the number of leprosy cases within 
 proper limits. 
 
 When a revision was undertaken in France and Italy, at the beginning 
 of the sixteenth century, of the overcrowded lazar-houses, the fact came 
 out that in many of them by far the most of the inmates, and in some 
 of them the whole, were suffering from various chronic skin eruptions, 
 and that only a minority were suffering from true leprosy. Fracastoro,^ 
 for example, writing of Italy (Verona), says : " Et certe semper apud 
 nos visus raro fuit is moi'bus, quamquam per civitates domus, quae hos- 
 pitalia vocantur, et suppellectiles sumptibus publieis paratae structaeque 
 videantur Elephantiacis suscipieudis. Verum quos ego hactenus vidi : 
 nemo quidem aut pauci e suspectis Elephantiaci mihi visi sunt, sed 
 leprosi [i.e. affected with scaly exanthems] solum, aut impetigine 
 quadam fere detenti." ^ 
 
 Still, we must recognise the fact that leprosy was preva- 
 lent in Europe as an endemic disease during the middle 
 ages, that it gradually lost its importance as such from the 
 sixteenth century onwards, and that there now remain to it 
 in Europe only a few disease-centres, and these for the most 
 part small, in which it still preserves its old endemic 
 character. 
 
 This extinction of leprosy as an endemic took place, sometimes 
 earlier, sometimes later in the various countries of Europe. In Italy 
 a considerable remission of the disease was already noticeable towards 
 the end of the fifteenth century ; thus Beniveni^ says, when speaking of 
 a case of leprosy observed by him in a foreigner : " Morbus qui in 
 Italia " — he lived in Florence — " pene nunquam visus a medicis vix 
 diagnoscitur." During the sixteenth century leprosy disappeared 
 almost entirely from that country, remaining confined to a few districts 
 to be mentioned in the sequel.'* In the same period falls the general 
 
 ^ ' De morbis coutagiosis,' lib. ii, cap. xiii, 0pp. Venet., 15S4, p. 946. 
 
 * See also Hensler, p. 232, and Siiiipsou, 1. c, 1842, Jan., p. 148. 
 
 ^ ' De abditis morbor. causis,' cap. 98, iu Dodonaeus, ' Med. observ. rara 
 exeuipla,' Lugd. Eatav., 1585, p. 241. See also the above-quoted passage from 
 Fracastoro, 
 
 ■* De Rcnzi, ' Storia della mcd. in Italia,' Napol., 1845, i'i> 587.
 
 LEFEOSY. 9 
 
 decline of tlie disease in Spain,' wliere a few centres of it have main- 
 tained themselves down to the present time. In France also its sub- 
 sidence began then, although it was observed at various places in con- 
 siderable diffusion in the seventeenth and even down to the end of the 
 eighteenth century. Thus, Simonin^ states that leprosy was still 
 common in Lorraine in the beginning of the seventeenth century ; 
 Briende,^ writing in 1787, says that it was still endemic in Upper 
 Auvergne, especially in the district of Mont d"Or as far as the confines 
 of Limousin, being known by the name of " mal s. main ;" and Rochard' 
 points out that there were many lepers yet liviug at that time (1789) 
 on the island of Belle-Isle-en-mer, which had served as a refuge for 
 lei^rous persons driven from the mainland, and that he had himself 
 seen several at Rosaliere. The extinction of leprosy falls at a some- 
 what later period in Switzerland, where numerous leper-houses were 
 founded as late as the fifteenth century ; later also in the countries of 
 Northern Europe — in the Netherlands towards the middle of the seven- 
 teenth century,* in Germany, where the disease, according to many 
 observers, continued to be somewhat widely prevalent in the sixteenth 
 century, in Denmark^ and in England and Scotland, from which last 
 we have a notice of numerous cases of leprosy in Kingcase in the 
 year 1 693." From the Shetland Isles, we have the following by Edmond- 
 stone :^ " The session records mention that a day of public thanks- 
 giving was observed in the ministry in the year 1742, when this disease 
 [leprosy] was almost extinguished ;" but he had himself seen several 
 cases there at the beginning of the present century. On the Faroe 
 Islands leprosy has completely disappeared since the middle of the 
 eighteenth century.^ 
 
 For tlie history of lejJi'osy in the countries of Nearer Asia 
 our information goes no farther back than the ninth and tenth 
 centuries of the Christian era, the period from which date 
 the writings of the so-called Arabian physicians Rhazes, 
 Janus Damascenus," Ali Abbas/^ Avicenna^'^ and others, all 
 
 1 Morejou, 1. c. - ' Recliercli. topo-r. ct mcd. sur Nancy,' 1854, p. 306. 
 
 3 ' Histoire de la Soc. de med. de Paris,' 1787, v, nicm., p. 311. 
 
 " 'Journ. gen. de med.,' 1789, Ixxx, 365; Cabrol (' Kcc. de lueiu. de med. 
 uiilifc.,' 1848,11, serie vi, p. 51) makes the conjecture that tbe intractable skin 
 diseases which are still met with on the island are the snrvivuls of leprosy. 
 
 * Israels, 1. c. 
 
 " Dauielssen et Boeck, 1. c, p. 136. 
 
 ' Simpson, 1. c, 1841, Oct., p. 328. 
 
 » ' Edin. Med. and Surg. Journ.,' 1810, Jan., p. 162. 
 
 » Mauicus, ' Bibl. for Laeger,' 1824, i, 15. 
 
 i« ' Liber ad Almansorem,' v, cap. 32-35, 0pp. Basil, 1544, P- i27- 
 
 '1 ' Practica,' tract v, cap. 3, 5, 14. Lugd., 1525, pp. 48, 49, 51. 
 
 '2 ' Disp. theor.,' i, cap. 74, viii, cap. 15, 16, 18; ' Pract.,' iv, cap. 3. 
 
 *^ ' Canon.,' lib. iv, Pen. iii, tract, iii, cap. i, 3, 3, Feu. vii, tract, i, cap. 5. 
 
 10
 
 10 GEOGRAPHICAL AND IIISTOKIOAL PATnOLOGY. 
 
 of whom give definite information of the prevalence oE the 
 disease in Mesopotamia, Syria, and Persia. There is no 
 medical history from those regions for the later mediaeval 
 period ; but for the last three centuries the accounts of 
 travellers, who had informed themselves as to the state of 
 health and sickness there, are unanimous in declaring 
 leprosy to be still endemic at many points. In the Western 
 Hemisphere, according to the uniform statements of authori- 
 ties in Guiana^ and the West Indies," leprosy was unknown 
 until the arrival of the negro. For Bahia the earliest 
 account of its occurrence goes no farther back than 1755. 
 Also in Parana and Uruguay^ it is said to have become more 
 widely spread in recent times, and in these countries also the 
 outbreak of the disease is traced to the introduction of the 
 negro race.'* The older observers considered it proved that 
 the disease had been conveyed by contagion from the negroes 
 to the natives of those countries ; v. Leent, however, points 
 out that these observations are plainly based upon a con- 
 founding of leprosy with syphilis, and that the conveyance 
 of true leprosy from the one race to the other can only have 
 taken place by way of intermarriage and inheritance. For 
 Surinam the first information as to leprosy dates from 1728 ; 
 in 1763 the number of lepers had increased so much that a 
 leper-house had to be founded, and in 1812 they were 
 counted at 500. 
 
 § 2. Present Distribution op Leprosy. 
 
 The more recent history of leprosy, and its geographical 
 distribution at the present time, tend to confirm the data^ very 
 
 * Schilling, 'Diss, de lepra,' Triij. ad Ilh., 1769; Eaioii, ' Nachrichteu zur 
 Gcscluclite von Cayenne,' from the French, Erfurt, 1 780, iii, 24 ; Campet, 
 ' Traitc prat, dcs maladies graves des pays chands,' Par., 1802, p. 290 ; Bancroft, 
 'Natural History of Guiana,' p. 385 ; v. Leant, 'Arch, de mod. nav.,' 18S0, Nov., 
 p. 405. 
 
 - Peyssonel, ' Philos. Trans.,' 1, part 1, p. 38 ; IHllary, ' Observ. on the Changes 
 of the Air, and the concom. Epid. Dis. iu Barbadoes,' 2ud ed., Lond., 1766 (Ger- 
 man transl., Leipzig, 1776, p. 385). 
 
 ^ Wudierer, in 'Virch. Arch.,' 1S61, xxii, 345. 
 
 "^ Brunei, 'Observ. topogr. et med. . . . faitcs dans In Rio de la Plata,' Par., 
 1842, p. 4G.
 
 Lf] PROSY. 11 
 
 defective and iu part untrustwortliy, wliicli we possess as to 
 the history o£ the disease in antiquity^ the middle ages^ and 
 the modern period, and which point to Africa and Asia as- 
 its earliest and chief seats. 
 
 This holds good, first of all, for Eijypt, where the medical 
 accounts of the present and preceding- centuries,^ as well as the 
 reports of all scientific travellers, represent the disease to be 
 widely diffused as an endemic, equally throughout the whole 
 basin of the Nile and on the shores of the Mediterranean and 
 tlie Red Sea. To tlie same effect are the statements of all 
 observers on the wide prevalence that leprosy has attained 
 in Abyssinia,^ both on the coast and in the plains and hill 
 districts. Accounts to tlie same effect come from the coast 
 territory of East Africa, — from Zanzibar^ and Mozambique,'^ 
 from Madagascar^ (both plains and mountains) and the 
 adjoining small island of 8t. Marie,^ — from Mauritius,'^ where 
 150 patients had been admitted in 1874 into the leper-house 
 near Port Louis,^ from Reunion^ and from St. Helena. 
 Among the North African coast states, Tripoli and Tunis 
 are said to enjoy an immunity from leprosy, but the infor- 
 
 ' Sec Prosper Alpimis, ' Medicina iEgyptiorura,' Lugd. Batav., 1719, p.s6; 
 Larrey, ' Memoires de Chinirgie Miiitairc, et Campagues,' Taris, 1812-17, vol. i ; 
 Pruiier, • Kranklieiten des Orients/ p. 164; Griesiuger, in ' Vircli. Arch.,' v 
 (1853), p. 236 J Vauvray, 'Arch, de mcd. iiav.,' 1873, Sept., p. \(n (rehUiug to 
 i'ort Said). 
 
 " Combes et Tamisicr, 'Voyage en Abyssinie/ Paris, 1S39, p. 280; Aubert- 
 lloche, ' Annal. d'hyg.,' 1846, xxsv, 5 ; Pruner, 1. c; Courbon, ' Observ. topogr. 
 et mcd.,' &c.. Par., 1861, p. 3,:^ ; 151ane, ' Gaz. hcbd. dc mod.,' i874,FeuilI, p. 3.^0 
 (met witli leprosy west of Lake Tana). 
 
 3 Semanne, ' Essai d'une topogr. med. de Tile de Zanzibar,' Pur., 1864, p. 36 ; 
 Lostalot-Bachoue, 'Etude sur la constitution phys. et mod. dc I'ile dc Zanzibar,' 
 Par., 1876, p. 48. 
 
 ^ Koquette, ' Arch, de med. nav.,' 1868, Mar., p. 161. 
 
 = Davidson, 'Edin. Med. Journ.,' 1863, Mar., p. 832 ; Borchgrcvink, 'Norsk. 
 Magaz. ior Laegevideusk,' 1S72, iii, Kaek. ii, p. 246. 
 
 G Borius, ' Arch, de med. nav.,' 1870, Aout, p. 81 ; he estimates the number of 
 lepers on the island at 20 to 30, or 4 to 6 per 1000 inhabitants. 
 
 ' Kinnis, ' Edin. Mcd. and Surg, Jonrn.,' 1824, Oct., p. 286 ; Leboutc, ' Ediu. 
 Med. Journ.,' 1877, Sept., p. 224. 
 
 « ' Statist. Sanitatsbcricht der kaiserl. deutschcn Marine,' 1874-5, p. 104. 
 
 '■> Couzier, ' Journ. gen. de mcd.,' vii, p. 406 ; Allan, ' Monthly Journ. of Med.,' 
 1841, Aug., p. 565; Pcllissier, 'Consider, sur I'cLiologie des maladies Ics plus 
 communes a la Reunion,' Paris, 18S1, p. 49- 
 
 McRitchic, 'Transact, of the Calcutta Mcd. Soc," 1S36, viii, App. xxi.K. 
 
 Ju
 
 12 GEOGEAPniCAL AND lIISTOlilOAL PATHOLOGY. 
 
 mation^ is of a scarcely trustworthy kind. In Alrjiers, at any 
 ratCj tlie disease is widely diffused (especially among" tlie 
 Kabyles);" and tlie same is true for Morocco^ the Canary 
 Islands,^ and Madeira} In the Azores it is said to be less 
 frequently met with.*" 
 
 According to Leared, there is in the vicinity of the city of Morocco 
 a leper colony consisting of 200 persons, who are, however, in free 
 commnnication with the whole neighhourhood. In the Canarij Islands 
 the first leper-house was founded in 1542, but the disease had probably 
 existed there at an earlier date. The statement of Mendl that leprosy 
 had decreased there in recent times in consequence of the improved 
 wellbeing of the people, is not in agreement with the results (given 
 by Friedel) of the official census taken in 178S, 1S31, 1857, ^^^ i860, 
 which make the number of lepers then living to be respectively 195, 
 346, 500, and 600, so that we must suppose either the disease to have 
 increased or the enumeration in later times to have been more carefully 
 carried out. In Madeira the existing leper-house near Eunchal, was 
 founded in 1658 ; witliin the last thirty or forty years the disease has 
 become rarer, most of the lepers being met with in a few districts on 
 the west side of the island. 
 
 A very extensive region of leprosy is formed by the West 
 Coast of Africa from Senegambia down to Cape Lopez. In 
 Senegamhia the disease is prevalent equally on the coast and 
 in the more elevated regions of the interior / it is the same 
 in Sierra Leone, where there were 103 lepers counted in 
 i860 among the 40,000 natives residing within the English 
 colony.^ Erom the same region we have further accounts 
 
 ' ' Eoport on Leprosy by tlie Coll. of Pliys./ Loud., 1S67, p. 53. 
 
 - Bautlouiu, ' Gaz. iiied. de Paris,' 1838, p. 771; Btrtheraud, 'Medecine ct 
 hygiene des Arabes,' Par., 1855 ; Guzon, ' Gaz. des hopit.,' 1852, No. 27, p. 427; 
 Bertiaud, ' Itec. de mem. de med. milit.,' 1867, Mars, p. 199 (who I'cmarks tliiit 
 the disease known as " lepre des Kabyles" is not leprosy but syphilis). 
 
 2 Jaekson, 'Account of the Empire of Morocco,' Lond, 1814; Leared, 'Brit. 
 Med. Journ.,' 1873, April, p. 404. 
 
 •* Friedel, in ' Virchow's Arcliiv,' xxil (1S61), p. 340; Bolle, ib., p. 367; 
 Mendl, ' Wieu. med. Wochenschr.,' 1S66, No. 35, p. 557. 
 
 * Heineken, ' Edin. Med. and Surg. Journ.,' 1826, July, p. 15; Kimiis, ib., 
 1842, July, p. 1 ; Kampfer, ' Hamb. Zeitschr. iiir Med.,' x.\.xiv, p. 161 ; Meudl, 1. c. 
 
 " Bullar, ' Boston Med. and Surg. Journ.,' 1840, xxvi, p. 135. 
 
 J' Theveuot, • Traite des maladies au Senegal,' &c., Paris, 1840, 249; 
 
 Chassianol, ' Arch, de med. nav.,' 1865, Mai, 515 ; Borius, ' Considerations med. 
 sur le poste de Dagana,' Montp., 1864, and ' Arch, de med. nav.,' 18S2, Mai, 375. 
 
 s Winter bottom, ' Ace. of the native Africans of Sierra Leone,' II, 1 13 ; ' Report 
 on Leprosy,' 52.
 
 LEPROSY. 13 
 
 for tbe Gold Goast^ for the Benin Districts {Lagos), ^ for the 
 Niger^ country, and for the Gaboon {Cameroon Districts) ^ It 
 may bo inferred from the statement of Danioll'' that leprosy 
 occurs in these countries not merely on the coast, but as an 
 endemic also in the interior ; according to him leprous per- 
 sons are not unfrequently found among the slaves brought 
 from the Soudan to the West Coast. On the Loango Coast 
 (from Cape Lopez southwards) we come upon a territory free 
 from leprosy ;" but the very defective medical information 
 from these parts does not enable us to decide how far this 
 immunity pertains to the most southern districts of the West 
 Coast, to Angola, and the region of the Congo. It is certain 
 that leprosy is endemic to a very considerable extent at the 
 Cape,'^ the fruitful districts on the east side forming an 
 exception (Kretzschmar) ; Natal^ also is said to be free from 
 the disease. 
 
 At the Cape there were in 1858 two leper asylums, or places of deten- 
 tion for lepers, the one being " Hemel-en-Aarde " (heaven and earth), a 
 solitary place shut in by the mountains, distant a few days' journey 
 from Cape Town and the coast ; the other, Robben Island in Table Bay, 
 thirty miles from the Herrnhnt colony of Gnadenthal. According to 
 the missionary Merensky,^ an endemic centre of leprosy has sprung up 
 since 1850 among the Zulus who had migrated into Natal. 
 
 Besides Africa, the continent of Asia ivith the archipelagos 
 adjoining it forms one of the headquarters of leprosy at the 
 present day. This applies mostly to India and the eastern 
 parts of Asia. On the other hand, in the countries of 
 
 1 Clarke, 'Transact, of the Epidemiol. Soc.,' i860, i, 106; Moriarty, 'Med. 
 Times and Gaz.,' 1866, Dec, 663. 
 
 ' ' Statist. Rep. of the Health of tbe Navy for 1S64.' 
 
 3 Oldfield, 'London Med. and Surg. Journ.,' 1835, Nov., 403; McRitchic, 
 'Monthly Journ. of Med. Sc.,' 1852, May. 
 
 ■* Ballay, ' L'Ogooue, Afrique equatoriale occidentale,' Paris, 1880, 40. 
 
 5 Daniell, ' Sketches of the med. topogr. ... of the Gulf of Guinea,' Lond., 
 1849, 56. 
 
 « Falkcustein, in ' Yirchow's Arch.,' 1877, Ixxi, 421. 
 
 7 Berucastle, 'Lancet,' 1851, Sept., 257; Kretzschmar, ' Sudafrikanische 
 Skizzen.,' Leipz., 1853; Black, ' Edinb. Med. and Surg. Journ.,' 1853, April, 257 ; 
 Scherzer, ' Ztschr. "der Wiener Acrzte,' 1858, Nr. 11 ; Ref. in 'Lancet,' 1876, 
 July, 32; Fritsch, in 'Vircbow's Arch.,' 1865, x.xxiii, 160 and 'Arch, fiir Anat. 
 und Pliysiol.,' 1866, 733. 
 
 ^ ' Report on Leprosy,' xi. 
 
 8 In ' Vircbow's Archiv,' Ixxxix (1882), p. 187.
 
 14 GEOGRAPHICAL AND IIISTOEICAL PATHOLOGY. 
 
 Ncai'cr Asiai, so far as avo can judge of tlieii* conditions of 
 health from the available data^ the disease has the character 
 of a true endemic only within a few limited areas. Thus we 
 have accounts of its occurrence at a few points on the 
 southern coast of Arabia (particularly Muscat^), and in the 
 heart of the country f further, in the mountainous districts 
 of Fersia? and Syria,^ in Cyprus,^ and in some parts of 
 Turl-estan (especially Samarcaud, Miankal, and Hissar*') . lu 
 Asia Minor'^ in recent times, only isolated cases have been 
 observed — at Smyrna, in the neighbourhood of Sinope, and at 
 other points on the shore of the Black Sea ; in the Bi'oussa 
 district the disease appears to have become quite extinct, 
 and it is said also that it no longer occurs in Trcbizond. 
 
 In Syria leprosy is ofteuest met with in tlie valleys of tlie Lebanon 
 and Anti-Lebanon, mostly in small villages and seldom in tbe larger 
 towns. The great number of lepers in Jerusalem, where there are 
 several leper-houses, may be explained by their resorting thither from 
 the country around. At Hebron, Nazareth, Safet, and Nablous, only 
 occasional cases occur, just as at Beyrout, Jaffa, and other places on 
 the coast, where leprosy is almost unknown. In Cyprus the disease is 
 mostly found in the districts of Morfn, Lapethus, and Oythraea, situated 
 on a damp level ; the leper-house at Nikosia contained thirty-five 
 patients in 1867. In Persia it is confined as an endemic to a few dis- 
 tricts of the hill country of Irak Ajemi, in the provinces of Azerbijan 
 and Khuzistan, particularly the localities of Chamsc, Kaswin, Sendjan, 
 and Karadagh. It does not occur at all on the shores of the Caspian. 
 The Persian lepers live together, outcast from society, in a most miser- 
 able state, in small and wretched colonies situated at some distance 
 from the towns or villages. 
 
 *o^ 
 
 ' Lockwood, ' Amcr. Journ. of Med. Sc.,' 1846, Jau., 82 ; Moore, ' Assoc. Med. 
 Jouni.,' 1856, Nov., 996. 
 
 * Palgnivc, ' Journey through Arabia,' Lond., 1865, ii, 3. 
 
 ^ Polak, ' Wien. med. Woch.,' 1855, ^i'- i7> ' Wochenbl, der Ztschr. tier Wiener 
 Aerzte,' 1857, Nr. 47, 753, and in ' Virchow's Arch.,' 1863, xxvii, 175 ; Hiiutzsclie, 
 ib. ; ' lleport on Leprosy,' 71. 
 
 ^ Pruncr, 1. c. ; Tobler, ' Beitr. zur. med. Topogr. von Jerusalem,' Berl., 1855, 
 47; Piobertsou, ' Edinb. Med. and Surg. Journ.,' 1843, April, 246, 'Report on 
 Leprosy,' xi, 54-56; 'Brit. Med. Journ.,' 1868, Sept., 341, and 'Wicn. med. 
 Wocb.,' 1875, Nr. 13, 14,; Langerbans, in 'Virchow's Arch.,' 1870, 1, 453; 
 Wortabct, ' Brit, and For. Med.-Chir. Review,' 1873, July, 173, and * Med. Times 
 and Gaz.,' 1880, Oct., 445. 
 
 ^ ' Report on Leprosy,' 55. 
 
 ^ Burncs, 'Transact, of the Calcutta Med. Soc.,' J835, vii, 460. 
 
 7 Riglcr, 'Die Tiirkci uud deren Bewohner,' ii, 102; 'Report on Lef>rosy,' 
 xiii, 60.
 
 LEPKOSY. 15 
 
 From none of tlie extra-Europcau regions tliat ai'e most 
 afflicted with leprosy, do we obtain so complete information on 
 tlie distribution of tlie disease and on its endemic extent 
 within the several divisions of the country, as from India or 
 that part of India which is under British rule. The exceed- 
 ingly numerous accounts to hand/ which apply in part also 
 to the Protected States and to the allied or Independent 
 Native States, as well as to the French possession of Pondi- 
 cherry, go to prove this much at the outset, that no part of 
 that vast empire (including Ceylon), from Peshawur to 
 Point-de-Galle, and from the Assam mountains to the Indus, 
 is altogether free from leprosy ; that there are, however, 
 very considerable differences in the amount of it in various 
 parts of the country, and that, in British India proper, there 
 are three regions where the disease reaches a maximum — the 
 hill country of Kumaon, the Province of Burdwan (Lower 
 Bengal), and those parts of the Deccan and the Konkan that 
 belong to the Bombay Presidency. According to the 
 census of 1872, there were in the three Presidencies 99,073 
 lepers in a population of about 183 millions, or 5-4 per 
 10,000 inhabitants; of these 71,287 belonged to the Bengal 
 Presidency with 136 millions (5-2 in 10,000), 13,944 to the 
 Madras Presidency with 31 millions (4-4 in 10,000), and 
 13,842 to the Bombay Presidency with 16 milbons (8*5 in 
 10,000). An analysis of these aggregates, carried out for the 
 several provinces in each presidency, gives the following 
 totals and the proportions per 10,000 inhabitants. 
 
 1 The following are general references : Robinson, ' Med.-Cbirurg. Transact., 
 1819, X, part i, 27, 'Report on Leprosy,' xv—xix, 100—213; Lewis and Cun- 
 ningham, 'Leprosy in Lidin,' Calcutta, 1877. For Bengal, see : Macnaiuara, 
 'Leprosy,' Calcutta, 1866; Evans, 'Transact, of the Calcutta Med. Soc.,' 1829, 
 iv, 245 (Tirhoot); Breton, ih., 1826, ii, 245 (Chota Nagpore); Shortt, ' Ind. 
 Annals of Med. Sc.,' 1858, July, 506 : Richards, ib., 1873, July, 303 (Orissa) ; 
 Lewis and Cunningham, 1. c., 14 (Kumaon), ' Report of the Governm. Charitable 
 Dispens. established in Bengal and N. W. Provinces,' Calcutta, 1843, passim; 
 Planck, 'Report on Leprosy in the N. W. Provinces,' Calcutta, 1876 (X. W. 
 Provinces). For Maciras, see: Van Someren, 'Med. Times and Gaz.,' 1874, 
 April, S7I (District of Madras) ; Aubocuf, 'Contributions Ti I'etude dc I'hyg. et 
 des maladies dans I'Lide,' Par., 1862,63 (Pondicherry) ; Day, ' Madras Quart. 
 Journ. of Med. So.,' i860, Oct., 286 (Cochin). For Bombay Prcs., see : Vandyke 
 Carter, 'Lancet,' 1872, Aug., 198, and ' Med.-Chir. Transact.,' 1873, Ivi, 267 
 (general) ; Morehead, ' Clinical Researches,' ii, 664 ; Waring, ' lud. Annals of 
 Med. Sc.,' 1856, April, 506 (City of Bombay) ; Gibson, ' Transact, of the Bombay 
 Med. and Phys. Soc,,' 1838, i, 66 (Gujerat) ; Don, lb., 1840, iil, 4 (Sind).
 
 IG 
 
 GEOGRAPHICAL AND IlISTOEICAL PATHOLOGY. 
 
 Table of the number of Lepers in the various Provinces of 
 India, ivith the 'proportion per 10,000 Inhabitants. 
 
 cngal — 
 
 
 Madras — 
 
 
 Bengal Proper 
 
 28,403=7-8 
 
 Littoral . 
 
 • 9.872=? 4"9 
 
 Beliar 
 
 7.773=3-9 
 
 Inland Provinces 
 
 . 4,072= 3-6 
 
 Orissa . 
 
 1,077=2-4 
 
 
 
 Chota Nagpore 
 
 567=2-6 
 
 Bombay — 
 
 
 Assam 
 
 309=1-6 
 
 Deccan . 
 
 . 9,246=11-6 
 
 N. W. Provinces 
 
 10,099=3-3 
 
 Konkan . 
 
 • 2,753= 8-4 
 
 Oudh 
 
 7,831 = 7-0 
 
 Gujerat . 
 
 • 1.534= 5-4 
 
 Berar 
 
 • i,432='^'o 
 
 Sind 
 
 • 309= I '4 
 
 Central Provinces 
 
 • 2,807=3-0 
 
 
 
 Punjaub . 
 
 10,989=6-2 
 
 
 
 These figures, it hardly uoods to be said, afford no com- 
 plete picture of the distribution of the sickness, inasmuch as 
 they relate to very largo territories, within which there are 
 considerable differences for the several districts and even 
 for the villages of a district. Carrying the analysis still 
 further, we find that the following have the largest nuuiber 
 of lepers, amounting to 20 or more per 10,000 inhabitants. 
 
 Table of the most leprous districts of India. 
 
 District. 
 
 Beerblioon (Prov. BurcTwan, Pres. Bengal) 
 Bancoora „ „ 
 
 Burdwan „ „ 
 
 Kumaon and Garhwal (Bengal) 
 Banda (Prov. Allahabad, Pres. Bengal) 
 Dehra Dhun (Prov. Meerut „ 
 Barsi (Prov. Sholapoor, Pres. Bombay) 
 Sowda (Prov. Kandeish ,, 
 
 Rajapoor (Prov. Rutnagherry „ 
 
 Population. 
 
 695,921 
 .S 26, 7 72 
 
 2,o.u,74.'? 
 74.^.602 
 108,771 
 
 IIS. 771 
 
 1.^0.853 
 
 124,519 
 168,498 
 
 No. of lepers. 
 
 Per 10,000 
 inhab. 
 
 2,872 
 
 41-2 
 
 i.-'sys 
 
 30-0 
 
 4,604 
 
 2 2-6 
 
 1,571 
 
 2I-I 
 
 214 
 
 19-6 
 
 220 
 
 19-0 
 
 .^.>5 
 
 25-6 
 
 312 
 
 25-0 
 
 .S95 
 
 23-4 
 
 The disease is least frequent in the Madras Presidency, 
 within which the Madras districts themselves are the worst, 
 having i leper per 1000 inhabitants, and next to them Pondi- 
 cherry, while, in the district of Coimbatore, the proportion 
 falls to o'2 per 1000. 
 
 On the extent of the sickness in the Protected and Inde- 
 pendent States, we have only general data ; the most con-
 
 LEPEOSY. 17 
 
 siderable leper-centres in these are on tlie plateau of Mysore 
 (especially the district of Bangalore),^ in the coast districts 
 of Kattiwar/ in the State of Malwa/ in Kashmir and Ladak,* 
 and in the State of NepauP adjoining the severely affected 
 Himalayan district of Kumaon. 
 
 We have no very particular facts as to the number of 
 lepers in Ceylon; but, from the accounts to hand/ we may 
 conclude that the disease is common there also, chiefly on 
 the southern and western coasts (provinces of Colombo, 
 Galle, Matura, and Ballepittinge), less so in the interior and 
 mountainous districts. From 1802 to 1862, 272 lepers had 
 been admitted into the leper-house on the north bank of the 
 Kalany some twenty miles above Colombo; during 1862 
 there were from 50 to 60 patients in it. 
 
 In Lower India, we find a very considerable area of leprosy ; 
 we have accounts of its endemic occurrence from British 
 Burmah,'^ from the peninsula of Malacca (Penang, Singapore/ 
 Prince of Wales's Island), from Slam? and from Cochin 
 China }^ In British Burmah, according to the latest census,^^ 
 the number of lepers was as follows : 
 
 Aracan, 125 in 484,362 inhabitants, or 3-8 per 10,000 
 Pegu, 2072 in 1,662,658 „ or 12-4 „ 
 
 Tenasserim 946 in 600,727 „ or I5'7 „ „ 
 
 In the East Indian Archipelago, the most important leper- 
 centres are on the west coast of Java, and in the mountainous 
 districts, the disease being rare on its south and east coasts ;^' 
 
 ' 'Report on Leprosy,' 188 ; van Someren, 1. c. 
 
 - Vaudyke Carter, 'Modern Indian Leprosy,' Bombay, 1876. 
 
 '■" ' Report,' 1. e. 
 
 4 Moorcroft, ' Travels.' 
 
 * ' Report,' 191. 
 
 ^ Pridham, ' Ilistor. and Statistical Account of Ceylon,' &c., Lond., 1849; 
 Pcaconi, ' Edinb. Med. and Surg. Journ.,' 1840, Jan., 136; Kinnis, ib., 1842, 
 July 6, October, 265 ; ' Report on Leprosy,' 90. 
 
 ^ Dawson, ' Philad. Med. Examiner,' 1852, May; Richards, 1. c. 
 
 ^ ' Official Papers on the Med., Statist, and Topogr. of Malacca,' &c., Penang, 
 1S30 ; Dick, ' Brit. Army Reports' for 1873, xv, 329 ; ' Report on Leprosy,' 197. 
 
 " Friedel, in ' Vircliow's Arch.,' 1863, xxvi, 183. 
 
 '" Sarrouille, ' Trois ans en Cochinchine,' Par., 1875, 17; Beaufils, ' Arch, dc 
 med. uav.,' 1S82, April, 279. 
 
 •^ Accoi'diug to Lewis and Cunningham, 1. c, 9. 
 
 '" Lesson, ' Voyage med.,' 98; in 'Nederl.Ti3dschr.v00r Geneest.,' 1858, ii, 
 223; 'Arch, de med. iiav.,' 1S68, Sept., 165, 1S69, Jan., 90. 
 
 VOL. I[. 2
 
 18 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 other centres are in the Andamans and Nicobars^ in the 
 elevated inland regions of Sumatra (especially Paya- 
 Combo)/ on the west coast of Borneo (particularly among 
 the Dyaks)/ in Celebes (Province of Menahasse)/ in Florcs 
 and in the interior of Timor,^ in Bancla and some other 
 islands of the Moluccas,^ and in the PJiilippinesJ On the 
 other handj it is seen rarely on BanJca (chiefly among the 
 Chinese working in the mines)/ on Amhoina^ in the 
 Lampong territories of Sumatra,^^ or in the Grovernment of 
 Macassar (Celebes)?^ 
 
 In the Chinese Empire,^" the southern and eastern coast 
 districts^ as far np as the mouth of the Yang-tsze-Kiang, 
 have been the headquarters of the disease from time 
 immemorial. It is met with more rarely in the interior^ 
 and mostly towards the north of the empire. The provinces 
 most afflicted by it are Quaug-Tung' (Canton)^ Tu-Kiang, 
 and Che-Kiang, between the latitudes of 22° and 31° X. In 
 Pekin it is seldom seen. 
 
 The number of lepers living in the Province of Canton is estimated 
 at 10,000 ; in the villages round the city, there is i leper to every 1000 
 or 2000 of the population ; and there is hardly a district in the whole 
 province without them, although it is the coast districts that are mostly 
 aifected. In the neighbourhood of the City of Canton there are two 
 leper villages, the one harboui-ing 700 to 800 and the other 1000; but 
 most of their inhabitants are nothing more than the descendants of 
 lepers. 
 
 In Japan^^ leprosy is prevalent in widest diffusion, from 
 the coasts far into the interior ; only the Loo-Choo Islands, 
 according to a credible report, enjoy an immunity. Here, 
 
 ^ Hodder, ' Brifc. Ai-my Reports ' for 1875, xvii, 261. 
 
 ^ In 'Arch, de med. uav.,' 1867, Oct., 248. 
 
 3 lb., and 1872, Jan., 22. ■• lb. 
 
 ^ ' Archiv de raed. nav.,' 1867, Oct. 
 
 '' Heymann, ' Kraukh. der Tropenliinder, 204, ' Arch, de med. nav.,' 11. cc. 
 
 7 Taulier, ib., 1877, Dec, 411. 
 
 ^ lb., 1873, Feb., 10.3. 
 
 ^ v. Hattem, ' Nederl. Tijdschr. voor Geueesk.,' 1858, li, 538. '" L. c. 
 
 '^ In 'Arch, de med. nav.,' 1871, April, 248. 
 
 12 SeeLockhart, 'Med.-Clur. Rev.,' 1842, July, 150, 'Monthly Journ. of Med, 
 Sc.,' 1846, March, 164; Wilson, 'Med. Notes on China,' Loud., 1846; Hobson, 
 1. c, ' Report on Leprosy,' 72-79; Shearer, ' Edinb. Med. Jom-n.,' 1872, Jan., 
 596 ; Wong in Leudesdorf s ' Nachrichten,' ix, 22. 
 
 '3 Schmid, 'New York Med. Eecord,' 1869, July, 193 ; Weruicli, ' Geogr.-med. 
 Studien,' Berlin, 1878, 200.
 
 LEPROSY. 19 
 
 as in all otlici' countries, there are some points much more 
 severely aifected than others, such as the Bay of Nao-asaki, 
 the Bay of Yeddo, Miako, and Oruma. Weruich found 
 almost the whole population leprous in a considerable villao-e 
 between Yeddo and Yokohama. Of the occurrence of the 
 disease in Slhcria, I have no information ; in Kamtschatha it 
 is said to be very often met with, but the statement^ is not 
 quite trustworthy, as there seems to have been some con- 
 founding of it with syphilis. 
 
 On the Continent of Australia, leprosy has been found 
 hitherto only in occasional cases among the Chinese immi- 
 grants, and principally in the gold districts of Victoria (in 
 the vicinity of Ballaarat, Castlemaine, and Boechworth) .'^ 
 It is quite unknown in South Australia, Western Australia, 
 and Tasmania. On the other hand, it is widely prevalent 
 among the natives of New Zealand, being known by the name 
 of " Ngerengere." According* to information dating from 
 1 854,^ the disease had decreased very much in recent times — 
 whether in proportion only to the frightful depopulation of 
 the native territory or absolutely, is not stated — and it is now 
 met with almost exclusively in the interior. 
 
 How far Brunet^s statement is justified, that leprosy occurs 
 on all the islands of Oceania,'^ I am unable to decide in 
 the absence of relevant information as to points of detail. 
 In the Society Islands^ (Tahiti), the disease is known under 
 the name of " Oovi,^' but it is rare. The Hawaiian 
 Islands (Honolulu), are the only group from which we have 
 accounts of leprosy spreading widely within quite recent 
 times ; but this intelligence, also, is wanting in trust- 
 worthiness. 
 
 In the small tract on lepx-osy by Macnamara (Calcutta, 1S66), already 
 quoted, a statement is given of a physician Hillebrand, practising at 
 Honohilu, according to which leprosy was imported into the island in 
 1840 by Chinese, and rapidly attained so enormous a diffusion that, at 
 
 » ' Inosemzoff, 'Med. Ztg. Russl.,' 1844, Nr. 6. 
 * ' Report on Leprosy,' xiv, 80-82. 
 
 3 Thomson, 'Brit, and For. Med.-Chir. Rev.,' 1854, April. 
 ■* ' La race Polyncsiennc,' Par., 1876, 44. 
 
 •'■' Hereoiiet, 'Etude sur les maladies des Europccns auK ilcs Tahiti,' Par. 
 1880, 71.
 
 20 GEOGlUrniCAL AND IIISTOUICAL rATIIOLOGY. 
 
 tbe time of writing (1865), 3'5 per 1000 of tlie wlaole population were 
 affected witli it. The same story lias been told subsequently by Knee- 
 land,i and after him by Emerson,^ who places the date of the importa- 
 tion, however, in 1856; he adds that there were 684 persons — Roma- 
 nowski^ gives 806 — living in the leper colony on Molokai. Milroy'' has 
 thrown doubts — and, it seems to me, with good reason — on the state- 
 ment of Hillebraud ; and the matter in question is rendci'ed still 
 more doubtful by the remark of Enders,* that many so-called cases of 
 leprosy in Honolulu are to be counted as syphilis. 
 
 On tlie soil of EuroiJe, leprosy occurs endemically at the 
 present day only in small and^ for the most part, closely cir- 
 cumscribed areas. It is still prevalent to a considerable extent 
 in the Iberian Fcninsula. In 8pain, as far as I am able to 
 judge from the very scanty, and in part somewhat antiquated, 
 data before me,® the headquarters of leprosy are the Provinces 
 of Catalonia, Andalusia, Galicia, Asturia, and Granada, being 
 coast territories ; in Portugal, the Provinces of Beira, Estre- 
 madura^ and Algarvo. There are not many facts as to the 
 number of lepers in the two kingdoms. In 185 1, the official 
 returns for Spain gave 284 lepers as living in nine provinces. 
 In 1877 a new enumeration of the lepers was undertaken, 
 which has proved, in the result, to be very imperfect ; thus 
 in Valencia, only 116 are returned, while it could be shown 
 that many leprous persons there had kept themselves con- 
 cealed J in Malaga, also, as Martinez y Montes states, the 
 number of lepers is much greater than has come to official 
 cognisance. In the Province of Alicante a new leper-house 
 has been opened lately — a proof that the disease is still 
 somewhat prevalent there. For Portugal, the number of 
 lepers was given in 1821 at 800; in his report dating from 
 1838, Baptiste assigns the mountainous district of Lafoes 
 (Prov. Beira), as the headquarters of the disease, the number 
 of lepers in 477 communes being 3000 (Avhich d^ Almeida 
 says should read 300).'^ 
 
 1 ' Boston Med. aud Surg. Journ.,' 1873, March, 233. 
 
 2 ' Brit. Med. Journ.,' 1880, Sept., 401. 
 
 3 'Arch, de med. nav.,' 1881, Oct., 314. 
 
 4 'Med. Times and Gaz.,' 1875, July, 66. 
 ^ 'Brit. Med. Journ.,' 1876, Dec, 731. 
 
 ° See, for Spain : Scares, ' Joni. da Soc. das sc. med. de Lisboa,' vi, i ; 
 Borrow, 'Five Years in Spain.' Gor. Transl., Brcsl., 1844, ii, 183 j Webster, 
 'Med.-Cliir. Transact.,' i860, xliii, 27; Virdiow, ' Arcb.,' i88j, Ixxxiv, 417. 
 
 7 For Portugal: Baptiste, ' Jorii. da Soc. das sc. mod. de Lisboa,' 1838, May;
 
 LEPROSY. 21 
 
 Two small centres of leprosy, on wliicli a good deal of 
 liglit has been tlirown recently, are met with in Itahj, tlic 
 one on the Gulf of Genoa [Riviera di Ponente), the other on 
 the Adriatic in the neighbourhood of the small town of 
 Comacchio situated in the marshes of Ferrara. Quite lately 
 attention has been directed to a somewhat more considerable 
 endemic in Sicily, which has been increasing within the last 
 thirty or forty years. As regards Comacchio, where the 
 disease is said to have appeared first in 1806/ the number 
 of lepers in the town amounted in 1S45 only to about a 
 dozen ;" occasional cases from Comacchio were observed in 
 Bologna as late as 1868/ but the endemic in that quarter 
 appears to be now extinct. The small endemic on the 
 Geoncse Biviera is cleai-ly a survival of the great leprosy 
 centre that once extended from Chiavari (on the Riviera di 
 Levante), along the Italian and French coasts as far as the 
 mouths of the Rhone, being represented in Provence down 
 to the end of last century by the somewhat frequent cases 
 in Martigues, Vitrolles, and a few localities in the neighbour- 
 hood of Marseilles and of Toulon/ and on the Riviera di 
 Levante as late as the first ten years of the present century, 
 by the persistence of the disease in Chiavari, Yarezza, and 
 other places. At all these points, as well as in the villages 
 of PigEa, Castel Franco, La Turbie, and others belonging 
 to the quondam Duchy of Nice, leprosy has died out entirely 
 during recent years, and it is now confined to a few valleys 
 opening towards the coast. An enumeration made in 1843 
 puts the number of lepers in the whole district at 100.^ In 
 1858 the Italian Government fitted up a monastery on the 
 highest point of San Remo as a leper-house, into which forty 
 
 d' Almeida, ib., Aug.; Scares, 1. c. ; Kessler, in ' Vircbow's Arcb.,' i86s,'xxxii, 
 257 J Vircbow, 1. c. ; Peacock, 'Lancet,' 1870, Dec, 773. 
 
 1 Parola, 'S:iggio di climatol. e di googr. nosol. dell' Italia,' Torino, 1881, 502. 
 
 2 Medici, 'Anual.univ. di lued.,' 1836, Sept.; Verga, 'Sulla lebbra,' Milano, 
 1846. 
 
 3 Sgarzi, ' Gaz. med. Lombard,' 1868, Nr. 11. 
 
 4 Vidal, 'Hist, de la Soc. de med. de Paris,' 1779. »' M*^"'"-' i^' ' Valentin, 
 ' Bull, de I'ecole de med. de Paris, 1S07, 48 ; Fodcre, ' Jouru. conipU'm. du dic- 
 tioun. des sc. med.,' 18 19, iv, 3 5 l''"cbs, 'Diss, de lepra Arabum,' Wirceb., 
 
 5 Trompeo, ' Giorn. delle sc. mod. di Torino,' 1843, Gennajo ; Bocck ct 
 Dauiclssen, 1. c, 185.
 
 22 GEOGRAPHICAL AND HISTOEIOAL PATHOLOGY. 
 
 patients were received;^ on visiting- it in 1877, I found only six 
 or seven lepers, and tlie doctor in cliarge informed me tliat no 
 new cases liad presented tliemsolves for two years, so tliat 
 we may look for a complete extinction of tlie endemic there 
 also. The first beginnings of the recently developed endemic 
 of leprosy in Sicily'^ go back to the end of the seventeenth 
 century, when the disease showed itself in the village of 
 Avola (Prov. Syracuse), which had been quite free from it 
 up to that time ; fifty years later, it appeared at Buccheri, 
 Floridia, Solarino, and Naso (Prov. Messina) ; towards the 
 end of the eighteenth century (1780 and 1790) at Trapani 
 and on the adjoining island of Faviguana ; in the early years 
 of this century at Cefalu (Prov. Palermo) and Lipari (Prov. 
 Messina), in 1830 at Monte San Giuliano and at Mirto (Prov. 
 Trapani), in 1854 at Carini (Prov. Palermo) ; while, finally, 
 from i860 to 1870, occasional cases have occurred at Petralia, 
 Girgenti, Polizzi, and Sciacca. 
 
 Of 114 cases observed lately, and all well autlienticated, 75 came from 
 Avola, 10 from Eloridia, 9 fi-om Trapani, 8 each from Palermo, Solarino, 
 and Naso, 7 each, from Castellamare, BuccLeri and Lipari, 6 eacli from 
 Cefalu and Monte San Giuliano, 5 from Favignana, 3 from Mirto, and i 
 each, from Carini, Petralia, Polizzi, Girgenti, and Sciacca ; so that 
 while there were 2 lepers to every 9000 inhabitants of the coast, there 
 were 5 to the same number of residents inland. 
 
 Only a few general references to the endemic occurrence 
 of leprosy in the Balhan Peninsula are to hand from recent 
 times. According to these, there are still existing small 
 centres of the disease on the coast of the Ejalet of Salonica 
 (Thessaly and Macedonia) ; in Constantinople cases occur 
 very seldom, and the leper-house in the Scutari suburb 
 is mostly used for leprous patients coming from Asia Minor. 
 In Monastir, Janina, and many other places, leprosy is now 
 quite unknown.^ 
 
 An enumeration of lepers in Greece^ in 1851 puts them at 
 350,^ but there are unfortunately no precise facts as to their 
 
 1 Thaon, ' Nice medical,' 1876, Nr. 3; Kobner, 'Viertelj. fiir Dermatologic,' 
 1876, iii, 3. 
 
 - Profctii, ' Lo Sperimentale,' 1875, Sept., 294 ; Ferrari, ' La lebbra in Sicilia,' 
 Catania, 1S78. 
 
 3 ' Report on Leprosy,' xiii, 68. 
 
 ■* Rigkr, L c.,ii, ii4- * Ibid.
 
 LEPROSY. 23 
 
 distribution in various parts of the country. More recent 
 information^ indicates tbat tlie endemic centres of tlie disease 
 occur mostly in the eastern districts, particulai'ly in a few 
 villages in the neighbourhood of Parnassus. On the Ionian 
 Islands leprosy would appear to be now rare (eighteen lepers 
 were counted in Corfu in 1862);" on the other hand, the 
 disease is prevalent as an endemic to a greater or less extent 
 on many Islands of the ^gean, such as Samos,^ Rliodes^ 
 (with the small islands around it), where there were some 
 300 lepers living in 1862, GJdos^ and Mytilene, where there 
 is a village forming a completely isolated leper colony, 
 although many lepers travel the island as beggars in the fine 
 weather.^ But the chief seat of leprosy in this region is 
 Crete; an enumeration made there in 1833 of persons noto- 
 riously leprous gave a total of 628, of whom 522 were in the 
 province of Candia, 64 in Retino, and 42 in Cauea ; but 
 many more cases, who had only lately become leprous, or who 
 had been hidden by their relatives, remained uncounted ; and 
 we shall not go far wrong in following Smart,^ and placing 
 the number of lepers living on the island, among a popula- 
 tion of 250,000, at goo, giving a ratio of 3*6 in the 1000. 
 This enormous prevalence of leprosy in Crete has lately been 
 confirmed by Brunelli.^ 
 
 In Boumania^ and in Hungary, ^^ as well as at many other 
 parts of Europe, occasional cases of leprosy occur ; but in 
 those countries the disease has long since ceased to be endemic. 
 In the region of Southern Russia also, — which had been much 
 afiiicted with leprosy even as late as the first quarter of this 
 century, — extending from the Crimea, along the Sea of Azov 
 and the Caucasian Frontier as far as the Ural Steppe, the 
 
 I Dekigalla, ' Gaz. hebd, de med.,' i860, 108; Cigalla, ' Annal. univ. di med.,' 
 1865, Gennajo 3 ; Ornstein, ' Jouru. des connaiss, med.-chir.,' 1866, 367. 
 
 ^ 'Report ou Leprosy,' xiii, 65. 
 ^ Mengozzi, ' Gaz. med. d'Orieut,' 1861, April. 
 ■* ' Report,' xii, 58. 
 
 s Pasqua, 'Bull. gen. de therap.,' 1880, 15, Dec, 507. 
 « Bargigli, ' I'Union med.,' 1878, Nr. 49, 633. 
 7 «Med. Times and Gaz.,' 1853, Oct., 444. 
 s 'Annali univ. di med.,' 1866, Dec, 461, 1867, Gcnnajo 3. 
 » Scheiber, ' Viertelj. fiir Dermatol.,' 1875, i, 363. 
 ^o Sclivvimmer, ' Pester med.-chir. Presse,' 1880. 
 
 II See Martins, ' Abliandl. iiber die krimmische Krankhcit,' &c., Frcib.,
 
 24 
 
 GEOGEAPHICAL AJJD HISTOEICAL TATnOLOGT. 
 
 disease appears to have decreased materially o£ late.^ The 
 same applies to the Baltic Provinces in recent times. "^ 
 
 In a fishirig village at the moutli of the Danube, inhabited by Rus- 
 sians and Gi'eeks, a small centre of leprosy has developed within the 
 last twenty years, — it is said in consequence of importation.^ In the 
 Caucasus the disease still occurs in a few Cossack villages (" stanitzas " 
 or fortified stations) ; Popoflf^ I'efers to a leper-house opened since 1850 
 in a Cossack village in the Government of Stavropol, and Liebau*" found 
 another in a " stanitza " on the Terek, in which, however, there were 
 only three patients. 
 
 In Sweden, where many cases of leprosy were met with at 
 the end of last century and beginning of this/ in the dis- 
 tricts of Angermanlandj Medelpad, Helsiugland, Upland, and 
 Bohus, a considerable decrease of the disease has been 
 observed of recent years, as will appear from the following 
 statistics :'' 
 
 Table of Lepers in 
 
 Sweden 
 
 from I 
 
 S67 
 
 to I 
 
 879 
 
 • 
 
 
 District. 
 
 1867-68-69 
 
 -70 
 
 1871 -73 
 
 1 
 
 -74 
 
 -75 
 
 -76 
 
 -77 
 
 -78 
 
 -79 
 
 Gefleborg . 
 
 6.3 
 
 .S8 
 
 77 
 
 s.-; 
 
 86 
 
 10.3 
 
 94 
 
 91 
 
 8q 
 
 90 
 
 8.3 
 
 86 
 
 Jemtland . 
 
 I 
 
 X 
 
 I 
 
 I 
 
 I 
 
 2 
 
 2 
 
 
 
 
 
 I 
 
 Wester-Norrland 
 
 3 
 
 .3 
 
 .3 
 
 .3 
 
 .3 
 
 .s 
 
 .S 
 
 6 
 
 6 
 
 6 
 
 7 
 
 7 
 
 Kopperborg 
 
 10 
 
 9 
 
 12 
 
 9 
 
 8 
 
 10 
 
 9 
 
 9 
 
 9 
 
 2 
 
 2 
 
 4 
 
 Blekinge . 
 
 1 I 
 
 I 
 
 I 
 
 I 
 
 I 
 
 I 
 
 I 
 
 
 — 
 
 — 
 
 
 Gottlaiid 
 
 — 
 
 I 
 
 I 
 
 I 
 
 I 
 
 1 
 
 I 
 
 
 
 I 
 
 I 
 
 I 
 
 I 
 
 Upsala 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 
 2 
 
 2 
 
 I 
 
 Wermland 
 
 ~ 
 
 ~ 
 
 
 
 
 ' 
 
 " 
 
 **"^ 
 
 
 — 
 
 I 
 
 — 
 
 1819 ; PlachofF, 'Von dem tuberculosen Aussatz der donisclien Kosaken u. s, w.,' 
 Moskau, 1842 (in Russian); Krebel, 'Med. Zfcg. Russl.,' 1846, Nr. 38. 
 
 ^ The most recent accounts of leprosy in Astrakhan by Oldekop (' Vircbow's 
 Archiv,' xxvi (1863), p. 106), and Meyerson (ib., xxxi (1865), p. 446) are based 
 on only a few observed facts. When I was in Astrakhan in the spring of 1879, 
 I got sight of only a single case, and that a doubtful one, notwithstanding every 
 inquiry. In reply to my questions, the practitioners there all assured me that 
 the disease is now very rare. 
 
 • Wachsmuth, 'Arch, fur klin. Med.,' 1867, iii, i ; Bergmann, ' Die Lepra in 
 Livland,' St. Petersburg, 1870. 
 
 3 Vignard, ' Gaz. med. de Paris,' 1877, 563. 
 'Med. Ztg. Russl.,' 1854, 381. 
 Liebau, 'Petersb. med. Ztschr.,' 1866, xi, 284. 
 
 Huss, ' Om Sverges endem. sjukdomar,' Stockh., 1852, 10, 11, 14, 34, 43. 
 I have taken the data from the ' Sundhets-Collegii Berattelse ' for the 
 respective years.
 
 LEPROSY, 
 
 25 
 
 From tliis it appears that during the past twenty years 
 tliere lias existed only a small endemic centre in Gefle- 
 borglan ; of tlie 86 cases living there in 1S79, 17 belonged to 
 Ljndal^ 18 to GerfsOj 15 to Delsbo^ and 7 to Alfta, the re- 
 mainder occurring singly here and there. 
 
 One of the most considerable leprosy-regions of Europe 
 is the west coast of Norway, from Stavanger up to Tromsoe, 
 most of the cases belonging to the departments of Sondre 
 and Nordre Berghus, which have been the headquarters of 
 the disease in Norway from the first.^ 
 
 Since 1856, a careful reckoning of the numbers of lepers 
 in Norway has been made every year, from which the satis- 
 factory conclusion is drawn that the number of cases has 
 decreased nearly by one hal£ in nineteen years, having fallen 
 steadily from 1859. The figures are as follows : 
 
 Tahle of the numher of Lepers in Nor way from 1S56 to 1874. 
 
 856 . 
 
 . 2,847 
 
 1863 . 
 
 . 2,660 
 
 1869 .. 
 
 . 2.276 
 
 857 • 
 
 • 2,773 
 
 1864 . 
 
 ■ 2,639 
 
 1S70 . 
 
 . 2,050 
 
 85S . 
 
 • 2,774 
 
 1865 . 
 
 . 2,603 
 
 1871 . 
 
 • 1,987 
 
 859 • 
 
 • 2,785 
 
 1866 . 
 
 • 2.563 
 
 1872 . 
 
 . 1,943 
 
 860 . 
 
 • 2,741 
 
 1867 . 
 
 • 2,497 
 
 1873 • 
 
 . 1,874 
 
 861 . 
 
 • 2,717 
 
 1 868 . 
 
 ■ 2,413 
 
 1S74 . 
 
 . 1,832 
 
 862 . 
 
 . 2,685 
 
 
 
 
 
 The following table gives a summary of the number of 
 cases in the various departments of the country, and shows 
 
 ^ Among older authorities, see : Pontoppidan, ' Versuch einer naturliclieu His- 
 toric von Norwegeu,' Kopenh., 1 754, ii, 480 ; Murtin, ' Abhaudl. dur Scliwcd. Akad. 
 der Wiss,' xxii, 301 ; Strom, ' Pliys. oecon. og mcd.-cliir. Bibl.,' 179S, July, 223 j 
 Pfcfferkorn, ' Ueber die Norweg. Kadesye und Spedalskhed,' Altona, 1 797. Recent 
 authorities: Horn, ' Norsk. Mag.,' 1841, ii, 42; Boeck, ib., 1842, iv, i, 127; 
 Danielssen, ib., v, 131 ; Stcffens, ib, 1843, vi, 229 ; Hoffmann, ib., 1846, i.x, 251 ; 
 Boeck et Danielssen, 1. c. ; Hjort, ' Norsk. Mag.,' 1856, N. Ii., x, 649 ; ' Discussion 
 i det Norske med. Selske angaaende spedalskheden,' Christ., 1857; Holmsen, 
 'Norsk. Mag.,' 1857, ix, 129; Bidenkap, ib., 1858, xii, 398, i860, xiv, 535, 713, 
 809, 889; Lochmaun, ib., 1871, Tr. R., i, 129; Hjort, ' Om spedalskheden i 
 Norgc,' Christ., 187 1, and ' Norsk. Mag.,' 1872, ii, 105 ; Buchholz, ' Om spedalsk- 
 heden som folkesygdom.,' Christ., 1872 ; Hansen, ' Norsk. Mag.,' 1872, ii, i, and 
 ' Unders5gelser angacnde spedalskh. arsager.,' Christ., 1874 ; Broch, ' Le royaunie 
 de Norvege,' &c., Christ., 1876, 52, and App. 7 ; Eklund. ' Om spctclska,' Stockh., 
 1879. See also ' Beretninger om Sundhetstilstanden i Norgc,' and ' Tahellcr over 
 de spedalske i Norge.'
 
 2G 
 
 GEOaRAPlITCAL AND HISTORICAL PATHOLOGY. 
 
 at tlie same time tliat the decrease lias been nearly uniform 
 all over, 
 
 GomiJarative Table of Leprosy in Norway in 1856 and in 1870. 
 
 
 
 1856. 
 
 1870. 
 
 Department. 
 
 Lepers. 
 
 Per 10,000 
 iuhabitimts. 
 
 T »vo Ter 10,000 
 I"=P"^- inhabitants. 
 
 Finnmarkeu . 
 
 Tromsoe 
 
 Nordland 
 
 Nord. Trondjhem 
 
 Sondre ,, 
 
 Romsdal 
 
 Nord. Bergenhus 
 
 Bergen (Town) 
 
 Sondre Bergenhus 
 
 Stavanger 
 
 Other Department 
 
 s 
 
 16 
 
 58 
 
 275 
 197 
 
 193 
 336 
 926 
 
 47 
 
 519 
 225 
 
 55 
 
 8-3 
 i6-i 
 
 354 
 26*9 
 
 20"0 
 
 37"2 
 
 113-6 
 
 i8-2 
 
 50-2 
 24-6 
 
 07 
 
 12 
 
 30 
 231 
 
 170 
 
 169 
 
 288 
 
 591 
 26 
 
 349 
 
 157 
 
 27 
 
 5*9 
 6-6 
 
 25-8 
 
 20-6 
 
 15-5 
 
 276 
 68-1 
 
 94 
 308 
 
 150 
 
 03 
 
 In the whole Kingdom . 
 
 2,847 
 
 19-1 
 
 2,050 
 
 117 
 
 On tlie Faroe and tlie Shetland Islands, as already re- 
 marked, leprosy has entirely disappeared since the beginning 
 of the century. In Iceland,^ on the other hand, ib still 
 persists, although there too it is considerably less than it 
 used to be. 
 
 Table of Lepers in Iceland, 1768 — 1869. 
 
 Year. 
 
 Inliabitauts. 
 
 Lepers. 
 
 Proportion. 
 
 1768 
 
 1838 
 184S 
 1869 
 
 38,000 
 55,000 
 
 P 
 
 70,000 
 
 280 
 
 1 28 
 
 66 
 no 
 
 73 in 10,000 
 23"3 
 
 15-7 in 10,000 
 
 ' Older authorities : Petersen, ' Deu saakaldto islandske Skorbug,' Soroe, 
 1 769 ; Thorstensen, ' Bibl. for Liiger,' 1830, ii, 91. Recent authorities : Sclileisner, 
 ' Island undersogt fra ct laegevidensk. synspuukt.,' Ivjobenh., 1849, 23 ; Hjal- 
 teliu, ' Sundhedskoll. Aarsberetn. for 1855,' ^S, 1856, 424, 1859, 435, 1866, 443, 
 and in 'Dobell's Reports,' 1870, 283 ; Finscn, ' Jagttagelser uugaaendo sygdoms- 
 forholdene i Island,' Kjobenh., 1874, 53.
 
 LEPEOSY. 27 
 
 Tlie considerable decrease of cases between 1S38 aud 
 1848 is explained by tlie fact that many of tbem were swept 
 off by tlie severe epidemic of measles in 1847. Between 
 1854 and 1859, the number rose again materially, but in 
 i86g, as the above table shows, tlie proportion of lepers in 
 10,000 inhabitants was only 23*3, as against 67*3 from 1768 
 to 1838. The disease has always been most common on the 
 south coast. 
 
 The Western Hemisphere, as we have already seen, was 
 invaded by leprosy first in the seventeenth century, in con- 
 nexion, it has been thought, with the importation of negroes. 
 North America, however, has remained free from it, if we 
 except the somewhat wide diffusion of the disease in Mexico, 
 the occurrence of it among Chinese immigrants in Cali- 
 fornia,^ and two smaller foci, the one in Louisiana' and the 
 other in New Brunsiuiclc. (The statement that leprosy occurs 
 in Greenland rests upon errors of diagnosis, as more recent 
 inquiry has shown.^) In Louisiana the disease has been 
 endemic for a long time ; in New Brunswick it is strictly 
 confined to a few French settlements in the counties of 
 Gloucester and Northumberland, between Chaleur Bay aud 
 the Miramachi, being properly endemic only in the village 
 of Tracadio. The disease did not show itself there until 
 1 8 15, and it is highly pro])able that it was imported by 
 French eniigres (" Acadians ") from the coast of Normandy, 
 and has been propagated among them by inheritance. The 
 British Government had their attention first drawn to its 
 occurrence in 1844, and they caused a leper-house to be 
 founded on Sheldrake Island, into which thirty-two patients 
 (out of a population of 4000 in the infected districts) were 
 admitted during the five years down to 1849. The leper- 
 house was afterwards transferred to Tracadie, and sixty- 
 four new cases were admitted down to 1863, at which 
 date there were twenty -one lepers in it, the rest having 
 died.'' Later information^ tells us nothing more than that 
 
 1 PifEard, 'New York Med. Record,' 1881, Marcb, 305. 
 - Schmidt, 'New York Archives of Med.,' 1881, Dec. 
 
 3 Lange, 'Bemacrku. cm Gronlauds sygdomsforhold.,' Kjolionh., 1864, 25. 
 * See Skene, ' Loud. Med. Gaz.,' 1844, June, 353; lioylc, il).,Aiig., 609; Alex- 
 ander, ' L'Acadic,' Lond., 1849, ii, 226, ' Report on Leprosy,' viii, 1-6, 203-207. 
 5 Welch, 'Lancet,' 1874, Dec., 795 ; Adams, ib., 852.
 
 28 GEOGRAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 the disease still continues^ its extent not being men- 
 tioned. 
 
 In Mexico leprosy occurs in general diffusion, mostly indeed 
 among the native Indians, both on the coast and at the 
 more elevated if not even the very highest points.^ From 
 Central America we have only a few facts about the disease ; 
 in Nicaragua it is said to bo almost unknown/ and there is 
 no mention of it in the accounts of sickness from Guatemala, 
 Honduras, and the Mosquito Shore ;^ only in Gosta Rica is it 
 spoken of as occurring often, — in the valleys of Cartago and 
 San Jose at elevations of 3000 to 5000 feet, the number of 
 lepers being estimated at from 50 to 100.* 
 
 More uniformly diffused, and in some places more frequent, 
 is leprosy in the West Indies, particularly in Guba,^ Jamaica^ 
 (where there were in 1861 some 800 lepers in a population 
 of 440,000, and of these 41 in Kingston with 27,000 inhabit- 
 ants), 8t. BartJioloinew,'^ St. Kitts^ (47 lepers in a population 
 of 24,000 in 1 861), Nevis,^ Antigua^^ (22 persons in a leper- 
 house, the population being 36,400), Guadeloupe,^^ St. Vin- 
 cent,^^ Barhadoes^^ Trinidad}'^ (50 inmates of the leper-house 
 in 1 86 1, population 83,000), and the Bahamas}^ On the 
 
 ^ Blacquiere, 'Journ. des counaiss. med.,' 1838, Nov.; Simpson (quotiuj^ 
 Cheyne), ' Edinb. Med. and Surg. Jom-n,,' 1842, April, 410; Newton, 'Med. 
 Topogr. of the City of Mexico,' New York, 1848 ; Luvio e Alvaredo, ' Opusculo 
 sobre el mal de San Lazaro,' Mexico, 1852 ; Jonrdanet, * Le Mexique, &c.,' Par., 
 1864,413; Heinemauu, in 'Virehow's Arch.,' 1867, xxxix, 607. 
 
 - Bernbard, ' Deutsche Klin.,' 1854, Nr. 8. 
 
 3 Young ('Narrative of a Residence on the Mosquito Shore,' Lond., 1847, 
 p. 26) speaks of " leprous " spots which had been seen in natives of the Mosquito 
 Shore; perhaps the reference is here to the skin affection known as the " Pintas " 
 (vide infra), which is endemic among the Mexican Indians and has often been 
 confused with leprosy. 
 
 ■• Schwalbe, 'Arch, der Hcilkde,' 1865, Heffc. 6. 
 
 5 'Notes on Cuba,' Bost., 1844. 
 
 ^ 'Report on Leprosy,' ix, 9; Piddes, 'Edinb. Med. Journ.,' 1857, Juno; 
 Report in ' Philad. Med. and Surg. Reporter,' 1868, Jan., 21. 
 
 7 Lauren, ' Svensk. Lak. Siillsk.,' Hdl. ii, 177 ; Goes, ' Hygiea,' 1868, xxx, 460. 
 
 8 'Report,' 16. » lb. '" lb., 19. 
 '^ Rufz, ' Bull, de I'Acad. dc med.,' 1859, xxiv, 105 1. 
 12 lb., and ' Report,' 24. 
 
 '2 Rufz, 1. c, ' Report,' 26. 
 
 14 'Report,' 38; 'Report of the Medical Superintendent [Esjjinet] pf the 
 Leper Asylum (of Trinidad) for the year 1874.' 
 
 15 ' Report,' 7 ; Sweeting, ' Med. Times and Gaz.,' i860, Sept., 208.
 
 LEPROsr. 29 
 
 other hand, the disease is but rarely seen on Porto Rico,^ the 
 Virgin Islands,^ Dominica,^ Martini rjue,'^ Sta. Lucia,^ Gre- 
 nada,^ and Tohago -^ rarely also on the Bermudas.^ 
 
 I am unaLlo, in the absence of medical information, to 
 say whether leprosy is still as prevalent as it was described 
 to be (in a report^ dated 1823) in Colombia — in the districts of 
 Cartagena, Socorro, Pamplona, Bogota, Tunja, and Canasara. 
 For Venezuela also I have no recent information. There are, 
 however, trustworthy accounts^*^ of its endemic occurrence in 
 Ecuador (less on the coast or in the upper basin of the 
 Maraiion, than in the elevated regions), and at various parts 
 of Guiana, which agree with the reports on the disease in 
 those countries during the last century. 
 
 For Cayenne^' and Surinam'- there are no definite data as to tlie 
 number of cases. In British Guiana'^ in 1 864 there were counted (exclu- 
 sive of 131 patients in the leper-house at the village of Mahaica, and of 
 60 patients under treatment in a private hospital), 338 lepers, who were 
 distributed throughout the various districts of the colony as follows : 
 Berbice 136 lepei's in 24, 1 19 population, or 5'6 per 1000. 
 Demerara 85 „ 62,195 „ 1-3 „ 
 
 Essequibo 53 „ 27,959 „ 1-9 
 
 Georgetown 64 ,, 29,174 „ 22 „ 
 
 Taking the total population as 148,000, the number of lepers (529) in 
 British Guiana in that year gives a proportion of 3"6 per 1000, 
 
 The headquarters of leprosy in South America is Brazil}'^ 
 With the exception of the provinces of Maranhao and Rio 
 
 1 Thomiis de Cordolj;i, 'Mem. geogr. de la Isla de Puerto-Rico,' Samniltaii, 
 J8.31. 
 
 2 ' Report,' 15. 3 11,.^ 21. •* Rufz, 1. c. 
 
 ' Levaclicr, ' Guide med. des Antilles,' Par., 1840, 263, ' Report,' 22. 
 
 '^ lb., 34. ' lb., 36. '•* lb., viii, 6. 
 
 ^ Restropo, ' Memoria . . . . al primero Congr. costit. do Columbia,' &c., 
 Bogota, 1823. 
 
 '0 Echeverria, ' Bull, de I'Acad. de med.,' 185 1, xvi, Nr. 1 7, ' Gaz. mod. de Paris,' 
 1851, 329 (from his experience in the leper-house of Quito) ; Duplouy, ' Arch, 
 de med. nav.,' 1864, Oct., 283; Gait, 'Amer. Journ. of Med. So.,' 1872, Oct., 
 395 ; Gayraud et Daumec, ' Moutpellier med.,' 1878, Aug., 97, Dec, 491. 
 
 '1 Noyer, 'Revue mod.,' 1834, May, 235. 
 
 1- Hasselaar, 'Besclirijv. der in de Kolou. Suriname voorkom. Elephantiasis 
 en Lepra,' Amstcrd., 1835, 22; v. Leent, 'Arch, de mod. nav.,' 1880, Nov., 405. 
 
 '3 Hancock, ' Loud. Med. Gaz.,' 1837, Oct., 'Report on Leprosy,' .x, 42-48, 213- 
 15; Milroy, 'Med. Times and Gaz.,' 1873, May, 575; Ilillis, 'Lancet,' 1879, 
 Oct., 589. 
 
 '^ See Sigaud, ' Du climat et des nialad. du Brcsil,' Pur., 1844, 157, i6.|.
 
 30 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Grande, where the disease is comparatively rare, tlie wliole 
 country is afflicted witli it to a frightful extent, more espe- 
 cially the inland provinces of Matto Grosso and Minas 
 Geraes and the coast province of San Paulo. According to 
 Tschudi there are villages on the frontier between Minas 
 and San Paulo, in which almost every family is " morfetico/^ 
 In his report for 1 840 to the Provincial Estates of San Paulo, 
 the president says:^ " C'est un spectacle digne de compassion, 
 sur la route de Rio de Janeiro a Saint-Paul, de recontrer, 
 echelonnes, tant de nialheureux infectes de la lepre. A 
 chaque ville, on trouve une cahane aux environs qui sort de 
 refuge a ces proscrits de la societe." 
 
 In the leper-house at Bahia (besides which there are two large hos- 
 pitals for lepers at Rio de Janeiro and Pernambuco), 1029 patients were 
 admitted from 1787 to 1842. These figures do not give even an 
 approximate measure of the frequency of the disease, inasmuch as it is 
 diffused mostly among the poor, who endure their lot with indifference 
 and do not seek a refuge in the leper-houses. 
 
 From the southern provinces of Brazil, this area of leprosy 
 extends over Paraguay and the northern parts of the Argen- 
 tine Ttepublic, particularly throughout the provinces of Entre 
 Rios and Salta, stretching across the continent as far 
 as the eastern frontier of Bolivia." The disease does not 
 appear to occur at all on the west coast of South America ; 
 this fact is explicitly stated by the authorities for Bolivia, 
 and there is no mention of leprosy in the numerous accounts 
 of the state of health in Chili and Peru. 
 
 Sporadic cases. — To conclude this geographical and his- 
 torical survey of leprosy, it remains to add that accounts 
 are continually being published of the occurrence of isolated 
 
 382; Rendu, ' Etude topogr. ct mod. sur leBresil,' Par., 1848, 122, Ref. iu ' Gaz. 
 raed. de Paris,' 1848, 625; Dundas, 'Sketches of Brazil,' Loud., 1852, 359; 
 Tschudi, ' Wien. med. Wochenschr.,' 1858, Nr. 31, 1866, Nr. 40; Plagge, 
 ' MonatsbL fiir med. Statist.,' 1857, ^^'- io> 7' ; Wuchercr, in ' Virchow's Arch.,' 
 i86i,xxii, 345. 
 
 ' Quoted by Sigaud, I.e., 164. 
 
 ^ Brunei, ' Observ. topogr. et med. faitcs dans le Rio-de-la-Plata,' Par., 1S42, 
 46; Lallemant, in 'Virchow's Arch.,' 1S61, xxii, 341 ; Mantegazza, ' Lettere sulla 
 America meridionale,' Milano, 1860-63, i, 100, 141, ii, 208; Mastermau, in 
 ' Dobell's Reports,' 1870, 382; Coni, 'Contribucion al estudio de la lepra 
 anestesica,' Buenos Ayres, 1878 (see Virchow-Hirsch's ' Jahresbericht,' 1878, i, 
 
 3.^9)-
 
 r 
 
 I 
 
 LEPROSY. 31 
 
 cases in many countries, such as Eng-land, Germany, France, 
 and Italy, wliore the endemic disease has been long extinct. 
 The origin of these cases is not referred to endemic centres, 
 but they are taken as having without doubt developed 
 autochthonously in the midst of regions otherwise exempt 
 from the disease. Many of these accounts appear certainly 
 to be open to a good deal of suspicion, inasmuch as the dia- 
 gnosis is anything but sure ; others, however, admit of no 
 doubt as to the nature of the disease, and these are just the 
 cases which have an especial interest for the etiological 
 inquiry, being well adapted, if due attention be given to 
 them, to preclude onesidedness in estimating the morbific 
 causes. 
 
 § 3. The Etiology much obscuked by Narrow Hypotheses. 
 
 " The investigation of the causes of diseases," says Sir 
 James Simpson, in his classical ^Antiquarian Notes on Lep- 
 rosy,'^ "has, probably more than any other departmeut of medi- 
 cine, been marked by belief without evidence, and assertion 
 without facts. The history of the opinions which have at 
 different times been so freely offered and adopted with 
 regard to the production of leprosy, and the numerous expla- 
 nations which have been proposed with respect to the causes 
 of its almost epidemic prevalence in Europe in the middle 
 ages, and its nearly complete suspecsion in the same region 
 of the world at the present day, might easily, if time and 
 space permitted, be made to form a chapter highly illus- 
 trative of the above general remark.'^ These words of Simp- 
 son describe the fortunes of the etiological doctrine of lep- 
 rosy in all ages down to the present day, with that fitness 
 and exhaustiveness of expression which an impartial testing 
 of the facts always makes it possible to use ; and we may say 
 without any reservation that superficiality or inacuracy in 
 observing facts, and onesidedness or bias in judging of 
 them, have nowhere obtruded themselves so much to swell 
 the doctrine of morbific causes with empty hypotheses as in 
 the etiology of leprosy. 
 
 1 « Edin. Med. and Surg. Journ.,' 1842, April, p. 407-
 
 32 GEOGKAPHICAL AND HISTORICAL PATHOLOGY. 
 
 § 4. Influence op Climate. 
 
 In seeking to make good tliis assertion^ we come first to 
 a criticism of tlie views that liave been lield as to the influ- 
 ence of climate on the genesis of the disease. Either these 
 views have had regard only to the prevalence of the disease in 
 lower latitudes, laying' especial stress on tropical climate ; 
 or, taking due account of the fact that leprosy occurs both 
 in the tropics and in the extreme north (Norway and Ice- 
 land) they have found the material factor in the etiology to 
 be extremes of temperature wn.^ frequent and rapid transitions 
 of temperature along luitli high degrees of atmospheric mois- 
 ture} How little justice there is in this will appear from a 
 glance at the present map of leprosy, which shows that it is 
 indigenous in all latitudes, equally the tropical and polar, 
 and the temperate (Ionian and ^gean Islands, Iberian 
 Peninsula, River Plate States, Japan, the Cape, and New 
 Zealand). But the history, also, of the disease in past cen- 
 turies tells no less against that view, a history of far-reaching, 
 if not quite universal, diffusion over Europe from the twelfth 
 to the sixteenth century, and of the malady appearing and 
 spreading, as well as gradually becoming extinct, altogether 
 independently of climatic conditions or states of the weather. 
 
 As bearing on this point, and on the question of the 
 etiological factors of leprosy in general, it is especially 
 noteworthy that the disease is not found to be uniformly 
 diffused over wide stretches of country at those points of 
 the globe where it is now prevalent ; but that its visitation 
 falls upon single districts or even single villages within these 
 limits, while neighbouring districts or villages, subject to 
 the same, or approximately the same, conditions of climate, 
 are either exempt altogether or only slightly touched by it. 
 Lastly, there is the consideration that the greatest incidence 
 of the disease within the tropics does not by any means 
 correspond to the more or less pronounced tropical climate 
 of the affected locality. 
 
 Out of 174 parislies in the district of Lafoos (Portugal), which Las 
 leprosy endemic in it, tliere are many quite free from the disease,, the 
 
 1 Brassac, ' Arcli. de med. uav.,' iS6C>, Marcli, p. 189.
 
 LEPROSY. 33 
 
 sickness being confined, on the whole, to tlie eastern parts of tlie 
 valley; yet there is no difference, as d' Almeida expressly states, 
 between the weather-conditions of the sevei'al parishes. Leprosy in 
 Crete, as Smart informs us, has its head-quarters on the high land of 
 the interior, badly situated as regards climate, while it is rare in the 
 coast towns enjoying a mild climate ; on the other hand, in Ceylon, it 
 is most widely diffused in the southern coast districts, while the inha- 
 bitants of the interior, and particularly of the hills, are almost entirely 
 exempt from it. On the east coast of Sweden, leprosy is extinct all but 
 a small remnant ; on the Norwegian west coast, however, an important 
 centre of the disease still persists ; while a comparison of the conditions 
 of climate at the two points reveals no such material differences as 
 would serve to explain the extinction of the endemic at the one and its 
 continuance at the other. In the Bombay Presidency, says Carter, 
 leprosy is severest at two points, which prove to be most widely different 
 as regards climate — along the stretch of coast of the Southern Konkan 
 (with a sick-rate of i in 430 inhabitants), and on the table-land of the 
 Deccan (with a sick-rate of i in 550) ; and he adds :' " The disease is 
 found under all climatic conditions, whether of soil, vegetation, tempe- 
 rature or rain-fall ; its intensity has no ascertained relation to the sub- 
 varieties of climate in Western India, and if it have to geographical 
 conditions, this is only because they are connected with racial distri- 
 bution." 
 
 It sliould not be forgotten tliat unfavorable conditions of 
 climate, liigli degrees of atmosplieric moisture, frequent and 
 extreme fluctuations of temperature, and the like, predispose 
 the human organism to the specific sickness by their dis- 
 turbing effects on the well-being; and herein, perhaps, 
 there may lie one cause of the relative frequency of leprosy 
 in the tropics. But in its genesis the disease is altogether 
 independent of this factor in the etiology ; its proper cause 
 is to be sought rather in conditions which exert a specific 
 effect, which are bound up with the locality or the manner 
 of life, and very materially also with the racial characters of 
 the inhabitants of the tropics, inasmuch as they make them- 
 selves felt there in a much greater degree than in higher 
 latitudes. 
 
 Hansen^ claims to find, in the fact that erythema nodosum, which 
 some observers regard as a form of rheumatic sickness (?), is sometimes 
 the precursor of leprosy, a reason for believing that the influence of chill 
 is an important element in the production of the disease. The associa- 
 tion herein implied I cannot regard as a perfectly good analogy ; and 
 
 1 ' Med.-Chir. Trans.,' 1. c, p. 270. 
 ^ ' Norsk. Mag.,' 1. c, p. 3. 
 
 VOL. II. ^
 
 34 GEOGRAPHICAL AND HISTOEIOAL PATHOLOGY. 
 
 Hansen himself admits tliat " it is hardly fair to assign tlie causation 
 of the disease solely to influences of climate." 
 
 § 5. Question op a Special Eelation to the Sea Coast. 
 
 The origin and endemic prevalence of leprosy cannot be 
 brought into direct causal relation with definite conditions of 
 soil any more than it can with climatic influences. The 
 opinion held by many early observers, which was in currency 
 until not so very long ago and was shared at one time by 
 myself, that the disease mostly occurs on the sea coast and 
 along the banks of rivers, and that we may make an infer- 
 ence therefrom as to the pathogenetic influence of a damp 
 soil, can no longer be maintained, at least in its full extent, 
 now that we have got more accurate information of the 
 range of the disease within the modern period and at the 
 present day, and that information, too, not only for the soil 
 of Europe, but also for many other parts of the globe. It 
 cannot, certainly, be denied that the greater part of the more 
 considerable leprosy-areas still existing in Europe, do possess 
 the character of soil above referred to ; in Norway, in Spain 
 and Portugal, and on the Ligurian and Adriatic littoral, we 
 find leprosy confined pi'actically to the coast ; and the same 
 is true for many centres of the malady in India, China, 
 Ceylon, Egypt, Brazil, and the West Indies. But to set 
 against such facts bearing out the rule, there are many more 
 which do not accord with it ; and the latter are so numerous 
 that we come to doubt in the end what is rule and what is 
 exception. Or rather — and this seems to me to be the 
 correct standpoint from which to judge of the facts — we 
 come to abandon the rule altogether, and admit that no 
 definite factor of the pathogenesis can be found in states of 
 the soil taken by themselves, that is to say, in anything 
 therein that is physically discernible — the high or low eleva- 
 tion, the situation on the coast or in the interior, the damp- 
 ness or dryness, the porosity or impermeability, and the 
 like. 
 
 In speaking of the distribution of the disease in Sicily, 
 Profeta^ has the following : — " That which a considerable 
 
 ^ L. c, p. 297. •
 
 LEPROSY. 3 
 
 number of writers tave taken to be a condition for the deve- 
 lopment of leprosy, namely, residence on the sea-coast, does 
 not find confirmation in Sicily. In fact, while there are only 
 2 lepers to gooo inhabitants of the coast, the proportion is 
 about 5 among the population living at a greater or less 
 distance from the sea." On Madeira, leprosy occurs at 
 elevations from 2000 to 3000 feet (Heinecken). In Alnjs- 
 sinia, the disease is just as prevalent on the plains and in 
 the hill- country (particularly the mountainous district of 
 Samen), as on the coast (Pruner, Aubert-Roche, Blanc). 
 In Madagascar, it is met with as commonly among the hills as 
 on the flat country (Davidson). Of the distribution of the 
 disease among the Hottentots in Cajye Colony, we read :^ " It 
 is common at the Cape, principally among the Hottentots 
 and half-castes .... The Hottentots usually reside 
 away from the sea, in open valleys, high and dry, not liable 
 to malaria." In Syria, leprosy is rare on the coast, and 
 properly endemic only in the mountainous districts or on the 
 plains (Pruner, Wortabet) . In India, the head-quarters of 
 the disease are the mountainous tract of Kumaon with an 
 elevation of 5000 feet and upwards (Lewis and Cunning- 
 ham) ; in the hill-country belonging to the Bombay 
 Presidency, leprosy occurs at a height of 2000 feet, upon 
 perfectly dry and scantily watered soil (Carter), and, under 
 the same circumstances, on the plateau of Mysore (Van 
 Someren). In Sumatra, the disease is found as an endemic 
 mostly in elevated parts of the interior, notably in the 
 beautiful park-like country of Paya- Combo. ^ In Japan, the 
 area of leprosy extends from the coast far into the interior 
 (Wernich). In Mexico, the table-land is afflicted no less than 
 the coast (Jourdanet). In Gosta Rica, it occurs nowhere but 
 in the mountain valleys of Cartago and San Jose, at eleva- 
 tions of from 3000 to 5000 feet (Schwalbe). Of leprosy in 
 Barhadoes, Carrington says :^ " It shows itself in all parts of 
 the island, in towns, rural districts, on the sea coast and 
 inland, in low damp situations and on dry hills." In 
 Oolomhia and Ecuador, it is endemic only on elevated parts of 
 
 1 Ebdea, in ' Report on Leprosy,' pp. 49-50. 
 
 2 « Arcb, de med. nav.,' 1867, Oct., p. 248. 
 
 3 ' Report on Leprosy,' p. 30.
 
 36 GEOGRAPHICAL AND ITISTORICAL PATHOLOGY. 
 
 the interior, while the coast regions, particularly those of 
 Ecuador, are exempt. In Brazil, it is found to a frightful 
 extent in the interior (especially in the province of Minas), 
 and much more widely diffused than on the coast (Tschudi). 
 I think that, in adducing these facts, to which many 
 more of a like significance from the most various parts of 
 the world might have been added, I have said enough to 
 justify the opinion that I have already expressed. The 
 evidence should at the same time serve to show how entirely 
 groundless is the opinion, which has been already contro- 
 verted by Carter, Espinet (for Trinidad), and Durand-Fardel 
 (for China) ,^ that leprosy can be brought into some causal 
 connexion with malarious influences . 
 
 § 6. Influence of Fish as the Staple Food. 
 
 The opinion that the true cause of the disease is to be 
 looked for in the immoderate use of fish as food, or of salt fish, 
 or of fish tJtat has become putrid or has undergone some morhid 
 change, is obviously connected with the foregoing assump- 
 tion of the sea coasts being the chief seats of endemic 
 leprosy. This view, which is foreshadowed in Galen,^ and 
 in the Arabian and other physicians of the middle ages 
 (Gordon), as well as in the medical chroniclers of later 
 centuries,^ has found its staunchest representative most 
 recently in Hutchinson.'* 
 
 " All localities," says that author, " which either are now, or ever 
 were, noted as the homes of leprosy, have this in common, that they 
 are either on the sea-shore, or on the banks of marine estuaries. The 
 most probable conjecture is that it is caused by some peculiar diet 
 common to marine localities ; that it is due to fish eaten in some 
 peculiar state, may bo plausibly suspected. The fact tbet it is met 
 Avith in such widely distant parts, renders it improbable that it is due 
 to any particular variety of fish. . . . The sum of our conjectures, then, 
 appears to amount to this : that leprosy is far too specific and peculiar 
 in its symptoms to allow of our supposing it due to the influence of 
 general poverty ; that the cases in which Europeans are attacked, all 
 
 1 ' Gaz. med. de Paris,' 1S77, ^o- 2>i' P- 403- * ^*^^ supra, p. 5. 
 
 ' Thus, Heberden (' Lond. Med. Transact.,' 1768, 5, 23) states that the use of 
 salted or putrid fish was the cause of the prevalence of leprosy in Madeira. 
 
 4 Not having the original before me, I quote the passage from Liveing, 
 ' Elephantiasis Graecorum or True Leprosy,' Lond., 1873, p. 81.
 
 LEPBOSY. 37 
 
 iutlicate tlie powex' of endemic influences ; that, of endemic influences 
 food is the one which has the most of probability as to its being the true 
 cause ; and, lastly, as the disease is only met with near the sea, we 
 may plausibly guess that it is in some way connected with the fish diet." 
 
 lu a subsequent paper/ in wliich he adduces observations 
 from Norway, Russia, and India in support of this view, lie 
 remarks that leprosy lias obviously spread along the shores 
 of the Pacific in company with the Chinese immigration : 
 " wherever they go the disease appears, and the explanation 
 seems to be that, wherever they go, they carry their habits 
 with them, and especially that they establish themselves 
 everywhere as cooks ; they are skilful cooks, and they can 
 make use of many things which no one else would look at ; 
 decomposing fish and potted fish are amongst the delicacies 
 in which they deal.'^ 
 
 Numerous other writers have quite recently adopted the 
 same opinion, on the ground of observations made in Spain 
 and Portugal," Sweden,^ Norway, Iceland,'^ the Steppes of 
 Southern Russia,^ Corfu, Crete, Ceylon,'' Japan,''' Abyssinia,^ 
 New Brunswick,^ Guiana,^*^ and the West Indies.^^ They 
 support their opinion by various arguments : either that, in 
 the localities in question, fish, and more particularly salt or 
 putrid fish, is almost the only food of the people ; or that 
 the disease has died out when the practice of subsisting on 
 fish had been given up (as on the Bohuslan coast of Sweden) ; 
 or, finally, that the fishes themselves had been subject to 
 a specific malady, resembling leprosy, so that the eating 
 of fish so tainted had set up the disease in man. It will 
 be seen at once how one-sided and untenable this theory 
 is, Avhen we consider that leprosy is endemic in many 
 places where there can be no question of a fish diet at all, and 
 still less of the exclusive use of that kind of food ; that the 
 disease in many regions is limited as an endemic to particular 
 localities, the population of villages in the immediate neigh- 
 bourhood being quite exempt ; that leprosy has disappeared 
 
 ^ ' Med. Press and Circular,' 1880, August 11. 
 
 * Grasset, Baptiste, Peacock. ^ Huss. 
 
 * Mackenzie, Sclileisner. ^ Oldekop. 
 
 * ' Report on Leprosy.' 7 Schmid. '^ Blanc. ' Skene. 
 i» Bergeron, Milroy, in 'Med. Times aud Gaz.,' 1873, May, 575. 
 
 11 'Report on Leprosy.'
 
 38 GEOGEAPHIGAL AND HISTORICAL PATHOLOGY. 
 
 from many places not merely as an endemic but altogether;, 
 although no material change has taken place in the kind of 
 sustenance of the inhabitants which would account for its 
 disappearance ; and that the alleged communicable leprous 
 disease of fishes has turned out to be a perfectly harmless 
 parasite upon them, being found in many localities where no 
 leprosy occurs. 
 
 With reference to the opinion that the use of decomposed 
 fish, or of the greasy flesh of sea birds, is the true cause of the 
 leprosy that is prevalent on the Norwegian coast, Danielsseu 
 says :^ " The coast population, who suffer mostly from the 
 disease, are in the habit of eating the fish in its fresh state 
 or well salted ; in preparing the seagulls, which are by no 
 means a general article of food there, most of the fat is 
 taken away with the skin. Many persons fall into leprosy 
 there whose diet is only exceptionally fish or the flesh of 
 sea-fowl, their every day food consisting rather of meat and 
 cereals." As to the " leprosy of fishes," Messrs. Boeck and 
 Danielssen remark :^ " Careful inquiries have shown that 
 these suspected ' tubercles ' are formed of a vegetable 
 parasite, which is found in some species of soles even at 
 places where there is not a trace of leprosy ; the people are 
 afraid to eat the fish disfigured in that manner, and throw 
 them away. The parasite has not the very slightest con- 
 nexion with leprosy." Of this particular etiological factor 
 the opinion of Profeta, based on his observations in Sicily, 
 is : " Residence on the coast, with a seafaring life, or the 
 prosecution of fishing and the use of salted or putrid fish, are 
 regarded by a good many writers as the conditions likely 
 to generate leprosy ; but this opinion is not borne out by 
 the facts as regards Sicily." By far the larger number of 
 authorities in India are opposed to the notion that the disease 
 stands in any definite relation to a fish diet.^ Thus, Richards 
 points out that in Balasore (Orissa), leprosy is less common 
 than in Burdwan, Bancoora, and other districts adjoining, 
 although the use of fish as food is much more universal in 
 the first-named than in the others ; Macnamara * says that, 
 
 1 'Norsk. Mag.,' 1851, v, 147. = 'Traite/ p. 31. 
 
 * See 'Brit. Med. Journ.,' 1880, April, 527. 
 
 i e 
 
 Virchovv's Arch.,' 1861, xxii, 312.
 
 LEPEOSY. . 39 
 
 of all the cases of leprosy which he saw in India, there was 
 not one for which this causal element had to be taken into 
 account. Startin^ mentions that the inhabitants of Rawal- 
 pindi (Punjaub), and of the Naga Hills (Assam), eat no fish, 
 and yet suffer from leprosy ; whereas in Araccan, where that 
 article of diet plays a prominent part, the disease is rare. 
 In Rutnagherry, one of the chief seats of leprosy, it is much 
 more prevalent, as Carter points out,^ in the interior, where 
 no fish is eaten^ than on the coast. It is remarked by Kirk- 
 patrick ^ that, in Bangalore (Mysore), leprosy is anything 
 but rare among the Brahmins, although they are strict 
 vegetarians, their partaking of flesh or fish being visited by 
 immediate expulsion from the caste. Observations to the 
 same effect come from various parts of the leprosy regions 
 of China (such as Hankow), where, according to Shearei-'s 
 experience/ the use of fish food has no significance whatso- 
 ever for the genesis of the disease, and where lejDrosy, as 
 Reid ^ tells us, is often met with among the poverty-stricken 
 population of the interior who live mostly on rice, millet, 
 or other vegetable food prepared with a little oil, and who 
 eat flesh only now and then, and fish more rarely still. In 
 Hankow, on the other hand, and other centres of traffic, 
 where fish is an article of diet the whole year round, the 
 disease is rare. " Fish eating,^' Reid adds, " is essentially 
 in Central China the privilege of the well-to-do, while 
 leprosy is usually found among the poor vegetable-feeders." 
 The Jajianese physicians also, as we learn from Wernich, have 
 declared against any connexion between living on fish and 
 the development of the disease. When Skene refers the 
 occurrence of leprosy among the Acadians of New Brunswick 
 to their kind of food, Welch makes the reply, that the 
 English and Indian inhabitants of that region have just the 
 same kind of diet as the former, and yet remain free from 
 the disease. 
 
 Moreover, it is not a fish diet only that has been blamed 
 for causing leprosy, but also other ai^ticles of food, such as 
 
 1 'Lancet/ 1880, Oct., 692. ^ lb., 1872, Aug., 199. 
 
 3 lb., 1880, Dec, 922. * 'Liuicct,' 1871, Dlc, p. Soi. 
 
 5 lb., 1880, Nov., p. 878.
 
 40 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 decomposed rice ^ or maizer' But, most of all, a specific 
 importance for tlie development of the disease lias been 
 ascribed to tlie immoderate use of ])orli, particularly in 
 Brazil, where Candido^ would explain its prevalence in 
 the provinces of San Paulo and Minas by the fact that 
 swine's flesh forms one of the chief articles of the people's 
 food. On the other hand_, we have the recent statement of 
 Lucio and Alvaredo* from Mexico : " There are many lepers 
 who have never eaten pork, others who have partaken of it 
 rarely, and still others who have lived on it to an excessive 
 extent; but among all these the disease has occurred with 
 equal intensity. We conclude from this that the use of that 
 article of diet has no influence whatsoever either upon the 
 production of the disease or upon the severity of its type." 
 
 §. 7. Influence op Insanitaey Conditions. 
 
 But although there is no reason, so iixv, to look for the 
 real cause of leprosy in dietetic influences, still, the predis- 
 position of individuals to take leprosy ajjpears to be very 
 considerably heightened by deficient, unsuitahle, or had food, 
 either in itself or along* with other defects of well-heing , such as 
 inadequate shelter from the weather, filth, and the like. There 
 is almost complete unanimity on this point among observers at 
 the most diverse points of the globe. The opinion is further 
 confirmed by the fact that the disease has been at all times 
 especially prevalent among the necessitous classes, and much 
 more occasional within those strata of society which are well 
 found in the needs and comforts of life. We cannot, there- 
 fore, summarily dismiss the conjecture that the extinction of 
 the disease at many places, or the considerable remission in 
 its amount, has been a result of progressive improvement in 
 hygienic conditions in the course of years, particularly of 
 improved cultivation of the soil, and of a greater acreage ; 
 
 ^ In India (Brett, * Essay on some of the principal Surgical Diseases of India,' . 
 Calcutta, 1840, p. 163). 
 
 ^ In Brazil (Sigaud, p. 382). 
 
 ^ * Revista nied. flumiu,' 1842, p. 501. Tschudi also mentions that this opinion 
 is widely held in Brazil (' Wien. med. Woch.,' 1858, 1. c). 
 
 ^ L. c, p. 29.
 
 I 
 
 LEPROSY. 4l 
 
 for tlie more abuudaut harvests, bringing- a better kind 
 o£ sustenance^ and more o£ it, liavo been a gain wbicli 
 cannot be too highly estimated in this respect. But those 
 are etiological factors which one must not over-value. On the 
 one hand, cases of leprosy have been not so very i-are, both 
 of late and in past times, among individuals of the well-to- 
 do class, removed from the harmful influences in question ; 
 and, on the other hand, the malady has disappeared from 
 many localities Avhich used to be much afflicted by it, 
 although the most wretched hygienic conditions are found 
 in them still; while, hnally, it should not bo forgotten that, 
 within the regions where leprosy is or has been endemic, 
 there are particular villages, or even considerable tracts of 
 country, quite exempt from the disease, although these 
 nowise differ, in the manner of life of their inhabitants, from 
 the parts of the country that are subject to the leprous 
 infliction. 
 
 It is impossible to decide liow far we can trust tlie statements* that 
 have come down to us from the Middle Ages, as to leprosy occurring in 
 crowned heads, princes, prelates, and other personages — whether, in many 
 of these cases, it is not rather a question of syphilis. But there can 
 be no doubt that the classes of the people in better circumstances fur- 
 nished no inconsiderable contingent of the leprous in former times, and 
 that they continue to do so in those countries where there are still 
 intense centres of leprosy, such as Sicily,"^ Madeira and the Canaries,* 
 the North- West Provinces of India,-" Tirhoot,^ Orissa," Malacca,^ and 
 Madagascar.^ The very narrow limitation of many of the leprosy- 
 centres has already been dwelt upon more than once in the sketch of the 
 historical and geographical circumstances. Vidal," in his account, 
 dating from last century, of leprosy in the vicinity of Martiguez (Pro- 
 vence), points out that the disease was confined to a few villages and 
 to perfectly definite groups of families ; and precisely to the same eifect 
 are the statements of Valentin,'" on its distribution in Pigna, Castel 
 Franco, and other places on the Ligurian coast. Referring to the small 
 focus of leprosy in Comaccio, Verga'' says that the disease no longer 
 occurs even at a short distance from the town in the directions of 
 
 1 See Simpson, 1. c, 1842, Ap., p. 394 5 I^oeck and Danielsseii, 1. c, p. 97. 
 
 2 Profeta. ^ Bolle. •• Planck, ' lieport.' ^ Macuamara. 
 6 llicbards. ' Official papers. ** Boicligrevinok. 
 
 9 'Hist, de la soc. de mod. do Paris,' 1779, i. Mom., uS8. 
 
 i» ' Bull, de Tecole de mod. do Paris/ 1808, 45 ; also Fodcre, ' Jourii. complciu. 
 dudict. des so. med.,' 1819, iv, 3. 
 " < Sulla lebbra,' Milano, 1846.
 
 4^ GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Ravenna and Forli. Similar observations have been made in tbe district 
 of Sondfjord (Amt Bergen),^ in tbe affected parts of Greece,^ in Crete,* 
 at various places in India,"* at Hankow,* in Japan," and elsewhere ; 
 and it has not been possible to find a reason for this in any difference 
 between the affected and the exempted villages as regards the habits of 
 living. 
 
 §.8. The Docteine or a Specific Infective Virus. 
 
 All tliese facts are opposed, as we have said_, to tlae 
 opinion, adopted by various inquirers, that the sum total of 
 hygienic defects, and these in and hy themselves, furnish the 
 proper cause of the disease ; or that leprosy ranges itself 
 alongside of scurvy and the other constitutional anomalies 
 of nutrition^ E-ather do the facts go to prove that this 
 etiological factor has the significance merely of a predis- 
 posing cause, even if it be a potent one ; that, for the pro- 
 duction of the disease, v^^e must have a definite and specific 
 noxious agent, a peculiar infective substance, which had been 
 more or less widely diffused through Europe in former times, 
 but is now active only at certain points in this part of the 
 world, although it still makes itself felt over a great range 
 of territory outside Europe. Many observers have arrived 
 at this opinion by a process of exclusion, being convinced 
 that the production of the disease is not to be explained as an 
 effect of atmospheric, dietetic, or other unhygienic influences, 
 and that an ignotum quid must accordingly be invoked.^ 
 Others, again, go a step farther, and develop the doctrine of 
 the "virus of leprosy," and of its infectious character. Thus, 
 it was said by Schilling in the last century :^ " Neque tamen 
 
 1 Bidenkap, 1. c, 1858, xii, 466. ^ Dekigalla, Ornstein. ? Brunelli. 
 
 4 Carter, ' Med.-Chir. Transact.,' 1, c. 5 Shearer. ^ Wernich. 
 
 ■^ See, for instance, Vinkhuijzcn, p. no; Hjort, 1. c, 1872, ii, 115. 
 
 ® This is the view of Eoeck and Danielssen, 1. c, 407-9 (Norway) ; Welhaven, 
 ' Svcnsk. Liik. Siillsk. HandL'iii, 188 (Sweden) j Dundas, 369 (Brazil); Kaempfer, 
 161 (Madeira); Bargigli, L c. (Mytilene) ; Wachsinuth, L c. (Livonia); Profeta 
 (Sicily) ; and Davidson (Madagascar). " If poverty in diet, or personal wants, 
 filth, and wretchedness in their deepest degrees, could generate the malady," says 
 Simpson (1. c, April, 409), " there are certainly still numerous spots in Conti- 
 nental Europe, and even in our own land, where, unfortunately, all these elements 
 of disease are in our own day in full and active operation, without any such 
 specific result following; the alleged causes are present without the alleged 
 efEeets." 
 
 3 ' Diss, de lepra,' Traj. ad Rhen., 1769.
 
 LEPEOSY. 43 
 
 negaverim, peculiarem esse materiam et quasi virus quoddam, 
 sine quo vera lepra non producatur.^' In later times, the 
 same opinion lias been expressed by Holmsen, Lockmann, 
 and Hansen. To tlie last mentioned observer^ the priority 
 belongs of successfully demonstrating that there are organic 
 elements in the morbid products, which are " perhaps ^' (as 
 he cautiously puts it) the proper virus of leprosy. 
 
 He found uniformly, in the cells of tlie leprous nodules, " small rod- 
 like bodies " whicli had the perfect type of bacilli ; and, in the older 
 morbid pi'oducts, brownish cells of a larger size, which contained 
 zooglcea-masses and aggi'egates of bacilli. Examination of the blood 
 yielded no results at first ; but when the device was adoj^ted of keeping 
 the preparation a few days in a moist chamber, there were found 
 jointed filaments, which he was constrained to regard as likewise 
 specific formations, inasmuch as they could not be made out in prepara- 
 tions of blood treated the same way, taken from healthy persons or 
 from persons with syphilis. 
 
 These observations have been subsequently confirmed by 
 Carter," although with many modifications in points of detail, 
 and more recently by Neisser,^ Cornil,^ and Kcibner.^ 
 
 Neisser found the bacilli not only in the leprous products, but also in 
 the skin, in the mucous membrane of the mouth, gums and larynx, in 
 the liver, spleen, and lymphatic glands, and in the interstitial prolonga- 
 tions of the peripheral nerves of the cornea, of cartilage, and of the 
 testis. He satisfied himself, also, of a formation of spores proceeding 
 from the break-up of the bacilli ; and of the growth of the latter into 
 filaments. Alterations in the blood at large Hansen and Neisser could 
 in no case discover ; and the latter is accordingly obliged to conclude 
 that the difi"usion of the spores within the body takes place by way of 
 the lymphatic system. In blood taken from leprous nodules Kobner 
 found bacilli ; but he is not sure that they may not have got into the 
 preparation owing to pressure exerted on the tissue. 
 
 In Neisser' s opinion, the results of his inquiries have con- 
 clusively proved that in leprosy we have to do with a specific 
 
 1 ' Undersogelser, &c.,' Christhui., 1874,75, ami in ' Vh-chow's Arch.,' 1S80, 
 Ixxix, 32. 
 
 ■■^ ' Transact, of the Pathol. Soc. of London,' 1876, xxxvii, 297. 
 
 3 'Bresl. urztl. Zeitschr.,' 1879, Nr. 20, 21, and in ' Virchow's Arch.,' 1881, 
 
 Ixxxiv, 514. 
 
 * 'Bull, dc I'Acad. de lucd.,' 18S1, Nr. 43, p. 1.308; 'Union med., i88r, 
 Nr. 134, 178, 179 ; ' Aunal. de Dermatologic,' 1881, ii, 653 (alon- with Suchard). 
 
 5 In 'Virchow's Arch.,' 1882, 13d. 88, 282.
 
 44 GEOGRAPHICAL AND HISTOEIGAL PATHOLOGY. 
 
 Icind of hacteriitm, wliicli can be brouglit iuto causal relation 
 witli every manifestation of tlie disease ; along witli i-elapsing' 
 fever and anthrax^ he says^ leprosy is entitled to a place as 
 one of the best authenticated bacterial diseases. 
 
 § 9. Question of Contagiousness. 
 
 If the infectious nature of leprosy is rendered highly pro- 
 bable — I will not say proved — by the facts above adduced, 
 I am nevertheless unable to share the opinion of those who 
 have drawn conclusions therefrom, and particularly from 
 the parasitic character of the disease, as to its contagiousness, 
 and have thereby sought to rehabilitate with the credit 
 of the very latest times a notion that had been almost 
 entirely abandoned and condemned. During the Middle 
 Ages, there was hardly any doubt among physicians and 
 the laity as to the contagiousness of leprosy ; and it was 
 that conviction which really gave occasion to the founding 
 of leper-houses and to the isolation of the leprous. We 
 shall, perhaps, not err if we attribute this assumption of a 
 leprous contagium to an error in diagnosis, to the confound- 
 ing of it with syphilis, the nature of which latter remained 
 quite unknown to the mediasval practitioners. Pointing to 
 this, at least, is the fact that as early as the i6th century, 
 when men had learned to distinguish the one disease from 
 the other, doubts about the contagiousness of leprosy became 
 current. The adherents of the doctrine that leprosy was 
 catching became fewer and fewer as the disentanglement 
 proceeded and unjjrejudiced observation gained ground ; and, 
 in the end, the belief was held only as a tradition within 
 ever-narrowing circles. '^Belief without evidence,^' as 
 Simpson says,^ "and assertion without facts," preserved this 
 dogma in existence ; or, as Brunelli very aptly says : 
 " L'opinione era contagiosa, e non la malattia." In more 
 recent times, the number of those who believed in it had 
 dwindled to a minimum ; only among the public did 
 " opinione ^ still play a considerable part, finding among the 
 profession only a very few who were so cautious as not to 
 
 ' L. c, p. 412.
 
 LEPROSY. 45 
 
 deny the possibility of leprosy Iseing communicable through 
 coutagion. Thus it happened that Landre's coming forward 
 as a contagionist/ although it made a considerable stir, was 
 without result^ the more so that he did not rely upon obser- 
 vations of his own, but took as the text of his declamations 
 the extremely unreliable accounts which his father had 
 brought from Surinam. The doctrine of the contagiousness 
 of leprosy has been lately revived by Hansen,^ who supports 
 his opinion, in the first instance, by a series of cases where 
 persons, previously in good health, took leprosy after corning 
 into communication with lepers (which, of course, proves 
 nothing, as all the cases occurred within endemic foci of the 
 disease). But he was doubtless materially strengthened in 
 his conviction by the discovery of bacteria in the leprous 
 products ; and this surmise is borne out by the fact that 
 Carter, who was still anti-contagionist in 1873, became con- 
 verted to a belief in contagiousness in the following year, 
 after he had witnessed Hausen^s researches and become per- 
 suaded of the trustworthiness of that discovery. In like 
 manner it is only an a priori proof of the conveyance of 
 leprosy by contagion which Neisser adduces when he states, 
 on the ground of the finding of bacteria and of the hypothesis 
 therefrom deduced, that the malady is '' contagious in its 
 specific products," and, '' contagions not only directly, but 
 also indirectly by articles which serve to carry the bacilli of 
 leprosy or their spores.'" 
 
 That the contagiousness of leprosy is not proved by these 
 arguments, nor even made probable, goes without saying ; 
 while, against the notion, there are all those facts, positive 
 and negative, from the history of the disease, about which 
 the observer who rests on "his own experience" does not 
 concern himself. In judging of the question before us, I 
 would not lay any emphasis on the want of success attending 
 the experiments of Danielssen,^ Hansen, and Kobner to 
 inoculate the disease upon rabbits (of Kobner also upon rats, 
 mice, guinea-pigs, pigeons, fishes, and monkeys), inasmuch 
 as experiments of that kind can only have a correct siguifi- 
 
 1 ' De la contagion seulc cause de la propagation de lalepre,' Par., 1869. 
 
 2 L. c, p. 53. 
 
 » 'Norsk. Mag. for Laegevidensk.,' 1871, i, 195.
 
 46 GEOGRAPHICAL AND HISTORICAL TATHOLOGY.. 
 
 cance wJien tlicy are made upon animals wliose susceptibility 
 to the morbid poison we are otherwise assured of. I attach, 
 equally little value to the felonious experiment by which 
 Bargigli attempted (also without success) to inoculate the 
 ichorous matter from a leprous ulcer upon children six to 
 eight years old,^ inasmuch as it is not proved that the bacilli 
 of leprosy do occur in the pus derived from leprous persons. 
 Finally, the statement of Davidson, from Madagascar, that 
 " leprosy is contagious only by inoculation and not by simple 
 contact,^' amounts to nothing, as he has omitted to say on 
 whom the inoculation is made, and how it is made. 
 
 Equally indecisive, in my opinion, are the data of those 
 observers who refer the outbreak of the disease in the 
 Western Hemisphere (Guiana, Brazil, &c.) to the negro 
 importation. Not only is the information b}^ no means 
 guaranteed ; but, even admitting it to be trustworthy, the 
 fact might be explained in other ways than the spread of the 
 disease through contagion ; besides that all the more recent 
 observers in those countries deny most emphatically that 
 leprosy is contagious at all. Lastly, if negroes had intro- 
 diTced leprosy into South America and the West Indies, it 
 would be difficult to understand why Central America, and 
 most of all the United States, where there has been truly no 
 lack of negro importation, have remained exempt from the 
 disease. 
 
 More recently Macnamara has given a similar history of importation 
 of the malady by the Chinese to Honolulu in 1848, which had been told 
 to him by Hillebrand, a practitioner of that place ; but this maybe said 
 to have turned out a fable, as Milroy, Boeck, and others had already 
 hinted, inasmuch as Emerson, a later authority, refers the same 
 affair to the year 1856, adding that more than 1000 of the natives of the 
 island had subsequently become affected with leprosy.^ The statement 
 of a French missionary, Btienne Brosse, author of a tract " La lepra est 
 contagieuse," vrhich has been quoted by Piffard,-* reads almost comically ; 
 
 ^ As this statement may sound somewhat incredible I give the autlior's owa 
 words : " Afiu de fixer mon opinion [on the non-contagiousness of leprosy], j'cntre- 
 pris d'inoculer la matiere sanieuse d'un ulcere de lepreux sur des enfauts de 6 a 8 
 ans de cette classe. Jo ne pus obtenir que deux fois seulement (!) I'autorisation de 
 pratiquer cette operation. Cependent ces deux operations ayant cte negatives, 
 ma conviction etait faite." 
 
 2 'Brit. Med. Journ.,' 1880, Sept., 401. 
 
 ^ 'New York Med. Record/ 1881, Marcb, 305.
 
 LEPEOST. 47 
 
 tLe Chinese, lie says, have bi'ouglit leprosy to California, and there 
 can be no doubt that they will give the disease to the inhabitants of 
 the State : " There is not the shadow of a doubt but that it will pass 
 from them to the other inhabitants of the country. Thus far it has 
 been confined to the Chinese, but it certainly will not be resti-icted to 
 them." We still await the fulfilment of this prophecy. 
 
 Lastly^ even tbose cases where Europeans have acquired 
 the disease after comiug- into close connexion with leprous 
 patients^ cannot be regarded as giving proof of the con- 
 tagiousness of leprosy, for the reason that they might very 
 well have fallen ill apart from this intercourse, it being 
 always in such cases a matter of acquiring the disease within 
 the endemic seats of leprosy. My conviction is that there is 
 not a single fact which tells decisively and indisputably for 
 the conveyance of the disease by contagion. On the other 
 hand the facts are very materially against the notion, inas- 
 much as they entirely fail to accord with our whole experi- 
 ence of the mode of diffusion of the true contagious diseases. 
 These facts I tabulate as follows : 
 
 (i) The extremely narrow limitation of leprosy in certain 
 centres, often very small, while there is free communication 
 between their inhabitants and the neighbouring population, 
 and where the sanitary conditions are such as would especially 
 favour the conveyance of the disease sooner or later. This 
 applies to the malady as it is distributed over the steppes of 
 Southern Kussia, in the Caucasus, in the northern districts of 
 Persia, and in New Brunswick, referring to which last 
 Jeffries says ■} " I do not know where non-contagiousness of 
 leprosy is better proved than among those descendants of one 
 French family that brought the disease to New Brunswick." 
 
 (2) The observation made not unfrequcntly of the malady 
 being confined, at certain places with a mixed population, to 
 particular races or nationalities, notwithstanding unrestricted 
 social intercourse throughout the community. Thus, m the 
 East Indian Archipelago, the Arabs enjoy a striking immu- 
 nity, while the Malays, the Javanese, and the mixed races 
 are heavily afflicted.^ To show how much truth there is in 
 the opinion stated above, that leprosy had been imported 
 into Honololu with the Chinese, we may take a fact oC the 
 
 1 « Lancet,' 1875, March, p. 358. 
 
 - 'Arch, de med. nav.,' 1867, Oct., p. 248.
 
 48 GEOGRAPHICAL AND HISTOEIOAL PATHOLOGY. 
 
 same class, vouclied for by several medical officials in Mel- 
 bourne : viz. tliat there has not been a single case observed 
 of leprosy communicated by the Chinese living there, notwith- 
 standing that their intercourse with all other sections of the 
 community is perfectly free.^ 
 
 Vinklinijzen^ quotes from an official report by Ublig, who had seen 
 mucli of leprosy in Surinam and afterwards in Batavia, the interesting 
 fact that the Indian races do not suffer from the disease either at the 
 one place or the other, although tliey mix with the negroes in the most 
 intimate way. " Since I have been resident," says Uhlig in his report, 
 " at the settlement of Batavia, near which there are 500 Indians living, 
 I have seen some of the latter coming here every day, or leprous 
 persons going to them ; they eat and drink together out of the same 
 vessels, they house together, they wear each other's clothes, and what 
 is more remarkable, they smoke the same pipe or the same cigar, pass- 
 ing it from one mouth to another, and no one declining to take it. 
 This relationship has subsisted as long as the settlement itself, that is 
 to say, for upwards of forty years, and yet no Indian has been infected 
 with leprosy." 
 
 (3) The fact that, in innumerable cases, the acquiring of 
 leprosy by one member of a family has led to no other out- 
 breaks of it in that family, and that, too, under insanitary 
 conditions which must have been quite peculiarly favorable 
 to its conveyance ; while it has been so rare for both parents 
 to take it, that the circumstance, when it has occurred, may 
 be referred, not to conveyance of the morbid poison from one 
 to the other, but to infection of both from a common source, 
 or to an endemic influence in general operation. 
 
 I select the following from a very large number of observations bear- 
 ing on this point. Wortabet-* meutions a case that came under his 
 notice at Beyroiit (Syria) in which a leprous woman lived for many 
 years with her husband and children, doing all the household work 
 (cooking, washing, and the like) so long as she was able, and yet the 
 husband and children continued in good health. Brimelli'* adduces the 
 fact that in Crete there wei-e as many as 127 persons living among the 
 lepers from year to year, without one of the number taking leprosy. 
 Bidenkap* informs us that, in 1857 in the Sondfjord district, leprosy 
 existed in 148 families, in 132 of which only one parent was affected, 
 both being leprous in the remaining 1 6. Manget,'' who is a believer in 
 the contagiousness of leprosy, adduces a few cases which seem to him 
 
 1 'Australian Med. Journ.,' 1874, March. " L. c, S. 129. 
 
 3 ' Med. Times and Gaz.,' 1880, Oct., 445. * ' Report on Leprosy,' 64. 
 
 '" 'Norsk. Mag.,' 1858, xii, 477. * 'Report on Leprosy,' 45.
 
 LEPKOSY. 49 
 
 to tell tliafc way; but lie is constrained to add: "I have known 
 instances [in Guiana] where black women have cohabited for years 
 with their husbands while labouring under confirmed and ulcerative 
 leprosy, and have children by them, without manifesting the slightest 
 trace of the disease," According to Planck's^ information for the 
 ISTorth-West Provinces of India, there were among S55 leprous 
 marriages, 831 in which the leprosy was on one side only; among the 
 remaining 24, with leprosy on both sides, there were only 1 1 in which 
 the possibility of the disease having been conveyed could not be 
 excluded ; but the small probability of disease-communication in the 
 latter cases will appear from the fact that, where leprous men had 
 married two or three wives, not one of these had ever become infected. 
 There arc accounts to the same effect by Bolle for the Canaries, Benson" 
 for New Brunswick, Saturnin^ for Trinidad, and Ebden^ for the Cape. 
 
 (4) There lias never been a case known, in which, the 
 physicians or nurses of a leper-house have caught the 
 disease, although they mix with the patients without 
 restraint, dress their sores, and sometimes even wound them- 
 selves in so doing. 
 
 Thus, Browne'' writes from Barbadoes : '* None of those in attend- 
 ance, during the last nine years, upon the inmates of the lazaretto have 
 contracted the disease; and I, after receiving a wound from a knife 
 moistened with the fluids of an inmate, have escaped, although the 
 wound was followed by great constitutional irritation and loss of the 
 finger." To the same effect is the statement of Saturnin'' for Trinidad : 
 '' Ulcers with ichorous discharge are dressed several times a day by the 
 surgery man, who has been employed for twelve years at the leper 
 asylum. The washerwoman, who has been there for sixteen years, and 
 bundles the clothes of the lepers, and the medical superintendent, 
 delivering women in labour, amputating limbs, and performing other 
 surgical operations, have escaped." Powell,' writing from Mauritius, 
 says : " I know two instances where medical men have wounded them- 
 selves in dissection [of lepers], but without any bad results;" and we 
 have similar information from the lepei'-houses of Madras, Calcutta, and 
 Cawnpore.** Hende'' says that during the nine years when he had 
 medical charge of the Nagpore prison, there was not a single case of 
 conveyance of leprosy from the sick to the healthy, although the inter- 
 course between them had been perfectly free. In the Java hospitals, 
 where lepers are admitted along with other patients, there has never 
 been a case of the communication of leprosy observed.'" Drs. Lucio and 
 
 ' 'Report on Leprosy iu the North-West Provinces,' 1876, and ' Brit. Med. 
 Journ.,' 1880, April, 527. 
 
 2 ' Pi,ci)ort on Leprosy,' 1867, 4. •' lb., 39. ■• lb., 50. 
 
 * lb., 32. G lb., 39. 7 lb., 86. s Ih., xliv, xlv. » lb. 
 
 i» In ' Arch, de me'd. nav./ 1868, Sept., 1C5, 
 VOL. II. 4
 
 50 GEOGRAPHICAL AND HISTORICAL TATHOLOGY. 
 
 Morado make tlie following statement on tlie alleged contagiousness 'of 
 leprosy, from their experiences in Mexican leper-liouses :' 
 
 " Si efectivamente fuera contagioso, inoculable, los empleados del 
 hospital lo habrian contraido alguna vez, viviendo como vivere continua- 
 mente en los salas, dui'miendo algunos dentro de estas, y estando la 
 mayor parte del dia en contacto immediato con los infermos. Por otra 
 parte, los lazarinos que ban copulado con mugeres sanas, y al reves, 
 jamas ban trasmitido el mal per un contacto tan immediato como este. 
 En las autopsias, repetidas veces, los que las ban practicado se ban 
 picado las manos, ban seguido ponieudo la berida que resulta del 
 piquete en contacto con los liquidos del cadaver sin baber tenido jamas 
 accidente alguno." 
 
 This exemption of doctors, medical assistants, nurses, and others in 
 leper-houses is confirmed by the reports of a number of other observers, 
 — Kobner" for San Remo, Sweeting for the Bahamas, Lewis and Cun- 
 ningham^ for Kumaon, and Pasqua for Chios. 
 
 (5) No cases have come to light hitherto, in which the 
 disease has spread from the leper-houses to residents outside. 
 
 Bargigli mentions that, although the leprous poor in Mytilene leave 
 the leper-houses and wander about the island as beggars, no conveyance 
 of the disease by them has been made out. Boeck'' saj's that patients 
 received into the leper-hospital of Bergen have had unrestricted inter- 
 course with the town, but that, so far as he knows, not a single case has 
 occurred of the disease having been communicated by them to the 
 town's-people ; he remarks at the same time that none of the attendants 
 who have been employed in that hospital bad become afi'ected Avith 
 leprosy. 
 
 (6) Lastly, among the numerous cases of leprosy in 
 Europeans, who had acquired the disease in leprous districts 
 (having been affected with it either at the time of their 
 return to Europe or having developed it subsequently), not 
 one has ever been the occasion of the disease sj)rcadiug in 
 the immediate neighbourhood. 
 
 To these arguments — unanswerable, as I think, — for the 
 non- contagiousness of leprosy,^ I will add the result of the 
 collective inquiry on the matter before us which the College 
 
 ^ L. c, 29. 
 
 ■•^ ' Vierteljahrschr. fiir Dermatol.,' 1S76, iii, 12. 
 
 ^ L. c, 71. 
 
 '' Quoted by Carter, ' Report on Leprosy in Norway,' 1874, 49, 
 
 5 Vinkhuijzen, who has come to the same conclusion, ends his elaborate inquiry 
 on the point (p. 151) with these words: " AUes resumerende ontkenuen wij dus 
 geheel de besmettelijkheid der mclaatschheid onder welke omstandighedeu ook, 
 zoo wij vermeenen, op degelijke gronden en ware feiten ous steuende."
 
 LEPKOSY. 51 
 
 of Physicians of London addressed to a large number 
 of practitioners in all parts of the world where leprosy is 
 prevalent. 
 
 " The all but unanimous conviction of the most experienced 
 observers in different parts of the world/' runs the report/ 
 '' is quite opposed to the belief that leprosy is contagious or 
 communicable by proximity or contact with the diseased. 
 The evidence derived from the experience of the attendants in 
 leper-asylums is especially conclusive upon this point. The few 
 instances that have been reported in a contrary sense either 
 rest on imperfect observation^ or they ai-e recorded with so 
 little attention to the necessary details as not to affect the 
 above conclusion.'' 
 
 Many other observers of recent date have arrived at the 
 same opinion: among them are Rigler" (Turkey), Smart 
 (Crete), Peacock (Portugal), Milroy^ and Uhlig* (Guiana), 
 Schmid and Wernich (Japan), Labonte (Mauritius), Profeta 
 (Sicily), Echeverria (Quito), London (Jerusalem), Auboeuf 
 (India), Durand-Fardel (China), and Hercouet (Tahiti). 
 
 § lo. The Influence of Hekedity. 
 
 There is only one kind of conveyance of leprosy which 
 cannot be questioned, I mean that which takes place hy ivay 
 of inheritance. There is almost complete unanimity on this 
 point among the observers of all times / there are merely 
 certain shades of difference between them, as to how high 
 this pathogenetic factor is to be rated for the spreading of 
 the disease, and whether the disease is inherited as such, 
 or whether it is only a predisposition thereto that we are 
 concerned with, a morbid diathesis which inclines the 
 
 ' ' Report on Leprosv,' 1867, Ixix. 
 
 '■^ " As regards contagiousness," he says (' Zeitsclir. der Wiener Aerzto,' 1847, 
 Jahrg. iii, Bd. ii, 275), " I can give my word that there is not a trace of it to be 
 found here." 
 
 3 'Med. Times and Gaz./ 1873, May, p. 575. 
 
 ■* L. c. (quoted by Vinkhuijzen, p. 129). 
 
 5 The Arabians, as well as the mediseval physicians of the West, held very 
 pronounced opinions about it.
 
 52 GEOGRAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 individual to fall into tlie sickness, or makes him specifically 
 susceptible to the morbid poison. The discussion of the 
 latter question comes within the limits of our inquiry only 
 in so far as it requires us to adduce evidence that leprosy 
 may also develop altogether independently of this inherited 
 disposition ; whei'eof more in the sequel. But in answer- 
 ing the first of the two questions, which it is clear we 
 can only do by means of statistics, we are met by two 
 serious difficulties. One of these is that many of the best 
 series of observations have been collected in parts of the 
 world where it is especially difficult to get reliable informa- 
 tion as to the state of health in the family of the leper. The 
 other difficulty is that by far the larger number of cases 
 belong to the endemic seats of leprosy ; so that there are many 
 cases with the doubt attaching peculiarly to them whether 
 the persistence of the disease in the family is really due 
 to heredity, or whether it should not rather to be set down to 
 the fact that each case individually, and quite independently 
 of the hereditary factor, had developed itself out of endemic 
 influences. And in fact, that kind of scepticism as to the 
 propagation of leprosy by hereditary conveyance has been 
 expressed by some of the Norwegian physicians, especially by 
 Hjort and Hansen, who were subsequently joined in 1874 by 
 Carter — although ho wrote, in 1873, '^ I am of opinion that 
 heredity is the common cause of the complaint "^ — and 
 more recently by Neisser, although he does not specially 
 state the grounds of his belief. Hjort, directing his polemic 
 chiefly against Lochman, who had declared hereditary or 
 contagious conveyance to be the only mode of origin of the 
 disease, remarks" that the data as to the diffusion of the 
 disease by inheritance had at any rate been much over- 
 valued, and that, if we are to attach as much importance to 
 that factor as many were inclined to do, it would be imjoos- 
 sible to explain the somewhat rapid extinction of the disease 
 in the Faroe Islands, in Bohusliin (Sweden), and in other 
 places. That criticism seems to me to be perfectly 
 justified ; but it does not suffice to set aside altogether the 
 large mass of positive facts which tell in favour of heredity, 
 
 1 ' Med.-Chir. Transact.,' Ivi, 276. 
 - 'Norsk. Mug.,' i8'/2, ii, 122.
 
 LEPROSY. 53 
 
 and it only sorvcs to prove how far we still are from a per- 
 fect iusiglit into tlie patliogenesis of leprosy. 
 
 Hansen confined liimself, at the outset/ to the statement 
 that the heredity of leprosy, although there was much ia its 
 favour, could not always bo proved, and that the question 
 was to be treated as still an open one ; but he afterwards" 
 denied "hereditary" conveyance altogether: 
 
 " Only those diseases," lie says In so many words, " wLicIi depend on 
 defects of development, whicli are occasioned, therefore, or called forth 
 by a non-specific cause, may be designated 'hereditary diseases.' 
 Contrasting with them, are those diseases which have a specific morbid 
 cause underlying them, and are usually characterised, be they conta- 
 gious or non-contagious, by perfectly definite and typical disorders o£ 
 the normal functions of the body. If the disease be a contagious one, 
 it may communicate itself by its virus to the fostus in the womb, but 
 then it is not hereditary ; if it be non-contagious, it cannot be conveyed 
 to the fujtus in any way whatsoever," 
 
 It is clear that we have to do here first of all with a 
 conflict of words. There is no " hereditary " syphilis, saj^s 
 Hansen, but that which is usually so called is an infection 
 of the foetus in ntero — whicli comes to the same thing 
 as a mental concept. But Dr. Hansen forgets that there 
 is such a thing as a congenital morbid diathesis, in which 
 there can bo no question of infection, a disposition towards 
 a definite kind of sickness, residing in the organisation of 
 the individual and determined by inheritance® — such as 
 scrofula or gout. His definition of " hereditary " is, therefore, 
 too narrow, and his definition of " intra-uterino infection " 
 too wide. I am inclined to think that if Dr. Hansen had 
 admitted among his general pathological concepts the idea 
 of " conveyance " of the disease instead of " contagion " of 
 the same, he would very soon have found himself occupying 
 the same standpoint as those whom he controverts. 
 
 The best ground on Avhich to try this question is obviously 
 afforded by the small, closely circumscribed, and therefore 
 easily surveyed leprosy-spots, with a fixed population subject 
 
 ^ 'Nord. med. Ark.,' 1870, ii, 21. 
 
 - ' Uiidersogelser, &c.,' 1874, p. 20. 
 
 3 The heredity of leprosy is understood in this sense also by Bidenkap (' Norsk. 
 Mag.,' i860, xiV, 843, by Holmboe (ib., 1865, xix, 15.;), and by Bocck ('Nord. 
 med. Ai-k.,' 187 1, iii, i).
 
 54 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 to no cliangeSj whore the state of health in the several fami- 
 lies may be learned with the least possible trouble and 
 followed with certainty through a long series of generations. 
 Areas of observation of that kind existed at the beerinnins: of 
 the century at various points on the coast of Provence, espe- 
 cially around Martigues,^ in Comacchio, and in several of 
 the coast districts of Sweden -^ and we still meet with them 
 on the Ligurian coast, in Sicily/ in certain provinces of 
 Spain and Portugal, in Southern Russia'* and the Caucasus/ 
 in Greece, among the Dutch population of the Cape,^ in the 
 northern districts of Persia, on some of the islands of the 
 East Indian Archipelago (especially Ternate)'^ and in New 
 Brunswick.^ For all these places we do in fact find, in the 
 authorities quoted, classical proofs that the disease clings to 
 particular families as a consequence of continuous inheritance 
 from generation to generation, and that the extension and 
 multiplication of these small centres of disease is due to inter- 
 marriages among members of leprous families and of families 
 which had been hitherto healthy. An interesting contribu- 
 tion to the subject is supplied by the observations of 
 Holmboe and of Boeck (11. cc.) on the outbreak of leprosy 
 among Norwegian emigrants to the United States, who had 
 settled in localities (of Illinois and Minnesota) quite free from 
 the endemic. In i8 cases of this kind in Minnesota, 
 reported on by Boeck, the disease had begun to develop in 
 9 before they left Norway, and of those 9, 5 belonged to 
 families in which there were other lepers (all in the collateral 
 line) still living ; the other 9 cases did not develop until 
 some considerable time (two-and-a-half to fourteen years) 
 after their removal to America, and in all of them but one 
 there was proof forthcoming of leprosy among their relatives 
 in Norway. The natural supposition is that we have here to 
 do, either with an inherited disease lying latent for Tnany 
 years, or with a congenital morbid diathesis. But there 
 are other similar accounts of leprosy spreading by means 
 
 ' Vidal, Valentin, Fodere, II. cc. 
 
 - Profeta. 3 Huss, * Plaeliof. » Liebau. 
 
 ^ Sebwarz, * Zeitsclir. der Wien. Aerzte,' 1858, Nr. 40. 
 
 '' In 'Arch, de med. nav.,' 1870, Mai-s, 176. 
 
 « Skene, Welch.
 
 LEPROSY. 55 
 
 of heredity, from all the great leprous regions ; although, 
 as we have seen, the opinions diiier as to the extent to 
 which this factor influences the production of the disease, 
 the statistics collected to elucidate the point having an un- 
 equal value. 
 
 The heredity of leprosy was ascertained in Bergen by Boeck and 
 Danielssen^ for 185 out of 213 cases, by Holmsen in the sanitary district 
 of Midt-Nordland for 55 out of 93 cases, by Bidenkap- in the Sondfjord 
 district for 393 out of 538, by Brunelli in Crete for 76 out of 122, by 
 Prof eta in Sicily for some three-fourths of a total of 114, by Fiddes in 
 Jamaica for 184 out of 213, by Hillis in British Guiana for 31 out of 
 1 88, by Schwalbe in Costa Rica for 1 2 out of 1 5, by Planck in the North- 
 West Provinces for 20 per cent., by Richards in Orissa for 53*4 per 
 cent., by Day in Cochin for some 40 per cent., and by Lewis and 
 Cunningham in Kumaon for 35 per cent, of the sick. Among 17 
 leprous families who were living, according to the last-named 
 observers,^ in the Kumaon Leper Hospital, and in 4 of which both 
 parents were leprous, there were 68 children born, and of these 27 were 
 already the subjects of leprosy at the time the report was written. 
 
 Thus the opinion of Simpson"* holds good to the present 
 day: " Few facts in the history of tubercular leprosy seem to 
 he more universally admitted hy all writers on the disease, both 
 ancient and modern, than the transmission of the predisposition 
 of it from, ptcifents to offspring." . 
 
 § II. SrECTAL Liability of the Negro and other Eaces. 
 
 This predisposition to fall iuto leprosy, accruing from 
 heredity, may be applied to explain, in part at least, the vary- 
 ing amount of the sickness met with in different races and 
 nationalities, although doubtless the manner of life is also not 
 without its influence. All observers agree that, in countries 
 with a mixed population, such as the West Indies, British, 
 French, and Dutch Guiana, the Bahamas, Zanzibar, the 
 Mauritius, India, Ceylon, and the Argentine States, the 
 disease is commonest among the negroes and those of mixed 
 blood (mulattoes, sambos, mestizzos), and rarest, if not 
 absolutely rare, among the Europeans. At the Cape, 
 
 3L. c, p. 61. ■» L. c, p. 404-
 
 56 GEOGEAPHICAL AND inSTORIOAL PATHOLOGY. 
 
 similar differences are found between the Hottentots and tlie 
 white residents/ and, in Oliina, between the Chinese and the 
 Europeans." In Algiers it is mostly the Kabyles that suffer, 
 the Arabs very much less -^ and, in Crete''' and the East 
 Indies,^ the Arabs enjoy a certain immunity from leprosy. 
 The same immunity is very notable among the Indian race in 
 Surinam and in Java, in contrast to the severe incidence of 
 the disease upon the negro population and the Malays.^ 
 The differences in the frequency of the disease among the 
 Jewish population in various parts of the world are very 
 remarkable ; while they come nest to the negroes in their 
 great liability to leprosy in the West Indies (Jamaica,'^ St. 
 Vincent)^ and in Surinam,^ they are but rarely subject to it 
 in Syria (notably Damascus^" and Jerusalem), ^^ in Cliios^" and 
 Crete,^^ at Bombay,^^ Aden,^^ and other places. That this is 
 not to be explained altogether, as Hassclaar seems to say 
 for Surinam, by unfavorable conditions of living, may be 
 inferred from the statement of Bowerbauk, who points to the 
 enormous frequency of leprosy among the Jewish population 
 of Jamaica, and adds : " The well-to-do and the poor Jews 
 suffer equally." 
 
 § 12. Acquired by Europeans who had resided in Leprous 
 
 Localities Abroad. 
 
 However highly we may rate the element of heredity in 
 the history of leprosy, there cannot be the slightest doubt 
 that, in innumerable cases, the disease had developed, and 
 still develops, independently , that is to say, solely under the 
 influence of the proper jjathogenctic factor and quite apart from 
 specific congenital predisposition. Irrespective of those well- 
 authenticated cases of the spontaneous development of 
 
 ' Black, Kretzschmar, Ebden, in ' Report on Leprosy,' 1867, xxx. 
 
 2 Wong. 3 Guyon, Bertrand. •* Brunelli. 
 
 * In 'Arch, de med. nav.,' 1868, Sept., 165. 
 
 ^ Compare the account of Uhlig, quoted from A^inkliuijzen on p. 48. 
 
 ' Fiddes, \. c, Bowerbauk, in ' Report,' xxix. 
 
 " Sprott, ib. 9 Hasselaar, 22. '" ' Report on Leprosy,' xxx. 
 
 '^ London, Langerhans. ^'^ Pasqua. '^ Brunelli. 
 
 " Carter, ' Report,' xxx ; Waring. '■^ Steinhauser, ' Report.' xxx.
 
 LEPBOSY. _57 
 
 leprosy among- the indigenous inhabitants of its endemic 
 scats, the most telling evidence is furnished by the cases 
 of individuals who have acquired the disease after spending 
 some time at a centre of leprosy, having been born of 
 healthy parents who had either resided all their lives in 
 parts of Europe that are free from leprosy, or had migrated 
 from these to tropical countries where leprosy is prevalent. 
 The literature is full of such cases j^ and it furnishes us, 
 moreover, with a few cases which give evidence of a spon- 
 taneous origin of the disease even in regions where leprosy 
 as an endemic had been extinct for centuries." These latter 
 cases remain just as much a puzzle in their genesis as was 
 the historic sickness itself in its extinction ; we are here at 
 the limits of our knowledge, and there is not a single lucll- 
 fjrounded hypothesis to show us the way beyond. 
 
 ^ See Go,2:ueliu, 'Bull, de la Facultc de mod. dc Paris,' i8io, 91; Larrey, 
 ' Denkwiirdigkeiteii,' j, 170J Alibert, ' Journ. couipleiii. dii diet, des Seined.,* 
 181S, i, 159; Lee, 'New England Journ. of Med.,' 1818, vii, 41; Uiett (from 
 ' Gaz. med. de Paris'), ' Lond. Med. Gaz.,' 1829, Sept., 481, 513; Thevenot,. 
 •Traite,' 249; Kiunis, ' Edinb. Med. and Surg. Journ.,' 1844, Jan., 54; Eoeck et 
 Danielsson, 'Traite,' 339; Wilson, 'Lancet,' 1856; 'Brit. Med. Journ.,' 1866,. 
 Oct., 456, 1870, July 8 ; Derazey, ' De la lepre des anciennes,' Strasb., 1866 j 
 Huet, ' Nederl. Tijdschr. voor Geneesk., 1868, i, 113; Lignerolles" * Gaz. des 
 liopit.,' 1867, Nr. 128; llees and Mo.Kon, ' Guy's IIosp. Hep./ 1868, xiii, 189, 
 1869, xiv, 248 ; Arnott, 'Transact, of the Pathol. Soc.,' 1869, xix, 35 ; PifPard, 
 'New York Med. Gaz.,' 1869, iv, i ,• Soltmann, ' Zur lepra nervosa,' Diss. Berl., 
 1869; Squire, ' Med. Times and Gaz.,' 1870, March, 296, and ' Ti-ansact. of the 
 Pathol. Soc.,' 1871, xxi, 403 ; Benson, ' Dubl. Journ. of Med. Sc.,' 1872, April,. 
 290; Thoma, in ' Virchow's Arch.,' 1873, Ivii, 455; Espinet, ' Ivapport,' 1874; 
 'Lancet,' 1875, Feb., 199, Marcli, 339; Soutbey, 'Med. Times and Gaz.,' 1S75, 
 March, 299; Startin, 'Lancet,' 1880, Oct., 692. ITercouet (1. c.) saw four cases 
 of the disease in Tahiti in Europeans who had lived several years there. 
 
 2 Berndt, in Kansch's 'Memorabilien,' iii, 210; Wilson, ' Lancet,' 1856; Busch,^ 
 ' Annal. des Berl. Charite-Krankenh.,' 1858, viii Ileft, 2, 9 ; Noiirse, 'Med. Times 
 and Gaz.,' 1865, Sept., 251 ; Steudener, ' Beitr. zur Pathol, dcr Lepra mutilans,' 
 Erlangen, 1867 ; Gaskoin, 'Biit. Med. Journ.,' 1S73, Dec, 655, and ' Mod. Time* 
 and Gaz.,' 1878, Jan., 86, May, 475 ; Langhans, in ' Virchow's Arch.,' 1S75, Ixiv,. 
 175 ; Donor, ' New York Med. Ilecord,' 1875, Nov., 20 ; Vidal, ' Gaz. des hopit.,' 
 1875. 691 ; Kochler, ' IJcrl. klin. Woch,' i877, Nr. 46; Breuer, ' Vierteljahrsckv 
 fiir Dermatol.,' 1880, vii, 529, &e.
 
 -58 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 §. 13 The An;estttetic and Tobercular Varieties. 
 
 As regards the relative frequency of tlte two forms of 
 leprosy — the anesthetic and the tubercular — at the several 
 affected points of the globe, we are unable to judge with 
 certainty from the data before us whether there are any 
 very great differences. The anaesthetic form is in general 
 more frequent than the tubercular ; it is very often the form 
 in which the disease begins, tubercles appearing in the sub- 
 sequent course and so producing the mixed form, while the 
 inverse order is less frequent. If we take the statistics from 
 a few leper-houses, giving the patients siiffering from one 
 form or the other, thnt relation would appear to be the 
 general rule.
 
 I 
 
 CHAPTER II. 
 
 SYPHILIS. 
 
 § 14. Antiquity op all the form.s op Venereal Disease. 
 
 The liistoiy of venereal diseases^ particularly of syphilis, 
 has so often been made the subject of exhaustive inquiries, 
 and the historical data bearing more or less directly on the 
 occurrence of these maladies in former centuries have been so 
 carefully collected, sifted, and critically elucidated in the 
 writiugs of various investigators,^ that I think I may decline 
 to assume once more the whole armour of historical contro- 
 versy. I shall content myself, accordingly, with putting 
 together, in the following resume, the conclusions which the 
 facts, as at present ascertained, warrant concerning the 
 history of the venereal diseases in ancient and mcdixval times,' 
 and concerning ^/ie epidemic outhreaJc of syphilis at the end of 
 the fifteenth century, referring the reader to the works quoted 
 below, and particularly to latest comprehensive and thorough 
 handling of the subject by Haser. 
 
 (i) Undoubted evidence of diseases of the genitals due to 
 lewd or impui-e sexual gratification comes down to us from 
 
 ' The principal authorities are : Astruc, ' De morbis venereis libri vi,' Paris, 
 1736 (and otlicr editions); Hcnsler, ' Geschielite der Lustseucho, die zii Ende 
 des 15 Jahrhundei-ts ausbrach,' I5d. i (the only vol. published), Altoua, 178.S 
 (1794); Thiene, ' Sulla storia dei mali venerei,' Venez., 1823; Huber, ' Bemer- 
 kungen iiber die Geschichte der vcnerischen Kraukheiten/Stuttg-., 1825 ; Roscn- 
 b.aum, ' Geschichte der Lustseucho im Alterthuuie,' Ilalle, 1839 ; Simon, ' Kritischc 
 Geschichte des Urspruugcs, der Pathologic und Behandluug der Syphilis u. s. w.,' 
 Th. i, ii, Abth. i, Iliimb., 1857, 5^ 5 Friedberg, 'Die Lehre von den vcnerischen 
 Kraukheiten in dem Alterthumc und Mittelalter u. s. w.,' Berlin, 1865; Giintz, 
 ' Beitr. zur Geschichte der Medicin : uber Alter und Ursprung der Syphilis,' 
 Leipz., 1868 ; Miiller, ' Die vcnerischen Kraukheiten im Alterthum u. s. w.,' 
 Erlangen, 1873; Iliiscr, ' Lehrbuch der Geschichte der Medicin,' 3 Aufl., Jena, 
 I876-82, iii, 213-325.
 
 GO GEOGEArfllCAL AND HISTORICAL PATHOLOGY. 
 
 every period o£ the world's liistory, even from biblical and 
 mythical times. ^ 
 
 (2) It is more especially the venereal catarrh of the 
 urethra {elaji), and its consequences, whose occurrence may 
 be followed with certainty into the remotest periods of 
 antiquity.^ 
 
 (3) Minute descriptions of ulcerous conditions of the 
 male or female sexual organs are found not only in tlio 
 ancient and media)val compendiums of medicine and in 
 prescription-books, but also in the erotic and satyric poets of 
 Greece and Rome, as well as in many chroniclers of the 
 Middle Ages ; and these sores, when we bear in mind the 
 frequency with which they occurred and the indications 
 sometimes given as to their origin, cannot be regarded as 
 other than venereal affections, that is to say, as chancres, or 
 ])riinar]j syiihilitic ulcers? 
 
 (4) There can be equally little doubt tliat constitutional 
 syiihilitic atjections also occurred in antiquity and in the 
 Middle Ages ; although, for reasons to be mentioned in the 
 sequel, the evidence relating to them is not so obvious as it 
 is for the venereal diseases previously mentioned. In the 
 descriptions given by the Greek and Roman physicians, of 
 excrescences on the sexual organs and about the anus, which 
 they designate by such names as Qvf.101, ^u^tora, /coi'SuAw/iara, 
 tubercula, pustulw, or Jici, it is not difficult to recognise, among- 
 otlier morbid forms, the Jiattened or syphilitic condylomata; and 
 in the writings of the Middle Ages, whether medical treatises- 
 or lay chronicles, there is no lack of passages which afford 
 us perfectly unambiguous evidence of the occurrence of 
 constitutional syphilitic disease. 
 
 There are several things to explain the extreme scantiness 
 of the knowledge of the venereal diseases in general which 
 the ancient and medieeval practitioners of medicine possessed. 
 Thi-oughout the whole of antiquity, and even at the time when 
 loose living had reached its highest development, a certain 
 inversion of the moral sense restrained the public from 
 confiding to medical practitioners those cases of disease which 
 affected the parts of the body that they called mdo'ia or 
 pudenda ; to discover and expose these to the eyes of 
 
 ^ Ilascr, 1. c, 21S, 226. - lb., 219, 22;. ^ lb., 220, 228.
 
 SYPHILIS. 61 
 
 another person wus regarded as disgraceful. The feeling was 
 one that prevailed much more among the female sex than 
 iimong men, and it is well known that the same feeling was 
 the real hindrance to a knowledge of gynaecological and obste- 
 trical subjects. It appears, moreover, that this aversion to a 
 consultation with a medical practitioner in diseases of the sexual 
 organs was not only a feeling that existed on the side of the 
 compromised patients ; the doctors themselves, both in ancient 
 and mcditeval times, avoided them, preferring not to be occu- 
 pied with so "ungenteel" maladies. 
 
 Another circumstance, connected with the former, which 
 stood in the way of a correct understanding of the diseases 
 in question, was the defective state of the etiological inquiry ; 
 only the most oblique glance at the source and origin of 
 these affections was tolerated — for obvious reasons. It 
 seems to mo to bo quite certain that the Greek and Eoman 
 practitioners of medicine, as well as the contemporary public, 
 knew of the connexion between sexual jjromiscuousness and 
 the outbreak of these diseases, for there are many indications 
 of this in the writings of the ei'otic and satyric poets of . 
 antiquity. But here again the reserve about such " secret 
 things " prevented further inquiry into the question ; and 
 the solution of it was all the less practicable for another 
 reason, namely, that the idea of a fixed contagion was not 
 acquired until a later date. All these matters were regarded 
 sub rosa, and there was an unwillingness to call them by 
 their right names. It is not until the Avritings of the 
 mediaeval physicians and chroniclers, that the source of these 
 lesions of the sexual parts, together with the constitutional 
 eiiects, begins to be quite plainly indicated. One of the most 
 interesting references of that kind occurs in a manuscript of 
 the thirteenth century by the Paris physician Gerard de 
 Berry,^ who observes, in his chapter " de ulceribus et 
 apostematibus virgae :" " virga patitur a coitu cum mulieri- 
 bus immundis de spermata corrupto vel ex humore venenoso 
 in coUo matricis recepto ; nam virga inficitur et oliqnando 
 altered totum corpus.''" It is obvious that this " altcratio 
 totius corporis " means a constitutional malady associated 
 
 1 Quoted by Littrc, iu ' Janns,' 1846, i, 593. 
 - See also Iliiser, 1. c, p. 233.
 
 62 GEOGEAPHICAL AND HISTORICAL PATHOLOGY. 
 
 with a preceding local infection of the virga. But unfortu- 
 nately the author leaves us in uncertainty as to what the 
 " alteratio " consisted in ; and it is precisely that want of a 
 correct and full understanding and description of the special 
 phenomena arising out of constitutional diseases which has 
 retarded the progress of inquiries into the ancient and 
 mediasval history of constitutional maladies in general and 
 of syphilis in particular. 
 
 The ancients were^ at the outset_, entirely without the 
 notion of chronic constitutional sickness ; their concepts of 
 disease went altogether in the direction of a local patho- 
 logy ; and after the physicians of that period began to have 
 some knowledge of one disease of that kind^ when they made 
 acquaintance with leprosy, they still set down (like the 
 mediaeval practitioners after them) all the varieties of local 
 and general morbid process as an " outcome " (Aitssatz), 
 dwelling especially upon the process localised in the skin 
 and mucous membranes. They had no single precise 
 concept, no definite and comprehensive grasp of the group 
 of symptoms distinctive of the disease ; and, just as " plague " 
 was their idea of severe epidemic sickness running an acuie 
 course, so they took leprosy as the representative of various 
 chronic diseases. That syphilis played a leading part 
 among the latter, we may infer from the opinion, widely 
 diffused and passing unchallenged among mediaeval 
 practitioners, as to the origin of lepra " ex coitu cum foeda 
 muliere.^^ Thus Michael Scotus says ■} "Si vero mulier 
 fluxum patiatur, et vir earn cognoscat, facile sibi virga 
 vitiatur, ut patet in adolescentulis, qui hoc ignorantes 
 vitiantur quandoque virga, quandoque lepra." Gordon^ says 
 of the etiology of leprosy : '^ Et provenit etiam ex nimia 
 confibulatione cum leprosis, et ex coitu cum leprosa et qui 
 jacet cum muliere, cum qua jacuit leprosus ;" and the same 
 language is used by Gaddesden, Gilbertus Anglicus, Vitalis 
 de Furno and others. This confounding of leprosy with 
 syphilis has been the source, in my view, of the opinion which 
 I have already mentioned (p. 7) as being held by contem- 
 porary writers, that "lepra" became widely diffused at the 
 
 ^ ' De procreatione hominis phisionomia,' cap. 6, 
 
 " * Lilium medicinac/ Pars i, cap. 22, eel. Lugd., 1574, 95.
 
 > 
 
 SYPHILIS. 63 
 
 time of the Crusades and in consequence of tliem ; the same 
 explanation applies to the doctrine held by several of those 
 who witnessed the epidemic outbreak of syphilis towards the 
 end of the fifteenth century — a doctrine rigidly maintained 
 down to recent times — that the disease at that time began 
 to develop out of leprosy, and that it is to be regarded as 
 an " offshoot of lepra." Thus Manardus^ records the 
 following opinion, which he thought a very credible one, of 
 the outbreak of the malady in Spain and of its extension to 
 Italy : " Coepisse hunc morbum (sc. Gallicum) per id tempus 
 dicunt, quo Carolus, Francorum rex, oxpeditionem Italicam 
 parabat : coepisse autem in Valentia Hispaniae Taraconensis 
 insigni civitate a nobili quodam scorto, cujus noctem elephan- 
 tiosus quidam ex equestri ordine miles, quinquaginta aureis 
 emit : et cum ad mulieris concubitum frequens juventus 
 accurreret, intra paucos dies supra quadringentos infectos : 
 e quorum numero nonnulli Carolum Italiam petentem sequnti 
 praeter alia quae adhuc vigent importata mala et hoc 
 addiderunt." 
 
 § 15. The Gkeat Epidemic op SYrmus in the end op the 
 
 Fifteenth Centuky. 
 
 If these facts, then, justify us in concluding that the 
 venereal diseases, and particularly syphilis, had not only 
 occurred during antiquity and the Middle Ages, but were 
 even by no means uncommon, the fact ilxat syijiliilis hroJce out 
 in the form of a wide-sjyread and malignant epidemic toivardt; 
 the end of the fifteenth century is still a very remarkable 
 episode in its history. It is the strangeness of this outbreak 
 that explains the enormous interest which the occurrence 
 excited at the time, an interest which must have been all the 
 greater that both the profession and the public found in it 
 a form of sickness that was almost unknown to them. From 
 that event we have to date the lively interest through which 
 the attention of practitioners in all subsequent times down 
 to the present has been enlisted, and elaborate inquiries 
 into the causes of the outbreak have been set on foot. 
 1 ' Epistol. mcd./ lib. vii, Epjst. ii, Basil, 1549, p. i.l7-
 
 64 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 When and Iioav this epidemic of syphilis began cannot be 
 made out with certainty. This much only appears to be 
 ascertained, that its first appearance was in the south-west oi: 
 Europe, and that it spread thence with great rapidity and 
 with a wide sweep over tlie Continent and the insular king- 
 doms.^ So far as wo may conclude from data before us, 
 France was the starting point of the sickness ; at least it is 
 from that country that we have the first more or less trust- 
 worthy accounts of it for the period between 1488 and 1492.^ 
 
 At the same time, or a little later (1493), it appeared in 
 Spain, and in Italy in 1494.^ It spread over Germany and 
 Switzerland in 1495 and 1496 ; in the Netherlands,* as well 
 as in Denmark and England,^ its outbreak was in 1496, and 
 in Scotland^ in 1497. Our earliest information of the disease 
 in Bohemia and Russia dates from 1499. 
 
 The extent of the disease in the various countries, or the 
 number of persons attacked by it, is very variously stated.^ 
 The duration of the epidemic can be estimated with equally 
 little certainty ; at some places the disease appears to have 
 become extinct as early as the beginning of the sixteenth 
 century, at others not until after the first twenty years of 
 the same ; and doubtless circumstances of locality and of 
 social life were not without influence upon the duration of 
 the sickness, as well as upon its intensity and severity. But 
 it may at all events be inferred from the medical writings 
 of the third and fourth decades of the sixteenth century, that 
 syphilis had everywhere lost its epidemic character by that 
 time, and was occurring in its milder forms ; so that it finally 
 
 ^ See Hiiser, iii, 252. 
 
 * It is a noteworthy fact that the oklest designation of the disease, widely 
 current in subsequent times and still met with in many countries outside Europe, 
 is " moi'hus gallicus." For the various other names by which the malady has been 
 known, sec Hiiser, iii, 250. The term "syphilis" fii'st occurs in the poem of 
 Pracastori; it is derived, he tells us, from the name of a king's son, the sheijherd 
 Syphilus, who had blasphemed against the sun and was punished with the 
 infliction of this disease. 
 
 ■* The most recent information on the subject is given by Corradi, in the 
 'Giornale delle malatt. vener.,' 187 1, vi, 65, 145. 
 
 ■^ Fokker, ' Ncderl. Tijdschr. voor Gence.sk.,' iS6i, v, 451. 
 
 5 Mansii, ' Journ. for Med. og Chir.,' 1833, Mar., p. 278. 
 
 'i Simpson, 'Transact, of the Epidemiol. Soc./ 1862, i, 144. 
 
 ' Sabellicus (quoted in the ' Aphrodisiacus,' of Luisiniis, Ajjpend. ed. Gruner, 
 Jer.a, 1789, p. 116) puts it at one twentieth of the population.
 
 k 
 
 SYPHILIS. 65 
 
 assumed tlie type whicli it had probably borne in antiquity 
 and tbe Middle Ages, the type in which it is found to occur 
 at the present day. 
 
 § 1 6. The Characteks op Syphilis in the Great Epidemic. 
 
 The descriptions left by contemporary writers^ of the type 
 of syphilis at the time of its epidemic •prevalence, lead us to 
 suppose that, while in very many cases ulcers on the genitals 
 were the starting-point of the disease, yet the infection took 
 place not unfrequently in other ways. We already find 
 indications, also, of congenital syphilis in infants at birth. 
 
 Montesaurus^ observes t " Plurimos enim vidimus, quibus in partibus 
 pudendis nullum erat nocumentum." Cataneus^ says : " Quinta causa 
 est longa mora et assidua dormitia cum infecta vel cum infecto sine 
 coitu : vidimus enim quam pluries genetrices, filios suos tali modo 
 infectos tractantes et eis ministrantes, post aliquod tempus infectionem 
 hausisse. Hoc etiam modo vidimus pluries infantulos lactantes, tali 
 modo infectos, plures nutrices infecisse." In like manner Torella* : 
 " Si aliud membi-um [in contrast to the genital organs] pustulum 
 tangeret virulentum, aut sordidum, illud primo inficeretur, ut videtur 
 in pueris lactantibus, in quibus prima affectio apparet in ore aut in 
 facie et hoc accidit propter mammas infectas, aut faciem aut os matricis 
 seu alicujus alterius . . . . et saepius vidi infantem infectum hoc modo 
 multas nutrices infecisse." 
 
 Among the local manifestations observed in the further 
 course of the disease were condylomata, and scaly or tuber- 
 cular exanthems, which often induced very considerable 
 destructive ulceration ; next to these, affections of the mucous 
 membrane of the mouth and throat, which were also fol- 
 lowed often by great loss of tissue extending even to the 
 nose. Further, there is mention made of lesions of the skull 
 and of the bones of the extremities, attended by unusually 
 acute pains occurring especially in the night and robbing the 
 patient of sleep ; and, lastly, of affections of the eye, even 
 leading to blindness. A few observers state, also, that the 
 disease was sometimes diverted from the outer parts to the 
 organs within ; but it does not appear from the descriptions 
 what was the nature of these visceral lesions. As to the 
 
 ' See the detailed account in the first edition of this work, i, p. 337; also 
 Hiiser, iii, 259. 
 
 ' Quoted by Luisinus, p. 115 E, ' lb., p. 141 B. * lb., 504 B. 
 
 VOL. II. 5
 
 66 GEOGEAPHICAL AND HISTORICAL PATHOLOGY. 
 
 duration and issue of the disease, it lias to be said farther, 
 that it lasted from several months to several years, and that 
 one or more recurrences made it chronic. A perfect cure 
 appears to have been rarely effected ; in most cases the 
 disease led to death, either suddenly in consequence of severe 
 complications supervening (such as haemorrhage), or under 
 the symptoms of general cachexia due to gradual exhaustion. 
 
 § 17. Venereal Disease in Former Times in other parts 
 
 OP THE World. 
 
 The information relating to the older history of the venereal 
 diseases, and particularly of syphilis, in extra- European coun- 
 tries is but slight. In the Ayur-Veda of Susruta there are 
 several statements which make it at least very probable that 
 venereal disease had occurred in India from the very earliest 
 times.^ Of the great antiquity of these diseases, particularly 
 syphilis, in China, there can be hardly any doubt, according 
 to the results of a thorough investigation into the subject 
 made by Thin ;^ it is possible to trace the occurrence of the 
 disease in that country as far back as the sixth century B.C. 
 (time of Confucius), and we meet with a specific name for 
 venereal sores in writings which date from the time of the 
 Tang dynasty (618 to 906 a.d.). Dudgeon^ also traces the 
 antiquity of syphilis in China back to the time of Confucius, 
 and says that the disease at that time was prevalent in the 
 Kingdom of Tei (now the province of Shan-Tung), whence it 
 had spread southwards.* 
 
 From an interesting notice quite recently published by 
 Scheube^ we learn that a detailed account of syphilis in its 
 various forms is contained in a recently-discovered Japanese 
 
 * Friedberg gives the passages, taking tbem from Hessler's translation as 
 revised by tbe well-known Sanscrit scbolar Professor Weber. Wise's handling of 
 the history of syphilis in India (in his ' Hindu System of Medicine/ p. 375) is 
 quite untrustworthy, as Friedberg justly pronounces it to be. 
 
 " ' Edin. Med. Journ.,' 1868, July, p. 47. 
 
 » 'Med. Times and Gaz.,' 1872, July, p. 56. 
 
 < See also Morache, * Annal. d'hyg.,' 1870, xxxiii, 25. The account by Dabry 
 •La medecine chez les Chinois,' Par., 1863), of the occurrence of syphilis in 
 China in tbe time of the Hoang-Ti dynasty (i, e. 2600 B.C.), is, like the rest of 
 his book, unworthy of any credit. 
 
 * ' Virchow's Archiv/ xci (1883), p. 448.
 
 SYPHILIS. 67 
 
 medical work belonging to the ninth, century, and that the 
 authors of the treatise had been well acquainted with the 
 link of connexion between these various local affections, 
 recognising and correctly appreciating the constitutional 
 character of the disease. 
 
 As to the earliest occurrence of syphilis in the East 
 Indian Archipelago, I know only of the notice by 
 Virchow, according to which the disease was introduced 
 into the Moluccas and Philippines by the Portuguese in the 
 beginning of the sixteenth century (1522 ?). I shall after- 
 wards have to speak of certain places in this archipelago 
 which have remained exempt from syphilis down to the most 
 recent dates, as well as of the history of the disease in 
 Oceania, Australia, and New Zealand, and in the western and 
 southern divisions of the African continent. 
 
 One of the most interesting points which I have to men- 
 tion in connexion with the question before us is the fact that 
 syphilis did not occur in the Western Hemisphere until after 
 the arrival of the Europeans, and as a consequence of import- 
 ation of the disease. Dr. John Hunter,^ speaking of the 
 occurrence of syphilis in the West Indies, says : '' Of the 
 few things peculiar to this disease in the West Indies, it is 
 perhaps the most singular that it should, at the present day, 
 be much less frequent in a country supposed to have pro- 
 duced it, than in any part of Europe. This will not be con- 
 sidered as a proof that the venereal disease had its origin in 
 the West Indies." 
 
 Clark^ and Cordoba^ have subsequently expressed the 
 same opinion, the latter remarking that the disease had been 
 introduced into Porto Eico probably by the Spaniards. All 
 the recent authorities in Brazil agree with Martius* that 
 those Indian tribes of the interior who have kept out of 
 contact with European immigrants, enjoy an immunity from 
 syphilis. The same observation has been made in Fara- 
 fjuay,^ on the pampas of Peru^ in the Sacramento Valley, and 
 
 1 ' Observ. on the Diseases of the Army in Jamaica,' 2nd ed.. Lend., 1 796. 
 
 * ' Madras Quart. Med. Joum.,' i, 1839, Oct., p. 385. 
 
 3 'Memor. geogr de la Isla dc Puerto-Rico,' Sanmiltan, 1831. 
 
 * ' Das Naturell, die Krank. . . . der Urbowohner Brasilicns/_Munclieu,p. 85. 
 5 Masterman, in ' Dobell's Reports,' 1870, 382. 
 
 •« Gait, ' Amer. Journ, of Med. Sc.,' 1874, Aug., 396.
 
 68 GEOGEAPEICAL AND HISTOETOAL PATHOLOGY. 
 
 among the Indian tribes in tlie interior of Northern Califor- 
 nia, whither the Spanish colonists had never penetrated.^ 
 
 Facts such as these are summed up by Jullien, in his 
 inquiry into the geographical distribution of syphilis, in the 
 following words i*^ — "Un fait indiscutable, c'est que la syphilis 
 est aujourd'hui encore a peu pres inconnue chez les peuplades, 
 qui n'ont que peu de rapports avec les Europeens, et que dans 
 toute I'etendue des Ameriques, c'est au developpement de la 
 verole qu'il faut, toutes choses egales d'ailleurs, mesurer les 
 progres de la civilisation. Bien loin d'y avoir pris naissance, 
 il est done aujourd'hui prouve que la syphilis est pour 
 I'Amerique une maladie d'importation." 
 
 From the facts above stated, we may, in my opinion, con- 
 clude : that the venereal diseases had occurred in JEuro;pe, 
 and, so far as we Jcnow, also in various ^jarts of Asia, from 
 the earliest times; that syphilis overran a large part of Europe 
 toivards the end of the fifteenth century in epidemic-lihe diffu- 
 sion, when it attracted the general attention of the profession 
 for the first time and was first recognised hy its peculiar 
 features; that after the extinction of that epidemic, which 
 lasted about thirty years, the disease fell again to its form.er 
 level; that it was imiiorted from Europe to other parts of the 
 glohe as a consequence of commerce between countries ; but that 
 even at the present day there are some places, remote from the 
 general stream of traffic, which it has not reached (as we have 
 already indicated and shall show at greater length in the 
 sequel) . 
 
 But however remarkable that epidemic explosion of 
 syphilis in the fifteenth century will always seem, it is by 
 no means an isolated occurrence in the history of spreading 
 sickness in general. Even in the after history of syphilis 
 itself, we meet with a series of epidemic outbreaks, as we 
 shall see presently, which, although they were confined to 
 much narrower territories, present striking analogies with that 
 event ; and the inquiry into the circumstances under which 
 these developed, and not unfrequently attained a vitality of 
 many years, seems to offer the means of reaching more 
 accurate conclusions as to the causes which were at work to 
 produce that great pestilential outburst of the disease. 
 
 1 Keeney, «U. S. Army Statist. Report from 1855-60,' Washingtou, i860, 241. 
 
 ^ 'Arch, de med. nav.,' 1878, Aug., 150.
 
 SYPHILIS. 69 
 
 § 1 8. Present Distribution op Syphilis. 
 
 The geographical area of the venereal diseases at the present 
 day, and particularly of syphilis,^ extends over the greater 
 part of the habitable globe. In the prevalence and intensity 
 of the disease, however, we notice considei'able differences at 
 various points ; differences which can be shown to depend in 
 a definite way upon certain exterior conditions, above all upon 
 the degree of culture and civilisation, and upon the rational 
 foresight and concern of the population in things medical. 
 Thus it happens that where these hygienic matters are either 
 altogether or even in part in a backward state, syphilis is 
 prevalent in its worst forms and has more or less the 
 character of an endemic disease. 
 
 On European soil, the amount of syphilis is very nearly 
 uniform in Germany, Denmark, Austria, Switzerland, France, 
 Northern and Central Italy, Greece, Spain and Portugal. 
 But, within these countries, there are local conditions, such 
 as the luxurious life of great cities, the great development 
 of industry, active commercial intercourse, and position on 
 the seacoast, which make the differences in the amount of 
 the disease not inconsiderable at the various points. In more 
 extensive diffusion syphilis occurs in Sweden and Norivay, in 
 Great Britain (to judge by its frequency among the military), 
 in Southern Italy, in Sicily and in Turkey." It reaches its 
 
 » In what follows, I use the term " syphilis " in the sense of the unity doctrine : 
 that is to say, I include therein both the so-called soft chancres, and the consti- 
 tutional syphilitic disease. Apart from the fact that, in nearly all the data 
 before us relating to the difPusion of syphilis in various parts of the world, we 
 fail to find any separation between those two forms of disease (the distinction 
 drawn being rather between the primary and the secondary syphilitic affections) I 
 am myself of opinion that the dualist standpoint in the doctrine of syphilis is 
 fundamentally wrong. There is undoubted evidence of the development of con- 
 stitutional syphilis out of so-called soft chancres (see Kobner, ' Klin. Mittheil. 
 aus der Dermatologie,' Erlang., 1864, p. 7°> and the recent highly interesting 
 -paper of Rieger on cases from the clinic of Prof. v. Fviuecker, in the ' Viertel- 
 jahrschr. fiir Dermatologie,' 188 1, viii, 189). We have also the pathological 
 curiosity which Professor Rollet has brought to light in his " chancre mixte," 
 and the doctrine lately developed by Tarnowski (' Vierteljahrschr. fiir Dermato- 
 logie,' 1877, iv, 9) of the " pseudo-indurated chaucrc ;" and these may be said to 
 be bridges which the dualists have been constrained to build in order to rescue 
 themselves from the dilemma that their doctrine has landed them in. 
 
 ' Roser, 'Ueber einige Krank. des Orients," Augsb., 1837, 67; Rigler, 'D»e
 
 70 
 
 GEOGEAPHIOAL AND HISTORICAL PATHOLOGY. 
 
 greatest extent in many parts of Russia, sucli as the Baltic 
 Provinces,^ the Ukraine/ the Governments of Viatka/ Samara^* 
 and Astrakhan,^ and the Kirghiz Steppe/ as well as in 
 Finland,'^ and in Boumania. In Montenegro^ on the other 
 hand, syphilis is rarely met with ; while the Faroe Islands 
 and Iceland enjoy an almost perfect immunity. 
 
 An approximate measure of the amount of the disease in 
 the several countries of Europe may be got from the statistical 
 returns of syphilis among the soldiery. 
 
 Table of Syphilis in the various European Armies per looo men. 
 
 Country. 
 
 Period. 
 
 Admissions per 
 1000 men. 
 
 Great Britain'' 
 
 1 860 — 69 
 
 236 
 
 j> 
 
 
 1870 79 
 
 124 
 
 Italyio 
 
 
 1864—65 
 
 120 
 
 » 
 
 
 
 1874—76 
 
 66 
 
 Bavaria" 
 
 
 
 1857—69 
 
 116 
 
 rra,Tice^2 
 
 
 
 1862—69 
 
 106 
 
 »y 
 
 
 
 "1872-73 
 
 85 
 
 Holland'^ 
 
 
 
 — 
 
 105 
 
 Belgium!'* 
 
 
 
 1858—60 
 
 100 
 
 PortugaP" 
 
 
 
 1861—67 
 
 96 
 
 Austria^^ 
 
 
 
 1869 
 
 63 
 
 Prussia'- 
 
 
 
 1867 
 
 54 
 
 Tiirkei, &c.,' Wien, 1852, ii, 123; notice taken from the ' Gaz. med. d'Oricnf 
 in ' Presse med. Beige,' 1868, 155. 
 
 1 Bluhm, • Versuch einer Beschreibung der in Reval herrschenden Krankh.,' 
 Marb., 1790, 148; Baer, 'Diss, de morbis inter Esthonos endemicis,' Dorp., 18 14; 
 Adelmann, * Med. Ztg. Russl.,' 1844, Nr. 43 ; Attenbofer, • Med. Topogr. von St. 
 Petersburg,' Zurich, 1817, 246. 
 
 = Podolinski, ' Gaz. med. de Paris,' 1881, Nr. 36, Feuill. 
 
 3 Jonin, «Med. Ztg. Russl.,' 1849, ^r. 45. 
 
 * Ucke, ' Das Klima und die Krankheiten der Stadt Samara,' Berl., 1863, 203. 
 5 Hirsch and Sommerbrodt, ' Mittheilungen iiber die Pest-Epidemie u. s. w./ 
 
 Berl., 1880, 9. 
 
 ^ May dell, * NonnuUa topogr. med. Orenburg, spect.,' Dorpat, 1849. 
 7 Hjelt, 'Norsk. Mag.,' 1873, iii, 675. 
 
 * Boulongne, 'Mem. de med. milit.,' 1868, Dec, 486. 
 3 'British Army Report for the Year 1879/ xxi, 11. 
 
 ^o Sormani, ' Geogr. nosol. dell' Italia,' Roma, 1881, 226. 
 
 '1 Rothmund, ' Bayr. iirztl. Intellgzbl.,' 1872, Nr. 23. 
 
 ^- Laveran, ' Traite des maladies . . . desarmees,' Paris, 1875, 446. 
 
 13 Granier, 'Lyon medical,' 1880, Nr. 18, i. 
 
 ^* Vleminkx, 'Gaz. med. de Paris,' 1862, 445.
 
 SYPHILIS. 71 
 
 Tlie wide prevalence of sypliilis in Southern Italy and 
 Sicily, in contrast to the Northern and Central Provinces of 
 that peninsula,^ had been remarked by earlier observers, and 
 attention has lately been called to it by Celli^ and Sormani.^ 
 From the statistics given by the latter, relating to the pre- 
 valence of syphilis in the Italian army fi'om 1874 to 1876, 
 it follows that, while it averaged fifty-six per 1000 among 
 the troops in the northern and central military divisions, 
 it rose to eighty-eight in the southern division, and to seventy- 
 eight in Sicily. The earlier accounts by Blaustein* and by 
 Barasch^ of the enormous diffusion of syphilis in Roumania, 
 have lately been confirmed by the reports of Leconte^ and of 
 Champouillon,'^ the latter adding that a large part of the 
 population, both old and young, urban and rural, are the sub- 
 jects of the malady. 
 
 The Faroe Islands first received syphilis, according to 
 Panum,^ by importation, in 1844; in the two years following, 
 twenty cases came under observation, but in later reports 
 nothing more is said of it. Into Iceland also, as Schleisner^ 
 tells us, it has been imported twice (1756 and 1824). But 
 the disease subsequently died out entirely ; and although 
 Schleisner gave the closest attention to the subject, he was 
 not able to find a single case of primary or secondary 
 syphilis on the island, notwithstanding the somewhat active 
 sea-trafiic maintained with it by means of Danish, French 
 and Dutch vessels. These observations were afterwards 
 entirely confirmed by Fin sen. ^° 
 
 Among the regions of Asia most severely affected by 
 syphiHs, India, China and Japan,'^'^ having been the earliest 
 
 ^ Jansen, 'Briefe iiber Italien u. s. w.' From the Dutch, Diisseld, 1793,1. 
 297; Ziermann, ' Ueber die vorherrschenden Krankh. Sicilieus,' Haunov., 184; 
 Charlon, ' Gaz. med. de Paris,' 1852, Nr. 5. 
 
 2 'II Morgagni,' 1868, 800. 
 
 ' L. c, 104, 225. 
 
 4 ' AUgem. Ztg. fiir Chirurg.,' 1842, Nr. 49. 
 
 * ' Wien. med. Woch.,' 1855, Nr. 49. 
 
 6 'Consider, sur la pathol. des provinces du Bas-Danubc/ Montp., 1869. 
 
 ' 'Mem. de med. milit.,' 1868, xix, 177. 
 
 8 'Bibl. for Laeger,' 1847, i, .316. 
 
 9 'Island undersogt, &c.,' Kjobenb., 1849, 2. 
 
 10 ' Jagttagelser, &c.,' Kjobenh., 1874, 64. 
 
 " Cheval, ' Relation med. d'uue campagne au Japon,' Montp., 1868 32 ; New-
 
 72 GEOGEAPH[OAL AND HISTORICAL PATHOLOGY. 
 
 head-quarters of the disease, continue to hold the foremost 
 place down to the present time. Next to them, there are 
 very intense foci of syphilis in Loiver India, especially Cochin 
 China and Laos, where the disease is also said to have been 
 prevalent in primgeval times -^ further, in KamtschatJca and 
 Siberia, on many islands of the East Indies, on the coast 
 districts and along the great caravan roads of Arabia? and 
 Persia,^ on the littoral of Syria^ and on the table-land of 
 Armenia.^ 
 
 The authorities are unanimous in asserting the general 
 diffusion and the frequency of syphilis in India.^ An 
 approximate measure of the amount of this malady is fur- 
 nished by the sick-rate of the British troops, of whom there 
 were treated annually for syphilis (on the average of twenty 
 years, 1860—79)'^ no per 1000 in the Presidency of Bengal, 
 
 ton, ' Brit. Med. Journ.,' 1869, June, 521; Sclimid, 'New York Med. Record,' 
 1869, Sept., 314; Potocnik, 'Arch, de med. nav.,' 1875, Oct., 237; Manget, ib., 
 1877, May, 373; Godet, '^tudo sur I'hygicne au Japon,' Par., 1880,46. In 
 Japan, syphilis has been known from time immemorial by the name of " the 
 fire of lewdness." 
 
 1 Richaud, 'Arch, de med. nav.,' 1864, April, 348; Bcaufils, ib., 1882, April, 
 280 ; Thil, ' Remarques sur les princip. malad. a la Cocbinchine,' Par., 1866, 34. 
 
 ' Pruner, ' Krankh, dcs Orients,' 179; Palgrave, 'Narrative of a year's 
 journey thi'ough Central and Eastern Arabia,' Lond., 1865. 
 
 3 Moore, 'Assoc. Med. Journ.,' 1856, Nov., 996. 
 
 * Post, ' New York Med. Record,' 1869, June, 149; Barret, ' Arch, de med. 
 nav.,' 1878, August, 88. According to Robertson (' Edin. Med. and Surg. Journ.,' 
 1843, April, p. 247) it would not appear to have existed in the mountainous parts 
 of the country until recent times when it was introduced by the troops of Ibrahim 
 Pacha. 
 
 * Wagner, ' Relse nach dem Arrarat,' Stuttg., 1848. 
 
 « Macpherson ('Lond. Med. Gaz.,' 1841, June, 546) and Voigt ('BibL for 
 Laeger,' 1834, April, 358), for Lower Bengal; Curran (' Dubl. Journ. of Med. Sc.,' 
 1871, Aug., loi), for the southern slope of the Himalaya; Leslie ('Transact, of 
 the Calcutta Med. Soc.,' 1833, vi, 62) and McCosli ('India Journ. of Med. Sc.,* 
 1835, ii, 43). for Assam ; Shortt (' Madras Quart. Journ. of Med. Sc.,' 1866, April, 
 262), for the District of Madras; Huillet ('Arch, de med. nav.,' 1868, Fevr., 87) 
 and Auboeuf (' Contributions a I'etude de I'hyg. et des maladies dans I'lnde,' Par., 
 1882, 72), for Pondicherry; Shanks ('Madras Quart. Journ. of Med. Sc.,' 1839, i> 
 i, 248, 20, 1841, iii, 13, 31), for Bellary, Secunderabad, and various other places 
 in the Presidency of Madras; McGrigor (ib., 1842, iv, 159), for Bangalore; Day 
 (ib., 1861, April, 326), for Cochin; McKay (ib., 1861, July, 29), for the Nilgherry 
 Hills; Kinnis ('Edinb. Med. and Surg. Journ.,' 1851, April, 302), for Balgaum, 
 Poona, and other places in the Presidency of Bombay ; Gibson (' Transact, of the 
 Bombay Med. Soc.,' iii, 68), for Gujerat. 
 
 ' Estimated according to the ' British Army Reports.'
 
 SYPHILIS. 73 
 
 1 17 in that of Madras, and 104 in that of Bombay. In Ceylon, 
 the proportion is eighty-seven per 1000. Agreeing herewith 
 are the reports of French^ surgeons as to the frequent occur- 
 rence of the disease in Cochin CJiina ; in the hospital of 
 Saigon, as Harmand^ tells us, there are always some seventy 
 or eighty venereal cases to be found among the 300 patients. 
 Moreover, according to Thorel,^ syphilis is carried far into the 
 interior of Laos by Chinese and Burmese caravans, and the 
 only persons who escape it are the Anamese living in isolated 
 settlements in the forests or in mountainous regions difficult 
 of access. In Kanitschatha, syphilis is truly endemic,'* espe- 
 cially among the Koriaks and Tchoukchi; among the 300 
 persons forming the population of Petropaulovski, Maurin^ 
 counted no fewer than thirty cases of inveterate syphilis. 
 Eeferring to the diffusion of the disease in China, Morache'' 
 says : '' S'il etait besoin encore de demontrer I'antiquite do 
 la verole, de repousser une fois de plus la doctrine un pen 
 orgueilleuse de I'origine americaine, on pourrait en trouver 
 des preuves dans son existence parmi les populations du nord 
 de la Chine et surtout au milieu des tribus nomades de la 
 Mongolie: la syphilis regno dans toute I'etendue de la Chine." 
 
 These statements are confirmed by the accounts of the 
 prevalence of syphilis in Chinese ports,^ as well as by the 
 information of Dudgeon^ for Pekin and of Watson^ for Fung 
 Thian (Southern Manchooria). 
 
 The range and frequency of syphilis in the Islands of the 
 Malay Archipelago, as well as in Australia and in the Islands 
 
 ' Richaud, Thil, 11. cc. ; Girard la Barcerie, ' Consider, med. sur la Cochiiichiue,' 
 Montpell., 1868,46; Gimelle, ' Uniou med.,' 1869, Nr, 23; Sourrouillc, ' Trois 
 ans en Cochinchine,' Par., 1874, 17. 
 
 * ' Aper9u pathol. sur la Cochinchine,' Versaill., 1874, 47. 
 3 'Notes medicales, &c.,' Par., 1870. 
 
 * Bogorodsky, 'Med. Zeitung Russl.,' 1854, lo. 
 
 * 'Arch, de med. nav.,' 1877, aout, 90. 
 
 * ' Annal. d'hyg.,' 1870, xxxiii, 25. 
 
 7 "Wilson, ' Med. Notes on China,' Lond., 1846, 26 ; Rochefort, ' Arch, de med. 
 nav.,' J873, April, 281 ; Kerr, ' Edinb. Med. Journ.,' 1863, Aug., 189; Armand. 
 •Gaz.med.de Paris,' 1861, 262, Feuill. from Canton; Ref. in ' Arch. gen. de 
 med,,' 1866, Sept., 166, for Amoy; Cheval, 1. c, 79, and Henderson, 'Ediub.Med. 
 Journ.,' 1876, Nov., 405, for Shanghai; Rose, 'Pacific Med. Journ.,' 1862, Oct., 
 for Foo-chow. 
 
 * 'Med. Times and Gaz.,' 1. c. 
 
 9 'Edinb. Med. Journ.,' 1869, Nov., 442.
 
 74 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 of the Pacific, can be shown to depend upon the more or less 
 active traffic with other countries, and upon the efficiency 
 of the police surveillance of prostitution in the Dutch and 
 British possessions ; so that a comparison of the amount of 
 the sickness at the various points of this region brings out 
 very considerable differences. In the Malay Archipelago ifc 
 is most severe on the large and much frequented islands 
 of Java, Sumatra, and the like ; its widest diffusion is 
 along the coasts,^ although here again there has been an 
 importation of it into the mountainous districts of the interior 
 and a wide extension of its area." Of the smaller island 
 groups, those affected by the disease most are said to be the 
 Eiouw-Lingga Archipelago,^ and the Andaman Islands* which 
 have been used by the English (since the Sepoy Mutiny of 
 1858) as a convict settlement. In the Moluccas,^ where 
 syphilis down to 1840 was no less widely prevalent than it 
 was malignant, the state of matter is now materially better, 
 thanks to the efforts of the Dutch Government to keep 
 prostitution under control ; this applies more particularly to 
 Amboina,^ and less so to Ternate.^ The islands that suffer 
 least are the small and isolated ones, almost out of the course 
 of general traffic, such as the Nicobars,^ Banka,^ Billiton,^° the 
 Bauda^^ group and Timor.^" 
 
 Syphilis is said to have been imported into Polynesia, 
 particularly the Hawaiian or Sandwich Islands and Tahiti 
 (Society Islands), by the crews of Captain Cook's ships and 
 to have committed frightful ravages. As regards the 
 Hawaiian group, it had been already stated by Lockwood^^ 
 
 ' Heymann, ' Krankheiten in den Tropenlandern,' Wiirzb., 1855, 187. 
 
 ' V. Leent, * Arch, de med. nav.,' 1867, Oct., 246, 1874, Nov., 273. 
 
 3 Overbeek de Meijer, 'Nederl. Tijdschr. voor Geneesk.,' 1859, "'» 347 5 ^* 
 Leent, 1. c, 1873, June, 412. 
 
 •• Brander, 'Edinb. Med. Journ.,' 1880, Nov., 394. 
 
 * Lesson, ' Voyage med. autour du monde,' Paris, 1829, 100. 
 
 fi V. Leent, 1. c, 1869, Sept., 178. 
 
 7 lb., 1870, March, 177. 
 
 ^ Steen-Bille, ' Reise der Corvette Galatea uin die Welt.' From tbe Danish, 
 Leipz., 1852, i, 244. 
 
 5 V. Leent, 1. c, 1873, Feb., 103. 
 
 " lb., 86. 
 
 '^ lb., 1870, Jan., 14. I 
 
 1' lb., 1870, Sept., 15. 
 
 13 « Amei'. Journ. of Mod. Sc.,' 1846, Jan., 91 . 
 
 t I
 
 SYPHILIS. 75 
 
 and Gulick^ that tlie disease has become a good deal rarer 
 of late, being confined mostly to the shipping places; and 
 although the most recent authorities^ complain of its great 
 frequency in Tahiti, yet we should take their statements, as 
 Brunet^ does for the whole of Polynesia, as applying less to 
 the natives than to the foreigners who come under hospital 
 treatment. In other island-groups such as Fiji,* Tonga,^ 
 and Samoa,^ the disease is rare, or moderately diffused / and 
 the same applies to New Galedonia where there had been no 
 syphilis until the arrival of Europeans.^ It applies also to 
 the Australian Continent and Tasmania ; during the years 
 1 82 1 — 1 83 1 it happened to Scott^ to see only six cases of 
 syphilis (imported) at Hobart Town, and it would appear 
 from later information^^ that the disease occurs there only to 
 a moderate extent. In New Zealand, where syphilis is 
 said to have been imported also by Cook's men (according 
 to another account'^^ not until the beginning of this century) 
 and to have become widely diffused,^" it now exists within 
 moderate limits.-^^ 
 
 The position of syphilis on the continent of Africa and in 
 the islands adjoining it claims a peculiar share of interest in 
 our inquiry. The disease has its chief distribution-area on 
 the coast territories, to many of which it can be shown to 
 have been imported from Europe ; in the more inland districts 
 
 ^ 'New York Journ. of Med./ 1855, March. 
 
 * Vauvray, ' Arch, de med. nav.,' 1865, Dec, 527; Chassaniol et Guyot, ib., 
 1878, Jan., 71 ; Hercouet, ' Etude sui" les raaladies des Europeans aux iles Tahiti,' 
 Par., 1880, 74. 
 
 3 'La race Polynesienne, &c.,' Paris, 1876, 37. 
 
 * Messer, 'Arch, de med. nav.,' 1876, Nov., 321. 
 ^ Wilkes, 'Narrative of a Voyage, &c.,' iii, 32. 
 
 e lb. 
 
 ^ The statements made by several observers, that syphilis is common in these 
 and other island-groups of Polynesia, have their origin in a confounding of the- 
 disease with chronic exanthems (the so-called Tonga-disease). 
 
 8 De Rochas, 'Topogr. med. de la Nouvelle-Caledonie,' Par., i860, 21 ; Char- 
 lopin, 'Notes rec. en Caledonie, &c.,' Montpell., 1868, 22. 
 
 9 'Transact, of the Prov. Med. Soc.,' 1835, "'» ■'^PP- ^"• 
 
 1° Dempster, 'Calcutta Med. Transact.,' 1835, vii, 359; Hall, ' Transact, of thfr 
 Epidemiol. Soc.,' 1865, ii, 84. 
 
 ^1 'Revue des Deux-Mondes,' 1879, 793. 
 
 1= Power, 'Sketches in New Zealand,' Lond., 1849, 146; Thomson, ' Brit, and 
 For. Med.-Chir. Rev.,' 1854, Oct. 
 
 " Tuke, 'Edinb. Med. Journ.,' 1863, Sept., 227.
 
 76 GEOGEAPHICAL AND HISTORICAL PATHOLOGY. 
 
 it is met with to a less extent, and in some places it is a 
 modern or even quite recent intruder ; while Central Africa, 
 if not altogether free from it, is subject to syphilis only to a 
 comparatively slight degree. These differences in the amount 
 of the sickness are explained, as we shall see, not merely by 
 the fact of no importation having taken place hitherto into 
 certain parts of the continent, but also by other circum- 
 stances, which do not appear, however, to consist in the 
 ethnological characters of the various nations. 
 
 One of the worst regions of syphilis in Africa is met with 
 on the East Goast, and in the East African Islands of Mauri- 
 tius^ and Reunion,^ but particularly in Madagascar, Mozam- 
 bique and Zanzibar, where the number of the syphilitic is 
 estimated at five -sixths of the whole native population,^ and 
 from whence the disease has penetrated into the interior as 
 far as the shores of Lake Tanganyika.* Of the enormous 
 diffusion of syphilis in Madagascar, not only on the coast 
 but also in many mountainous localities,^ we have detailed 
 information from Davidson^ and Borchgrevink.^ 
 
 " Syphilis," says the latter, " har paa en forfaerdelig Maade gjcnnem- 
 traengt det hele Folk. Fru Hofet og til den usleste Hytte findes 
 Syfilis, og det ikke sparsomt, men rijeligt. Der vil neppe findes nogen 
 Familie, hoor der ikke er sorgelige Spor af dens Virksomhed. Henved 
 Halvparten af de under Behandling komne Syge ore i en eller auden 
 Form Syfilispatienter." 
 
 In Madagascar, as well as on the adjoining islands of 
 St. Marie and Mayotte, to which the disease is said to have 
 been imported first in 1854,^ a remarkable phenomenon, 
 vouched for by Borius^ and Dauvin,^^ has to be noted : viz. 
 that the disease among the indigenous inhabitants is almost 
 exclusively confined to the Hovas, who are the dominant 
 
 * From the ' British Army Med. Reports,' 1859-66, it appears that the mcau 
 annual admissions for syphilis amounted to 122 cases per 1000 troops. 
 
 2 Lesson, 'Voyage,' 144; Collas, ' Arch, de med. nav.,' 1866, Nov., 405. 
 ^ Lostalot-Bachoue, ' Zanzibar,' Par., 1876, 51. 
 
 * Destrieux, ' Aunal. de la Soc. de med. de Gand., 1880, 78. 
 ^ Vinson, ' Gaz. hebd. de med.,' 1866, Nr. 49, Feuill. 
 
 6 'Edin. Med. Journ.,' 1863, March, 831. 
 
 ^ 'Norsk Mag. for Laegvidensk.,' 1872, iii, Ser. ii, 242. 
 
 ^ DauUe, 'Observ. med. dans I'etablissement fran9. de Madagascar,' Par., 1857. 
 
 9 'Arch, de med. nav.,' 1870, Aug., 109. 
 
 1" ' Sur la syphilis a Reunion, &c.,' Montpell, 1873, 9.
 
 SYPHILIS. 77 
 
 class of the population, and closely allied to the Malay race, 
 while the Malagasys, who have the characters of the negro race 
 in a marked degree, enjoy an almost complete immunity. 
 
 With reference to the occurrence of syphilis on the island of St. 
 Marie, inhabited by the latter race, Borius observes : " Malgre la pros- 
 titution habituelle et generale des femmes, les accidents syphilitiques 
 primitifs s'observent fort rarement, les autres affections veneriennes 
 paraissent peu frequentes." And Dauvin speaks still more decidedly 
 as follows : "Les indigenes de Sainte-Marie malgre leurs rapports con- 
 tinuels avec les etrangers, tant Europeens que Creoles des iles voisines, 
 Maurice et Reunion, ou la syphilis est tres repandue, ne presentent 
 que tres exceptionellement les traces de I'infection .... Cette 
 espece d'immunite me frappa d'autant plus, qu'a une lieue a peine de 
 Sainte-Marie, separee par un chenal etroit et facilement navigable, la 
 grande ile malgache [Madagascar] est ravage par la syphilis. Mais la 
 encore la race noire est a peine atteinte, tandis que la caste de Hovas, 
 d'origine malaise, semble lui offrir un theatre tout prepare, ou elle 
 deroute les diverses phases de son action." 
 
 Among the European settlers in the coast-regions of Cape 
 Colony, syphilis is found to a considerable extent ; and here 
 again we observe the protective influence of certain circum- 
 stances of nationality against the development of the disease. 
 Among the Hottentots syphilis is comparatively rare,^ and it 
 is still rarer with the Bechuana tribes farther towards the inte- 
 rior, notwithstanding that the disease has often been imported 
 among them by the colonists f while we learn from Living- 
 stone that the negro races of unmixed blood, whose seats are 
 in the central regions of Southern Africa towards the Kala- 
 hari Desert, are absolutely exempt from syphilis. 
 
 " A certain loathsome disease," he says,^ " which decimates the 
 North-American Indians and threatens extirpation to the South Sea 
 islanders, dies out in the interior of Africa without the aid of medicine. 
 And the Bangwakatse, who brought it from the west coast, lost it 
 when they came into their own land south-west of Kolobeng. It seems 
 incapable of permanence in any form in persons of pure African blood 
 anywhere in the centre of the country. In persons of mixed blood it is 
 otherwise ; and the virulence of the secondary symptoms seems to be 
 in all the cases that came to my care in exact proportion to the gi-eater 
 or less amount of European blood in the patient. Among the Coronnas 
 and Griquas of mixed breed it produces the same ravages as in Europe; 
 
 » Scherzer, ' Zietschr. der Wien. Aerzte,' 1858, 166; Schwarz, ib., 630. 
 ' Fiitsch, 'Arch, fiir Anat. iind Physiol.,' 1867, 764. 
 2 ' Travels,' Lond., 1857, p. 128.
 
 78 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 among half-blood Portuguese it is equally frightful in its inroads on 
 the system; but in the pure Negro of the central parts it is quite 
 incapable of permanence." 
 
 In Abyssinia, wliere the disease is said to have been 
 imported by the Portuguese as early as the fifteenth century, 
 it is now so universally prevalent through almost the whole 
 o£ the country (but in the northern highlands and in the 
 kingdom o£ Schoa, it is said, only since the beginning of the 
 present century) that the number of those affected is estimated 
 at nine-tenths of the population.^ At the date of Rigler's 
 information (1852), it would appear not to have penetrated 
 into the country of the Gallas. There is but one opinion 
 among the authorities as to the enormous diffusion of syphilis 
 in Egypt^ and Nubia ^"^ and the malady is prevalent to an 
 equal extent, or in true endemic proportions, throughout the 
 whole littoral of Northern and Western Africa — in Tunis ^ 
 Algiers, Morocco,^ Senegambia and the Guinea Coast. 
 
 As to Tunis, Ferrini^ says : " Syphilis in this country is 
 the most widely spread of all contagious maladies, the most 
 serious and the most terrible ;" and in like manner Rebatel 
 and Tirant® say of it there : " It reigns as sovereign in this 
 country ; those who do not have it are the rarest exceptions." 
 Algiers forms one of the most frightful seats of syphilis, 
 particularly, as Furnari^ tells us, since the French occupa- 
 tion -^ it penetrates as far as the Sahara,^ and reaches the 
 maximum of intensity in the districts of Kabylia.^^ Some 
 
 ' Aubert-Rocbe, 'Anual d'hyg.,' xxx, 5; Rigler, 123; Courbon, 'Observ. 
 topogr., &c.,' Paris, 1861, 35 ; Blanc, 'Med. Times and Gaz.,' 1868, Jan., 82, and 
 'Gaz. hebd.,' 1874, 350, Feuill. 
 
 " Pruner, 179; Griesinger, 'Arcb. fiir pbys. Heilkde,' 1853, xii, 517; Anelli, 
 ' Annal. univ. di Med.,' 187 1, Sept. ; Vauvray, * Arch, de med. nav.,' 1873, Sept,, 
 161 ; Nicoll, 'Annal. d'hyg.,' 1878, Sept., 210. 
 
 3 Veit, 'Wiirtt. med. Corrspdzbl.,' 1839, i^' i°7* 
 
 * Ref. in 'Med. Times and Gaz.,' 1877, July, 96; Derugis, 'Voyage dans 
 rinterieur du Maroc,' Paris, 1878, 94. 
 
 5 'Saggio, &c.,' Milano, i860, 118. 
 
 ^ 'Lyon medical,' 1874, Nr. 13, ii, 249. 
 
 7 'Voyage med. dans I'Afrique septentrionale,' Paris, 1845. 
 
 s See Bertherand, ' Med. et hyg. des Arabes,' Paris, 1855 ; Armand, ' Med. et 
 hyg. des pays chauds, &c.,' Paris, 1853, 415; Daga, 'Arch. gen. de med.,' 1864, 
 Sept.; Bertrand, 'Mem. de med. milit.,' 1867, Mars, 199; Soyard, 'Consider, sur 
 quelques-unes des affections ... en Algerie,' Montp., 1868, 44. 
 
 9 Creissel, 'Mem. de med. milit.,' 1873, Juill., 337. 
 ^^ With reference to the disease known there under the name of " lepre kabyle,"
 
 SYPHILIS. 79 
 
 evidence of the frequency of syphilis among tlie Europeans 
 in Senegamhia is furnished by the statistics of sickness in 
 the French hospitals at St. Louis and Goree ; from the obser- 
 vations of twenty years (1853 — 1872) the mean annual 
 admissions for venereal disease were 121 per 1000 men.^ 
 Among the natives, the disease is still more prevalent, being 
 described by Hebert/ from observation of it in Dagana, as 
 the 'heritable scourge of the country." According to 
 Berger's^ facts, there occurred from ist January, 1862, to 
 31st July, 1865, in a battalion of Senegalese troops 812 
 strong, 585 cases of venereal disease, mostly syphilis, giving 
 a mean annual sick-rate of 206 per 1000. As to the Guinea 
 Coast, it is stated in an old account by Daniell* (for the 
 Benin and Biafra Coasts) that " syphilis is perhaps the most 
 frequent and fatal of those maladies to which the male 
 inhabitants are liable, and predominates more among them 
 than among the females ;" and more recent observers write 
 to the same effect of the enormous amount of the disease on 
 the Gold Coast^ and the Cameroon Coast.*' The statement 
 of Bailey is worthy of note, that in the Gaboon country 
 syphilis is more rarely met with the farther one travels from 
 the coast into the interior. Lastly, that syphilis is no stranger 
 to the Soudan follows from the statements of Pruner as to 
 the importation of the disease into Kordofan by Turkish 
 troops, as well as from the accounts of its occurrence in Darfur,'^ 
 
 see Arnould, ib., 1862, viii; Bazille, 'Gaz. med. de I'Algerie/ 1868, 40; Challan, 
 ib., ii7j Claudot, 'Mem. de med. mQit.,* 1877, May, 271. 
 
 1 Beranger-Ferand, ' Traite des malad. des Europeans au Senegal,' Paris, 1878, 
 ii, 254. 
 
 » • Une annee med. ^ Dagana,' Paris, 1880,40. See also Borius, 'Consider, 
 med. sur le poste de Dagana,' Montpell., 1864; Chassaniol, 'Arch, de med. nav.,' 
 1865, May, 518; Thaly, ib., 1867, Sept., 185; Gauthier, 'Des endemies au 
 Senegal,' Paris, 1865, 18. 
 
 * 'Consider, byg. sur le bataillon de Tirailleurs Senegalais, 1862-65,' Mont- 
 pell., 1868, 59. 
 
 * ' Sketches of tbe med. topogr. of the Gulf of Guinea/ Lond., 1849, 43. 96. 
 114, 138. 
 
 * Clarke, ' Transact, of tbe Epidemiol. Soc.,' i860, i, 112; Moriarty, ' Med. 
 Times and Gaz.,' 1866, Dec, 663 ; Michel, ' Notes med. rec. a la Coted'or,' Paris, 
 
 1873. 
 
 6 Griffon du Bellay, ' Arch, de med. nav.,' 1864, Jan., 77 ; Abelin, ' Etude med. 
 
 sur le Gabun,' Paris, 1872, 31 ; Ballay, ' L'Ogooue,' Paris, 1880, 39, 
 
 ^ Ebn-Omar-el-Junsy, ' Voyage au Darfur,' Paris, 1845.
 
 80 GEOGRAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 and from the information of Quintius,^ according to 
 Tvhom it has been imported quite recently from the West 
 Coast into Segu-Sicorro (in 13° 32 N., 8° 26 W.). It is 
 impossible, in the absence of further reliable data, to say 
 how far syphilis extends through the Soudan generally. 
 
 In the Western Hemisphere, syphilis appeared first, as we 
 have already remarked, in the sixteenth century, in conse- 
 quence of importation from Europe ; its diffusion there has 
 followed the track of immigration and colonisation from east 
 to west, so that, as Jullien aptly says,^ the development of 
 syphilis in America affords a measure, cseteris paribus, of the 
 progress of civilisation in the several parts of that continent. 
 To some regions, which had remained a long time remote from 
 traffic, the disease has penetrated only in quite recent times ; 
 while still others continue exempt to the present day. 
 
 In the extreme northern parts of North America, we come 
 first to two regions which, like Iceland, enjoy an almost 
 absolute immunity. One of these is Greenland, where, in 
 spite of prostitution flourishing to the utmost, and the busy 
 traffic with Danish trading ships and British and American 
 whalers, the disease is altogether unknown.^ The other is 
 the island of Miquelon (in Fortune Bay, Newfoundland), 
 where syphilis was introduced by the first immigrants, but 
 took no permanent hold.* In striking contrast hereto, is 
 the great diffusion of the disease in the north-west of the 
 continent, in Alaslia^ British Columbia^ and Vancouver's 
 Island,'^ where the native population are frightfully afflicted 
 with the malady. Among the Eskimos inhabiting the 
 Aleutian Islands, syphilis is said to have become considerably 
 less common of late ; on the other hand, in Vancouver's 
 Island, to have become more general and very malignant in 
 consequence of the complete neglect of sanitary police regu- 
 lations. In Canada, where syphilis was imported from the 
 
 * ' Extrait d'un voyage dans le Soudan,' Paris, 1869, 39. 
 " 'Arch, de med. nav.,' 1878, Aout, p. 150. 
 
 3 Lange, 'Bemaerkn. om Gronlands Sygdomsforhold,' Kjobenh., 1864, 30. 
 ■• Gras, 'Quelques mots sur Miquelon,' Montpell., 1867, 39. 
 
 * Blaschke, ' Topogr. med. portus Novi-Archangelcensis,' Petropol., 1842,66; 
 Ecf. in 'Arch, de med, nav,,' 1864, Dec, 475. 
 
 ® Simpson, ' Narrative of a Journey round the World.' 
 " Maurin, 'Arch, de med. nav.,' 1877, Aug., 93.
 
 SYPHILIS. 81 
 
 ■soutli at the beginning- of last century, afterwards sproadino- 
 destructively among tlie Indians/ and persisting down to the 
 present in the form of severe endemics at various places 
 C'Maladie de la Bay de St. Paul/' and the ''Ottawa 
 disease "), it is now as prevalent as in the civilised states of 
 Europe ; and the same is true of the United States, Avhero 
 syphilis extends equally to the remnants of the Indian popu- 
 lation wherever these have come into close communication 
 with the European settlers. 
 
 Hunter,^ who was in his youth cavviecl off by a tribe of Indians living 
 in the west, and who spent several years among them, says: "The 
 venereal disease was entirely unknown among them [the Indian tribes] 
 until they contracted it from the whites. . . . Those who go amon^ 
 the populous white settlements on the Missouri and Mississippi, where 
 the disease prevails in its most inveterate forms among the traders and 
 boatmen who navigate the river to New Orleans, frequently return to 
 their families and tribes infected with it." 
 
 In California, it has become very common since the 
 opening of the gold-fields, and it makes frightful havoc also 
 among the Indians^; it was introduced by the Spaniards 
 from Mexico, but it remained confined to the Indians of the 
 south, the tribes living* to the northward, whom the Mexicans 
 did not reach, continuing down to the present day to enjoy 
 an exemption from the disease.* The state of matters is found 
 to be the same among the Indian ti'ibes occupying the 
 Colorado plains, and the banks of the Missouri and the Red 
 River ; only tliose of them who haye come in contact with 
 Europeans or Mexicans suffer from syphilis.^ In Texas also 
 the records show that, at the time when the territory was 
 taken possession of by the United States, syphilis was found 
 only among those Indian tribes who had trafficked with the 
 Mexicans.^ 
 
 Mexico, then, would appear to be the focus whence the 
 
 ^ Swediaucr, Tract. Observ. on Venereal C'ouipluints,' Edinb., 1788, 172; 
 Stmttoi), ' lidiiib. Med. and Surg. Jouru.,' 1849, Apiil, 276. 
 
 - 'Amer. Mod. Recorder,' 1822, July, 412. 
 
 ^ Praslow, ' Calil'oniion,' Gutting., 1S57, 56; Laiitoin, ' Arcli. de med. nav ,' 
 ■1872, mars, i 79. 
 
 * Kecuey, in ' U. S. Army Statist. Report,' 1855-60, Washington, 1S60, 241. 
 
 ^ Hofl'mann, ' Rliilad. Med. and Surg. Reporter,' 1879, Feb., iTpo. 
 
 ^ Husson, iu'U. S. Army Statist. Report,' 1839-54, riuladelphia, 1856, 377 ; 
 5v\ iCt, ib., .^85. 
 
 VOL. 11. 6
 
 82 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 infection of tlie indigenous inhabitants of adjoining parts of 
 Nortli America had chiefly proceeded ; and that country, 
 in fact, takes a foremost place among the most intense centres 
 of syphilis in the Western Hemisphere. The disease is 
 prevalent there not only to an unusual extent, but also of a 
 peculiar malignancy ; whereof the surgeons of the French 
 army had abundant opportunities of assuring themselves 
 during the occupation of the country by French troops.^ 
 Syphilis is widely spread, also, in Central America — 
 Nicaragua^ Gosta Bica^ Guatemala^ and San Salvador^ — 
 where it is again those Indian tribes that have kept out 
 of contact with the immigrant population which remain 
 free from it. It is widely spread in some of the Antilles, 
 such as Hayti^ and Barbadoes -^ while in the larger number 
 of them (Jamaica, St. Bartholomew,^ Martinique^ and others) 
 it occurs only to a moderate extent. It is in South America, 
 that the disease reaches the maximum of diffusion and of 
 intensity ; and here too, the Indian population have kept free 
 from it (some of them being still exempt) only for so long 
 and in so far as they have had no intercourse with the 
 immigrants from Europe.^*^ 
 
 Of the frightful extent to which syphilis prevails in Brazil 
 there are reports and complaints of the same tenour from all 
 parts of that great territory .^^ Thus, from Bahia we learn 
 
 ij 
 
 1 Newton, 'Med. topogr. of the City of Mexico,' New York, 1848; Porter, 
 ' Amer. Journ. of Med. Se.,' 1853, Jan., 40; Jourdanet, ' Lc Mexique, Sac.,' Par., 
 1864, 412; Douille, ' Montpellier medical,' 1872, aout, 1195 Heiueinann, in, 
 ' Virchow's Arch.,' 1867, xxxix, 613, 1873, Iviii, 177. 
 
 2 Bernhard, ' Deutsche Kliu.,' 1854, Nr. 11. 
 
 3 Schwalbe, ' Arch, fiir. klin. Med.,' 1875, xv, 342. 
 
 * Bernoulli, 'Schweiz. Zeitschr, fur Med.,' 1864, iii, 100, 
 
 ^ Guzmann, ' Essai d'une topogr, med, de la republique du Salvador,' Paris,. 
 1869, 121. 
 •' Blacas, 'De la syphilis observee a St. Domingue,' MontpcU., 1853. 
 
 7 Jackson, ' Boston Med. and Surg,,' 1867, July, 447. 
 
 8 Goes, ' Hygiea,' 1S68, 460. 
 
 9 Rufz, 'Arch, de med. nav.,' 1869, Nov,, 351. 
 
 1" Compare the accounts by Varnhagcu (' Hamb, Mag. fiir Heilkde,' 1822, iv, 
 367), and Martius ('Krauk, der Urbcwohner Brasilicns,' Miinch., p. 85), for 
 Brazil, by Masterman for Paraguay, by Poppig for Chili, and by Gait for Peru. 
 
 11 Rendu, 'Etude topogr. et med. sur le Bresil,' Paris, 1S48, 78; Sigaud, 1. c.,. 
 117 ; see also Rey, 'Arch, de med, nav.,' 1877, Jan., 28. 
 
 '* Ref., ib., 1869, mars, 340.
 
 SYPHILIS. 83 
 
 " La syphilis est tellement commune dans toutes las families, 
 qu'on ne clierche nullement a la dissimuler, et on parle aussi 
 volontiers du gallico dont est atteint un parent ou uu ami, 
 que s'il s'agissait d'un rlieumafcisme ou d'uno attaque de 
 goutte." 
 
 In Pernambuco, according to Beriuger,^ there are in eveiy 
 I GOO deaths^ lo from syphilis. The accounts from Paraguaij 
 and the Argentine States^ are similiar, " Patients with 
 syphilis,^' saysTschudi, '^'^are found to a frightful extent all over 
 the Argentine Confederation. Everywhere, even at the most 
 remote posts, we find persons with the most horrible disfigure- 
 ments of the face. In Cordova there are some dozens of 
 them begging in the streets. Dr. Oster assured me that one 
 would not be far out in taking every third person in Cordova 
 for syphilitic.'^ But we meet with the disease in Cldli^ 
 Bolivia,^ and Peru, as extensively as in the eastei'n states of 
 South America. It sounds almost incredible to read in the 
 account by Fournier,^ that of 912 deaths in the hospital of 
 La Caridad at Valparaiso from May, 1 871, to March, 1873, 52 
 were from syphilis (15 males and 37 females) ; and yet we 
 shall be quite disposed to credit this statement on learning, 
 as we do from Savatier,^ that of 972 patients admitted into 
 that hospital in a year (1877-78), 485 were syphilitic. In 
 Peru, where the disease is equally common,^ it was quite 
 unknown before the Spanish conquest of the country 
 (Tschudi) ; and even down to the present day it has not 
 penetrated, according to Galt,*^ into the pampas of Sacra- 
 mento in the basin of the Ucayali. 
 
 ^ ' ArcL. de med. nav.,' 1879, mars, 222. 
 
 ^ Brunei, ' Observ. topogr. et med. faites dans le Rio de la Plata,' Paris, 1842, 
 45; Tschudi, ' Wien. med. Wochenschr.,' 1858, Nr. 45; Mautegazza, ' Letterc 
 med. sulla America meridionale,' Milano, i860 — 63, i, 305, ii, 208; Mastcrman, 
 in ♦ Dobell's Reports,' 1870, 382. 
 
 3 Poppig, in Clarus' ' Beitr. zur Heilkde.,' 1834, i, 529; Lafargue, 'Bull, de 
 I'Acad. de med.,' i85i,xvii, 189; Accounts in 'Arch, de med. nav.,' 1864, juli 
 22, aout, 108 ; Boyd, ' Ediub. Med. Journ.,' 1876, Aug., 116. 
 
 •* Bach, ' Zeitschr. fiir vergl. Erdkunde,' iii, 543. 
 
 * ' Arch, do med. nav.,' 1874, Sept., 147. 
 
 *^ lb., 1880, Jan., 14. 
 
 ' Tschudi, ' Oester. med. Wochenschr.,' 1846, 474; Lesson, 'Voyage,' 27; 
 Accounts in 'Arch, de med. nav.,' 1864, Sept., 181, 189, Oct., 274. 
 
 s 'Amer. Journ. of Med. Sc.,' 1847, April, 400.
 
 84 GEOGRAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 § 19. Has spread over the Globe through the Conveyance 
 
 OP a Virus. 
 
 A glauce at tliis outline of tlie history and geography of 
 syphilis shows us that the disease had been originally 
 indigenous at a few points, and has gradually become diffused 
 over almost the whole globe. From what points it issued, 
 or what was its native hahitat, we can form no more definite 
 opinion than we can of the origin of the plague, the small- 
 pox, typhus, and, indeed, of every other infective disease. 
 This much, only, we may conclude with some px'obability from 
 the data before us, that the disease existed in Eui'ope and in 
 Eastern Asia from the earliest times, that in the course of 
 centuries it spread in ever-widening circles by means of the 
 commerce between countries, that there were large territories, 
 such as the whole of the New World, the centime of Africa, 
 Australia and Oceania which it did not reach until com- 
 paratively modern times, or even quite recently, and that even 
 at the present day there are regions exempt from syphilis 
 where the population keeps itself free from communication 
 with the infected country around. There can be no question 
 that a specific infective substance underlies syphib's (which 
 substance we may take to be an organic body from its power 
 of reproduction), that the disease never develops autochthon- 
 ously now, but occurs always in consequence of the convey- 
 ance of the morbid poison, and that this transmission may 
 take place either by way of contagion, in the strict sense of 
 the word, or by way of inheritance. Accordingly, with regard 
 to the pathogenesis, the only questions that can arise are 
 whether external influences such as climate, soil, and hygienic 
 conditions, may perhaps determine the frequency and 
 severity of type of the disease, or whether certain racial or 
 national peculiarities may not sometimes afford a protection 
 against it (relative or absolute) or at other times increase the 
 predisposition of individuals to it. 
 
 There lias naturally been no lack of inquiry into tlic nature of the 
 specific ijoison of sypliilis. Salisbury' was the fii'st who professed to 
 find it in a filamentous fungus {Cryptos sypliilitica), which developed 
 
 ' 'Amer. Jouni.of Med. Sc.,' 1S68, Jan. 17.
 
 SYPHILIS. 85 
 
 from spores ; it took root in tlie connective tissue, extending its destrnc- 
 tiveness to tlie tissues around, and, when the disease became consti- 
 tutional, it could be detected also in the blood. Shortly afterwards 
 Hallier^ announced that he had discovered the parasite of syphilis in a 
 micrococcus, which, when it was cultivated, grew into a fungus named 
 by him Coniothecium syijliiliticum. A few years later Lostorfer" came 
 forward with his discovery of " syphilis corpiiscles " in the blood, biit 
 these were soon given up as illusory.^ Then came the announcement 
 by Cutler'' that he had obsei'ved peculiar changes in cases of syphilis, 
 the white corpuscles being " enlarged and distended by inter- 
 cellular vegetations, the spores of which were copper-coloured," while 
 the blood-serum contained "mycelial filaments" also copper-coloured. 
 This discovery has obtained biit scanty recognition at the hands of the 
 commission appointed by the American Medical Association to inquire 
 into 'it. The same year (187S) Klebs'' published the results of his 
 microscopic study of syphilitic subjects, and of his experiments to infect 
 animals ; according to these there are rod-like moving bodies (Helico- 
 monades) discoverable in syphilitic tissue, which, when cultivated, 
 become spiral-shaped masses, and, if given to monkeys, produce the 
 characteristics of syphilitic disease. This result was confirmed in 
 essential points by Bermann ;'' while Pisarewski" found in the chancrous 
 indurations a finely granular zooglooa-like mass packed into the 
 spaces of the tissue, and consisting of small round particles, out of 
 which he conjectures that the rods seen by Klebs (but not seen by 
 himself) might develop. 
 
 § 20. Severity op Type not specially affected by Climate. 
 
 Whether the prevalence of syphilis is at all influenced by 
 circumstances of climate, appears more than doubtful when 
 wo keep in mind the fact that it is almost equally common 
 in all latitudes, and that many parts of the cold zone in both 
 hemispheres are as much affected by it as temperate or 
 sub-ti-opical or tropical regions ; and although many coun- 
 tries of the temperate zone_, especially in Europe, appear to 
 
 1 ' Bayr. iirztl. lutelligenzbl.,' 1868, 233. 
 
 "^ ' Wien. med. Prcsse,' 1872, Nr. 4, ami 'Med. Jalu-b. der Wien. Aerzte,' 
 1872, 96. 
 
 3 See also W'edl, Neumann, and others, in 'Wien. allgem. med. Ztg.,' 1872,. 
 Nr. 7, 8, and Kiibuer, m ' Bcrl. Iclin. Woclienschr.,' 1872, 209. 
 
 ^ 'Transact, of the Amer. Med. Assoc.,' 1878, xxix, 165. 
 
 * ' Prager med. Wochenschr.,' 1878, Nr. 41. 
 
 « 'The Fungus of Syphilis,' New York, 1880. 
 
 ' ' Centralblatt fiir Chiriirgie,' 1880, Nr. 32.
 
 86 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 be more favorably situated in this respect^ the reason of 
 that is to be sought,, not in the climate but in the hygienic 
 circumstances. I am equally unable to persuade myself that 
 the climate has any influence on the severity, or on the 
 greater or less malignity of the type of sypliilis. There are, 
 indeed, a series of data tending to show that syphilis has a 
 milder type in warm or tropical climates, that it is not only 
 slighter in its symptoms but also more quickly got over. 
 These observations come from Italy ,^ Greece," Turkey,^ the 
 littoral of Syria (contrasting with the mountainous region),'* 
 Persia,'' the coast of Abyssinia,^ the interior of Egypt,^ 
 Tunis,^ the West Indies,^ the littoral of Mexico,^° and Peru.^^ 
 But the data in question rest in part upon errors ; and further, 
 it is by no means made out that this comparatively mild 
 course of the disease is actually dependent on conditions of 
 climate ; while, lastly, we have the well-established fact that 
 many of the most intense centres of syphilis are met with 
 actually in lower latitudes, and that in these it is not the 
 Europeans only, as often asserted, but also the natives who 
 suffer from the disease in its severest forms. 
 
 All the more recent authorities for Italy'" state that syphilis runs a 
 much more sevei-e course in the southern provinces (and Sicily), than 
 in the northern. Sj)eaking of Portugal, Rohertson'^ and Wallace'* 
 are agreed that the disease among the English troops was of no hetter 
 type than in England. The malignancy of sypliilis in Egypt and Nubia 
 is vouched for by Griesinger,'^ Veit, Broccbi, and others, contrasting 
 with the account above mentioned, by Rebatel and Tirant, of the mild 
 type of the disease in Tunis — an opinion derived, as they themselves 
 admit, from only a few cases, and going directly against the experience 
 of practitioners in Algiei's. Ferrini"* gives it as not only the most wide- 
 spread, but also the most dangerous and frightful of the diseases preva- 
 
 ' Menis, 'Topogr. statist. -tned. della provincia di Brescia,' 1837, '> '^S- 
 
 ■■' Roser, ' Krank. des Orients,' Augsb., 1837, ^7 J Olympios, ' Bayr. med. Cor- 
 respondenzblatt,' 1840, Nr. 13. 
 
 ^ Oppenlieim, * Volkskrankh. in der TUrkei,' Hamb., 1833, 79. 
 
 '' Robertson, I.e.; Yates, 'Lond. Med. Gaz.,* 1844, Feb., 567. 
 
 5 Polak,' Wocbenbl. zur Zeitscbr. der Wien. Aerzte,' 1856, Nr. 29. 
 
 •"' Aubert-Roebe, 1. c. '' Pruner, 1. c. ^ Rebatel, 1. c. 
 
 ^ Rufz, 1. c., for Martinique. '" Jourdanet, Heinemann, 11. cc. 
 
 " Tschudi, 1. c. 12 Supra, p. 71. 
 
 " ' Lond. Med. Report,' 18 18, June, 459. 
 
 14 ' Edinb. Med. and Surg. Journ.,' 1829, Jan., 79. 
 
 '■'■' L. c, 517. 16 Supra, p. 78.
 
 SYPHILIS. 87 
 
 lent in tliat country. All autliorities (Shanks, McGrigor, Kinnis, 
 Aubceuf, and otliers) are agreed as to the malignant character of 
 syphilis in India and the Malay Archipelago. Heymann says i^ 
 " Cases of syphilis are found in exceedingly large numbers all over 
 
 the islands of the East Indian Archipelago While the extensive 
 
 distribution of syphilitic disease cannot easily escape notice, its inten- 
 sity attracts our attention in a still greater degree. Most of these 
 affections are very obstinate and difficult to cure." Pop's account^ is 
 the same ; and, in a subsequent paper,^ in which syphilis is spoken of 
 as being prevalent in the East Indies " d'une maniere ten-ible," he says : 
 " The climate of the tropics does not appear to be very favorable to the 
 treatment of constitutional syphilis." In like manner, Laure'' con- 
 cludes that a tropical climate has a particularly injurious influence on 
 the type of syphilis in Cochin China and China. Among the French 
 military surgeons in Algiers, there is only one opinion as to the 
 malignancy of syphilis there. Thaly says of the type of the disease in 
 Upper Senegambia : " The sequela- are very serious in this country ;" 
 and there are similar accounts from the Guinea Coast, from Brazil and 
 other countries. Further, we may here once more recall the fact that, 
 excepting in the Chinese ports where the Europeans suffer most from 
 the severe forms of syphilis, the disease in all the tropical or sub- 
 tropical countries mentioned above is just as malignant and as difficult 
 to cure in natives as in foreigners, and, in some localities such as 
 Algiers,^ is even of a more malignant type in the former. 
 
 § 21. Alleged unfavorable Influence op Altitude. 
 
 It appears to me to be questionable wliether the severity 
 of sypliilis on ihe table-lands of Armenia, Abyssinia and 
 Mexico, contrasting' with its alleged milder type on the plains, 
 is due to the elevation, or, in other words, to the influence of 
 altitude on the health of the inhabitants, as Jullien^ and Key 
 suppose ; whether also, as Eey conjectures, we are here con- 
 cerned with that '' anemie des altitudes " which Jourdanet 
 has observed on the Mexican plateau, and with a debility of 
 the organism thereby caused. At all events I have no know- 
 ledge of any such " anaemia of altitude " on the plateaux of 
 Armenia and Abyssinia. 
 
 1 L. c, 187. 
 
 2 'Nederl. Tijdschr. voor Geneesk.,' 1859, ill, 25. 
 ^ ' Arch, de mod. nav.,' 1867, Oct., 246. 
 
 4 ' Hist. med. de la marine francalse, &c.,' Paris, 1864, 67, 143. 
 
 * Supra, p. 78. 
 
 « 'Arch, de med. nav.,' 1878, aout, ij;;. 
 
 ' ' Annal. de Dermatol.,' 1880, ii, Ser. i, 686. 
 
 k
 
 88 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 § 22. Immunity from Syphilis in certain Countries ani> 
 
 AMONG certain EaCES. 
 
 Highly remarkable, again, is tlie comparative immunity 
 from sypliilis wliicli the inhal^itants, or certain sections of the 
 inhabitants, appear to enjoy in some parts of the world, 
 notwithstanding the open intercourse with other countries 
 and the abundant opportunities for infection. So far as we 
 know at present, this jjoculiar state of things, which has 
 been adverted to already in describing the geographical 
 distribution of syphilis, may be observed in Iceland, in the 
 island of Miquclon (Newfoundland), in Greenland, in the 
 central regions of South Africa, and among the black popula- 
 tion of Madagascar and the adjoining islands. 
 
 Syphilis can be shown to have been imported twice into 
 Iceland, in 1756 and 1824, and to have infected the inhabit- 
 ants to the extent of 22 cases in all. " When we consider,^' 
 says Finsen,^ " that Iceland is visited evei'y year by hun- 
 dreds of ships, partly Danish trading vessels, partly French 
 and English whalers, which give rise to communication with 
 the inhabitants in the most various ways, it must seem a piece 
 of great good fortune that the natives have not been infected 
 more often ;'^ during the nine years which he (Finsen) prac- 
 tised on the island, he saw only 5 cases of syphilis, and these^ 
 in strangers. As regards Miquelon, Gras says : " Syphilis 
 came into the island with its first settlers but it has not 
 taken root, I have not found a single trace of its having 
 been actually developed ; and, although I have found evidence 
 of secondary and tertiary lesions among the older generation, 
 I have never seen anything in infants which would justify 
 me in believing that the malady had been transmitted by 
 heredity." The following is Lange's literal statement 
 for Greenland : " It is remarkable that there is absolutely no 
 syphilis here; about the fact itself there is not the slightest 
 doubt, and the strangeness of it will perhaps seem less when 
 we remember that the same is true of Iceland. The circum- 
 stance is explicable simply and solely on the ground that 
 Greenlauders, like Icelanders, have an immunity from syphilis;. 
 
 1 L. c.
 
 SYPHILIS. 89' 
 
 for tliere is no lack of opportunities for infection, Green- 
 land is visited every year Ijy vessels from Denmark, at Avhose- 
 departure from the mother country there arc certainly pre- 
 cautions taken to prevent the importation of contagious 
 diseases ; but hardly a year passes, especially in the northern 
 parts of the country, without several settlements having- to 
 provide quarters, for a longer or shorter period, to consider- 
 able numbers of men shipwrecked from British and American 
 whalers ; and besides these there are other occasional 
 visitors. Now, considering that prostitutioii is carried on, 
 both onboard ship and on shore, with an absence of restraint 
 which baffles all belief, it certainly cannot be said that the- 
 Greenlandors have not had ample opportunities, during 
 nearly a century and a half, of becomiug infected with 
 syphilis." 
 
 I have already quoted at length the observation of Living- 
 stone on the immunity from syphilis which is enjoyed by the 
 negroes of the southern regions of Central Africa. To this 
 Fritsch adds the remai-k : " Syphilis is rare, and it occurs 
 in Bechuana Land only in very scattered cases, mostly impor- 
 tations from Cape Colony ; still there are materials with 
 which to controvert Livingstone's assertion that the disease 
 does not hold with pure Ethiopian blood." I have already 
 called attention to the accounts by Borius and Dauvin as to the 
 relative immunity from syphilis of the Malagasys (negroes) 
 in Madagascar, Mayotte and St. Marie, in contrast with the 
 frequent and serious cases of it among the Ilovas (of Malay 
 race) who live in the same localities. Eeferring to the inter- 
 course of the Malagasys of St. Marie with Madagascar, Dan- 
 vm says : " Les communications entre ces deux points sent 
 journalieres, la facilite des moeurs, le libertiuage, la debaucho 
 sent pour ainsi dire a I'ordrc du jour dans ces pays encore a 
 moitio sauvages, ot lo Betanimene (Malgacho de Sainte- 
 Marie), apres un sejour de deux ou trois mois au milieu de 
 ce foyer do contamination, pendant lequel il a obei a ses 
 appetits generiques assez develo^opes, revient a sa terre natale,. 
 en apparence indemne comme il en etait parti." Lastly, I 
 shall recall l^he fact that the Europeans at Chinese ports 
 suffer much more severely from syphilis than the natives. 
 
 It is obvious that it is not with i')ccuHarlties of race as.
 
 ■90 GEOGKAPHICAL AND HISTORICAL PATHOLOGY. 
 
 determining a relative immunity from sypliilis tliat we have 
 to do in all these cases. The inhabitants of Iceland belong 
 to the Scandinavian stock, which pays a not inconsiderable 
 tribute to syphilis in Norway, Sweden and Denmark. The 
 natives of Greenland differ in no respect from other Eskimo 
 tribes on the western side of North America, who have had 
 frightful visitations of syphilis. In contrast to .the negro 
 population of which wo have been speaking, the negroes on 
 the East and West Coasts of Africa suffer from syphilis at 
 least as often and as severely as other nationalities. If there 
 be no mistake in the facts, then we are confronted with a 
 riddle which our knowledge of the conditions of living among 
 these peoples does not enable us to solve. 
 
 . It has been often alleged that syphilitic infection is of a 
 particularly severe character and follows a very protracted 
 course, when it is the sequel of sexual intercourse between 
 persons of different nationalities ; but, whether that be so, we 
 have not facts enough to generalize upon. On the other 
 hand it is a truth borne out by all observations hitherto, 
 that syphilis finds its widest diffusion and its worst types, 
 cseteris paribus, in those countries or among those peoples 
 which are visited by the disease for the first time ; and that 
 circumstance, as we shall see in the sequel, is explained on 
 the ground of neglected hygiene. 
 
 § 23. Influence op Police Surveillance. 
 
 At all times, and at every point in its area of distribution, 
 syphilis has been the more widely spread and the more severe, 
 the more indifferent has been the attention to iniblic and 
 'private hygiene, the more prostit'ittion has been allowed to go 
 uncontrolled, or the more recklessly the population have given 
 themselves up to " Venus vulgivaga " and have borne the 
 effects of syphilitic infection Avith indifference. It is this that 
 explains the frightful ravages which the disease has wrought, 
 and is even still working, among peoples in the lowest stages of 
 civilisation ; this explains also the wide diffusion and the malig- 
 nancy of syphilis in every country where there is no regular 
 surveillance of pi-ostitution by the State, — in Algiers, Egypt,
 
 SYPHILIS. 91 
 
 China, Japan, Mexico, Brazil, Peru, and Chili ; and it explains 
 further, the increased prevalence of the disease in times of 
 war or in circnmstances where the concentration of large 
 masses of people for a considerable period makes surveillance 
 difficult. It is under the latter circumstances, and particu- 
 larly in regions with a poor and uneducated population 
 wanting the services of a medical profession, that syphilis 
 has not unfrequently broken out and become prevalent in 
 epidemic and endemic form. 
 
 Instances of the effect of tlie movement of troops in war upon tlie 
 diffusion of syphilis are given by tlie following writers : by Metzger,' 
 of the general spread of the disease in East Prussia in consequence of 
 the invasion by Russian troops ; by Boulgakoff,'- of its increase in the 
 Government of Tchernigov since the concentration of large bodies of 
 troops there ; by Rigler (1. c), of the increased prevalence of syphilis in 
 Asia Minor since the fourth decade of this century in consequence of 
 military operations ; by Olympios (1. c), of its general diffusion in 
 Greece since the war of liberation; by Lorenz/ of the remarkable 
 increase of it in Chur at the time of the French occupation in the 
 beginning of the century ; and by Ochwadt,'' of the enormous accession 
 of it among the Prussian troops during the Danish campaign of 1864, 
 when the average rose from 29 per 1000 in time of peace to 164 per 
 1000. How much can be done to diminish syphilis by a strict surveil- 
 lance of pi'ostitution is shown by the deci'ease of the disease in the 
 armies of several European states subsequent to the introduction of a 
 more strict control over syphilitic cases occurring among the troops. 
 Thus, in the British arnii/' within the United Kingdom, the proportion 
 per 1000 men fi'om i860 to 1863 [i.e. before the passing of the Con- 
 tagious Diseases Act) was 265; from 1864 to 1869 it was 207; from 
 1870 to 1S79 it was 124. In the Frencli armif from 1865 to 1S69 it was 
 106, and 85 from 1872 to 1873 ; in the Italian army,'' 120 from 1864 to 
 1865, and 66 from 1874 to 1876. 
 
 1 'Verm. med. Scbriften,' KouigsL., 1788, i, 81. 
 
 ^ ' Bull, des Sc. med.,' 1824, xxiii, 206. 
 
 =• ' Jaliresbcr. del- natui-forsch. Gesellscb. Graubiindeiis/ Cliui-., 1868-69, 66. 
 
 •* ' Kriegschirurg. Erfabrungen u. s. w.,' Eerl., 1865. 
 
 5 'Army Statistical Rejiort for the year 1879,' Lond., r88i, 11. 
 
 * GraniLT, ' Lyou med.,' 1880, Nr. 18, 5. 
 
 ' Sormani, 1. c, 226.
 
 92 GEOdRAPHIOAL AND HISTORICAL PATHOLOGY. 
 
 § 24. Eemakkable Epidemics and Endemics op Syphilis. 
 
 The liistory of sj^pliilis abounds in otlier proofs of the 
 decided influence of the social factor upon the amount and 
 character of the disease. I shall limit myself here to stating • 
 the facts relating to the iDreviously mentioned outbreaks 
 of syphilis in the character of an epidemic or endemic ; these 
 phenomenal occurrences are, from every point of view, 
 most interesting, and they are most important for under- 
 standing that great period in the history of syphilis which 
 falls in the end of the fifteenth century and beginning of 
 the sixteenth. 
 
 The first observation belonging to this group comes from 
 Scotland in the middle of the seventeenth century ; at the 
 time of Cromwell's invasion of the south-western districts of 
 that country, a disease appeared, under the name of Sibhens 
 (or Sivvens), which was afterwards (1694) can-ied by troops 
 to the Highlands.^ Its greatest prevalence was about the 
 middle of the eighteenth century in the south-western 
 counties of Dumfries, Kirkcudbright, Wigton, Galloway, 
 and Ayr; as late as 1825-40, there were sixty cases of it, 
 from Highland districts, admitted into the Glasgow Infir- 
 mary, but since that time, the name of the malady has dis- 
 appeared from Scottish medical writings. Descriptions of 
 the sibbens tend to show that we have to do here with 
 severe forms of syphilis, with framboesia-like exanthems, and 
 probably also with syphilis complicated with other diseases, 
 especially of the skin (scab). It appears that the malady 
 Avas endemic mostly among the poor, filthy, and neglected 
 inhabitants of certain districts, and that it was spread not 
 only by sexual intercourse, but also by contagion in other 
 ways (wearing clothes in common, sleeping in the same bed, 
 eating and drinking out of the same dish), as well as by 
 heredity. 
 
 ^ Sec : Freer, ' Diss, de syphilitle, ncc 11011 de iiiorbo Sivvans dicto,' Edinb., 
 1707; Blair, 'Miscell. Observ. in the Practice of Physik,' Lond., 17 18; Hill, 
 ♦Cases of Surgery,' Edinb., 1772; Gilchrist, 'Edinb. Med. Essays and 
 Obs.,' new ser., iii ; Swedlanr, 'Yon der Lustscuche,' from the French, 
 1799, ii, 247; Craigie, 'Elements of the Pract. of Physik,' Edinb., 1836, i, 681 ; 
 Faye, 'Norsk. Mag. for Lacgevid.,' 1842, v, 2 ; Skea, ' Monthly Journ. of Med.,' 
 1844, iv, 615; Wills, ib., 282.
 
 SYPHILIS. 93 
 
 Next in time after tlie sibbcus, comes the outbreak of 
 i endemic syphilis in Norway and Sweden/ which Avas known 
 as Radesijgc, or the "bad disorder." The earliest traces of 
 this endemic in Norway may be followed back to 1720; by 
 the middle of the century it had spread more widely, reach- 
 ing its acme in the last quarter when it was so prevalent, 
 mostly along the coast of the Bergen and Christiansand 
 departments, that special hospitals had to be provided for the 
 reception of the numerous patients. Within the last twenty 
 years, the radesyge has lost its endemic character in that 
 locality. In Sweden the disease first showed itself in 1762, 
 when the Swedish troops came back from the Seven Years' 
 war; so that a connexion between the outbreak and that 
 event may be traced. A second importation of syphilis falls 
 in 1790, at the time of the Swedish troops returning from the 
 war in Finland. During the present century, there has been 
 a considerable decrease of this malady in Sweden ; it is still 
 met with oftenest in Bohuslau, especially in the districts of 
 Tjorn, Orust and Lahne, but it has long since lost its 
 endemic character. In the radesyge, as in the sibbens, we 
 have to do with severe forms of syphilis, or that disease 
 complicated with scabies, lupus, and other things ; and here 
 again it is a malady confined mostly to the poverty-stricken 
 inhabitants of neglected districts, and spreading by the same 
 kinds of contagion as in the former case, as well as by 
 heredity. From being much confused with spedalskhed 
 (leprosy), it was a long time before radesyge was correctly 
 understood ; Hebra succeeded in showing that the various 
 
 ^ See the followiug : ' Afhaiidl. om Radcsygen,' Kjobcnli., 1792 (Goniiiui cd. 
 by Mangor, Altoua, 1797) ; Maiigor, ' Underretiiiug 0111 Kadesygeiis Kjeudetegu,' 
 ib., 1793; Pfeiferkoru, • Ueber die iiorwegischo Radesyge,' Altona, 1797; 
 Boecker, ' Edinb. Med. and Surg. Journ.,' 1809, Oct., 420; Vougbt, ' Obscrv. in 
 exanthema arcticiim vulgo Eadesyge dictum.,' Gryph., 181 1 ; ' Sammandriig af 
 beriittelser ora veneriska sjukdomar, &c.,' Stockh., i8n; Cederschjold, 'Iiilod- 
 niuff till en iiilrmarc kiinnedom om do sa kalladc ur^irtade veneriska sjukdoniarnc, 
 &c.,' stockh., 18 14; Hoist, 'Morbus qucm Radesyge vocant, &c.,' Christiania, 
 1817; Hcdlund, 'Svenska Lak. SiilLsk. Haudl.,' 1818, v, 176; Ilunefcld, • Die 
 Radesyge, &c.,' Leipz., 1828; Charlton, ' Edinb. Med. and Surg. .Journ.,' 1837, 
 July, 1 01 ; Hjultelin, ' Diss, do radesyge,' Kiel, 1839; Hjort, ' Norsk Mug. for 
 Laegevidensk.,' 1840, i, i ; Kjerulf, ' Hygiea,' 1847, xii, 173; Rocek, ' Xorsk 
 Mag. for Laegevidensk,' 1852, And. R., vi, 203; Hebra, ' Zeitschr. dcr Wien. 
 Aerzte,' 1853, i, 61, 1855, i, 121 ; Huss, ' Om Svergcs endem. sjukdom.,' Stockli., 
 1852, 10, 33, 43 ; Brocb, ' Le Royaume de Norvcge, &c.,' Christiania, 1876, 54.
 
 94 GEOGEAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 forms of disease described under that name were secondary 
 or tertiary sypliilis, or congenital syphilis, and that lupus and 
 common ulcers of the skin had been included in the general 
 conception of it. 
 
 Another relation of the same family is the so-called 
 Jutland syphiloid, the origin of which is traceable to importa- 
 tion of syphilis by Russian sailors, or more probably by 
 troops from Sweden or Norway, in the middle of last 
 century.^ It appears to have been confined as an endemic 
 mostly to the northern part of Jutland, where there were 
 still many cases to be seen during the present century (1837- 
 1842). The attention of the Danish Government was first 
 called to it in 181 7, and the report drawn up by v. Deurs 
 supplying the needed information, which tends to show that 
 this syphiloid is in all respects of the same type as the sibbens, 
 the radesyge, and the syphilis-endemics next mentioned. 
 
 Completely analogous to these endemics is the Dith- 
 marsian or Ilohtein diseased The origin of it is traced to 
 the circumstance of a largo number of stranger navvies, 
 especially from East Friesland, flocking into the Siider- 
 Ditmarschen for the work of embanking the Crown-Prince 
 dyke ; and if they did not introduce the disease, they 
 certainly were the chief occasion of its spreading. By the 
 year 1789, the malady was so prevalent in the marshes and 
 the Gheest that, in some villages, the whole population was 
 affected ; towards the end of the century, it showed itself in 
 other pai'ts of Holstein as well, so that, in 1801, the atten- 
 tion of the Government was drawn to it. In 1806 its 
 diffusion was almost universal, reaching at last to Kiel on 
 the cast coast ; it was not until 1840 that any considerable 
 decrease of this so-called " syphiloid " was remarked, but at 
 the present day it appears to have quite died out as an 
 endemic. 
 
 1 See V. Deurs, ' Joru. for Med. og Cliir.,' 1835, June; Otto, 'Transact, of 
 the Prov. Med. Assoc.,' 1839, vii, 212; Uldall, ' Bibl. for Lacger,' 1842,337; 
 Ditzel, ib., 1S45, ii, 270. 
 
 ^ Brandis, ' Bibl. for Lacger,' 1S13, i, i; Spierinc:, in 'Hufeland's Journ.,* 
 182 1, liii. Heft i, 64; Hiibeuer, ' De morbi Dithmursici natura ac indole,' Kiel, 
 1821; Diihrsen, in ' Pfafl''s Mittheiknigen,' 1832, Jahrg. i. Heft 3 u. 4, i, and 
 ' Nene Mitth.,' 1835, Jahrg. i, Heft 4, 69; Michaclis, in ' Hanib. Zeitschr. fur 
 Med.,' 1842, xxi, 433; Francke, 'Morbus dithmarsicus,' Kiel, 1838; Geuters, 
 ' Per morbus Dithmarsicus,' Kiel, 1878.
 
 SYmiLis. 95 
 
 The syphiloiih' of LUlmmnia and Gourland make another 
 addition to the history of these syphilitic endemics. In the 
 Lithuanian division of East Prussia, syphilis became epidemic 
 in 1757, after the invasion of Eussian troops during the 
 Seven Years' Avar ; and it retained its hold as an endemic 
 there down to the first twenty years of this century, when 
 the strict enforcement of police sanitary regulations put an 
 end to it.^ In Courland the epidemic is said to have 
 broken out in 1800 after the landing of Eussian troops on 
 the Dondanga coast. I have no precise information as to 
 the spread of the disease and its duration as an endemic/ 
 except that Adelmann/ under date 1844, speaks of*the 
 general prevalence of very malignant syphilis among the 
 country population around Dorpat. 
 
 We come next to certain syphilis-endemics of the same 
 kind on the shores of the Mediterranean, — in Italian and 
 Austrian territory. One of these, known by the name of 
 Fahadina, was prevalent in the Venetian province of 
 Belluno from the year 1790.* The disease is said to have 
 shown itself first in the village of Falcade, and to have been 
 imported from the Tyrol or from Fiume ; it spread quickly 
 through the mountainous district of Agordo as far as the 
 Tyrolese frontier, but it was not until 18 10 that it attracted 
 the notice of the authorities, and about 1830 the endemic 
 was stamped out by means of police sanitary regulations. 
 
 Another sickness of this kind, widely known under the 
 name of Skerljevo had been observed since the end of last 
 century on the Croatian and Dalmatian coast and for some 
 distance inland.^ 
 
 ^ Theden, ' Erfabrungen aus tier Wundarzeneikunst, &c.,' Beil., 1782,111,9; 
 Metzger, 1. c. ; Albcrs, 'Preuss. med. Vereins Ztg.,' 1836, Nr. 22, 23 ; Sclmulir, 
 ib., 1837, Nr. 50, 51, 1839, Nr. 17, 18, 1841, Nr. 2,3. 
 
 - Tilling, ' Ueber Syphilis und Syphiloid,' Mitau, 1833; Bolschwiiig, 'Ueber 
 Syphilis uiid Aussatz,' Dorput, 1839. 
 
 ^ 'Med. Ztg. Russl.,' 1844, Nr. 43. 
 
 •* See Zecchiuelli, ' Annal. univ. di med.,' 1820, Marzo, 335; Valenzasca, ib., 
 1824, Sept., and 'Delia Falcadina,' Venez., 1840; Marcolini, ' Memor. med.-cliir. 
 di Milano, 1839, 18; Facen, ' Gaz. Med. Lombard,' 1849, 183; Signiund, 
 ' Zeitscbr. der Wiener Aerzte,' 1855, i, 87. 
 
 5 Boue, ' Essai sur la maladie de Scherljevo,' Paris, 1814; Cambieri, 'Annal. 
 univ. di med.,' 1819, Oct., 5, Dec., 273; .Jennickcr, 'Ocst. mod. Jabrb.,' 1819-20, 
 V, Heft 3, 104, Heft 4, 43; Lorenzutti, ' Del male di Scerlievo,' Padua, 1830
 
 ^6 GEOGRAPHICAL AND HlSTOraCAL PATHOLOGY. 
 
 According to report, tlie disease (syphilis) was introduced 
 by sailors or soldiers into tlie village of Draga near Fiume ; 
 tlie first to take it is said to have been a loose Avomau named 
 Margarctta (whence the name that it got of Margaritizza) 
 who gave it to others, and so laid the beginning of an 
 endemic. From this village it spread along the coast as far 
 -as Novi, ti-avelling at the same time inland to Carniola, so 
 that a large district of country was infected within a few 
 mouths. Notwithstanding most energetic efforts of the 
 Government to combat the sickness by police sanitary 
 regulations, they did not succeed iu getting the mastery of 
 it ftntil 1855 ') '^^^^^ even at the pi'eseut day syphilis still plays 
 a prominent part in those regions. Belonging to this same 
 endemic was the disease known by the name of Male di 
 Breno which was prevalent at the beginning of the century 
 in the commune of Breno near Ragusa.^ 
 
 Whereas, in the endemics just mentioned, we have to do not 
 only with syphilis, but with a complex of diseases of various 
 kinds characterised by ulcerations of the skin (scabies, 
 lupus, cancer, scrofula), among which certainly the leading 
 part was always played by syphilis ; we meet, on the other 
 hand, with pure endemic syphilis in Servia (under the name 
 of Frenga), in Wallachia, Moldavia, Bulgaria, and adjoining 
 regions (under the name of Boala), and iu Greece, where it 
 is known as Spirolcolon. All these were connected in their 
 origin with the events of warfare.^ 
 
 In Servia, syphilis began to assume an endemic character 
 in 1 8 10, in those districts of the country which were occupied 
 that year by the combined Russo-Sei'vian and the Turkish 
 troops ; from them it spread over the adjoining mountainous 
 region on the right bank of the Morawa, and to a less extent 
 over the plains. 
 
 It was not until 1844 that accurate information about the 
 disease was obtained, and it remained for Sigmuud to give 
 
 (Trieste, 1844); Sporer, ' Oesfc med. Jalirb.,' 1831, Nouste Folge, ii, 2n ; 
 Micliahellcs, ' Dus Male di Scerlievo,' Niirnb., 18.^3; Moulou, 'Nouv. observ. sur 
 la nature . . . du Scherlievo,' Milan, 1834 (1840) ; Sigmund, J. c, 93, 142. 
 
 ' Id., 1. c., 91. 
 
 * Concerning Frenga and Boala, see Sigmnnd, 1. c., 33, 91. Concerning 
 Spirokolon, Olympios, 1. c. ; Wibmer, in ' Schmidt's Jahrb. fur Med.,' 184F, x.\x, 
 305; Pallis, ' Annal. uuiv. di nicd.,' 1842, April.
 
 SYPHILIS. 97 
 
 a complete elucidation of its sypliilitic nature. The Boala is 
 of somewhat later date ; or in other words, syphilis iu the 
 corresponding- region began to be endemic after the Russo- 
 Turkish war of 1828-29. The endemic syphilis of Greece, 
 known as SinroTiolon, has the same relations ; it took its 
 origin in the war-years of 1820-25, appearing first in a few 
 eastern districts of Livadia, Boootia, Locris, and Phocis, and 
 spreading subsequently over other parts of the country. 
 
 Another of these syphilis endemics arose out of the events 
 of 1 8 15 in the commune of Chavamie (Arroud. Lure, Dep. 
 Haute-Saone) ; the disease was brought by Austrian troops, 
 and it infected the district from end to end within twenty- 
 eight months.^ Another instance of the endemic occurrence 
 of the malady is in a few localities of the Circle of Bidschow 
 (Bohemia),^ where " it has taken deep root, sotting at nought 
 year after year all endeavours to eradicate the insidious 
 plague.^^ Still another case is the epidemic and endemic 
 prevalence of syphilis in the commune of Capistrello (pro- 
 vince of Abruzzo ulteriore II), of which we have an account 
 by Selli.3 
 
 The beginning of the last-mentioned endemic dates from 1859, i^ 
 whicli year a woman of the village took to nurse a strange child suffer- 
 ing from congenital syphilis, and became infected by it. Not knowing 
 the nature of the malady, and giving no heed to it in her family inter- 
 course, she soon gave the disease to those about her ; from these it was 
 conveyed to others in the village, and so extensively did it spread that 
 after a lapse of eight years (down to October, 1867, when the attention 
 of the authorities was first di'awu to it), during which we hear 
 nothing either of diagnosis or treatment, more than three hundred 
 persons — men and women, children and the aged — were infected with 
 syphilis out of some 3000 who formed the population of the locaHty. 
 
 The development of all these endemics, in which it is with 
 syphilis that we have to do mainly and sometimes exclusively, 
 had taken place principally under the influence of that genetic 
 factor which we started to inquire into in the previous 
 section, namely, a defective hygiene hoth j^mhlic and 'pri- 
 vate. In all such foci of sickness, the headquarters of 
 
 ' Flamaud, ' Joruu. coiuplJin. du dictionn. des sc. mod.,' 1S19, v, 1,34. 
 ^ Strcinz, 'Oest.med. Jahrb.,' 1831, Nst. F., ii, 336. 
 ■^ ' Auual. du dcrmutol. ct dc la syphiligr.,' 1S69, i, 15S. 
 
 VOL. II. 7
 
 98 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 the disease had been those districts or villages which lay 
 remote from the great lines of traffic, which were inhabited 
 by a poor and unintelligent population, indifferent to their 
 manner of life, wanting the comforts of a higher civilisation, 
 and most of all wanting medical supervision and care or 
 possessing only such kind of it as did not suffice for the 
 correct understanding* and treatment of the malady. On 
 this point all discriminating observers of the events are 
 agreed j^ and if any further proof be needed of the decisive 
 importance of that factor in the etiology, we j5ud it in the 
 circumstance that, from the moment the nature of the malady 
 was rightly understood and suitable regulations against it 
 applied with sufficient thoroughness, the disease began to 
 lose its endemic character. 
 
 It is further noteworthy that the development of the sick- 
 ness in many of these endemic centres was started, or at 
 least materially helped, by the concentration of troops, the 
 contingencies of campaigning and things of a like kind 
 tending to aggravate the hardness of living. Again, the 
 spread of the disease occurred not only through sexual pro- 
 miscuousness, as usual, but very often by other channels of 
 contagion as well, and, above all, in places where the 
 endemic had lasted many years and had deeply infected the 
 population, by way of inheritance. Lastly, the disease 
 developed unusually often into its most malignant forms, iu 
 consequence of the want of rational medical treatment. 
 
 § 25. The Oeigin op the Giieat Fifteenth- Century 
 
 Epidemic. 
 
 The mode of origin and the character of these endemics of 
 syphilis appear to me to furnish the key to an understanding 
 of that remarkable episode of the disease in the fifteenth 
 century, an episode which entirely resembles them as regards 
 its type and differs from them only as regards extent. Syphilis 
 had undoubtedly existed in Europe previous to that outbreak, 
 although we cannot now make out the extent of its diffusion. 
 But ]ust at that period there happened a series of events of a 
 
 ' See especially Sigmuud, 1. c. p. 142.
 
 SYPHILIS. 99 
 
 most unfortunate kind for the social condition of Europe, which 
 led to an increase of the disease both in its area and in its 
 intensity and stamped it with the character of an epidemic. 
 For several years in succession, inclement seasons and floods 
 over large parts of Italy, France, and Germany had brought 
 with them bad harvests, and famine affecting a great part of 
 Europe ; and these effects were felt to the most frightful 
 extent in those very years of 1491-95. Severe pestilences, 
 especially plague and typhus, had overrun the south and 
 west of Europe in disastrous epidemics. The corruption of 
 morals had at the same time reached a height which even 
 contemporary writers tell us was without parallel in ancient 
 times. To all these troubles there was added the turmoil of 
 war, which spared no country in Europe, and not only con- 
 tributed materially to the profound derangement of the 
 social order, but also gave syphilis its chief opportunity of 
 spreading. It was especially Charles VIII's army of merce- 
 naries returning from Italy relaxed by licentiousness, broken 
 up into lawless bands and overrunniug France, Switzer- 
 land, the Netherlands, and Germany, which carried with 
 them, as we are expressly told by many medical writers and 
 chroniclers of the time, the germs of syphilis over the whole 
 country wherever an adventurous life led them.^ But the 
 disease must have acquired a still wider range and a greater 
 malignancy than those circumstances gave it, for the reason 
 that practitioners were as yet unacquainted with its nature, 
 their attention being first called to its distinctive characters 
 by the general diffusion which it then reached. So much 
 was this the case that, like typhus, which was likewise spread- 
 ing universally at the time, it was regarded by them as a 
 malady " of new origin,'^ and was confronted at first with 
 no better weapons than the wise saws extracted from Galen 
 and Avicenna. Just as in the smaller syphilis-endemics of 
 which we have been speaking, so in the severe fifteenth- 
 century epidemic it Avas the class of low debauchees, the 
 loafers and sots, and those sections of the people hardest 
 pressed by poverty and misery, that supplied most of the 
 
 * It is probably to this that the disease owes the colloquial names " morbus 
 gullicus," " mala Frantzos," and the like, which were then iu guueral use uud 
 are so still in many parts of the East.
 
 100 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 victims ; aud if personages in high places of the State and 
 the Church did not escape, that will not surprise us when we 
 remember that their class had not held aloof from the moral 
 corruptions of the time. Again, as in the more recent 
 endemics, the sickness was sooner or later combated by 
 thorough-going sanitary measures, by an improved hygiene, 
 by the instruction and enlightenment of the people, and by 
 better professional knowledge ; so that at length the victory 
 was gained over the great syphilis-plague of the fifteenth 
 century through the correct recognition of it by the doctors 
 and through the enlightenment of the public. This was the 
 conclusion long ago stated by Benedictus in no obscure 
 words ■} " Cur autem tempore isto non reperiantur, diceret 
 quis, gallicantes cum tarn saevis accidentibus, sicut appa- 
 ruerunt ante aliquot annos, et in morbi liujus principiis : 
 ratio est in promptu, quia homines nunc sibi melius cavent 
 ab infectis, vel quia medici docti melius cognoscunt nunc 
 causam morbi, et melius applicant remedia quam tempore 
 anteacto." 
 
 I shall speak of the relation of syphilis to the so-called 
 Framhoesia {Pian, Ya^vs, ^-c.) and to Button- Scurvy , in treat- 
 ing of those diseases in the chapter immediately following. 
 
 ^ Quoted by Luislnus, 172, D. This excellent work of Benedictus, a German 
 physician who practised in Poland, dates probably from the second decade of the 
 i6fch century.
 
 CHAPTER III. 
 YAWS (PIAN), BUTTON SCUEVY, AND VERRUaA PERUVIANA. 
 
 § 26. Nosological Chaeactees op Yaws. 
 
 Undee siicli names as Yaws, Pian, and tlie like,^ and more 
 particularly under the name of " Framhoesia " introduced by 
 Sauvages," there is understood a peculiar disease of the skin 
 running a chronic course, which was known to the practi- 
 tioners of former centuries, although it is only in quite recent 
 publications that its nature and geographical distribution have 
 been determined with any degree of precision. 
 
 SJcetch of the clinical history. — As in the acute exanthemata, there is 
 a premonitory stage, sometimes faintly indicated (Nielen, Rodscliied, 
 Mason)^ but particularly well-marked in children, which declares itself 
 in feverishness, broken sleep, general weakness, pains in the limbs, loss 
 of appetite, sometimes even more intense gastric symptoms (Ferrier, 
 Charlouis), and in the dark races, especially the negro, in a peculiar 
 discoloration of the skin, which becomes dull and lustreless at the spots 
 
 ^ The words " Yaws " and " Pian," as Mason tells us (see Sauvagcs, as quoted 
 below), are the colloquial names used in the West Indies for strawberries by the 
 West African negroes and by the natives, the name having been applied to the 
 disease owing to the resemblance of the growths on the skin to that fruit. It is 
 this that led Sauvages to call the malady Framboesia (from framboise, a rasp- 
 berry). The following are some of its other colloquial names : Buba or Boba in 
 the West Indies, in Brazil, in Timor, and on the Mozambique coast ; Tatta in 
 the West Indies; Qattoo at several points on the West Coast of Africa; Framosi 
 on the Calabar coast ; Tetia on the Congo coast ; Momba in Angola ; Pateh at 
 various places in the Dutch East Indies ; Amboina pocks (Bouton d'Ambnine) in 
 the Moluccas; Bolento in Ternate; Tonga, Btliohe and Coco in the Fiji Islands 
 and New Caledonia ; Lupani and Tono in the Samoa Group ; and Parctngi in 
 Ceylon. In order to put an end to the confusion introduced into medical termi- 
 nology by the ambiguity of the word " Framboesia," Charlouis proposes to call 
 the disease in question " polypapilloma tropicum." 
 
 - ' Nosologia methodica,' CI. x, § 25, Lips., 1797, v, 205. 
 
 3 The references to authorities on yaws quoted in the sequel are given in 
 alphabetical order at the end of the section.
 
 102 GEOGEArHIOAL AND HISTORICAL PATHOLOGY. 
 
 wbere the exantliem afterwards breaks out, and looks as if dusted with 
 flour, from the furfuraceous scaling of the epidermis (Paulet, Levacher, 
 Thomson, Bajon, Milroy ('Report'), Kynsey). These phenomena 
 remit after lasting from eight to fourteen days (Koniger, Charlouis), and 
 the exanthem then comes out in the form of small dense nodules, vary- 
 ing in size from a lentil down to a pin's-head ; they increase rapidly in 
 size, and, when they are fully ripe, they form resistant nodes from the 
 size of a small nut down to that of a pea. The period of development 
 of the exanthem lasts two or three weeks, seldom a whole month 
 (Nielen) ; and, in the course of it, the epidermis covering the nodule 
 gets macerated and finally detached from the summit, whereupon a 
 strawberry-like or raspberry-like tumour comes into view, having a 
 granulating surface and secreting a thin, yellowish, ilLsmelling mois- 
 ture which dries into a crust. The disease has now reached its height, 
 if the case is to be a mild and simple one ; the nodules, which are 
 painful only under considerable pressure, as when their seat is the sole 
 of the foot or the palm of the hand, remain indolent and unchanged for 
 months. The secretion continues to be formed on the surface, and, if 
 the crust be removed, it soon forms afresh ; if the secretion adheres to 
 the tumour, it gradually acquires a conical shape like the crust of rupia 
 (Charlouis). The skin-tissues surrounding the nodule undergo a con- 
 current alteration ; it is only rarely, and under particular circumstances 
 to be afterwards mentioned, that an ichorous disintegration of the tumour 
 sets in, with considerable destruction of the soft parts adjoining, and 
 even of the bones. The swelling and tenderness of the lymphatic 
 glands which occur at the time when the exanthem begins to develop 
 (v. Leent, Charlouis), now disappear ; and, apart from an occasional 
 troublesome itching in the affected cutaneous spots (v. Leent, Koniger) 
 the patient feels quite well. The secretion on the free surface of the 
 tumours gradually ceases, the nodules become dry and shrivelled, and 
 ultimately fall off, leaving behind on the skin a red spot which dis- 
 appears completely after a longer or shorter period. The principal 
 seats of the exanthem are the palms of the hands and soles of the feet, 
 the forehead, the corners of the mouth, the lips, the armpits, the neck, 
 the prepuce, the scrotum, and around the anus ; but other parts of 
 the integument do not always escape, such as the scalp, the chin, the 
 external auditory meatus, and the skin of the chest and belly ; while 
 not unf requently nodules occur also on the mucous membranes — in the 
 nose, inside the cheeks, on the gums, and in the vulva. In many cases 
 there are only a few nodules formed, but in others it appears that the 
 exanthem is more widely difi'used over the body, the nodules being 
 sometimes so close together that several become confluent and make a 
 tumour the size of a small apple. The disease lasts from a few months 
 to a year or more ; its course is made especially protracted by the 
 not unfrequent recurrences ; and in such cases there will be an opj)or- 
 tunity of observing the exanthem in the several stages of its develop- 
 ment at one and the same time (Rodschied, Mason, Thomson). The 
 issue of the disease, in these uncomplicated cases where there are
 
 YAWS. 103 
 
 no special injurious circumstances, is always towards cure. On the 
 other hand, it has a less favorable type in feeble children, in whom 
 the extensive spreading of the exanthem — as exanthems usually do 
 spread in children — is very apt to be followed by exhaustion. The 
 type is less favorable, also, in those cases in which suppuration of the 
 nodules, with ulceration of the soft parts and even carious destruction 
 of bone, has been brought about by external irritation, for example, 
 when the nodules are on the sole of the foot ; and, again, in patients who 
 are suffering at the same time from some other dyscrasia, such as 
 scrofula or syphilis, or where there has been unsuitable treatment, 
 pai*ticularly the application of caustics or the abuse of courses of mer- 
 cury (Koniger, Kynsey). It is doubtful whether the intei-nal organs 
 (lungs, liver, spleen, kidneys) are affected by the disease, as is believed 
 in some quarters (v. Leent) ; the occurrence of these visceral lesions 
 and the fatal result of them, may be always referred to other diseased 
 states, either existing coincidently with yaws, or appearing inter- 
 currently. 
 
 Morbid anatomy. — According to the anatomical examinations of the 
 affected tissue made by Paulet, Ferrier, Charlouis, and Pontoppidan, it 
 appears that in yaws we have to do with a chronic dermatitis proceeding 
 from the papillary layer and extending deeper into the corium in the suc- 
 cessive stages of the malady. Charlouis has found, at the beginning of 
 the skin-affection, dilatation and tortuosity of the surface vessels, and 
 afterwai'ds of the deeper, together with escape of colourless blood- 
 corpuscles and extensive accumulations of these in the tissues ; and he 
 is convinced that the progressive enlargement of the papillae of the skin 
 and the changes in the deeper parts associated therewith, have kept pace 
 with the changes in the vascular system. He has found, also, that, 
 as the disease progresses, the hair-follicles, as well as the sebaceous and 
 sweat-glands and the muscles of the skin, are implicated in sympathy. 
 After repeated microscopic examinations of the morbid tissues, he is 
 nnable to arrive at the actual cause of these pathological changes. 
 Pontoppidan found, on cutting out a nodule and examining it under 
 the microscope, after it had been hardened in alcohol, that the crust 
 consisted of a conglomerate of dried-up epidermis and pus-corpuscles, 
 beneath which was a stratum of granulation-cells (as in granulomatous 
 growths), the papillary stratum being entire although somewhat 
 flattened, the rete mucosum, on the other hand, wasted and occupied by 
 round cells, while the corium was free from adventitious elements. He 
 could never discover fungi, such as Trichophyton or Microsporon, 
 either in the slough or in the layers beneath. 
 
 In the opinion of nearly all observers, yaws is a 
 j)€culiar and specific infectious onorhid process, a disease sui 
 generis, which has nothing whatever in common with syphilis. 
 The view o£ the syphilitic nature of yaws, which was started 
 "by several of the earlier observers and has found adherents
 
 104 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 more recently in Rollet, Grenet, Copland, and Roquete, rests' 
 upon errors of diagnosis. Against it there are not only the 
 typical characteristics of the disease as above sketched, which 
 perfectly distinguish yaws from syphilitic diseases of the skin, 
 but more especially the fact that yaws has none of the pro- 
 perties of a constitutional disease, that it has markedly the 
 character of a local malady, that it always ends in complete 
 recovery without medical treatment, and that the use of 
 mercury in yaws has been found to be absolutely injurious. 
 It is farther to be observed that both diseases have several 
 times been found together in the same person, each running 
 its course with the phenomena peculiar to it (Levacher, Pau- 
 let, Charlouis) ; and lastly, there is the fact that yaws is 
 especially common among children of from one to ten years 
 of age. 
 
 § 27. HiSTOEY AND GeOGEAPHY OF YaWS. 
 
 The earliest historical notice of yaws^ occurs in the narra- 
 tive of travel by Oviedo,", who came to know the disease in His- 
 paniola (St. Domingo) and who speaks of it under the Spanish 
 name of " Bubas,^' afterwards in use in Brazil. Next in order 
 of time come medical accounts of the disease from Brazil by 
 Piso and from the East Indies by Bontius, as well as from 
 the West Indies by Labat, who travelled there about the same 
 date (17th century). In later times, the malady was recg- 
 nised both by medical practitioners and travellers in the 
 tropical parts of Africa and in some of the island-groups of 
 Oceania ; and with these extensions the limits of its geogra- 
 2)hical distribution were laid down practically as they exist at 
 the present day. 
 
 • The disease described by the Arabian physicians (Avicenna, in ' Canon,' lib. 
 iv. Fen. vii. Tract, iii, cap. i, and Ali Abbas, ' Theoric.,' lib. viii, cap. 18), nnder 
 the name " Safat " or " Sahafat," might be inferred to be syphilis rather than 
 yaws. Equally ambiguous and uncertain are all those other notices by mediajval 
 physicians, in which Sprengel (' Beitrage zur Geschichte der Mcdicin,' iii, 61) 
 would find yaws described and proof afforded of its connexion with syphilis. 
 
 2 ' Hist, general y natin-al de las Indias,' lib. ii, cap. 13-14. It is a not unlikely 
 guess that Oviedo's opinion of the American origin of syphilis partly arose out 
 of confounding the latter disease with the " Bubas."
 
 
 TAWS. 105' 
 
 That part of Africa which lies within the tropics forms 
 one of the chief seats of yaws, the principal region, so far as 
 we can judge from the data before us, being the West Coast 
 from 8enegamhia down to the Coast of Angola,^ together with 
 the adjoining western i^arts of the So2ulait,^ from which we 
 have more particular accounts of the prevalence of the malady 
 in Timbuctoo and Bornou. On the northern and north-eastern 
 coast-territories of Africa, as well as in the iV^i7e valley,^ yaws 
 would appear to be of rare occurrence ; on the other hand, we 
 again meet with it somewhat frequently in Madagascar and the 
 Comoros,^ and in Mozambique.^ Its second more considerable 
 region of diffusion is found in several islands and island-groups 
 oi the East Indies, chiefly the il/oZ^tccfts,*' but also Java^ Sumatra^ 
 and Celebes (Macassar).^ Next in order comes the endemic 
 of it in Ceylon,^^ and in several of the island-groups of 
 Oceania, particularly New Caledonia ^^ Fiji}" and SamoaP On> 
 the other hand, it appears to be very rare on the mainland of 
 Hindostan and of Further India. In the exceedingly copious 
 medico-topographical literature of these countries I have 
 found one notice of yaws by Huillct, relating to its rather 
 common occurrence among the Hindoo population of Pondi- 
 cherry. Charlouis mentions that he had seen two cases of 
 yaws in European children, and all the other notices of it 
 from India likewise relate to merely occasional cases. From 
 Further India, there is not a single reference to this disease 
 
 ^ See the accounts by Mason, Boyle, Bryson, Ritchie and Nielen. 
 
 * See Peyrilhe, Gnyon (' Gaz. de Paris,' 1. c.) and Duncan. 
 
 ^ Guyon ('Mem. de nied. niilit.,' 1. c), Baudouin and Furnari have obsei-ved a 
 few cases among the Arab population of Algiers. Pruner states that yaws does 
 not occur at all in the basin of the White Nile as far up as 5° N.; he had seen, 
 a few cases, however, among natives of Egypt, of Abyssinia, and of the Arabian, 
 coast. 
 
 * Grenet. 
 
 '" Roquete, Bourel-Ronciere. 
 
 " Bontius, Heymann, v. Leent (!. c, 1870). 
 
 ' Heymann, Waitz, v. Leent (1. c, 1867), Charlouis. 
 
 8 V. Leent (1. c, 1867). 
 
 9 ' Arch, de mud. nav.,' 1871, April, 248. 
 
 10 Mllroy C Med. Times,' 1876, and 'Lancet,' 1S77, 11. cc), Kynsey. 
 ^' De Rochas, 1. c, 20. 
 
 1' Bennett (who gives the disease as endemic also in the Tonga, Society, am! 
 Navigator Islands), Fox, de Rochas. 
 1^ Bennett, Turner, Kouiger.
 
 106 GEOGRAPHICAL AND IITSTOEICAL PATHOLOGY. 
 
 known to me. The tliird of the more considerable seats of 
 the malady is the West Indies ; we have accounts of it from 
 St. Domingo^ Jamaica,^ Barhadoes,^ Martinique, Guade- 
 loupe,'^ 8ta. Lucia,^ and notably Dominica ;^ also from Guiana;'^ 
 and lastly from Brazil,^ where the disease is found to be 
 equally common in all the provinces of its vast territory. 
 From Central America there is only one reference^ to it, 
 describing its somewhat frequent occurrence in Punta Arenas 
 (Costa Rica). 
 
 § 28. Native Habitats of Yaws. 
 
 The opinion held by nearly all the earlier observers, and 
 maintained at the present day by Gama Lobo^*' and v. Leent,^^ 
 that the original habitat of yaivs is to be sought for in 
 Western Africa, and that the disease had been carried thence 
 lay the importation of negroes into those regions of the tropics 
 where it is now endemic, has been overthrown by the obser- 
 vations that have been made in the West Indies, in Brazil, 
 in the East Indies and in the islands of the Pacific. Oviedo's 
 account of its occurrence in Hispaniola belongs to the time 
 when the island was first colonised by the Spaniards, and 
 when there could be no question of negro importation ; and 
 for that reason Copland's opinion that the disease is of African 
 origin and had been introduced into the West Indies has been 
 pronounced by Milroy to be " a radical error." Bontius saw 
 it in the East Indies as early as the beginning of the 17th 
 <3entury, and he does not say a single word about importation 
 from outside ; it is precisely the African population there, as 
 Charlouis tells us, that enjoy a striking immunity from yaws, 
 
 ^ Pouppe-Desportes, Pontoppidan. 
 
 2 Ludford, Hunter, Sloane, Thomson. ^ Hillary, 
 
 * Labat, Savaresy, Ferrier, Paulet. ^ Levacber. 
 
 ^ Keelan, Milroy (' Report '), Nicliolls, Bowerbanlc. 
 
 ' Kunseiniiller, Schilling, Nielen, Ilille, Pop, v. Leent (1. c, 1880), for Suri- 
 nam; Rodschied, for Rio Essequibo (Brit. Guiana), Bajon ; Campet, Nissaeus, 
 Segond, Dumontier, for Cayenne. 
 
 s Cornciro, Sigaud, Rendu, Bourel-Ronciere. 
 
 3 'Arch, de med. nav.,' 1864, Nov., 374. 
 '" According to Bourel-Ronciere. 
 
 ^' 'Arch, de med, uav.,' 1880, 1. c.
 
 YAWS. 107 
 
 and it is prevalent at certain places in tlie soutli-western 
 islands wliei'o Africans have never come. lu Brazil also, it 
 was already endemic at the beginning of the 17th century, as 
 appears from the account by Piso ; and Sigaud, who is one of 
 those opposed to the doctrine of importation and in favour of 
 the indigenous nature of the disease in Brazil, makes mention of 
 a manuscript preserved in the Royal Library at Rio de Janeiro, 
 and dating from the year 1587, which treats of the yaws in 
 that country. Least of all, as Koniger says, can there be any 
 question of the disease having been imported into the Samoa 
 Group, which were till lately cut off from all intercourse with 
 other countries ; and the less so that the natives of these 
 islands speak of yaws as a malady prevalent among them 
 from time immemorial. If we reflect, further, that many 
 regions of the tropics, such as India and Further India, have 
 been little if at all visited by yaws, notwithstanding an exten- 
 sive negro immigration, we shall be justified in concluding 
 that the native habitat of the disease is as wide as the area 
 of its diffusion. 
 
 § 29. Yaws a Disease op the Teopics. 
 
 The limits of this area, however, are very closely drawn, 
 as will appear from the above sketch ; and, so far as relates 
 to a strictly endemic prevalence of yaws, its territory is 
 exclusively within tropical latitudes. The disease is there- 
 foi-e an exquisitely tropical one, or, in other words, it is 
 dependent for its origin and continuance upon trojpical 
 climate. This is so strikingly the case that, while every pro- 
 vince of Brazil is a seat of the malady, it is quite unknown 
 in the Argentine Republic, notably in Monte Video and 
 Buenos Ayres (with a temperature like that of Portugal), 
 notwithstanding the large negro population. We cannot 
 decide, on the basis of any facts known to us, ia what way 
 this influence of climate tells upon the production of the 
 disease ; it would seem, at any rate, to be an indirect one, 
 for we shall see that there are considerable differences in the 
 amount of the malady among the various races exposed to
 
 108 aEOGRArnioAL and historical pathology. 
 
 tho same climatic influences, and that many regions are quite 
 free from yaws notwithstanding their tropical climate. 
 
 § 30. Yaws not accounted foe by Defective Hygiene. 
 
 Indirect, also, must be the influence on the production of 
 the disease exerted by an injurious hygiene, — by deficient food, 
 damp and filthy dwellings, and the like. The opinions 
 expressed by Levacher, Bryson, Dumontier and others, that 
 yaws is purely the consequence of these disadvantages in the 
 manner of life of the inhabitants, and particularly of that 
 part of the inhabitants most exposed to them, namely, the 
 negroes, is open to the objection that this race is as much 
 subject to these disadvantages in many regions of the tropics 
 which are quite exempt from yaws, as in the actual habitats 
 of the disease ; and we may take it to be a radical error of 
 Chassaniol to suppose that the whites would suffer to the 
 same extent as the negroes if they were subject to the same 
 influences of climate and hygiene. 
 
 § 31. Contagiousness op Yaws — Inherited and Racial 
 
 Peedisposition. 
 
 There can be no doubt that yaws has underlying it a spe- 
 cific cause, a morbid poison. There is, indeed, indisputable 
 proof of this in its exquisite contagiousness. On that point all 
 authorities without exception are agreed, and the evidence of 
 it is not only in the clinical observation that those who avoid 
 contact remain exempt from the disease, but also in the 
 results of various attempts to convey the disease of purpose, 
 by inoculating the morbid poison.^ There are other points 
 which the available data do not enable us as yet to decide : 
 whether, as most of the authorities assume, the virus keeps 
 itself alive solely by continuous reproduction within the bodies 
 of the sick and by successive transmissions, somewhat in the 
 manner of the syphilitic or smallpox poisons, or whether, 
 
 * See Mason, Milroy (' Report '), Bonrcl-Ronciere, p. 55, v. Leent, 'Arch, de 
 mecl. nav.,' 1880, 1. c, and particularly Charlouis, p. 460.
 
 I 
 
 YAWS. 109 
 
 under certain circumstances, it may not really originate ; and 
 what is tlie nature of the virus — whether it is Vk })arasitic body 
 that we have to do with, as v. Leent^ conjectures and as the 
 power of reproduction of the poison would seem to show. 
 The disease is also taken to be parasitic by Pontoppidan, but 
 he has not succeeded, as we have already seen, in discovering 
 any fungous elements in the affected parts. 
 
 The opinions are divergent as to hereditary transmission of 
 the disease (congenitally, at all events, it seems never to have 
 occurred, as there is not a single case of that kind given in 
 the whole literature) ; Nielen, Paulet, Legoud, Kendu and v. 
 Leent^ consider it as proved, while Thomson, Charlouis and 
 Kyusey hold it to be at least doubtful, and Rankine, Mason 
 aud Gama Lobo deny it altogether. 
 
 On another point we find observers again almost absolutely 
 unanimous, namely, that the susceptibility to the disease 
 differs much among the various races. If no race enjoys an 
 absolute immunity from yaws, still the coloured races, and 
 above all the negroes, supply the largest contingent of cases, 
 mulattoes and other half-tints, with Creoles, being more rarely 
 affected, and rarest of all the whites. The reason for the 
 exemption of the latter may be in part that they avoid con- 
 tagion as much as possible ; but that is by no means a com- 
 plete explanation of the fact, as even Mason, the chief 
 exponent of this argument, would admit. " I can recall 
 several white men," says Forrier,^ ''who have never taken 
 this disease notwithstanding the intimacy of their relations 
 with negresses or mulatto women infected by it ;" and that 
 observation carries all the more weight, when we consider 
 that all observers are especially emphatic about the unusual 
 intensity of its contagiousness among the coloured races.* 
 
 § 32. One Attack usualt.y gives Protection but not 
 
 invariably. 
 
 Wherever yaws has been observed hitherto, it is especially 
 during cidldliood (from the 3rd to the I2tli year) that it has 
 
 » L. c, 1870 and 1880. ' lb. ^ L. c, p. 54. 
 
 < Pruner thinks that the greater development of the papUhiry processes of the 
 sklu in the coloured races may be applied to explain their predisposition to yaws.
 
 110 GEOGRAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 occurred. But tlie often expressed opinion that having sur- 
 vived the disease in youth abrogates the predisposition to it 
 for the rest of life, does not hold good absolutely at all events. 
 Bajon and Thomson had already stated that this removal of 
 susceptibility to subsequent attacks was much the same as in 
 smallpox : that is to say, it was the rule but there were 
 exceptions. Ferrier also speaks of the same person taking 
 it more than once, and Charlouis^ says : " I can confidently 
 vouch for the fact that frambccsia may attack the same person 
 more than once ; and the truth of that may be proved not 
 only by inquiring into the history of cases, but also by inocu- 
 lation.''^ 
 
 LiTEKATUEE OF YaWS. 
 
 Bajon, Nachricliten zur Gesch. von Cayenne. From the Frenuli. Erfurt, 
 1780,111,49. Baudou in, Voyage dans le Petit-Atlas, &c. Bennett, Lolid. 
 Med. Gaz., Ix, 1832, Jan., 630. Bontius, Medicinalndorum, cap. xix, Lugd. 
 Batav., 1718, 94. Bourel-Ronciere, Arch, de med. nav., 1872, juill., 49 
 (founded on the information of a Brazilian physician, Gama Loho). 
 Bowerhank, Med. Times and Gaz., 18S0, April, 368. Boyle, Med.-Histor. 
 Account of the Western Coast of Africa, Lond., 1831, 3S7. Bryson, Eeport 
 on the Climate and Diseases of the African Station, Lond., 1847, 260. 
 
 Campet, Traite pratique des maladies graves des pays chauds. Par.^ 
 1802, 301, Charlouis, Vierteljahrschr. fiir Dermatologie und Syphilis, 1881, 
 viii, 431. Chassaniol, Arch, de med. nav., 1865, mai, 515. Corneiro, 
 Rivist. med. Flumin., 1835 (quoted in Sigaud). 
 
 Desportes, Histoire des maladies de St. Domingue. Par., 1770, ii, 61, 85. 
 Dumontier, Nederlandsch Lancet, 1855, Sept. Duncan, Travels in Western 
 Africa. Lond., 1847, "' 9^- 
 
 Ferrier, Repertoire gen. d'anatomie et de dhysiol. pathol., 1827, iv, 170. 
 Fox, in Wilkes' Narrative of the U. S. Exploring Expedition, Philad., 
 1 845, iii, 336. Furnari, Voyage med. dans I'Afrique septentrionale. Par.,. 
 
 1845. 
 
 Grcnet, Journ. des connaiss. med.-chir., 1867, Nr. 15, 404. Guyon, 
 Mem. de mdd. milit., xxix, 159 ; Gaz. med. de Paris, 1853, 44*5- 
 
 Heymann, Darstellung der Krankheiten in den Tropenliindern. Wiirzh., 
 1855, 219. Hillaiy, Obs. ... on Epidemical Diseases in Barbadoes. Lend., 
 1766. Hille, in Casper's Wochenschr. fiir die ges. Heilkde., 1S43, Nr. 6, 
 92. Huillet, Arch, de mod. nav., 1868, Jan., 29. (Hume), in Edinb. 
 Med. Essays and Observ., v, 1027. Hunter, Diseases of the Army in 
 Jamaica. Lond., 1796. 
 
 Keelan, Lancet, 1876, Aug., 201. Koniger, in Virchow's Archiv, i8j8> 
 
 1 L. c, p. 457.
 
 EUTTON SCURVY OF IRELAND. Ill 
 
 Bd. 72, 419. Kunsemiiller, Spec, de morbo Yaws, &c. Hallis, 1797. 
 Kynsey, Eeport on the " Parangi Disease " of Ceylon. Colombo, 1881. 
 
 Labat, Nouveau voyage aux Isles de rAmeriqne. Amsterd., 1722, iv, 
 358. van Leent, Arch, de med. nav., 1867, Oct., 249, 1870, Jan., 15, 1880, 
 Nov., 425. Levacher, Guide med. des Antilles, &c., ed. il. Par., 1840, 278. 
 Ludford, Diss, de Framba3sla. Edinb., 1791. 
 
 Mason, Edinb. Med. and Surg. Journ., 1831, Jan., 52. Milroy, Eeport 
 on Leprosy and Yaws in the West Indies. Lond., 1873 ; Med. Times and 
 Gaz., 1876, Nov., 514 ; Lancet, 1877, Feb., 169. 
 
 Nicholls, Brit. Med. Journ., 1879, Dec, ; Med. Times and Gaz., 1880, Jan., 
 5, 33. Nielen, Verhandel. der maatsch. der weetenschapen te Haarlem, xix, 
 135. Nissaeus, Spec, de nonnull. in colon. Surinamensi observat. morbis. 
 Hardrov., 1791. 
 
 Paulet, Arch. gen. de med., 1848, Aug., 385. Pedrelli, Annotaz. stor.-clin. 
 soil pian, &c., Bologna, 1872. Peyrilhe, Precis, theor. et prat, sur le Plan, 
 &c. Par., 1783. Piso, De medicina Brasillensi, lib. ii, cap. 19. Pontop- 
 pidan, Vierteljahrschi-. fiir Dermatologie, 1882, ix, 201. Pop, Nederl. 
 Tijdschr. voor geneesk., 1859, ill, 213. Pmner, Die Krankheiten des 
 Orients. Erlang., 1847, 174. 
 
 Ranklne, Edinb. Med. and Surg. Journ., 1827, April, 283. Rendu, Etude 
 topogr. et med. sur le Bresll. Par., 1848, 88. Ritchie, Monthly Journ. 
 of Med., 1852, May. de Rochas, Essai sur la topogr. hyg. et med. de la 
 Nouvelle-Calcdonie. Par., i860, 20. Rodschied, Med. und Chir. Bemerk. 
 liber Rio Essequibo. Frankf., 1796, 226. Rollet, Arch. gen. de med.,. 
 1861, Fevr. Roquete, Arch, de med. nav., 1868, mars, 161. 
 
 Savaresy, De la fievre jaune, &c. Napoli, 1809, 92. Schilling, Diatribe 
 de morbo Yaws dicto. Utrecht, 1770, reprinted in Schlegel's Thesaurus, II, 
 Part i, 217. Segond, Journ. hebdomad, de med., 1835, Nr. 13, 1836, Nr. 
 23. Sigaud, Du cllmat et des malad. du Bresll. Par., 1848, 117, 375. 
 
 Sloane, Diseases of Jamaica. Germ. Transl., Augsb., 1784, 92. 
 
 Thomson, Edinb, Med. and Surg, Journ., 1819, July, 321, 1822, Jan., 32. 
 Turner, Glasgow Med. Joum., 1870, Aug., 502, 
 
 Waitz, On Diseases incident to Children in Hot Climates. Bonn, 1843^ 
 282.
 
 112 GEOGEAPHIOAL AND IIISTOKIOAL PATHOLOGY. 
 
 Button Scurvy of Ireland. 
 
 § 33. Characters of Button Scurvy. 
 
 A disease of Ireland, very like yaws and known by tke 
 colloquial name of button- scurvy, formed tke subject of a 
 number of papers between 1823 and 185 1, by Auteni'ietli/ 
 ■by Wallace" (wlio liad named it " morula/' owing to the like- 
 ness of the excrescences on the skin to mulberries), and by 
 Corrigan/ Osbrey/ Faye/ Patterson/ Wade/ and Kelly .^ 
 
 Clinical characters, — Having been usually preceded for a longer or 
 sliorter period by an intense itcbing of tbe skin, coming on particularly 
 at nigbt, tbe disease is usbered in by an outbreak of small round spots, 
 •wbicb gradually raise tbemselves above tbe skin and grow into tumours 
 in size from a pea to a nut. Tbe colour of tbese tumours is at first dark 
 red but becomes paler, tbe epidermis over tbem becoming at tbe same 
 time thinner and tbinner, and finally disappearing altogetber; a granu- 
 lating surface now protrudes and secretes a serous fluid, wbicb becomes 
 a dry crust on tbe summit of tbe tumour, and is quickly reproduced if it 
 be taken off. Tbe excrescence is elastic to tbe feel, and somewbat 
 painful on pressure; tbe skin around it shows no kind of morbid alter- 
 ation. Tbe number of such nodules in the same person varies from one to 
 fifty, or even more. Tbe favoui'ite seats of the exantbem are the palms 
 of tbe bands, and tbe inner side of tbe tbigbs and arms ; more rarely 
 the hairy scalp, and sometimes even tbe scrotum and perina3um, wbere 
 it migbt be very easily mistaken for condylomata. When tbe tumours 
 have lasted some time they begin to sbrivel, tbe scabs fall off, and 
 disclose a red spot, wbicb shortly assumes tbe normal colour of tbe 
 ckin. Only in tbe event of suppurative disintegration of tbe tumours, 
 which seems to be on tbe wbole rare, is there a cicatrix formed in tbe 
 skin. 
 
 The duration of the malady is usually many montbs, and it appears 
 to depend as mucb upon tbe long persistence of individual nodules as 
 iipon recurrences. It is only tlie exbaustion following a very copiously 
 developed exantbem or one of long persistence tbat makes button 
 
 1 ' Untersucbungcn iiber die Volkskrauklieiteu iu Grossbritauieu u. s. w.,' 
 Tiibing., 1823, 132. 
 
 2 'Med.-Cliir. Transact.,' 1827, xiii, 469. 
 
 3 ' Loud. Med. and Surg. Journ.,' 1835, July. 
 ■* ' Dubb Journ. of Med. Se.,' 1842, July. 
 
 ■'> ' Norsk. Mag. for Lacgcvideusk.,' 1842, v, 16. 
 
 c ' Uubl. Med. Tress,' 1844, Feb. 
 
 ' lb., March. « 'Lancet/ 1851, Sept.
 
 BUTTON SCURVY OF IRELAND. 113 
 
 scurvy dangerous to tlie health or life ; in the great majority of cases 
 the general well-being a^jpears to have heeu in no wise affected, and 
 symptoms of constitutional disturbance were never observed. Con- 
 cerning the anatomical structure of the tumours Wade, Corrigan, and 
 Kelly agree in saying that they should be considered as hypertrophic 
 growths of the papillae of the corium. 
 
 The history of this disease is shrouded in impenetrable 
 obscurity. When and where it first showed itself in Ireland 
 is not known ; this much only is certain^ that it has been 
 more rarely seen in recent times than formerly, and it must 
 now be quite extinct if we are to judge from the silence of 
 Irish practitioners about it at the present day. All the 
 authorities above mentioned agree that the disease is 
 certainly not of the nature of syphilis, as was formerly 
 supposed,^ that it has just as little in common with scurvy/ 
 but that there is discoverable in its type a striking likeness 
 to yaws.^ 
 
 Button scurvy has been observed mostly in the Southern 
 counties of Ireland, and as a true endemic only in the 
 interior among the country people. There are no doubts 
 among the observers as to its contagiousness, whether by 
 direct means or indirect, more particularly by conveyance of 
 the tumour-secretions by means of articles of clothing. A 
 fact stated by Wallace is worth noting in this connexion, 
 that the majority of the patients treated by him were such as 
 obtained their livelihood by dealing iu old clothes, by laundry 
 work, and the like. Kelly observed the disease most frequently 
 in shepherds who had either been employed among sheep 
 affected with the scab or had had to do with their wool ; and 
 he concluded that button scurvy was a communicated animal 
 disease. Assuming that this observation and the conclusion 
 
 ' The disease was at one time erroneously mixed up with sibbens, the endemic 
 sypliilis of Scotland. 
 
 2 Osbrey says that it is usual in Ireland to speak of chronic skin-diseases as 
 " scorbutic affections." 
 
 3 In consideration of the autlioritics abovo quoted, including physicians like 
 Wallace, Corrigan, and Fayc, I do not feel justilied in taking the whole story of 
 this disease for a piece of fancy, or as resting on errors of diagnosis. While cue 
 must admit that the statements about it are remarkable and puzzling to a 
 degree, yet they arc not more remarkable or more puzzling than those about the 
 verruga-disease referred to in the next sections, the existence of which, with all 
 its peculiarities, cannot longer be rationally doubted or called in question. 
 
 VOL. II. 8
 
 J 14 GEOGRAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 drawn from it are correct, the disease of slieep must at all 
 events have been a peculiar one, inasmuch as the scab exists 
 notoriously all over the world, and the conveyance of the 
 scab-mite to man is known to produce quite other effects than 
 those that have been described for button scurvy. 
 
 The Peruvian Wart {Verruga Peruviana) . 
 
 § 34. History and Characters op Verruga. 
 
 In the history of the conquest of Peru, published in 1543 
 by Zarate, Chancellor of Lima, there occurs a passage which 
 may be translated literally as follows •} " This country, situ- 
 ated between the tropic and the equator, is very unhealthy ; 
 the men here suffer from a wart or small tumour like a boil, 
 very malignant and dangerous, which appears on the face or 
 other parts of the body, and is more destructive than the small- 
 pox and almost as disastrous as the plague itself." Farther on 
 the chronicler states that the Portuguese soldiers were affected 
 by boils or warts of a very malignant kind, and that not a single 
 person in the army escaped them. Another historian of Peru, 
 who narrates the campaign of Pizarro's small army, tells us 
 that of the 700 men composing that force, more tlian one 
 fourth died of hgemorrhages following gangrenous ulcers of 
 the skin. Nothing had been heard in subsequent years of 
 any disease in Peru to which these notices might apply, 
 until Archibald Smith" in 1842, and after him Tschudi,^ 
 Oriosola,* and Salazar,^ followed in recent years by Dounon,^ 
 Fournier,^ Bourse,^ and Tupper," published accounts of a very 
 
 ' Quoted by Dounon, L c. 
 
 - ' Ediub, Med. aud Surg. .Tourn.,' 1842, July, 67. 
 
 ' ' Arch, fiir physiol. Heilkde.,' 1845, '^^' 378» ^'^^ ' Oesfcerx". mcd, WochcnscLr.,' 
 1846, 505. 
 
 4 ' Gac. med. di Lima,' 1858, April; ' Med. Times and Gaz.,' 1858, Sept., 280. 
 
 * ' Gac. med. di Lima,' i860. (Founded on his thesis of 1858.) 
 
 " 'litude sur la verruga, maladie endemique dans les Andes Peruviennes,' 
 Par., 1871. (Given also in ' Arch, de med. nav.,' 1871, Oct., 255.) 
 
 7 '■ Arch, de mod. nav.,' 1874, Sept., 156. 
 
 8 lb., 1876, May, 353. 
 
 ' 'Ueber die Verruca peruviana,' Inaug.-Diss., Berlin, 1877. (Of some interest 
 for the morbid anatomy only.)
 
 
 THE PERUVIAN WART. 115 
 
 peculiar disease of the skin, occurring endemically within a 
 very limited district of Peru, which was known by the name 
 of " the wart " (verruga). Between this and the severe cases 
 of sickness among the Portuguese troops in the sixteenth 
 century some connexion, they thought, might exist ; although 
 it was a noteworthy fact that the verruga is now met with in 
 only a few places on the western slopes of the Peruvian 
 Andes, being quite unknown in the rest of the country or 
 found only in an occasional imported case. 
 
 Clinical characters. — The outbreak of the disease is preceded for several 
 weeks by a feverish condition, during which the patient complains of 
 general weakness, want of appetite, headache, giddiness, a cramp-like 
 feeling of contraction in the gullet (very characteristic), and particu- 
 larly of exceedingly acute pains in the muscles, bones, and joints. 
 When the exanthem begins to appear all these troubles remit consider- 
 ably, and vanish altogether during its further development. The 
 exanthem comes out in the form of elevated reddish spots as large as a 
 lentil or a pea, which grow to tumours of cylindrical or hemispherical 
 or conical shape the size of a raspberry or filbert up to that of a pigeon's 
 egg ; the colour becomes more reddish-blue, the consistence being soft 
 at fix-st (or always if the growth be rapid), but more elastic afterwards 
 (or from the first if the development be slow), and the surface tender. 
 As the tumour increases in extent the epidermis becomes thinner, the 
 surface of the nodule appears to be cleft like a wart, and blood in larger 
 or smaller quantity begins to pour from the fissures and cracks, some- 
 times without any provocation, but more often in consequence of some 
 pressure or other mechanical irritation, such as lying on an uncomfort- 
 able bed. These bleedings are often difficult to stop, and they are some- 
 times so copious that ana3mia quickly ensues, Thenumber of the tumours 
 is, like their size, very various : sometimes there is only one to be found 
 on the patient, which may be an ordinary sized wart ; in other cases 
 the patient's body is covered with hundreds of excrescences of various 
 sizes. The exanthem is found most often and most abundantly on the 
 extremities, next to them on the face, on the hairy scalp, and on the 
 neck, more rarely on the sole of the foot or palm of the hand, and rarest 
 of all on the skin of the trunk, where Tschudi did not see it once 
 among the fifty cases obsei-ved by him. In many cases warts occur also 
 on the mucous membranes,— on the conjunctiva, in the mouth, nose, 
 pharynx, and larynx, and in the vagina ; in these situations they give 
 rise to bleeding likewise, and if we may infer from hajmorrhages occur- 
 ring by the mouth and anus in the course of the disease, the mucous 
 membrane of the stomach and intestine would appear to be also a scat 
 of the tumours. Whether the morbid product develops in parenchy- 
 matous organs as well (liver, kidneys) or, as Tschudi alleges, in the 
 bones, is very doubtful; post-mortem examinations have been made
 
 116 GEOGRAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 hitherto in only a few cases of death from verruga, and the information 
 from these is, at all events, not conclusive, the anatomical changes 
 that have been found in the solid viscera seeming to point rather to 
 complications with other diseases such as malarial sickness, dysentery, 
 and pneumonia. 
 
 The duration of the disease, or of the tumours in their developing 
 stage, amounts to several months (two to three on an average), unless 
 death had ensued prematurely either from the disease itself or from 
 some intercurrent malady at its commencement or at its height. The 
 issue of the local process may be a gradual drying and shrivelling of 
 the tumour until it falls off from the skin (this is particularly the case 
 with small warts) ; or it may be purulent disintegration beginning at 
 the base and leading to an ulceration of the affected area of skin, which 
 heals slowly and leaves behind it a deep red spot, often lasting for a 
 long time. The process is the same in the warts of mucous membranes, 
 which differ from those of the skin only in being more flattened, — in 
 such places as the conjunctiva and surface of the tongue where they 
 are continually exposed to pressure. The disease is seldom got rid of 
 altogether, a complete cure occurring only where the exanthem is scanty 
 and the bleeding slight; for the most part there remains over some 
 condition of weakness, due to the anaemia following profuse bleedings, 
 oi* there are nervous troubles, or dropsy, or the like, the patient never 
 quite recovering under such circumstances. Yery profuse hsemorrhage 
 which cannot be checked may cause death suddenly, or death may 
 sometimes occur at the commencement of the disease with typhoid 
 symptoms, as Tschudi would appear to have observed. Under the 
 usual circumstances (of which more in the sequel) the mortality fromi 
 verruga is from 6 to lo per cent, of the sick. 
 
 Morbid anatomy. — The excrescences, on anatomical examination, are- 
 found to be cavernous vascular tumours (with overgrowth and distension' 
 of the capillaries and veins), whose wide-meshed reticulum contains' 
 at first a small amount of embryonic connective tissue and afterwards- 
 an abundance of fibrillar tissue. This growth of connective tissue 
 proceeds either from the papillary layer of the corium or from its deeper 
 layers. The retrogression, or drying and shrinking, of the tumour is 
 preceded by obliteration of the vessels, and the detachment of it which 
 sometimes occurs through suppuration may bo referred to the same 
 cause. Of the state of the internal organs in fatal cases of verruga wo 
 have only two notices : one by Salazar of a case that ended fatally from 
 dysentery, the other by Tupper of two cases, in one of which death 
 ensued from pneumonia and in the other from smallpox. But there is- 
 no conclusion to be drawn from these observations as to any morbid 
 visceral changes belonging to verruga itself.
 
 THE PERUVIAN WAET. 117 
 
 § 35. Endemic Circumstances op Verruga. 
 
 Verruga occurs exclusively, so far as is known hitherto, 
 among the Peruvian Andes, in a few valleys between the 
 latitudes of 9° and 16 S., and at elevations of from 700 to 
 2500 metres (2500 to 8000 feet). Its headquarters are stated 
 to be Santa Ulaya (prov. Huarichi), Matucaua and a few 
 other villages in the province of Cocachacra, the valleys 
 at the foot of the Oerro de Pasco, inhabited by miners, 
 several valleys in the province of Chiquiang and the 
 mountainous districts to the south of Lima. Beyond these 
 limits only imported cases are observed, notably on the 
 littoral of Pern ; Tschudi had never seen it in the Sierra or 
 on the eastern slope of the Andes, and it is equally unknown 
 in Chili, Bolivia and New Granada. Under certain circum- 
 stances, chiefly, it would seem, in consequence of some 
 considerable concourse of strangers at its endemic centres, 
 the disease sometimes acquires a sort of epidemic character. 
 Thus, it is stated by Bourse that an epidemic of that kind 
 developed among the navvies employed in building the so- 
 called Trans- An dean Hallway passing right through the 
 vorruga-region, as well as among the English engineers who 
 directed the work ; the epidemic was declining at the time 
 of his arrival at Callao (beginning of 1874), having lasted 
 for eight months and caused a veiy considerable mortality 
 among the foreigners. 
 
 All the localities aifected by the disease have the same 
 natural features. They are deep-cleft narrow valleys, whose 
 sides are formed of bare rock (granite and diorite), and their 
 bottom of clay covered with luxuriant vegetation and traversed 
 by a mountain stream which may fall in cascades or flow 
 smoothly. The disease occurs in these valleys just for so far 
 as they continue to be narrow and gorge-like ; wherever the 
 valley widens, it may be not more than a few kilometres from 
 the verruga-centre, there is not a trace of the disease to be 
 found.^ Owing to the conformation of these valleys, the 
 
 1 Tschudi mentions tbat it may happen to troops marching' tlirough that 
 region to be quartered, some of them in Santa Uhvya, and others in the village of 
 San Pedro Mama, only a league (three miles) away ; among the former the 
 disease has often broken out to a disastrous extent, whereas those in the latter 
 village have remained quite exempt.
 
 118 GEOGKAPHIOAL AND HISTORICAL PATHOLOGY. 
 
 day temperature in them is higli (maximum of 95° to 103° 
 Fahr.) notwithstanding their elevation, whereas the nights 
 are cold, so much so that a diurnal range of 25° to 35*^ Fahr. 
 is not unfrequently observed. In contrast to the rainless 
 coast of Pern, there is here a rainy season (August to 
 November), although the rainfall is certainly not very copious ; 
 the dry season lasts from January to June, and in the 
 transition months (December and July), violent storms 
 blow from the Sierra. The population of the verruga- valleys 
 belong mostly to the Ando-Peruvian race; they are very 
 sparsely scattered, miserable in circumstances and degenerate 
 in body. Their food consists of fruits, salted flesh, rice, a few 
 esculent roots, and eggs ; their drink is spring-water turbid 
 from the admixture of mineral matters, which is fetched in 
 earthen vessels and allowed to stand until the suspended 
 substances subside. 
 
 § 36. Verruga a Disease due to a Specific Cause. 
 
 It is obvious that the proper cause of the verruga-disease 
 is not to be looked for in any one of these conditions, nor in 
 all of them taken together. But it has been at the same time 
 impossible hitherto to discover any other factor which might 
 be brought even remotely into relation with the pathogenesis. 
 The disease is undoubtedly specific, although it has nothing 
 more in common with syphilis, leprosy, yaws and other chronic 
 infective diseases than the locus affectus (Dounon, Fournier, 
 Bourse). That we have to deal with some noxious agent 
 acting generally and producing acute effects, may be inferred 
 from the fact that the disease has been observed in animals 
 also (dogs, cats, mules, poultry), and that a very short resi- 
 dence of strangers in one of the disease-centres is sufficient 
 to start the malady. One of the cases given by Dounon is 
 that of a missionary who fell ill of verruga after a thirty 
 days' stay at Matucana ; it has been alleged that it suffices 
 to acquire the disease merely to travel through the affected 
 districts, without delaying in them ; but this Dounon pro- 
 nounces to be a fable.
 
 THE PERUVIAN WAET. 119 
 
 § 37. Etiology of Yeerdga. 
 
 In verruga, as in many similar cases, it has been supposed 
 that the cause of the disease might be found in certain inju- 
 rious properties of the drinJcing water; it is not so much the 
 water of the mountain streams as of small springs issuing from 
 the rocks, which has been thought to be capable of inducing 
 the disease. This is the general belief among the natives, 
 and it has found a supporter in Tschudi, who adduces in its 
 favour the circumstance that if travellers abstain from drink- 
 ing the water of these suspected springs, — the " aguas de 
 verrugas," — they escape the disease altogether, while a single 
 draught of it is said to suffice for the production of the 
 malady. All the more recent observers are decidedly 
 opposed to that view. Apart from the fact that nothing, 
 either physical or chemical, is discoverable in the suspected 
 water which could possibly be blamed for causing the disease, 
 we have the observation of Dounon that he himself, and his 
 whole following, drank of the water from these springs despite 
 the urgent warnings of the natives, without taking any harm ; 
 whereas, on his questioning those suffering fx'om verruga, 
 they admitted that they had fallen victims to the disease 
 notwithstanding their avoidance of the spring-water. 
 
 It is not denied on the part of anyone that something spe- 
 cifically detrimental underlies the verruga ; but the source 
 and nature of this injurious influence are enveloped in com- 
 plete obscurity. Dounon has found nothing in the dejecta 
 of the sick or in the contents of the tumours, which would 
 indicate a parasitic orirjin of the disease ; he believes that it 
 is an affair of a miasma, like the malarial miasm, and that 
 is also the opinion of Bourse. The spread of verruga by con- 
 tagion is absolutely denied by the natives, and also by Smith. 
 Dounon declines to give a decided opinion on the question, 
 and Bourse thinks that contagiousness is at least doubtful ; 
 there is, farther, no unanimity among the observers, as to 
 whether the predisposition of an individual to infection is 
 abrogated by having had the disease once. On the other 
 hand, all authorities agree that, although no race enjoys an 
 immunity, the whites suffer much more frequently and much
 
 120 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 more severely tlian the Indians and negroes. No white 
 foreigner, says Bourse, who has lived some time in a focus 
 of verruga keeps free from the disease ; thus, the whole of 
 the engineers who were superintending the building of the 
 Trans-Andean Railway took verruga, and at the time of that 
 author's visit to the locality half of them had died of it ; of 
 forty sailors who had deserted from a British ship and had 
 gone to work on the railway, thirty died of verruga in the 
 course of seven or eight months. While the mortality from 
 it among the dark races amounts to about 6 per cent., it rises 
 among the whites to 12 — 16 per cent., and, when it is pre- 
 valent as an epidemic, to 40 per cent. When the esanthem 
 occurs in the internal organs the issue is nearly always fatal 
 (94 per cent.).
 
 CHAPTER IV. 
 
 ENDEMIC GOITRE AND CRETINISM. 
 
 § 38. Historical References. 
 
 In the medical writings of antiquity, there are many indi- 
 cations, in the statements made about tumours occurring in 
 the neck, which may bo taken as referring to goitre ; but 
 there is not a word said of its endemic prevalence. Their 
 silence is in part explained by the fact that the Greek and 
 Roman physicians could have had few opportunities of glean- 
 ing experience in the localities where centres of goitre existed ; 
 but it is accounted for doubtless in part also by the slight 
 interest that they took in the study of epidemic and endemic 
 diseases in general. It may be safely inferred, however, from 
 the statements of Pliny/ Vitruvius," Juvenal,^ and Ulpian,^ 
 that there were already endemics of goitre in the Alps in 
 their times. The first half of the mediaival period furnishes 
 no medical account of endemic goitre ; a few references to it 
 are to be found in some of the Lives of the Saints (the 
 disease being regarded in those days as a punishment from 
 God)^ and it is from that period that we have the stories of 
 
 1 ' Hist, natural.,' lib. ix, cap. 37, § 68, ed. Franzius, iv, 409 : " Guttur bomini 
 tantum et suibus intumesciL, aqiiarum qua? potantur pleruinque vitlo." 
 
 •■' 'De architectura,' ed. Sclmeider, i, 220: " Guttur bomini intumoscit pra3- 
 «ertim apud iEquicolas et MeduUos Alpinos " (probably tbe iubabitauts of tbe 
 Maurierme). 
 
 2 ' Satyr.,' 13 : " Quis tumidum guttur miratur in Alpibus." 
 
 ■» ' Fragmenta :' " Tumido gutturc prfficipue laborant Alpium iucolaj propter 
 aquarum qualitatem, quibus utuntur." 
 
 * Hinkmar, in bis account of tbe life of St. Ueuii (lib. viii), states tbat wbeu a 
 famine tbreatened in tbe country around Rbciuis (stb cent.), tbo saint caused 
 wbeat to be ground for distribution among tbe poor; but tbe Kelts, being pos- 
 sessed of the devil, burned the mills, whereupon the saint pronounced this 
 anathema upou them: "Omnes qui hoc egerunt, et qui dc corum gerniiue nati
 
 122 GEOGEAPHICAL AND HISTORICAL PATHOLOGY. 
 
 curing the goitre by touching with the King's hand.' 
 Belonging to the end of the 13th century is the account 
 by Marco Polo of its prevalence in Yarkand and other 
 regions of the Central Asian plateau. Then, in the 14th and 
 15th centuries, come the first medical references to ende- 
 mic goitre, by Arnoldus Villanovanus^ for the province of 
 Lucca, and by Valescus de Tharanta^ for the Comte de Foix. 
 Next we have the account of the disease in the Duchy of 
 Salzburg by Paracelsus,* who was the first to treat the sub- 
 ject with thoroughness on the basis of his own observations ; 
 he sketched the conditions for the endemic occurrence of 
 goitre in brief but forcible lines, indicating the relation of 
 goitre to cretinism, and supplying the first trustworthy 
 information of any kind about cretinism itself. A somewhat 
 more copious, but still hardly sufficient wealth of materials 
 for the study of the history of endemic goitre and cretinism 
 is provided by the medical writers and the chroniclers 
 of the 1 6th, 17th, and i8th centuries. Among these were 
 Miinster^ for the Vallais, Styria and the Pyrenees ; Agricola^ 
 for Salzburg, Tyrol and the Val Tellina ; Lange^ for 
 Salzburg, Tyrol, Styria and the Yallais ; Stumpf^ and 
 
 sunt, fiant viri herniosi et fceminsB gutturosse." A similar legend is given by 
 Hubert, in the Life of St. Gudula ; the Bishop Emebert (7th cent.) delivered an 
 anathema, it is said, upon the wicked persons who had despoiled the tomb of that 
 saint, the curse being that their offspring should all be cripples (claudicati) and 
 the women goitrous. Hubert, who was Bishop of Liege at the beginning of 
 the 8th century, adds : " Et permanent hodie mulctati." 
 
 ' See du Laurens, 'De mirab. strum, sanandi vi solis Gallia? rcgibus diviuitus 
 concessa,' Par., 1609. 
 
 ^ ' Breviar,' lib. ii, cap. iv, 0pp. Basil., 1585, 1 190 : "Nascitur in gula quan- 
 doque passio, quse botium dicitur .... fiunt nempe in quibusdam regionibus 
 forte ex natura aeris vel aquarum in quibus quasi omnes mulieres vel viri sunt 
 strumosi, sicut est quiedam regie quse est in comitatu civitatis Luca, quae dicitur 
 Cariphiana." 
 
 3 ' Philonium,' lib. vii, cap. 31, Lugd., 1490, fol. 338: " Botium est morbus 
 proprius aliquibus regionibus sicut est Savarte in comitatu Puxi ; et hoc est 
 ratione regiminis, aut ratione aquarum frigidarum quas bibunt et est morbus 
 hereditarius." 
 
 ■* 'De generatione stultorum,' 0pp. Strasb., 1616, ii, 74; and 'Von offenen 
 Schaden,' cap. xix, e. c. iii, 587. 
 
 5 ' Cosmographia univ.,' Basil., 1550, v, 1. 
 
 ^ ' De re metallica/ Basil., 1657, 542. 
 
 7 « Epistol. med.,' Basil., 1554, i, 43. 
 
 8 ' Chronik,' Ziir., 1 586, 588.
 
 ENDEMIC GOITRE AND CRETINISM. 123- 
 
 CampelP for the Rliine valley above the Lake of Constance, 
 Leo Africanus^ for the Atlas, Ortelius^ for Styria, Simmler* 
 for the Vallais, Eustachius Radius^ for Tyrol, Felix Plater® 
 (one of the best writers on cretinism during that period) for 
 the Vallais and Carinthia, Foreest'^ for the Val Tellina, De la 
 Vega^ for Peru, Gaye^ for Guatemala, Hofer^*' for Styria, 
 Tollius^^ for Schemnitz (Hungary) and Styria, Hoffmann^^ for 
 the Harz and for Kronstadt in Transylvania, Mittermayer^"" 
 for the Pinzgau (Tyrol) and the Riesengebirge, Keyssler^^ for 
 Savoy, Haller^^ for Aigle (Rhone valley) and the Bernese 
 Oberland, Bourrit^*^ for Aosta, Saussure^^ for Savoy and the 
 Yallais, Lentin^^ for the Harz, Marsden" for Sumatra, and 
 Lange^° for Kronstadt (Transylvania). 
 
 Towards the end of the i8th century there appeared the 
 first important work on the subject, that of Malacarne^^ 
 based on his observations in the valley of Aosta ; and there- 
 with the scientific inquiry may be said to have begun. All 
 that we know of the earlier history of endemic goitre arul 
 cretinism reduces itself to this : that a few centres of the ende- 
 mic were known to exist, the same that continue, as we shall 
 find, to be seats of the malady to the present day ; and that 
 
 ^ Gubler, ♦ Beitr. zur med. Topogr. v. Chur.,' Tiibing., 1824, 9. 
 ' 'De totius Africce descriplione/ Lugd. Biit., 1632, Pars ii, 420. 
 ' ' Theatrum orbis terraruiii,' Antw., 1570, 92. 
 * 'Valesiaj et Alpium descriptio/ Ludg. Bat., 1633, lib. i, 19. 
 
 5 ' De virtutibus et vitiis cordis,' Venet., 1587. 
 
 6 'Prax. med.,' lib. i, cap. 3, Basil., 1625, 80. 
 ' • Observ. et curat, med.,' lib. x, 242. 
 
 8 « Commentarios reales . . . del origin de los Yncas, &c.,' quoted ia Barton. 
 
 9 ' Reisebescbreibung nacb Neu Spanien.' From the French. Leipz., 1693, 
 238. 
 
 '" ' Hercules medicus,' 1655,43. 
 
 " 'Epistol. iterinar.,' Amstel., 1700, 237, 238. 
 
 '* 'De morbis cndemiis,' Hal., 1705, in 0pp., Gcnev., 1748, 203. 
 
 >3 'Diss, de strumis ac scrofulis Biisgensium,' Erford., 1723. 
 
 " ' Neueste Reisen durch Deutschland, &c.,' Hannov., 1751, 240, 291. 
 
 •5 ' Opusc. academ.' 
 
 16 'Description des glacicres, &c.' Germ, transl., Ziiricb, 1786, 210. 
 
 >7 'Voyage dans les Alpes,' Neuchat., 1779-96. i. 421, »', 389. >"» 25. 89, iv, 452- 
 
 18 'Memorabilia, &c.,' Gott., 1779, 127. 
 
 19 ' History of the Island of Sumatra,' Lond., 1783. 
 «o In Richter, ' Chir. Bibl.,' 1785, viii, 500. 
 
 21 «Sui gozzi e sulla stupidita, &c.,' Tor., 1789, and ' Lcttrc sur I'etat des 
 Cretins,' Tur., 1 789. Reprinted in Frank's ' Delectus opuscl. med.,' vi.
 
 124 
 
 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 endemic goitre is proved to have occurred as early as the 
 pre-Christian era. But as regards cretinism previous to the 
 1 6th century, the history is enveloped in complete obscurity. 
 
 § 39. Geographical Distribution. 
 
 The geographical distrihution of endemic goitre and cretin- 
 ism at the present day extends over nearly the whole of the 
 habitable globe ; but goitre, or goitre with cretinism, occurs 
 everywhere in more or less narrowly circumscribed spots, and 
 in very marked association with definite conditions of locality. 
 On European soil, the head-quarters are the western and 
 southern slopes of the Alps of Italy, Switzerland and France, 
 the eastern continuations of the chain in Austrian territory, 
 the Pyrenees, the Vosges and the Jura. 
 
 Italy. — The endemic prevalence and relative frequency of 
 goitre in Italy is shown in a serviceable if not absolutely ex- 
 haustive manner in the following table, which I have compiled 
 from the recruiting-lists published by Sormani,^ showing the 
 men pronounced unfit for service on account of this disease 
 from 1863 to 1876. 
 
 The number of persons liable to military service, examined during 
 those thirteen years, amounted to 2,000,000, and of these 42,863, or 
 209 per 1000, were declai-ed to be unfit on account of goitre. The table 
 shows the pi'oportion exempted for goitre in the respective provinces 
 per 1000 conscripts. 
 
 Table of Exemptions from Military Service on account of Goitre in the 
 
 various Provinces of Italy. 
 
 Territory. 
 
 I'roviuce. 
 
 Per ceut. 
 
 Lombardia- . 
 
 Sondi'io . . . . 
 Brescia . . . . 
 Bergamo 
 
 67-6 
 262*7 
 118-4 
 
 867 
 
 1 ' Geografia nosologica, dell' Italia,' Iloma, iSSi, p. 22, £f. In estimating the 
 results dei-ived from this statistical conspectus, it should not be forgotten that it 
 relates'only to the male population over tlic age of twenty. The statistical data 
 of cretinism cannot be used, inasmuch as cretinism and idiocy arc included in 
 the same list. 
 
 * See accounts in ' Oest. med. Jahrb.,' 1832, 1839, Nste. Folgc, iii, 349, 
 xxi, 3; Balardini, ' Topogr. med. dclla prov. di Soudrio,' Mil., 1834, 55 ; Meuis,
 
 ENDEMIC GOITRE AND CRETINISM. 
 
 125 
 
 Terrilorv. 
 
 Lombardia 
 
 Piemonte^ 
 
 Liffuvia^ . 
 
 Veneto^ . 
 
 Emilia . 
 
 Umbria . 
 
 Marche . 
 Toscana 
 
 Roma 
 
 Abbnizi e Molise 
 
 Campania 
 
 Province. 
 
 Como 
 Cremona 
 Milano . 
 Pavia 
 Mantua . 
 
 Cuneo 
 Torino . 
 Novara . 
 Alessandria 
 
 Genova . 
 Porto Maurizio 
 
 Belluno . 
 Udine 
 Vicenza . 
 
 Modena . 
 Reggio Em. . 
 
 Bologna 
 Parma 
 
 Perugia . 
 
 Massa c Carrara 
 
 Per cent. 
 
 So-S 
 59'2 
 48-4 
 262 
 6-9 
 
 59-4 
 
 109-8 
 
 78-1 
 
 21*9 
 2 1 '2 
 
 308 
 320 
 
 25"9 
 
 17-8 
 
 77-6 
 38-1 
 203 
 52 
 i4'o 
 
 94 
 
 6-6 
 
 4-2 
 
 io'6 
 
 187 
 12 
 27 
 
 187 
 06 
 19 
 29 
 
 ' Saggio cU topogr. med. della prov. di Brescia,' Bresc, 1837,1,134; Guislain, 
 •Lettrc med. sur I'ltalic,' Gand, 1840, 11 ; Coniolli, ' Gaz. med. Lombard.,' 1848, 
 304; Paleari, ' Anual. univ./ 1851, Oct. ; Strambio, ' Gaz. med. Lombard.,' 1856, 
 Nr. 22 ; Demortain, ' Gaz. hebd. de med.,' 1859, 683 ; Tacebini, ' Observ. intorno 
 al cretinismo, &c.,' Pavia, 1859; Lombroso, ' Eicercbc sul crctinismo in Lom- 
 bardia,' Milano, 1859; Castiglioni, 'II cretinismo nello Valtellino,' Mil., i860; 
 Lussana, 'Studi di cretinismo in Lombardia,' Mil., i860; ' Ilclazione della cora- 
 missione per lo studio del cretinismo in Lombardia,' Mil., 1864. 
 
 ' See : Fodere, ' Essai sur lo goitre ct le cretinismo,' Turin, 1 792, Germ, transl. 
 Berl., 1796, 72; Ferraris, ' Gioru. delle se. med. di Torino,' 1838, 1840, ii, 370, 
 vii, 385; Garbiglietti, ib., 184s, Giugno; Dubini, 'Gaz. med. di Milano, 1845, 
 Nr. 3^, 1847, Ni"- 46 ; Maffoni, ' Atti dell' Accad. med.-cbir. di Torino,' 1846, ii, 
 453; * Ilapport de la commission cree pour etudier le crctinisme,' Turin, 1848; 
 Grange, ' Compt. rend.,' 1850, ii, 58; Guista, ' Gaz. med. delle Stati Sardi,' 1851, 
 Nr. 12; Dallera, * Giorn. dcU' Accad, med.-cbir. di Torino,' 1851, xi; Bifli, ' Sul 
 cretinismo nella valle d'Aosta,' 1861. 
 
 - Lombroso, ' Ricercbc sul cretinismo endemico in alcuni pimti della Liguria,' 
 Mil., 1865. 
 
 3 Facen, ' Gaz, med. Lombarcl,' 1851, Nr. 19, 1869, Nr. 21,
 
 126 
 
 GEOGEArHICAL AND HTSTOEICAL PATHOLOGY. 
 
 Territory. 
 
 Province. 
 
 Per cent. 
 
 Puglie . 
 
 Basilicata 
 
 Calabria 
 
 Sicilia 
 
 Sardegna 
 
 ■ (.« ... 
 
 0.4 
 
 23 
 19 
 
 I '3 
 08 
 
 The following table shows whei'e the maximum amount of goitre, 
 a-angiug from 10 to 30 per cent., falls within the smaller ai-eas : 
 
 Aosta (Prov. Turin) 
 Val Tellina (Prov. Sondrio) 
 Crema (Prov. Cremona) 
 Saluzzo (Prov. Cuneo) ... 
 Breno (Prov. Brescia) ... 
 Salo ,, „ 
 
 Chiai'i ,, ,, 
 
 Treviglio (Prov. Bergamo) 
 Iiecco (Prov. Como) 
 Cuneo (Pi'ov. Cuneo) ... 
 Susa (Prov. Turin) 
 Pinerolo „ 
 Clusone (Px'ov. Bergamo) 
 
 317 per looo 
 
 263 
 
 182 
 
 179 
 
 170 
 
 166 
 
 163 
 
 154 
 141 
 
 131 
 124 
 
 117 
 
 116 
 
 u 
 
 We nnd accordingly, that tlie liead-qiiarters of endemic 
 'fjoitre in Italy are the district of Aosta at the foot of Mont 
 Blanc, and the valleys of the Alpine chain tohich traverses 
 Piedmont and Lonihardy, -pa,rticu\a,r\y the valleys of the Dora 
 the Po, the Adda and the Chiese, and to a less extent the 
 valleys of the Sesia, the Ticino and the Adige. In Venetia 
 territory there are considerable centres of goitre in the valleys 
 of the provinces of Belluno and Udine. The Mincio appears 
 to be the boundary towards Lonibardy of the goitrous region 
 there ; for, while the proportion of goitrous persons on the 
 western shore of the Lake of Garda (province of Brescia) is 
 112 per 1000, it amounts only to 4 per 1000 on the eastern 
 shore (province of Yerona). In like manner the Po marks 
 off the endemic goitre of the plain of Lombardy from the 
 Emilia; in the districts of Pavia, Lodi and Cremona 
 the number of cases is 30 to 80 per 1000, while in Voghera, 
 Piacenza, Parma and other places, the maximum is only 7 per 
 1000. 
 
 Cretinism also finds its most extensive diffusion in the
 
 ENDEMIC GOITRE AND CRETINISM. 127 
 
 same regions of Italy. The number of those liable to the 
 conscription who have been pronounced unfit for service on 
 account of cretinism (and idiocy) amounts to lo'y per looo 
 in Aosta, 5*9 in Sondrio, 5*4 in Brescia, and 4-5 in Chiari ; 
 and it is again the above-mentioned Alpine valleys of Pied- 
 mont, Lombardy and Venetia that have the largest number 
 of cases. We also meet with centres of goitre and cretinism, 
 of moderate extent, on the northern slopes of the Ajpennine 
 in Piedmont, Liguria and the -Emilia, as well as in a few 
 localities of Umbria and the Abruzzi,i and at some points in 
 the Terra di Lavoro." In the rest of Central and Southern 
 Italy, the two diseases, and especially cretinism, are far from 
 reaching the importance that they have in the three former 
 regions. In Sicily and Sardinia they do not occur 
 endemically at all, so far as I can judge from the information 
 before me. 
 
 According to the returns (very incomplete) collected by the Sardinian 
 Commission in 1845-46, of the diffusion of cretinism in the quondam 
 Kingdom of Sardinia, the number of cretins per 1000 of the population 
 reached the enormous figure of 27*9 in the district of Aosta, 2*2 per 
 1000 in Cuneo, 2*5 in Ivrea (Turin), and 2*i in Saluzzo. For Lombardy, 
 the number of cretins in 1859 "^^^ estimated by Lombroso at 5000, or 
 17 per 1000 inhabitants, the provinces of Brescia, Sondrio (Val TeUina), 
 Como and Cremona being most severely affected. 
 
 France. — Directly connected with the severe centres of 
 goitre and cretinism in Piedmont is the endemic prevalence of 
 both diseases in the Alpine Departments of France. I take 
 the following data on the distribution of goitre and cretinism in 
 France from the official report of the Commission of Inquiry 
 drawn up by Baillarger.^ 
 
 The total number of goitrous persons in France above the age of 20, 
 amounted to 370,403 ; the number of cretins and idiots to about 120,000. 
 Taking the population of tbc country to be 36,000,000, the proportion 
 of goitre per 1000 was io'4, and of cretinism and idiocy 3\3. The 
 following table shows the proportion of the goitrous per 1000 inhabi- 
 tants in the several departments. 
 
 ^ Guislain, 1. c. 
 
 =^ de Renzi, ' Topogr. e stafc. med. dclla citta dl Napoli, &c.,' Nap., 1845 ; Costn, 
 'Esculapio,' 1840, i, Nr. 6. 
 
 ^ ' Rapport de la commission d'cnquetc sm- le goitre et Ic cretinisme eu France,' 
 Paris, 1873.
 
 128 
 
 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 lahle of Goitre in the sever 
 Departmeut. 
 " Savoie 
 Haxites-Alf)es 
 Haiite-Savoie 
 Arricge 
 Basses-Alpes 
 Halites- Pyrenees 
 Jura . 
 Vosges' 
 Aisne 
 Alpes-Maritimes 
 
 Loire 
 Rhone 
 
 Puy-de-D6me 
 Haute-Loire 
 Oise . 
 Drome* 
 Meurtlie^ . 
 Cantal 
 Haute-Saone 
 Haute-Marne 
 11..^ Ardeclio . 
 Isere'' 
 Lozere 
 Dordogne . 
 Pyi'cnces-Orient 
 Meuse 
 Doubs 
 
 Saone-et-Loire 
 Hante-Garonnc 
 Basses- Pyrenees 
 Corrcze 
 
 Ardennes 
 Aveyron 
 Lot . 
 Ain . 
 Vaiicluse 
 Aude . 
 Allier 
 Cote-d'Or 
 Creuse 
 Nievro 
 Aube . 
 Marne 
 
 al Departments i 
 
 Per 1000. 
 
 1337 
 III'O 
 
 92*0 
 
 827 
 
 769 
 
 62-3 
 
 mJ 
 
 L 
 
 5S'9 
 568 
 
 529 
 507 
 
 73-8 
 49-0 
 460 
 44-6 
 42-8 
 369 
 369 
 
 33'o 
 33-0 
 31-6 
 
 308 
 
 295 
 29*0 
 29*0 
 250 
 24*0 
 
 22"6 
 22'0 
 2l''J 
 21'0 
 2I*0 
 20"0 
 
 30"9 
 lyo 
 170 
 170 
 160 
 
 157 
 117 
 
 I ro 
 
 io"6 
 
 100 
 
 97 
 
 i3'5 
 
 of France per 1000 inhabitants. 
 
 Department. Per 1000. 
 
 '^Euro .... 9'o 
 Haute- Vienne . . 7*8 
 Seine-Oise . . -77 
 Gard .... 66 
 Tonne . . . 6'^ 
 
 Orne .... 6*2 
 Somme . . . ^'g 
 Landes . . . 5*9 
 
 Charente . . -57 
 IV. -{ Sarthe . . .4-8 
 
 Seine infer. . . . 3*8 
 Bouclies-dia-Rlione . 37 
 Seine-Marne . . 37 
 Calvados . . . 3*4 
 Eure-Loire . . 3*3 
 
 Gers .... 3"2 
 Var . . . • 3'2 
 Corse .... 3'o 
 Tarn .... 3*0 
 
 V.^ 
 
 YL^ 
 
 Indre . 
 Maine-Loire 
 Tarn- Garonne 
 Gironde 
 Vendee 
 Seine . 
 Ille-Vilaino 
 Loiret . 
 Cher . 
 Nord . 
 Lot- Garonne 
 Herault 
 Pas-de-Cahiis 
 Mayenne 
 Loir- Cher . 
 
 r Indre-Loire 
 Vienne 
 Loii-e infer. . 
 Charente infer. 
 Finisterro . 
 Deux-Sevres 
 Morbihan . 
 Manche 
 Cotes-du-Nord 
 
 51 
 
 2"0 
 
 2-4 
 
 2 '4 
 2-3 
 
 2"2 
 
 21 
 
 20 
 
 2"0 
 
 2*0 
 
 16 
 
 V6 
 
 1-6 
 
 13 
 
 I"2 
 
 20 
 
 0-8 
 07 
 06 
 
 o'S 
 
 05 
 0-4 
 
 03 
 03 
 
 0'2 
 0-4 
 
 ^ See Anzouy, 'Gaz. dcs hopit.,' 1859, No. 79. 
 
 2 Sahit Lager, ' Deuxieme scrie d'ctudes sur les causes du crefmisme, &c.,' 
 Lyon, 1868, 3. 
 
 3 Anzouy, 1. c, and Ancelou, * Gaz. hebd. do med.,' 1857. 
 •* Ni^pce, ' Traite du goitre et du cretinisme,' Par., 1851.
 
 ENDEMIC GOITRE AND CRETINISM. 129 
 
 Of tlie relative amount of cretinism in the several French 
 I departments, tliese returns afford a less certain measure, 
 inasmuch as the data include both cretinism and idiocy. 
 The head quarters, however, of that malady are the depart- 
 ments of Hautes-Alpes and Savoie, with 22 and 16 per 1000 
 respectively ; next to them, as regards frequency of the dis- 
 ease (from 4 to 6 per 1000) come the Basses- Alpes, Hautes- 
 Pyreuees, Haute- Savoie, Isere, Ardcche, Drome, Alpes-Mari- 
 times, Arriege, and Haute- Garonne ; and there are further a 
 few minor centres of cretinism in Aveyron, Lot, Hauto-Loiro, 
 Vosges, Puy-de-Dome, Pyrenees Orientales, Oise, Aisne, 
 Meurthe, and Haute-Marne. 
 
 Comparing the amount of goitre and of cretinism in the 
 several departments, it will be seen that the frequency of 
 goitre is by no means a measure of the frequency of cretinism ; 
 it is only in the departments of Savoy and the High Alps, 
 which are among the worst centres of goitre, that we find at 
 the same time the worst centres of cretinism ; whereas in the 
 Jura, which takes one of the highest j^laces for goitre, cretinism 
 is met with to a very slight extent (2"5 per 1000, including 
 idiots) .■"■ 
 
 In the department of Savoy the head-quarters of cretinism 
 (and goitre) are the valleys of the Maurienne and Tarentaise, 
 with 22*7 and i4'5. cretins per 1000 inhabitants respectively.^ 
 In the Hautes-Pyrenec.';, both diseases are most widely spread 
 in the valleys of Luchon, Bigorre and Lavedan.^ The pre- 
 valence of goitre is very remarkable in the hilly country of 
 the Aisne, especially in the communes of Fouconcourt and 
 Suzy, while the amount of cretinism is at the same time very 
 small.'^ In the department of the Rhone, both diseases are 
 jirevalent, particularly in the mountainous parts (St. Laurent 
 and Beaujeu); in the arrondissements of Lyon and Villef ranch e 
 the number of goitrous persons (in 1S51) was i'5 and 2*4 
 
 ^ Monnier, ' Annal. du Jui-m,' 1S53; Moretiu, ' Etiologie du goitre,' Par., 
 1854. 
 
 ^ ' Riipport do 111 comiuissioii Sardiiignc,' 124; Grauge, ' Gaz. med. dc Paris,' 
 1848, 820. 
 
 •* See: Bouruiierc, ' Itiiicr. descripfc. des Ilautes-Pyreuees fraiif-.,' Par., 1825, 
 ii, 197 J Mardiaiit, ' Observ. . . u I'litmlo dcs causes du cictinisaie,' Par., 1842; 
 ■Garrigoii, ' Bull, de I'acad. de ined.,' 1868, x.\.\iii, 715. 
 
 * Maliuc, 'Gaz. des hopit.,' 1852,546. 
 
 VOL. II. 9
 
 130 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 per 1000 inliabitants, and of cretins 0*4 and i "O jDer 1000.^ In 
 tlie Piiy-de-Dome it is the soutliern valleys of the Upper 
 Auvergne that form the chief seats of goitre and cretinism ;^ in 
 the Oise, it is particularly the Nyonnais (arrond. Compiegne) 
 that suffers from endemic goitre f' for the Haute-Marne there 
 are definite accounts of goitre only for Bussieres •,'^ the Nievre 
 has goitre endemic but is free from cretinism ;^ in the Seine- 
 inferieure, goitre occurs only in the arrondissement of Rouen, 
 being confined to twenty-five villages on the banks of the 
 Seine between Pont d'Arche and Duclair, and in only one 
 family among them were cretins found.^ 
 
 Like France, Sj^ciin has goitre and cretinism widely pre- 
 valent and in considerable frequency, among the valleys of 
 the southern slope of the Pyrenees. The worst localities are 
 the valley of the Aran, and the valleys from Cardous to 
 Ribeira, corresponding to the department of Haute-Garonne 
 on the other side ; nest to these come Lladore and Ladrons 
 and the valleys of Paillas, d'Estaon, Cinca and Essera. There- 
 are also considerable endemic spots of goitre and cretinism 
 in the valleys of the Cantabrian mountains (Asturias and 
 Galicia) , in the valleys of the Sierra Morena and Sierra Nevada 
 (New Castile and Estremadura), and in the frontier district 
 between Estremadura and the Portugese province of Alemtejo, 
 in which latter botb diseases are likewise indigenous^ 
 
 Cretinism in Stvitzerland. — The following data will serve 
 to show the distribution of cretinism in Switzerland.^ In 
 
 1 Marmy et Quesnois, ' Topogr. et statist, rued, du Depart, du Rhone, &c.,'' 
 Lyon, 1866, 103. 
 
 2 Brieude, ' Hist, de la soc. de med. de Paris,' v, Mem., 313; Miral-Joudy,. 
 ' Journ. hebd. de med.,' 1831, May ; Saint-Lager, 1. c, 49. 
 
 3 Guilbert, 'Etude sur les eaux potables . . . du Nyounais, &c.,' Par., 1857. 
 
 * Lacordaire, ' Prec. anal, du trav. de la Soc. de med. de Dijon,' 1842, 128. 
 
 * Gaudin, ' Du goitre endemique,' Moutp., 1869. 
 
 ^ Vingtrinier, ' Du goitre endemique dans lo depart, dc la Seine-infer., &c.,'' 
 Rouen, 1854. 
 
 7 See Thiery, 'Observ. de phys. et de med. de I'Espagne,' Par., 1791, ii,. 
 117 J Saint-Lager, 'Etudes sur les cause? du cretinisme, &c.,' Par., 1867, 371. 
 
 s For goitre and cretinism in Switzerland, see : Ackermann, ' Ueber die Cretincu 
 u. s. w.,' Gotba, 1790; Troxler, ' Der Cretinismus und seine Formen,&c.,' Ziiricli, 
 1836; Denime, ' Ueber endemischen Cretinismus,' Bern, 1840; Mcyer-Alircns, 
 in 'Haser's Arcb. fiir die ges. Med.,' 1S45, ^'i'' 357, and in ' Roscb's Zeitscbr. 
 iiber den Cretinismus,' 1852, iii, 1; Gossc, ' De I'etiologie du goitre ct da 
 cretinisme,' Geneve, 1853.
 
 ENDEMIC GOITRE AND CRETINISM. 131 
 
 1868 an enumeration gave 3431 cretins in a population of 
 about 2,000,000, or 17 per 1000 -^ of these one-seventh 
 occurred in the Vallais. The condition is not more than 
 sporadic or moderately common in the cantons of St. Gall,' 
 TJnterivalden (excepting a small spot of cretinism in the 
 commune of Hergiswyl at the foot of Mount Pilatus), 8chaf. 
 hausen, Zurich (excepting the district of Meilen and therein 
 particularly Oetweil and Stiiffa), Thurrjau, Freiburg (69 cretins 
 and idiots in 1878 in a population of some 110,000, the 
 district of Broye having 18, Glane 16, and Greyerz 14),^ and 
 Geneva. The following is a list of the cantons with endemic 
 cretinism, showing the proportion of cretins per 1000 in- 
 habitants : 
 
 Uri . 
 
 9 pel 
 
 1000 
 
 Vallais 
 
 6 
 
 
 Bern . 
 
 4-2 
 
 
 Orisons 
 
 34 
 
 
 Glarus 
 
 3' I 
 
 
 Basel . 
 
 27 
 
 
 In the Vallais,^ ci 
 
 'etini 
 
 Solothuvn . 
 
 2-3 per 1000 
 
 Vaud . 
 
 2-1 
 
 
 Aargau 
 
 2-0 
 
 
 Liicerne 
 
 1-6 
 
 
 Neil oil atel . 
 
 i'3 
 
 
 Ticino 
 
 13 
 
 
 lais,^ cretinism is commonest in the upper part 
 of the Rhone valley (in Martinach, Fully, Saillon, Sitten, 
 &c.) and in the valleys of the lower part of the canton. 
 In Uri it occurs most in the valley of the Reuss (in Silenen, 
 Wasen, Schaddorf, Attinghausen^ Altdorf, Seedorf, and 
 Fliielen). In the Grisons, where the malady has diminished 
 considerabl}^ of late,^ the chief spots of cretinism occur in the 
 district of Yordcrrhein (Disentis, Somwik, Ilauz, Kiistris 
 and other places in the Oberalp valleys) ; further, in the 
 circle of Thusis (in Thusis, Kiitzis, and especially Domleschg), 
 in the circle of Maicnfeld (Trimmis, Zizers, Ems), and at 
 several points in the Lower Engadiue, such as SchulsJ 
 
 > 'Brit. Med. Journ.,' j868, Oct., 393. 
 
 '•' Meyer-Ahrens, ' Suliwciji. Zeitschr. f. Med.,' 1852, 173. 
 
 •* ' Rapport . . . sur I'inspcctiou geii. des aliunes dans lo canton Fribourjr,' 
 Bulle, 1878, 13; see also Berchtold-Beaupre, 'Diss, sur le crctiuisme,' Fribourg, 
 1843, as to the disease in the Gottei'anthal. 
 
 * Schneider, in ' Bcrncr Vierteljahrschr.,' 1840, and 'Zeitschr. dcr Wicu. 
 Aerzte,' 1845, 97. 
 
 * Meyer-Ahrens, in Rusch, I.e.; Fauconucau-Dufrcsne, 'Revue med.,' 1846, 
 June; Chatin, ' Compt. rend.,' 1853, i, 652, 
 
 ^ Lorenz, ' Jahresbcr. dcr naturforscli. CJescllseh.Graubundcus,' 1868-69, 65. 
 7 Meyer-Ahrens, in ' Ililser's Arch.,' 1. c; Erlenmeyer, ' Prcuss. mcd. Vereiiis-
 
 132 GEOGRAPHICAL AND HISTORIOAL PATHOLOGY. 
 
 Principal scats of cretinism in Appenzell are tlie communes 
 o£ Grub, Relitobel, Eeute, Walzenhausen and Heiden ; in 
 Glarus, tlie Linthtlial, Sernftlial and Krauclithal (especially 
 tlie localities of Engi, Matt, Elm, and BetscHwand) ; in 
 Basel the commune of Kleinliiiningen^ ; in Va2id the Ehone 
 valley (especially about Aigle and in Boisnoir), the upland 
 valleys of tlie districts of Chateau d'Oex and Ormonds (Sepay, 
 Rossinicre and Rougemont), and the valley of Broye (districts 
 of Mondon and Payerne).^ In the Canton of Aarcjau, the 
 disease is most prevalent in Aarau and Lenzburg in the 
 Aarthal, and near the confluence of the Reuss and Limmath 
 (Altenburg, Windisch, Reuss, Gebensdorf and Vogelsang).^ 
 In the Canton of Lucerne, mostly in the districts of Zursee, 
 Willisau and Entlebuch (notably in Romoos). The cretins 
 in the Canton of Ticino in 1855 were distributed as follows : 
 51 in the district of Bellinzona, 33 in Riviera, 30 in Lugano, 
 and 49 in the remaining districts. 
 
 At every place in Switzerland where endemic cretinism is 
 met with, there is also a considerable amount of endemic goitre; 
 but goitre is endemic at many places in Switzerland besides 
 these, notably in the Prattigau and Puschlav (Grisons), in the 
 parts of St. Gall bordering the lakes, in the Canton of 
 Schaffhausen, and in Geneva.* 
 
 The centi-es of disease in the Grisons and in Lombardy 
 join on to an endemic area of goitre and cretinism in the 
 Alpine provinces of Austria.^ In the Tyrof we meet with 
 both diseases chiefly in the Innthal and in the Vintschgau ; in 
 the Duchy of SahhirgJ at a few points in the Salzachthal 
 Ztg.,' 1854, Nr. 7, and ' Arch, dcr deutsch. Gesellscli. fur Psychiatrie,' 1859, 
 
 i, 13- 
 
 ' Erlenmejer, ' Arch.,' \. c Ou the BaseUand, with about 4000 inhabitants, 
 
 there are 28 cretins; in Basel town, with 24,000 inhabitants, 64 cretins, of whom 
 24 are in Kleinhuningen alone (with 465 inhabitants). In the Canton of Basel 
 cretinism is also on the deci'ease. 
 
 2 Lebert, ' Arch, fiir ph.ysiol. Heilkde.,' 1848, vii, 516 ; Account in ' Schweiz. 
 Zeitschr. fur Med.,' 1852, 365. 
 
 3 Zschokke, ' Annal. dcr Staatsar/.neikde.,' v, 537; Michaelis, ' Skizze der 
 Verbreitung des Crctinismus im Aargau,' Aarau, 1843. 
 
 •» Coindet, ' Annal. de Chimie ct de phys.,' xv, 49. 
 
 '=> Skoda, ' Referat iiber den Inhalt der Berichte, welche iiber den Cretinismus 
 in dcr ostcr. Monarchic eingelaugt sind,' Wien, 1861. 
 ^ See Gautieri and Mittermayer, 11. cc. 
 ' Michaelis, in Blumcnbach's 'Med. Bib!.,' 1789, iii, 640; Wenzel, 'Ueber den
 
 ENDEMIC GOITRE AND CEETINISM. 133 
 
 near Salzburg, at Hallein and Grolliug and as i-av up as 
 Werfeu, tlience laterally to Eadstadt and along tlie Salzacli 
 towards St. Johann,^ then in tlie Pongau valley (on the 
 southern slopes of the Tannen-Gebirge), in Lungau and in the 
 Pinzgau-Thal (at Niedersill, Mittersill and particularly at 
 Bramberg) . The goitrous districts in Gross-Arlthal and the 
 Gastein valley are free from cretinism. In Upper Austna~ 
 the chief seats of both maladies are the banks of the Danube 
 and the Traun : in the Danube valley, the villages of 
 Engelhartszell, Strudin, St. Nikola, Steyeregg, Sarmingstein ; 
 in the Traun circuit, the shores of the lake, the low grounds 
 of the Enns and Traun (Steyer, Losenstein, Garto, Enns), and 
 the marshy Kremsthal. In Lower Austria^ also, goitre and 
 cretinism occur mostly in the valley of the Danube (villages 
 of Gross-Pochlarn, Seisenstein, Krumm-Nussbaum, Worth 
 and Grading), and, next to it, in the valley of the Leitha, 
 particularly in the district of Sebenstoin. Both diseases are 
 prevalent very considerably in Styria and Garinthia, in the 
 latter to such an extent that about 9 per 1000 of the popu- 
 lation are cretins, the province being unable to send a full 
 contingent of troops proportionate to its population.* In 
 Styria,^ the cretins are 7 per 1000, the worst seats of the 
 malady being the circle of Judenburg (especially the Ennsthal 
 and Peltenthal) with 21*3 per 1000, and the circle of Bruck 
 (especially the districts of Pernegg and Marzzuschlag) with 
 1 5*4 per 1000, while the circles of Marburg, Gratz and Cilli 
 are less severely affected, the two latter having respectively 
 
 Cretinismus,' Wien, 1802 ; Streinz, in ' Oest. mcd. Jahrbb.,' 1829, Nste. F., i, 45 ; 
 Knolz, ib., 86, 146; Kirchuer, ib., 1835, ix, 395; Hofer, ' Wiirttcmb. med. Cor- 
 respondenzbl.,' 1838, viii, 161 ; Maffei, ' Der Cretinismus in den norischen Alpen.' 
 Erlang., 1844; Klebs, ' Studien iiber die Verbreitung des Cretinismus in Oester- 
 reich, u. s. w.,' Prag., 1877. 
 
 1 In St. .Tohann and two adjoining villages, with a total of 1557 inhabitants, 
 there are 91 cretins, or 58"4 per 1000 of the population. 
 
 2 Gugger, ' Oester. med. Jahrbb.,' Nst. F., 1839, xix, 85 j Ozlberger, ib., 1840, 
 xxiv, 265 ; Schaussberger, ' Oester. med. Woehenschr.,' 1842, 1091. 
 
 3 Schaussberger, 1. c; Knolz, ' Oester. med. Jahrbb.,' 1846, iv, 228. 
 ■» Fradeneck, ' Zeitschr. der Wien. Aerzte,' 1844,1, 440. 
 
 ' V. Vest, 'Salzb. med.-chir. Ztg.,' 1831, Nr. 46, ii, 3375 Waser, 'Oest. med. 
 Jahrbb.,' 1836, Nste. F., xi, 349 ,• Weiglein, ib., 1842, i, 278; Pilz, ib., 1848,1, 
 357, iii, 80, and 'Oest. med. Wochenschr.,' 1846, 293; Tengler, ' Wien. med. 
 Wochenschr.,' 1857, Nr. 11; Kostl, 'Der cndemische Cretinismus, u. s. w., 
 Wien, 1855.
 
 134 GEOGRAPHICAL AND HISTORICAL rATHOLOGY". 
 
 2'g and 2'o per looo. The valley of tlie Drave is absolutely 
 free from goitre and cretinism, and that is true also of the 
 Duchy of Caruiola.^ Again, the diseases do not occur endemi- 
 cally in the Alpine region of the South Slavonic provinces of 
 Anstria (Croatia and Dalmatia), oi% in other words, on the 
 eastern spurs of the Carnic and Julian Alps," small centres 
 of goitre being found at only two villages in the frontier 
 district of Warasdin,^ 
 
 A second centre of goitre (here and there also of cretinism), 
 but far inferior in extent to those of the Alpine countries, 
 is met with in the slopes and valleys of the Oarpatlhians, as, for 
 instance, in a few mountainous districts of Wallacliia and 
 Moldavia,* where cretinism, however, is for the most part 
 merely sporadic. The diseases are endemic in Transijlvania 
 in the circles of Hermannstadt, Kronstadt^ and Bistritz 
 (district of Rodna^), as well as at a few localities in the 
 Military Frontier (Banat), such as Orsowa, where goitre alone 
 occurs, and in the mountainous parts of Bulwwina^- where 
 cretinism is endemic at only one village in the southern 
 divison of the country. For Hungary^ we liave accounts of 
 endemic goitre from the administrative department of 
 Grosswardein (valleys of the Koros and Temes) ; from the 
 counties of Marmaros, Heves (around Erlau, Bodony and 
 other places), Zips, Gomcir, Hontli (Schemnitz), Bars (Krem- 
 nitz), and Neutra (Altgebirg, Herrengrund, Utmannsdorf) on 
 the right bank of the Danube ; from the counties of Pesth, 
 Raab and Wieselburg ; from the mountainous districts of 
 Western Hungary, the eastern spurs of the Norican Alps, the 
 Bakonyan Forest, the county of Eisenburg, and the valleys 
 
 ^ Fradeneck, L c. 
 
 ^ LaiuLl, ' Zeitschr. der Wieu. Aerzte,' 1853, ii, 58. 
 
 ^ Miiller, * Oest. med. Jalirbb.,' 1843, iv, 343. 
 
 '' Dobronrawow, iu * Heckcr's Annal. der gcs. Heilkde.,' 1835, xxxi, 34r ; 
 Barascli, ' Wien. ined. Wochensclir.,' 1854, Nr. 52; Champouillon, 'Mem. de 
 med. milit.,' 1868, Mars, 191. 
 
 ■' Mcyr, ' Wocheubl. der Zeitschr. der Wien. Aerzte,' 1861, Nr. 46, 370. 
 
 ^ Miiller, 'Oest. med. Jahrbb.,' 1843, iv, 344. 
 
 7 Mayer, 'Diss, dc strumis, &c.,' Hauiiov., 1817; Hampeis, 'Oest. med. 
 Jabrbb.,' 1846, iii, 109. 
 
 s Zipser, ' Mag. fiir Pharraacie,' 1826, Feb., 179 ; Lantz, ' Oest. med. Jahrbb.,' 
 1846, ii, 354; Olatter, iu 'Wocheubl. zur Zeitschr. der Gesellscb. der Wiener 
 Aerzte,' 1870, Nr. 38 ; Saint-Lager, ' Etudes,' 379.
 
 ENDEMIC GOITRE AND CRETINISM. 135 
 
 of tlie Danube and Drave within the county of Baranya. 
 Throughout Hungary, cretinism appears to be mostly sporadic. 
 The endemic occurrence of goitre in Oalizia, on the northern 
 slope of the Carpathians, is reported by Rohx^er,^ for the 
 circle of Wadowice (in the Mittelgebirg, from Zywiec and 
 Slemin through Makow and Jordanow to the villages south 
 of Myslovice). Kazubowsky" adds to this the statement that 
 the focus of disease has its commencement as far off as 
 Droguila ; that the malady is more frequently met with the 
 farther one penetrates into the mountains, as at Myslenice, 
 Stroza, Pcim, Kaszina, and Lubuia, decreasing as an endemic 
 towards the central Carpathian chain and disappearing 
 altogether around Neumarkt ; and that, in all these 
 localities, cretinism is indigenous along with goitre. 
 
 On the plateau of Southern Germamj there existed in the 
 earlier half of this century, a considerable centre of cretinism 
 in Lower and Middle Franconia (Bavaria),^ bounded by the 
 Spessart, the Rhongebirg, the Steigerwald and the Hassberg ; 
 but, in recent times, it has diminished materially, being now 
 limited in Central Franconia to Iphofen, a village where it 
 was always most intense, and to the villages of Einersheim, 
 Etzelheim and Hellmitzheim, and, in Lower Franconia, to a 
 few villages around Windsheim and Uffenheim, and to the 
 districts of Kitzingen and Gerolzhofen. Of goitre, there are 
 still considerable centres in Upper Bavaria, in the side valleys 
 of the Inn (near Rosenheim), of the Alz (at Trostberg), of 
 the Salzach (at Burghausen and Titmoning), the Traun, 
 Vilz, Isar, Lech, Iller and Wertach ; but there is no definite 
 information as to the extent of these endemics. 
 
 In Wurteviherg, goitre and cretinism have attained a much 
 wider diffusion than in Bavaria, although here also there has 
 been a material diminution (of cretinism) in recent years. 
 
 I 'Oest. med. Jahrbb..' 1845, iii, 353- 
 
 == lb., 1843, iii, 248, 376. _ J T. ^1 • e . 
 
 3 See Sensburs-, 'Der Cretinismus im Untennam- und Rezatkreise, inc., 
 Wlii-zb., 1825; Rosenthal, ' Ueber den Cretinismus, u. s. w.,' Miinch., 1839; 
 Hoffmann, 'Eini-es iiber den Cretinismus, &c.,' Wiirzb., 1841 ; Stahl, «Ver. 
 handl. der Leopold. Akad.,' xxi. p. i, 329 5 Vogt, ' Wiirz. phys.-med. Verhandl.,'^ 
 1856, vi, 431, 1858, ix, Sitzuugsber. viii ; Virchow, ' Gesammclte Abbaudl., 
 Frankf. a/M., 1856, 891; Major, ' Bayr. iirztl. Intelligenzbl.,' i860. Nr. 2,46; 
 liudel, ib., 1882, Nr. i ff.
 
 136 GEOGEArHICAL AND HISTOKICAL PATHOLOGY. 
 
 According" to tlie special accounts before me from that kint^- 
 dom/ which do not certainly go farther back than the middle 
 of the present century, the number of cretins in the circles of 
 the Jaxt, Neckar and Black Forest, amounted to 3'8 per 
 looo of the population; in the circle of the Danube, again, 
 cretinism occurs only in the village of Langenargen, situated 
 on an absolute level by the Lake of Constance, while goitre 
 exists to a slight extent in a few valleys of that circle (at 
 Blaubeuren and in the valley of the Ach)." The centres of 
 cretinism in the Jaxt circle join on to the above-mentioned 
 endemic in Lower Franconia, and include an important one 
 in the Tauberthal (Mergentheim), as well as considerable 
 spots at Gerabronn, Crailsheim and Ellwangen in the Jaxtthal, 
 at Schorndorf in the lower Remsthal, and at CEhringen, 
 Kiinzelsau, Gaildorf and Hall, which are respectively in the 
 E-oththal, Kocherthal and Blihlerthal. In the districts 
 belonging to the Swabian Alp (Aalen, Neresheim and Heiden- 
 heim) the disease occurs only to a limited extent in a few 
 valleys. Goitre is everywhere more or less prevalent where 
 cretinism is, and to such, a degree in the department of 
 Hall that, out of looo conscripts, 154 Avere discharged as 
 unfit for service on account of goitre. In the circle of the 
 Neckar, goitre and cretinism have their head-quarters in the 
 Remsthal and at Waiblingen in the Wieslaufthal opening 
 into it ; next in order come the various valleys within the 
 communes of Yaihingen, Maulbronn, Brackonheim, Marbach, 
 Backnang and Weinsberg, together with the valley of the 
 Enz ; whereas in the valley of the Neckar itself, where goitre 
 is endemic and, in some places, very common, cretinism is 
 for the most part found only in sporadic cases, but in occa- 
 sional villages to a more considerable extent. In the circle 
 of the Black Forest, goitre and cretinism occur mostly in the 
 
 ^ See Eiedle, 'Beitr. 7,ur mcd. Statistik Wiirttembcrgs,' Tiib., 1834; 
 Plieninger, ' Eesclireibuug vou Stuttgart, &c.,' Stiittg-., 1834, 115; Memminger, 
 • Beschreibung des Konigreicbs Wiirttemberg,' ix ; Kerner, ' Wiirttembcrg. 
 med. Correspondenzbl.,' 1839, ix, 202 j HOfer, ib., 275; Diirr., ib., 1840, x, 25 ; 
 Roscb, ' Untersucliuugen liber den Cretinisraus in Wiirttemberg,' Erlaiig., 1844; 
 Faber, 'Wiirttemberg. med. Correspoudenzbl.,' 1858, 220 ft".; Ludwig, ib., 
 1868, 159. 
 
 ^ Erleumayer, ' Preuss. med. Vereius-Ztg.,' 1S54, Nr. 7, 52; Voetscb, 'Wiirt- 
 temberg. med. Correspondenzbl.,' i866, iMr. 22, 327.
 
 ENDEMIC GOITRE AND CRETINISM. 13'3 
 
 communes of Rottweil, Oberudorf, Snlz and Freudenstadt ; 
 next to tliese^ in the Nagoldtlial and its side valleys, more 
 rarely and at more circnmscribcd spots in tlie valleys of the 
 Neckar and Aramer (in Horb, E,ottenbnrg, Tubingen, and 
 Herrenberg), At the highest points of the Black Forest, 
 neither of the diseases occurs at all. In Sigmaringen, they 
 are both found endemic in a side valley of the Neckar, on the 
 northern slope of the Alp.^ 
 
 The extent of cretinism in Baden is known to us very 
 imperfectly ; certainly there is no reliance to be placed upon, 
 the statement" that there were only 490 cretins in 1849 i^^ 
 See-kreis 54, in Mittelrhein-kreis 24, in Oberrhein-kreis 129, 
 and in Unterrhein-krois 223) ; for 260 cretins were counted'' 
 in the commune of Neustadt alone (See-kreis), and in Neu- 
 denau on the Jaxt (Unterrhein-kreis) they amount to 20 per 
 1000 of the population.^ The more particular accounts relate 
 to endemic cretinism in Paradies (suburb of Constance), 
 Hornberg, Lorrach and Sackingen (Oberrhein-kreis), to the 
 commune of Offenburg (Elgerswegen on the Kinzig, and 
 Ebersweiher), and to the village of CEschelbronn on the right 
 bank of the Enz (Mittelrhein-kreis) ; further, to Wiesloch, 
 Mosbach, Neckargemiind, Neudenau, the village of Rosenberg 
 in the commune of Adelsheim (Unterrhein-kreis), Hammer- 
 eisenbach (commune Neustadt, See-kreis), and to a few valleys, 
 of the Black Forest. 
 
 Weber's^ results, collected from the Baden recruiting-lists, 
 from 1 849 to 1855, afford us a moderately safe means of esti- 
 mating the amount of goitre in that country. According to 
 these, the number of persons declared to be unfit for service 
 because of goitre was, for the whole country, 39 per 1000 of 
 those examined. The cases grouped themselves, according 
 to locality, as follows : 
 
 I. From communes situated altogether in tlie plain . 17-1 per 1000.. 
 II. From communes on the plateau . • • • 3''4 >> 
 
 HI. From communes in hilly districts .... 36'8 „ 
 
 1 Heyfeldcr, in Schmidt's ' Jahrb. dor Med.,' 1837, xvi, 90. 
 
 - Ei-lenmeyer, 1. c, and ' Arch, dor deutsch. Gusellsch. fur Psycbiatr.,' 1859^ 
 i, 14. 
 
 ■i llossknecht, • Mitlhcil. des bad. arztl. Vereliis,' 1854, 25. 
 
 4 Guerdau, 'Auual. dur Staatsarzneilcdc,' xi, 599. 
 
 5 'Mittheil. des bad. iirztl. Vereius,' 1S57, 27.
 
 138 
 
 GEOGRAPHICAL AND HISTORTCAL PATEOLOGY. 
 
 IV. From communes on tlie plain, but surrounded by- 
 more or less lofty mountains 
 Y. From tlie lower mountain communes 
 YI. From tlie Lio-li mountain communes 
 
 . 44"o per looo. 
 
 . 48-0 
 
 . 56-8 „ 
 
 The largest number of goiti'ous cases (from 5 to 10 per cent, of tlic 
 men inspected) came from the following communes : 
 
 Wieslocli . 
 
 50*0 pel 
 
 • 1000. 
 
 Freiburg . 
 
 . 6o-o 
 
 per 1000 
 
 St. Blasien . 
 
 53-2 
 
 
 Rastadt 
 
 600 
 
 » 
 
 Triberg 
 
 53'2 
 
 
 Staufen 
 
 611 
 
 >> 
 
 Mosbach 
 
 53"3 
 
 
 Bonndorf . 
 
 613 
 
 >> 
 
 Hornberg . 
 
 . 536 
 
 
 Bretten 
 
 6r8 
 
 j> 
 
 Siickingen . 
 
 • 53"9 
 
 
 Salem 
 
 697 
 
 5> 
 
 Jestetten . 
 
 54-1 
 
 
 Neckargemiind . 
 
 70-2 
 
 J1 
 
 Constanz . 
 
 545 
 
 
 Sclionau . 
 
 . 70-8 
 
 J> 
 
 Ueberlingen 
 
 55-3 
 
 
 Wolfach . 
 
 709 
 
 J> 
 
 Heidelberg . 
 
 • 57-2 
 
 
 Waldshut 
 
 75-4 
 
 JJ 
 
 MiUlheim . 
 
 57"3 
 
 
 Pforzheim 
 
 84-8 
 
 )> 
 
 Neustadt . 
 
 • 579 
 
 
 Lijrrach . 
 
 • 963 
 
 5> 
 
 Pfullendorf 
 
 579 
 
 
 Stiihlingcn 
 
 105-2 
 
 5> 
 
 The returns of goitre and cretinism for Alsace and Lorraine 
 belong to tlie time when these provinces were under French 
 rule. According to a rather old account by Tourdes,^ there 
 was a somewhat considerable amount of both diseases in 
 Lower Alsace, in the valley of the Rhine, and more particu- 
 larly in the plain between the Rhine and the 111 ; and it was 
 found cndemically in the valleys of the Vosges and in two 
 villages of the Canton Schlettstadt." The following figures 
 were collected in 1852 : 
 
 AiTond. Strassburg, in 16 villages, 160 goitrous, 99 cretins. 
 ,, Schlettstadt, ,,17 „ 656 ,, 26 „ 
 
 Weissenburg, „ i „ 8 „ — 
 
 „ Zabern, „ 4 „ 50 „ ? „ 
 
 In that province also there has been noted a gradual 
 diminution of the disease, and the same is true of Lorraine,^ 
 where, according to Allaire* and Richon,^ goitre is now ende- 
 mic in a few villages near Diedenhofen and iu the Canton 
 
 * ' Du goitre a, Strasbourg,' Strasb., 1854. 
 
 ^ Diclelot ('Hist, do la soc. de med. de Paris,' 1780,1!, 119) had previously 
 •called attention to those two centres of goitre and cretinism. 
 
 ^ Siinonin, ' llecliercli. topogr. et nied. sui- Nancy,' Nancy, 1854, 415. 
 ■» ' Mem. de med. milit.,' 186 1, May, 365. 
 ^ lb., 1869, August, 97.
 
 ENDEMIC GOITEE AND CRETINISM. 139 
 
 of Metz. According to the official returns published by 
 Baillarger/ in every looo conscinpts there were discharged 
 as unfit for service by reason of goitre or cretinism, as 
 follows : 
 
 Depart. Haut-Rliin, 33 per 1000 for goitre, 27 for cretinism. 
 Bas-Rliiii, io"8 „ „ 2-7 „ 
 
 Moselle, 30-5 „ „ 3-8 
 
 In the Falatinate there are minor centres of goitre and 
 cretinism at Rheinzabern (14 cretins among a population of 
 2130), at the village of Glanmlihlenbach in the Glanthal, at 
 Hagenbach (13 cretins in a population of 1269) and Neuburg 
 (18 cretins among 1700 inhabitants), both of these in the 
 Canton of Kandel, and at Edigheira (8 cretins among 600 
 inhabitants)." Cretinism and goitre are found somewhat 
 frequently at other parts of the country besides these, parti- 
 cularly Landau," but not in the form of a true endemic 
 malady. 
 
 In the Grand Duchy of Hesse there are a few centres of 
 both diseases in the valley of the Neckar, in the valleys 
 of the Odenwald and in Yogelsberg ; according to the official 
 returns made in 1854, there were 151 cretins and idiots iu 
 the whole country, of whom 14 belonged to the province of 
 Rhenish liesso, 25 to Upper Hesse, and 112 to Starenburg. 
 These data, however, are quite unreliable. Far from trust- 
 worthy, also, is the enumeration of cretins made the same 
 year in BhenisJi- Prussia. The subsequent inquiries of Erlen- 
 meyer^have shown as a general result — that goitre is extremely 
 rare in the departments of Cologne and Aix-la-Chapelle ; 
 rather more common in the dejDartment of Diisseldorf, but 
 still merely sporadic ; properly endemic in the department of 
 Treves (where there is even a small spot of cretinism at the 
 village of Russhiitte in the circle of Saarbriicken) ; while the 
 department of Coblenz forms the head-quarters of both dis- 
 eases. In that department, goitre is mostly indigenous in 
 the circles of Zell, Kochem, St. Goar, Mayen, Ahrweiler, 
 
 ^ Yide supra, -p. 128. 
 
 - Erlcumeyer, 'Arch.,' 20; Herbergcr, in ' Wiirz. phys.-med. Verhandl., 1852, 
 ii, 270 ; Hermann, 'Blatter fur gericlitl. Med.,' 1882, 128. 
 ^ Pauli, 'Med. Statist, der Stadt Landau,' Land., 183 1, 176. 
 * ' Archiv fiir Psychiatric,' 1858,1, 97.
 
 140 GEOGEAPHICAL AND HISTORICAL TATHOLOGY. 
 
 Neuwied and Coblenz^ all of thera riparian. Tiro number 
 of cretins (estimated by Erlenmeyer at looo for tlie wliole of 
 Rhenisli Prussia) amounts in tlie department of Coblenz to 
 1 68 (under twenty j^ears) ; of these 104 occur in tlie circle of 
 Coblenz itself, chiefly at the village of Metternich (munici- 
 pality of Bassenheim), and on the Hhiue island of ISliederworth 
 (municipality of Vallendar), where there are 56 cretins in a 
 population of about 800. 
 
 When we come to Central and Northern Germany, cretin- 
 ism disappears almost entirely as an endemic malady. Of 
 endemic goitre there are considerable centres in the depart- 
 ment of ]Vic,shaile)L — in certain valleys of the E,hine, Main, 
 Lahn, Dille, and Aar, as w^ell as on the slopes of the Taunus 
 and the Westcrwald.^ In the recruitino- returns from tho 
 quondam Arch-Duchy of Nassau for the years 1831-40, tho 
 number of those pronounced unfit from the respective districts 
 was as follows per 1000 examined : 
 
 Braubach 
 
 . 28 
 
 Nassau 
 
 15-2 
 
 Weilburg 
 
 • 19 
 
 Eltville 
 
 14 
 
 Runkel 
 
 • 17 
 
 Montabaar . 
 
 13 
 
 Heiborii 
 
 • 1 6-5 
 
 Hocbst 
 
 12 
 
 Konigstein . 
 
 . 16 
 
 Langenscliwalbacb . 
 
 ii'3 
 
 Dillenburg . 
 
 . 16 
 
 St. Goarshausen 
 
 II 
 
 In the quondam principality of Hesse (corresponding to 
 the present department of that name) there are considerable 
 foci of goitre among the spurs of the Rhon mountain, in the 
 valleys of the Werra and Fulda, and especially in the circles 
 of Eschwege, Witzenhau'sen, and Kothenburg.^ It occurs to 
 a still greater extent on the southern slope of the Thuringian 
 Forest in the domain of Schmalkalden,^ where cretinism is 
 met with as well as goitre, pai^ticularly in the districts of 
 Schmalkalden, Brotterode, and a few villages in the Schleu- 
 singen cii'cle and in the Arch-Duchy of Saxe-Meiiingen" 
 From thence tho goitrous zone stretches in a wide sweep over 
 
 ' lb., 24 ; Falck, ' De iliyreoplijuiat. cudemico per Nassoviam et Ilessiaiu 
 Electoralein,' Marburg, 1843, and in 'Casper's Wocbuuschr.,' 1844, Nr. 8; 
 V. Fr.%nquc, 'Nass. nied. Jabrbiicber,' 1859, xv, xvi, C19. 
 
 2 Falck, 1. c. 
 
 3 Fucbs, ' Pliys.-nu'd. Topogr. des Kreises Scbm.alkaldcu,' Marburg, 1848 ; 
 Kircbboff, ' Mittbell. des Vereins fiir Erdkunde,' iSSo, 65, 
 
 * llehm, ' Zeitscbr. I'iir Kpideuiiologie,' 1870, Nr. 2.
 
 ENDEMIC GOITRE AND CRETINISM. 141 
 
 a number of upland villages in the Eisenacli country to Muns- 
 bacli (Gotlia)j Sonneberg^ and Griifentlial, to Hildburgliausen 
 and otlier places in Saxe-Meningorij to Rulila, and to many 
 localities in the valley of the Saal, and from Rudolstadt to 
 Jena and as far down as Dornborg.^ 
 
 A quite isolated little spot of goitre and cretinism is met 
 with at the village of Anraff situated in a deep- cleft valley 
 of the principality of WaldecJc." Bat in the Harz^ goitre 
 reaches a considerable diffusion, although the cretinism that 
 used to exist there appears to have now quite disappeared.'* 
 Also in the high valleys of the Erzgehirge, both on the north- 
 ern or Saxon side (Annaberg, Schweizerberg, Schneebcrg, 
 and the foot-hills in Tai'ant, the Muldethal, and around Frei- 
 berg)/ and on the southern or Bohemian side ; as well as in 
 the valleys of the Sudetic Mountains,^ equally among their 
 northern or Silcsian spurs and their southern or Bohemian.'^ 
 In all these regions last mentioned, cretinism occurs only 
 sporadically. The plain of North Germany and of the Nether- 
 lands is quite free from endemics both of cretinism and of 
 goitre. 
 
 1 See Witticli, in ' Baldinger's N. Maj,'.,' 1785, vii, 114; Loiler, ' Observ. 
 qiiaed. circa strumam,' Jen., 1796; IlofP, 'Dcr Thiirlngcr Wald ' ; Thieme, 
 ' Der Cretinismus,' Weimar, 1842; Scliwalbe, ' Correspondenzbl. des Thiiringer 
 arztl. Vereins,' 1880, Nr. 5. 
 
 * Robrig, ' Die med.-geogr. Verhaltnissc im Fiirstcntbum Waldeck,' Gott., 
 1857, 6. 
 
 3 Michaelis, Lentin, 11. cc. ; Baunigartcn, ' Ilannov. Annal. fiir die ges. 
 Heilkde.,' 1837, ii, 90. 
 
 * Ipbofeu bad previously called attention to tbis. How mucb foundation tberc 
 may be for Blum's statement (' Hannov. med. Correspondenzbl.,' 185.^, No. 20, 
 p. 153) as to tbc occurrence of cretinism in tbe mining town of Lautentlial, I am 
 unable to say. Hei-se's account (ib., 1850, No. 17) of a centre of cretinism 
 existing in tlio district of Hoya (department of Hanover) is clearly based upon 
 an error of diagnosis. 
 
 5 Ipbofen, Tbieme, 11. cc; Neubof, ' Dresdn. Zcitsclir. fiir Heilkde,' 1827, v, 
 359 ; Petrenz, in ' Oarus and Radius' wocbentl. Bcitr. zur Klinik,' 1833, i, 227 ; 
 Trautzsch, ib., 1834, iii, 346; Meyer, 'Med. Topogr. von Dresden,' StoUb., 1840, 
 256. 
 
 6 Lorinser, ' Preuss. med. Vereius-Ztg.,' 1833, Nr. 12; Hancke, in ' Ilufel. 
 .Tourn.,' 1838, Ixxxvi, Heft 5, 77; Preuss, 'Die klimatiscbcn Verbiiltnlssc des 
 Warmbrunner Tiiales u. s. w.,' Brcsl., 1843. 
 
 7 For tlie distribution of goitre in tbc mountainous districts of Bobemia see : 
 Streinz, ' Oest. med. Jabrbb.,' 1832, Nst. P., ii, 197, 336, 343, 1834, vii, 16; 
 Cartellieri, ib , 1843, ii, 354 J Klcbs, 'Allgcm. Wicn. med. Ztg.,' 1876, Nr. 
 32-34-
 
 142 GEOGEAPHICAL AND HISTORICAL PATHOLOGY. 
 
 In Belgium goitre is found endemically in a few of tlie 
 southern districts (Condroz, les Fagnes, I'Ardeune, la Fara- 
 enne, Luxemburg) ; it is rare in tlie coast districts and in 
 localities on a sandy formation, witli tlio exception of a few 
 villages in the soutliern division of East Flanders ; while in 
 the district of the " polders/^ it does not occur at all. Of 
 cretinism not more than 74 cases have been enumerated in 
 Belgium.^ 
 
 The amount of goitre in England is comparatively large, 
 and it seems that there is more of it in the southern and 
 midland counties than in the northern and mountainous dis- 
 tricts. In the south, one of the larger centres is found 
 among the chalk-hills of Sussex^ (in and around Horsham), 
 and Ham-psliire^ and in the more elevated parts of Surrey,^ 
 particularly Haslemere. In the western counties, goitre is 
 endemic at several places in Monmouth,^ in the Forest of 
 Dean [Gloucester),^ at Worcester, Stourport, and other places 
 in Worcestershire ^ in one district of Cheshire^ and in many 
 parts of Wales ^ In the Eastern Counties, there is a con- 
 siderable centi'e of goitre in Norfolh}^ It is endemic at 
 Eidgemont in Bedfordshire^^ and near Beaconsfield in BucJcs}" 
 In the Midlands, it is endemic in Warwichsltire, in the coal- 
 districts of Notts^^ stretching towards Derbyshire, above all 
 in I) ei'hy shire? '^ itseli (where the condition is so common as to 
 be known colloquially in England by the name of " Derby- 
 shire neck '') and in the hilly parts of Staffordshire}^ 
 
 1 Meynne, 'Topogr. med. tie la Belgique,' Brux., 1865, 317. 
 ' Inglis, 'Treat, on English Broncliocele, &c.,' Load., 1838; Maiison, 
 Researches on the Effects of Iodine, &c.,' Lond., 1825. 
 3 Inglis, Austin, ' Lond. Med. and Phys. Journ.,' 1822, xlviii, 29S. 
 •* Austin. * Holbrook, 'Lond. Med. Repository/ 1817, viii, 288. 
 
 « Currie, ' Glasgow Med. Journ.,' 1871, Feb., 153. 
 
 7 Watson, ' Prov. Med. Transact.,' ii, 194; Addison, ib., iv, 138. 
 
 8 Moffat, 'Brit. Med. Journ.,' 1870, Sept., 340. 
 
 9 Reid, ' Ediub. Med. and Surg. Journ.,' 1836, July, 47, 
 ^^ Reeve, ib., 1809, Jan., 31. 
 
 " Blower, ' Brit. Med. Journ.,' 1857, Nov., 924. 
 
 ^'^ Rurasey, 'Prov. Med. and Surg. Journ.,' 1844, June. *^ Ingl>s> Manson. 
 
 ^* Prosser, 'Account of Broncliocele,' Sec, London, 1769. Lettsoni, 'Mem. of 
 the Med. Soc. of London,' 1792, iii, 489; Manson, Inglis, &c., 'Lond. Mel. 
 and Phys. Journ.,' 1825, liii, 49; Wood, 'Mem. of the Philos. Soc. of Man- 
 chester,' 181 9, viii. 
 
 1* Garner, 'Nat. History of the County of Stafford,' Lond., 1844.
 
 ENDEMIC GOITEE AND CEETINISM. 143 
 
 Lastly^ from the nortliern counties^ we have information of 
 endemics of goitre at Bolton, [Padiham^ Church, and Accring- 
 ton] in LancciHliire^ in Yorkshire^ (especially frequent), in 
 some parts of Durham^ and of Westmorland,'^ in the lead- 
 mine district of Alston Moor (^Onmherland),^ and in the 
 western division of Northumberland. 
 
 In Scotland,^ goitre is much less frequent than in 
 England. The interior of Perthshire'^ and the east coast of 
 Fife^ are given as its chief seats, and there are also centres 
 of it in the southern counties^ — in the east of Wigtonshire 
 and Kirkudbrightshire, in Dumfriesshire and Roxburghshire, 
 in the west of Berwickshire, in the northern districts of the 
 counties of Selkirk, Peebles, and Lanark, and adjoining parts 
 of Ayr, and in the Isle of Arran.-^° The northern counties of 
 Scotland appear to be quite free from it. From Ireland wo 
 have no special information about goitre ; but, according to 
 Low,^^ the disease occurs endemically in a few localities. 
 
 Cretinism is very rare in Great Britain, the endemic 
 centre of it in the village of Chiselborough (near Petherton 
 in the south of Somerset) of which we have an account by 
 Norris^^ as late as 1847, being now quite extinct, according to 
 Fagge^s information.-'^ According to Blackie, cretinism (as 
 well as goitre) is still found on the east coast of Fife and on 
 the east side of Arran, and there is an earlier notice of its 
 occurrence in the latter locality by Reid. 
 
 Norwan/^ and Demnarh are quite free from endemic goitre 
 and cretinism. In Siveden^^ also, apart from minor centres 
 
 ^ Black, ' Transact, of tlic Prov. Metl. Assoc.,' 1837, v, 125. 
 
 2 InRlis, Low, 'Brit. Med. Journ.,' 1878, June, 29, 1882, Jan., 43. 
 
 3 Iriglis. 
 
 4 Watson, Bayers, ' Edinb. Med. and Surg. Journ.,' 1824, Oct., 325. 
 
 5 Savage, 'Lancet,' 1872, July, 20. 
 
 6 Account in 'Med.-Cliir. Beview,' 1825, vi, 243; Bcid, I.e. 
 
 7 Marshall, ' Edinb. Med. and Surg. Journ.,' 1832, Oct., 3,^3. 
 
 8 Blackie, ' Cretins and Cretinism,' Edinb., 1855, 49. 
 
 9 Mitchell, ' Brit. Med.-Chir. Rev.,' 1862. 
 
 '» Blackie, Reid. ^' 'Brit. Med. Journ.,' 1882, Jan., 43. 
 
 1* 'Med. Times,' 1848, Jan., 257. 
 '3 ' Med.-Chir. Transact.,' 1871, liv, 155. 
 " Broch, 'Le royaume de Norvege, &c.,' Christ., 1876, 55. 
 '^ Huss, 'Om Sverges cudein. sjukd.,' Stockh., 1852, 21; Berg, ' Bidr. till 
 Sverigcs uied. Topogr. cch Statistik.,' Stockh., 1853, 47.
 
 144 GEOGRAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 ill a few mountainous districts of Westnianlandsliin,^ the 
 occurrence of goitre is limited to tlie district of Faluh and a 
 few neighbouring villages of Stora Kopparbergslan (Dalarne). 
 In 1867 the whole number of goitrous persons in Sweden 
 was reckoned at 628, of wliom 579 belonged to that one 
 district -^ in the town of Faluh. itself, persons with goitres in 
 1S65 were nearly 7 per cent, of the inhabitants.^ 
 
 In Russia-in-Europe goitre occurs endemically in only a 
 few departments.'^ A minor centre of the disease exists on 
 the shores of Lake Ladoga, botli on the western side around 
 Wiborg and Willmansti'and, and on the eastern side in the 
 valley of the Ojat, especially in two villages on the left bank 
 of the stream (circle of Novaladoga, government of Olonetz) 
 where cretinism also is somewhat common.^ Goitre occurs, 
 besides, at a village in the Government of Vladimir, in and 
 ground the town of Nishni-Udinsk on the Uda,^ to a more 
 considerable extent on the slope of the Ural in the Govern- 
 ment of Perm — in the circles of Tsclierdiin (banks of the 
 Wiscliera), in Werchotui'je (also riparian), Jekaterinburg, 
 Ivungur and Krasso-Ufimssk/ and at various places in the 
 main chain of the Caucasus.^ In Siberia goitre and creti- 
 nism are met with in much wider diffusion, especially in the 
 Government of Irkutsk^ in the valleys of the Lena and its 
 tributaries (in this Government it was estimated that there 
 were in 1870, 34,000 goitrous persons and 161 cretins in a 
 population of about 366,000, the proportion of the goitrous 
 in some villages being from 12 to 25 per cent.) ■^'^ also in the 
 
 ' ' Svcrigcs Sunclhets-KoU.,' Bcrattclsc, 1858, 10. 
 
 - lb., 1867, 31. 
 
 ^ Hallin, ' Nord. incd. Arkiv,' 1870, ii, 53. 
 
 ■• See Baer, ' Zeitschr. der Wiener Aerzte,' i860, 170 (also in 'Melanges 
 biologiques,' ii), and ref. in ' Jonrn. de la Soc. de Statist.,' 1876, Jan. 
 
 5 Frank, 'Beliandl. der Kranklieiteu, &c.,' Berl., 1S35, i^-, 57; Oldekop, ' Mod. 
 Ztg. Russl.,' 1858, Nr. 8. 
 
 ^ ' Bericlit iiber den Volks-Gesundbeitszustand im russ. Reicbe fiir das Jabr 
 1856.' 236. 
 
 ' Heine, 'Med. Ztg. Russl.,' 1857, 244; Berkowski, ib., 1859, Nr. i; 
 Petuohof, ib., 164. 
 
 ^ V. Seidlitz, in ' Vircbow's Arcb.,' i88r, Bd. 86, 168. 
 
 ^ Gmelin, ' Rcise durcb Sibirien,' ii, 282 ; Ermann, ' Reise urn die Erde/ ii, 
 207; Krubse, ' Dorpater Jabresber,' 1833, i, 529; Heine. 
 '•^ Ref. in ' Juurn. de Statist.,' 1. c.
 
 ENDEMIC GOITRE AND CRETINISM. 145 
 
 Government of Tomsk on tlie slopes of tlie Altai range/ and 
 in the Chinese frontier districts beyond Lake Baikal in the 
 circle of Nertchinsk (on Baer^s authority). 
 
 On the Continent of Asia, the headquarters of goitre and 
 cretinism are the northern and southern slopes of the Hima- 
 laya. In the western regions of Asia, the two diseases occur 
 endemically only here and there in Asia Minor, particularly 
 around Bolat, in the valley of the Kutschuk-Mender, in the 
 neighbourhood of Aid in, in Mai'sovan, in the upper valley of 
 the Euphrates (north-east from Ai-abkir), and in Egin.^ 
 Syria/ Arabia/ the table-land of Persia^ and Bokhara'' are 
 quite free from endemic goitre and cretinism. The zone of 
 severe goitre and cretinism in Central Asia begins in the 
 upper basin of the Indus in the Yale of Kashmir (Balti or 
 Lesser Thibet and Ladak)'^ and extends through the moun- 
 tainous parts of the Punjaub/ and the provinces of Garwhal 
 and Kumaon'^ to JSTepaul^*^ and Bhootan.^^ Of the prevalence 
 of the two diseases in the valleys and plateaus of the Hima- 
 laya, we have more particular information only for the 
 southern slope ; although the accounts from Ladak, 
 Nepaul, and Thibet, as well as the occasional references by 
 travellers to the occurrence of goitre in the Mongolian dis- 
 tricts of Thian-chan (Mountains of Heaven), leave no room 
 
 1 Uspenslcy, 'Med. Ztg. Russl./ 1859, 164. 
 
 " Rigler, ' Die Tiirkei uiid deren Bewohner, &c.,' Wien, 1852, ii, 246 ; account 
 in ' Journ. of the Roy. Asiatic See.,' vi, 204. 
 
 3 Robertson, ' Edinb. Med. and Surg. Journ.,' 1843, April, 247 ; Tobler, ' Beitr. 
 zur med. Topogr. von Jerusalem,' Berl., 1855, 56. 
 
 * Pruner, ' Krank. des Orients,' 323. 
 
 * Polak, 'Wien. med. Woclienscbr.,' 1853, Nr. 14. 
 
 " Burnes, ' Calcutt. Med. Transact.,' 1835, vii, 461. 
 
 7 Mir-Izzet-UUah, ' Journ. of tbe Roy. Asiat. Soc.,' vii, 289, 303 ; Thornton, 
 ' Gazetteer, &c.,' Lond., 1844; Frazer, ' Journal of a Tour to the Himalaya, &c.,' 
 .349- 
 
 * Wilson, 'Med. Times and Gaz.,' 1874, Dec, 692; Milroy, 'Transact, of the 
 Epidemiol. Soc.,' 1865, ii, 157 (relating to the district of Simla). 
 
 ^ Bramley, 'Transact, of tbe Calcutta Med. Soc.,' 1834, vi, 181; Bell, ib., 
 457 J M'Clelland, ' Some inquiries in the Province of Kumaon, &c.,' Calcutta, 
 1835, and ' Sketch of the Med. Topogr. . . of Bengal and the N.W. Provinces,' 
 Lond., 1859, 63. 
 
 '" Bramley, Campbell, ' Tran.=act. of the Calcutta Med. Soc.,' 1835, vii, 1 ; 
 Brown, ' Ind. Annals of Med. Sc.,' 1859, Jan., 176. 
 
 " Saunders, ' Philos. Transact.' for the year 1789, L\.\i.x, 93; Gray, ' Lancet,' 
 1877, June, 937. 
 
 VOL. II. JO
 
 146 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 to doubt tliat tlie area of the disease extends also over fhe 
 nortliern slopes of tlie Himalaya ji roper, and over its side- 
 ranges to the north. There is equally little doubt that 
 cretinism is more or less common at many points of this 
 goitre-area, being intensely endemic at a few places.^ The 
 endemic influences which determine the occurrence of both 
 diseases on the slopes of the Himalaya make themselves felt 
 in a very marked degree beyond it, in the partly undulating 
 and partly flat and swampy plain known under the name of 
 Terai, which covers a breadth of sixty miles from the foot of 
 the range, extending between it and the Ganges and 
 Brahmapootra ; this region corresponds to a zone of very 
 intense goitre stretching from Assam, through Rungpeor, 
 Dinajeporc, Purneah, Tirhoot,^ Mallye,^ the plain of Patna* 
 and Bettiah, along the northern frontier of Oudh^ through 
 Gorackpore,*" Buraech, and Pilcabit to Hui'dwar and the 
 borders of Rohilkund.^ In this region also, cretinism is 
 endemic at occasional points.^ 
 
 Fayrer estimates the nuinher of goitrous persons in the Terai at lo 
 per cent, of the population. In the distinct of Tirhoot, Macuamara 
 treated 23,000 goitres in three years, and Cunningham treated 20,000 
 to 25,000 in Gorackpore during the cold season of 1854-55 (Mihoy, 
 Mouat). 
 
 There is a third region of goitre in Hindostan on the 
 plateau of Ramagar, Cliota N"agpore, Sirgooja, and Sumbul- 
 poor, forming the boundary between Bengal and Gondwana 
 and stretching away towards Orissa. In the mountainous 
 districts adjoining Orissa, we meet with cretinism as well as 
 goitre^. In the medical accounts from the Deccan, from the 
 Nilghiri Sills, from the Eastern and Western Ghats, and from 
 
 » M'Clellaud, Wilson. 
 
 ^ Evans, 'Transact, of the Calcutta Med. See.,' 1832, iv, 246; Milroy, Lc. 
 
 3 Tytler, ' Calcutta Tr.,' iv, 375. 
 
 * ' Report of the Dispensaries in the Bengal and North- Western Provinces 
 &c.,' Calcutta, 1843, a. v. O. 
 
 ^ Greenhow, * Iiul. Annals of Med. Sc.,' 1859, July, 435. 
 
 " Mouat, ib., 1857, April, 436, 
 
 7 M'Clelland, 'Sketch,' 112 ; Fayrer, ' Lancet,' 1874, Oct., 580, 617. 
 
 ^ Evans, M'Clelland, Fayrer. 
 
 3 Breton, 'Transact, of the Calcutta Med. Soc.,' 1830," ii, 245; 'Indian Annals 
 of Med. Sc.,' 1858, July, 508.
 
 ENDEMIC GOITRE AND CRETINISM. 147 
 
 the Bombay and Madras Presidencies generally, there is not 
 •a word said of the occurrence of goitre and cretinism. On 
 the other hand, we have information of endemic goitre in the 
 Galle district of Ceylon,^ and of both goitre and cretinism in 
 the mountainous parts of Burmah and Cochin China/ and on 
 the central table-lands of Java and Sumatra^ (districts of 
 Lepoetie and Toelang-Bawang, and particularly the Aboeng 
 •country). In China the two diseases appear to be endemic 
 chiefly in the northern provinces ; in Staunton's ' Account 
 -of Lord Macartney's Embassy to China '* we find mention 
 made of the great frequency of both maladies in Tartary ; 
 Morache^ speaks of them as occurring in Pekin and in the 
 adjoining valleys ; and Dudgeon^ states that goitre is 
 very often met with in Northern China, both on the plains 
 a,nd in the mountains. 
 
 Whether goitre and cretinism be endemic in Australasia 
 I am unable to decide for certain ; the only statements with 
 which I am acquainted are those by Polack'^ and Thomson,^ 
 who agree that goitre is quite unknown in New Zealand, 
 and of Bennet^ to the effect that it occurs sporadically in 
 Tahiti. The absolute silence of all other observers in these 
 regions should warrant us in concluding that endemic centres 
 of goitre are nowhere found there. 
 
 Little being known of the disease-conditions generally in 
 the central parts of Africa, there is accordingly little known, 
 ■of the occurrence of goitre and cretinism in particular ; but 
 what little we do know is not without interest for the etio- 
 
 ^ Bennet, 'Ceylon and its Capabilities,' Lond., 1843; Pridham, 'Historical . . • 
 Account of Ceylon, &c.,' Lond., 1849. 
 
 ' Thorel, ' Notes med. du voyage d' exploration du Mekong et du Cochinchinc,' 
 Par., 1870, 171 ; Beaufils, 'Arch, de med. uav.,' 1882, April, 291. 
 
 3 Marsden, ' History of Sumatra, &c.,' Lend., 1783,42; Heymann, ' Krank- 
 heiten der Tropenlander, &c.,' Wiirzb., 1852, 178; Account in 'Arcli. de med. 
 uav.,' 1867, Oct., 250 J ib., 1877, Feb., 81 ; v. d. Burg, ' De Geneesbecr in Nedel.- 
 Indie,' Batav., 1882, i, 81. 
 
 ■» ' Account of Lord Macartney's Embassy to China,' Ger. Trans. Berl., 1 799, 
 ii, 171. 
 
 = ' Annal d'hyg.,' 1870, Jan., 55. 
 
 « ' Glasgow Med. Journ.,' 1877, J^^^J' .i.^"- 
 
 ' • Manners of the New Zealanders,' Lond., 1840, ii, 98. 
 
 8 'Brit, and For. Med.-Chir. Review,' 1854. 
 
 3 * Lond. Med. Gaz.,' 1832, i.\, 639.
 
 148 GEOGEAPHIOAL AND HISTOEICAL PATHOLOGY. 
 
 logical inquiry. Like the coast regions of all other parts of 
 the world, those of the African continent, and the river-basins 
 adjoining them, are entirely free from endemic goitre and 
 cretinism ; these include Lower Egypt^ the Abyssinian- 
 Basing the Bast and West Coasts^ and the littoral of Algiers."^ 
 On the other hand, goitre is endemic on the Abyssinian 
 Plateau,^ in a few localities in Sennaar,^ on the slopes and in 
 the valleys of the Atlas {e.g. in Kabylia),'^ in the mountainous 
 parts of Morocco,^ and, to a very considerable extent in tha 
 Basin of the Niger. 
 
 The earlier accounts, by Mungo Park and Caille,^ of goitre- 
 on the slopes of the Cong mountains and in the upper basin of 
 the Niger (Bambera and Bambook in the Kankan country) 
 have been supplemented by the lately published information 
 of Quintin,^° whose own observations relate specially to 
 Segu-Sicorro, while he adds the general statement that goitre 
 is widely endemic in the valleys of the Greater Soudan, 
 From the islands lying oif the African coast we have intelli- 
 gence of minor centres of goitre in the mountainous interior 
 of Madagascar^^ and in the Azores ;^" on Madeira the disease- 
 is very rare.''^ Whether cretinism also is indigenous in those- 
 parts, or what its extent may be, does not appear from the 
 accounts ; the French authors are quite silent on the point,, 
 while Quintin explicitly states that he had not seen a single 
 case of it in the Soudan. It is only in the notice about 
 goitre in Madagascar that there is any mention made of 
 cretinism. 
 
 ' Pruner, 1. c, 323. 
 
 2 Courbon, ' Observ. topogr. . . . sur le littoral de la mer rouge, &c.,' Par.,, 
 1861, 35. 
 
 3 Daniell, ' Sketch of the Med. Topogr. of the Gulf of Guinea,' Lond., 1849,114 
 
 * Guyon, 'Gaz. med. de Paris,' 1845, 690; Bertherand, 'Medecine et hyg. des 
 Arabes,' Par., 1855, 409, and others. 
 
 ^ Blanc, ' Gaz. hebdoni. de med.,' 1874, 349. 
 
 * Brocchi, ' Giorn. d'osserv. ... in Egitto, &c.,' Bassano, 1843, v, 597. 
 
 7 Baudouin, 'Gaz. med. de Paris,' 1838, 771; Bertherand, 'Mem. de med.. 
 milit., lii, 115 ; Fiaot, ib., Ivi, 36; Challan, ' Gaz. med. de I'Algerie,' 1868, 117. 
 
 * Leo Africanus, 1. c. 
 
 ^ ' Journ. d'un voyage h Tombouktou,' Par., 1830. 
 
 '" ' Extrait d'un voyage dans le Soudan,' Par., 1869, 46. 
 
 ^' Blunienbach, ' De generis hum. varietate nativa,' Gott., i79S> 261, 
 
 " Bullar, 'A Winter in the Azores, &c.,' Lond., 1841, ii, 331. 
 
 '3 Heiuecken, 'Lond. Med. Eeposit.,' 1824, xsii, 15.
 
 ENDEMTO GOITEE AND CEETINISM. 149 
 
 Our information on tlie endemic occurrence of goitre in 
 
 JSforth America^ belongs for tlie most part to the early years 
 
 of this century and is very fragmentary. Proceeding from 
 
 north to south, we first meet with considerable centres of 
 
 goitre in Hudso7i's Bay Territory^ (below 52° N.), on the 
 
 banks of the Saskatchewan, and at the head-waters of the 
 
 Elk and Peace rivers, where Richardson found many cases of 
 
 goitre among the children of the native Indians. We come 
 
 upon it next in Lower Canada, on the banks of the Lorenzo, 
 
 between St. John and Montreal, and, in Michigan State, in 
 
 the Detroit district on Lake St. Clair. From New England 
 
 there are accounts of the occurrence of endemic goitre in 
 
 Vermont^ (Counties of Bennington and Chittenden, especially 
 
 nt some points on the Connecticut River), and in New Hamp- 
 
 shire,^ where the disease has been mostly found also on the 
 
 banks of the Connecticut. In Neiu York State there exist 
 
 (or did exist) ^ centres of goitre in Oneida County and on 
 
 the banks of the Mohawk and Genesee ; in Pennsylvania 
 
 they occur in Alleghany and Susquehanna^ Counties, and 
 
 on the banks of the French Creek, Sandusky, Monongahela, 
 
 Big Beaver, and Muskingum. Other notices of endemic 
 
 goitre relate to the mountainous parts of Maryland, to 
 
 Virginia (particularly to Morgantown, the principal place in 
 
 the coal-bearing county of Monongalia, and to the banks of 
 
 the Monongahela), to the town of Vincennes {Indiana) on the 
 
 Wabash, to the mountainous districts of North and South 
 
 Carolina, to the northern counties of Alabama'^ where there 
 
 is a good deal of it, and to the district of De Soto [Louisiana^), 
 
 ' See Barton, ' Abliandl. iiber den Kropf. ... in verschiedenen Theilen von 
 Kord-Auicrika, u. s. w.' From the Eugl., Gott., 1802, and Gibson, ' Pliilad. 
 -Journ. of Med. and Phys. Sc.,' 1820, i, 47. 
 
 " llichardson, in Franklin's ' Narrative of a Journey, &c.,' Lond., 1828, [16; 
 Simpson, 'Narrjitive of a Journey round the World,' Lond., 1847. 
 
 3 Mease, ' Observations on Goitre;' Dorr, ' New York Med. Kepos.,' x8o6, x, 
 141 ; Brown, ' Amer. Journ. of Med. So.,' 1847, July, in. 
 
 ■• Mease. 
 
 * Denny (' Philad. Journ. of Med. and Phys. Sc.,' 1825, N. S., i, 47) says that 
 in the town of Pittsburg, which used to have a bad reputation for goitre, no 
 new cases have occurred since 1S06. 
 
 ^ Later information is given by Smith, in the ' Transact, cf the Peunsyvl. 
 •estate Mod. Soc.,' 1858. 
 
 7 Taylor, ' Transact, of the Alabama State Med. Soc.,' 1854. 
 
 •^ Gibbs, in Fenncr's ' South. Med. Beports,' ii, 190.
 
 150 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 particularly tlie banks of the Bayou Pierre. Cretinism does 
 not appear to be at all common except at a few points in all 
 this region ; at any rate it is stated by Barton^ that cases of 
 it are rarely met with in the United States. Brown speaks 
 of its occurrence in the valleys of Vermont ; in Kneeland's^ 
 account of the health of Massachusetts (for which State I have 
 been able to learn nothing of the occurrence of goitre), it is 
 stated that there are at least 1200 idiots and cretins in a 
 population of about one million. Praslow^ also has observed 
 somewhat frequent cases of cretinism among a tribe of 
 Indians living near Cape Mendocino, in California, as well as 
 among the Spaniards in the mountainous parts of Southern 
 California. 
 
 It is in the upper basin of the Rio Grande del Norte (New 
 Mexico) that the great zone of goitre and cretinism begins ; 
 a zone which extends with increasing intensity along the 
 Cordillera through Mexico, Central America, and South 
 America as far as Chili, and forms a region of the disease 
 worthy to be named besides those of the Alps and the 
 Himalaya. The occurrence of endemic goitre in the moun- 
 tainous parts of Mexico had already been pointed out by 
 Gage,'* later accounts^ confirming the fact and placing the 
 head-quarters of the disease in the territory of Colima on 
 the western slope of the Cordillera, and in the mountain- 
 districts of Tobasco and Chiappas. From Chiappas the 
 endemic is continued direct into Ouatemala,^ in the " tierra 
 templada " of which there are whole villages afflicted with 
 goitre, and thence onwards through San Salvador,'^ Nicar- 
 agua,^ and Gosta Bica^ 
 
 In the countries hitherto mentioned cretinism does not 
 appear to occur ; for San Salvador its occurrence is positively 
 
 ^ L. c, 122. 
 
 ' ' Amer. Journ. of Med. Sc.,' 185 1, April, 349. 
 
 3 'Der Staat Californien, &c./ Gott., 1857, 64. 
 
 ^ 'New Survey of the West Indies,' Lond., 1699, 236. 
 
 ^ Heller, ' Wiener Sitzuiigsber.,' 1848, Nr. 3, 122; Matthieu de Fossey, ' Le 
 Mexique, &c.,' Par., 1857, 58 r. 
 
 ^ Gage, Bernoulli, ' Scliweiz. med. Ztsclir.,' 1864, iii, 100. 
 
 7 Dunlop, 'Travels in Central America,' Lend., 1847; Guzman, 'Essai de- 
 topogr. med. de la republique du Salvador,' Par., 1869, 124. 
 
 s Bernhard, ' Deutsche Klin.,' 1854, Kr. 8. 
 
 5 Schwalbe, 'Arch, fiirklin. Med.,' 1875, xv, 344.
 
 ENDEMIC GOITKE AND CEETINISM. 151 
 
 denied by Guzman. On the other hand;, we meet with a very 
 considerable endemic of it in New Granada, yvhich is also the 
 chief seat of goitre. According to data before us^ both 
 diseases occur there throughout almost the whole valley of the 
 Eio Magdalena, from Neyva in the '^tierra fria " downwards 
 through Santa Fe de Bogota, Maraquita, Honda, and other 
 districts as far as the plain of Pinto, at the confluence of the 
 Cauca and Magdalena. Neither in the lower basin of the 
 latter nver nor in the parallel valley of the Cauca, nor in the 
 mountainous province of Antioquia between the two, do goitre 
 and cretinism occur ; but we again come upon them in endemic 
 form in the basins of the Mcta and Apuro. 
 
 The enormous prevalence of goitre in some of those 
 districts may be judged of from the fact that Foote found 
 hardly a single person in Maraquita who was not the subject 
 of it more or less. It is remarkable that it did not happen 
 to this observer to find a single case of cretinism ; whereas 
 there can be no doubt, from the statements of Humboldt and 
 Roulin, and from an earlier account by Caldas," that this 
 disease also is endemic in the Magdalena valley. 
 
 In Venezuela, goitre occurs on the plain between Caracas 
 and Valencia,^ and in the mountain range Avhich stretches 
 from Barquicimeto, by Truxillo, Merida and La Grita, as 
 far as Pamplona and the frontier of New Granada.'* The 
 basin of the Orinoco is said by Humboldt to be free from 
 goitre, and there is no mention either of it or of cretinism 
 in the numerous medical reports that come to us from 
 Gti'iana.^ 
 
 Prom NeAV Granada the zone of goitre is continued along 
 
 ^ Brandin, ' De la influencia de los differentcs climas del uiiivcrso sorbe el 
 hombre, &c.,' Lima, 1826 (on the distribution of goitre and cretinism in Soutli 
 America generally) ; llestrcpo, ' Memoria que el Sccretario de Estada . . .'pre- 
 sento al primero congreso constitucional de Colombia, &c.,' Bogota, 1823 ; Hum- 
 boldt, 'Journal de physiol.,' 1824, iv, 109; Koulin, ' Bevuc med.,' 1825, iv, 138; 
 Boussingault, ' Annal. de chimie et de phys.,' xlvili, 41 ; Foote, ' Amcr. Journ. 
 of Med. Sc.,' 1852, Jan., 278. 
 
 ■■' 'Semenario del nuevo Keyno de Granada/ 1S16, 148. 
 
 ^ St. Imager, 430 (following Dubreuil). 
 
 * Iloulin. 
 
 5 Hille (in 'Casper's Wochensclir. der Heilkunde,' 1836, No. 36) says that it 
 did not happen to him to see a single case of goitre during a residence of many 
 years in [Surinam.
 
 152 GEOGEAPHICAL AND HISTOitlGAL PATHOLOOY. 
 
 tlie Cordillera througli Quito, Cacnca and Loxa (in Ecuador),^ 
 and thence onwards by Caxamarca, Huamacuclio, Huanuco, 
 and Pasco in the valley of the Hualaga, or in other words, 
 through the central valleys oiFcru" and particularly the sierra- 
 valleys of the provinces of Libertad and Ayacucho. Cretin- 
 ism, as Archibald Smith explicitly states, is not indigenous 
 there, and Tschudi makes no mention of it. In Bolivia the 
 chief seats of endemic goitre are the provinces of Yungas 
 and Ayopaya. From Ghili^ we have information of its 
 endemic prevalence around San Felipe, Santiago, and other 
 places. But it is on the eastern slope of the Cordillera, in 
 the States of the Argentine Reimhlic,^ that goitre finds its 
 widest diffusion — in the provinces of Salta, Jujuy, Tucumana, 
 Los Lueles, La Rioja (particularly the Famatina valley), and 
 Mendoza, in a few districts of the provinces of Cordova and 
 San Luis, and at many places in the States of Corrientes 
 and Entre Rois. As regards the coexistence of cretinism 
 with it, I find only one notice by Mantegazza, who mentions 
 it along with goitre in the province of Salta. We enter on 
 a farther extension of this great area of goitre in the river- 
 basins of the mountainous parts of Paraguay,^ and in the 
 goitre-region of Brazil^ which includes a great part of that 
 country, more especially the southern and central provinces 
 of Rio Grrande, Santa Catarina, San Paulo, Goyaz (both the 
 western and eastern slopes of the Sierra Geral, in Natividad 
 
 1 Humboldt. 
 
 2 Smith, 'Ediub. Med. and Surg. Journ.,' 1842, July, 66; Tschudi, ' Oest. 
 med. Wochenschr.,' 1846, 698. 
 
 ' Gilliss, in ' U. S. Naval Astron. Expedition to the Southern Hemisphere, &c.,' 
 Washingt., 1855; Guezenec, 'Arch, de med. nav.,' 1864, juill, 22; Duplou}', ib., 
 aout, 108; Guyon, ' Gaz. med. de Paris,' 1862, 345. 
 
 ■* Smith, 1. c.; Brunei, ' Observ. toj)ogr. et med. faites dans le Eio dela Plata,*- 
 Par., 1842, 47; Guyon, I.e. (on goitre in Mendoza); Mantegazza, ' Lettere med. 
 snlla America meridionale,' Milano, i86_^, ii, 208, 227; Lemos, ' Revista med.- 
 quir. de Buenos Ayres,' 1877, abstract in ' Jahrcsbericht iibcr Mcdicin,' 1878, 
 i> 336. 
 
 5 Mantegazza; Masterman, in ' Dobell's Reports,' 1870, i, 382. 
 
 ® Sigaud, 'Du climat et des malad. du Bresil,' Par., 1844, 162; Gardner, 
 'Travels in the Interior of Brazil,' Loud., 1864; Rendu, 'Etudes topogr. et 
 med. sur le Bresil,' Par., 1848, loi ; St. Hilalre, 'Voyage aux sources du Rio 
 Negro,' Par., 1848, ii, 72 ; Casteluau, ' Expedition dans les parties centrales de 
 I'Amerique du Sud,* Par., 1850; Tschudi, ' Wien. med. Wochenschr.,' 1858, 423; 
 Scbwarz, 'Zeitschr. der Wien. Aerzte,' 1858, Nr. 37, 580.
 
 ENDEMIC GOlTliE AND CRETINISM. 153 
 
 CouceicaO;, Arrayas, Villa-Boa, and the upper basin of the 
 Parahyba), and Miuas Geraes (districts of Barbacena, Ouro- 
 Preto, Sabara and otliers). In other words, it extends over 
 the whole country, excepting the coast territory and the 
 alluvial plains. According to the express statements of 
 Rendu, St. Hilaire, Castlenau and Tschudi, cretinism does 
 not occur endemically anywhere in Brazil ; and it is so 
 rare in its sporadic foi'ui that Dr. Faivre (as reported by 
 Rendu) who lived for a long time in the central pro- 
 vinces (the head-quarters of goitre), and had travelled 
 through them many times, had never seen but one case of 
 cretinism. 
 
 Of the occui-rence of goitre and cretinism in the West 
 Indies I can find no trustworthy information. 
 
 § 40. Instances of Decrease or Increase in Recent 
 
 Times. 
 
 The outline-sketch above given of the geographical distri- 
 bution of goitre and cretinism applies, generally speaking, 
 only to more recent times. A comparison of it with the 
 state of matters in former pei'iods, in so far as the history 
 enables us to follow it, brings out fluctuations in the amount 
 of one or both diseases, either in the way of diminution 
 or even entire diso'p'peara'nce of the endemic, or in the way of 
 more decided iirominence or increase. 
 
 Thus it had been observed by Fodere^ for Piedmont as 
 early as the beginning of this century, that " the number of 
 the goitrous and of the absolutely cretinous has diminished 
 within a few years, a fact which travellers who had visited 
 these valleys twenty years ago, and may now revisit them, 
 can easily convince themselves of." This holds good to a 
 still greater extent for more recent times, as appears from 
 the report of the Sardinian Commission and the statements 
 of Dubini. Some fifty years ago a decrease of cretinism 
 was observed in many parts of Switzerland" — in Lucerne, St. 
 
 1 L.c, 1 89. 
 
 - Mayer-Alireu?, in ' Eusch's Zcitscbr.,' iii, 7, 15.
 
 154 GEOGEAPHIOAL AND HISTORICAL PATHOLOGY. 
 
 Gall_, Scliaffliausen and the Yallais ; and more recently we 
 have accounts to the same effect from Chur-^ and Basel." In 
 the Pyrenees, as Bouliniere remarks, there has been a diminu- 
 tion of the endemic goitre and cretinism within the present 
 century ; and the same is asserted for the department of 
 Puy-de-Dome by Aguilhon/ and by Anzouy for certain valleys 
 of the Meurthe and the Yosges. 
 
 According to Durand/ goitre has gradually disappeared 
 from the valleys of Larboust and d'Oueil, where there were 
 still many cases in 1820. Simonin and Allaire are agreed 
 as to the decrease of goitre in recent times in Lorraine ; in 
 a few communes of the Canton Briey (near Metz), where 
 goitre used to be endemic, it has disappeared since 1789.^ 
 In the Department of Bas-Rhin also, according to Tourdes, 
 a considerable diminution in the endemic goitre and cretinism 
 has been observed. In Rheims, where goitre was formerly 
 very common, the disease occurs now only in isolated cases,^ 
 and the same holds good for Luzarches in the Department 
 of Seine-et-Oise.'' The number of cretins in Middle Fran- 
 conia has declined considerably of late ; whereas, in i860 they 
 numbered 47 at Iphofen, the chief seat of the endemic, in 
 1880 the number had fallen to 12.*^ On the other hand, in 
 Lower Franconia (especially around Gemiind), a slight 
 iucrease of the endemic has been noted.^ From the statis- 
 tics of Eosch^° it follows that, within the last thirty years, 
 cretinism has declined considerably in several parts of Wiir- 
 temberg (Weinsberg, Herrenberg, Gerabronn, Waiblingen, 
 and, more recently, in Schorndorf),-^^ while there has been a 
 small increase in certain communes of the administrative 
 districts of Oberndorf, Horb, Rottenburg and Tettnang. In 
 Thuringia, a few villages of the valley of the Ilm wherein 
 
 ^ Lorenz. 
 
 " Erlenmeyer, 'Arcliiv,' 13. 
 ' ' Gaz, med. de Paris/ 185 1, 135. 
 •* 'Union med.,' 1851, Nr. 32. 
 * Pascal, ' Conipt. rend.,' 1842, ii, 225. 
 « Maumene, ' L'Institut,' 1850, Nr. 870, 2S2. 
 '' Halm, ' Compt. rend.,' 1869, Ixix, Nr. 16. 
 s Majer, Iliedel, 11. cc. 
 3 Vogt, ' Wiirzb. Verhandl.,' 1. c. 
 '0 L. c, 130. " Faber, 1. e.
 
 ENDEMIC GOITRE AND CEETINISM. 155- 
 
 goitre and cretinism used to bo endemic, liave become quite 
 free from botli diseases recently,^ and in Sclimalkalden 
 cretinism lias been considerably less common of late." This 
 is true also of tlie Harz, wliero it can Imrdly be said now 
 tliat cretinism is endemic. In Cliiselbrough (Somerset) the 
 endemic of cretinism, o£ which we have accounts as late as 
 1847, is now quite extinct (see p. 142). The Government of 
 Perm has experienced a decrease in the number of goitrous 
 persons within the last twenty or thirty years ; on the other 
 hand, the endemic of that disease on the banks of the Lena, 
 as well as in the Government of Irkutsk generally, 
 has sprung up since the Russians took possession of the 
 country. 
 
 As early as the beginning of this century, Barton tells us, 
 a decrease of goitre had been observed in certain parts of 
 the United States ; and this statement is confirmed by Denny, 
 who says that, in Pittsburg at the time of the first French 
 settlement, goitre was unknown, that it became common in 
 the years following, so much so that in 1798 there were 150 
 goitrous in a population of 1500, that it remained at this 
 height until 1806, when it began to decline gradually. 
 Wotherspoon^ also states that goitre used to be very frequent 
 around Kent in Maine, but has become a good deal less com- 
 mon since the first thirty years of the century. 
 
 All the observers who have written of goitre in Granada' 
 agree in saying that the endemic, which was originally in the 
 "tierra templada," had spread towards the plateau about the 
 end of last century or the beginning of the present, that it 
 has penetrated as far as the " tierra fria," and has made such 
 enormous strides in some places where it was formerly quite 
 unknown {e.g. Maraquita in the upper basin of the Magdalena), 
 that only a small part of the whole population escape it. 
 According to Gardner's statements, the disease has assumed 
 an endemic character in the district of Natividad (Goyaz, 
 Brazil) since the first thirty years of this century ; and Sigaud 
 in like manner says of the southern provinces of Brazd :. 
 
 ' Hof., 1. c, i, 22. 
 
 2 Kirchofr. 
 
 3 ' Statist. Reports of tlic U. S. Army,' riiilad., 1856, 28. 
 ■* Restrcpo, HumboUlt, lloiilin.
 
 156 GEOGEAPniOAL AND HISTORICAL PATHOLOGY. 
 
 ^' Le goitre endemique daus les provinces de Saint-Paul^ de 
 Sainte Catherine et de Rio-Grrande-du-Sud s^enracine cliaque 
 jour davantage ... II y a vingt ans que cette maladie etait 
 a peine connue dans lo Rio-Grande-du-Sud : aujourd'hui on 
 I'observe dans Ics villes de E-io-Pardo, de Coclieira, etc.''' 
 In Salta (Argentine liepublic) tlie appearance of goitre, 
 according to Lemos, dates from the arrival of the first 
 Spanish settlers). 
 
 § 41. Epidemic outbreaks. 
 
 One of the most interesting phenomena of the kind 
 is the breaking out of goitre in the form of an epidemic, or, in 
 other words, the more or loss abrupt occurrence of cases of 
 goitre within a relatively short space among a section of 
 the population who had been hitherto exempt from the 
 disease. By far the larger number of cases of that kind 
 have occurred in France, and, it would appear, within the 
 present century (only one of the French accounts dating from 
 last century). At all events the occui-rence has been only 
 rarely noted outside France ; but in all cases whatsoever the 
 special external conditions under which the sickness has 
 developed en masse are the same. 
 
 The first account^ from France of a so-called epidemic of 
 goitre (the only one from last century) belongs to the years 
 1783 — 1789, and relates to Nancy. In a regiment which 
 had been quartered for five years at Caen and was moved to 
 Nancy in 1783, 38 men became goitrous in the winter of 
 1783-84, in the following year 205, in the next thereafter 
 (1786)425, then 257 in 1787, after that 132 in 1788, and finally 
 43 in 1789 ; being a total of iioo men out of 4 battalions. 
 At the same time, not a case of goitre occurred among the 
 troops that had been garrisoned in the town for some time 
 previously (excepting a few. cases in a cavalry regiment), nor 
 among the civil population of the town. Further, in this as 
 in almost all the other epidemics among the military, the 
 
 ^ I have t;\ken somo paius to make as complete a collection as possible of the 
 facts about these so-called epidemics of goitre, but the following sketch docs not 
 -by any means claim to be absolutely exhaustive.
 
 ENDEMIC GOITRE AND CRETINISM. 157' 
 
 disease was strictly confined to tlie common soldiers, tlie 
 officers, sergeants, and corporals remaining exempt. '^ From 
 Lorraine we liave only one account, relating to Pfalzburg 
 where goitre broke out in 1820-21, being confined to the 
 garrison as before." Next we have Eullier's account^ (and 
 Percy^s) of an epidemic outbreak of goitre in a boarding-house- 
 near Paris ; under similar circumstances the disease was 
 prevalent in 1815 in the college at Strasburg, to such an 
 extent that more than one-third of the pupils suffered from 
 it.* At Colmar in the autumn of 1859, 109 men of the 
 cuirassiers became affected with goitre j^ there was a recur- 
 rence in the spring of 1861, again among the cavalry solely; 
 while in 1863 there were cases first among the infantry and 
 afterwards in the cavalry.^ At Neu-Breisach there were 
 five epidemics of goitre from 1847 to 1871 / 23 cases in 1847, 
 27 cases in 1853, 24 cases in 1858, several cases in 1861, 
 and finally an outbreak in 1870 in which the number of those 
 affected in a single infantry regiment of 1002 men reached 
 the enormous figure of 647. From Belfort we have intelli- 
 gence of epidemics in the years 1876-79 ; in the first of 
 those years cases occurred only among the pupils of the 
 Lycee, in the following year in the garrison as well and to a^. 
 very considerable extent, in the next two years occasional 
 cases, and in the last year (1879) also in a boarding-house 
 for women.*^ In Autun, also, goitre has been epidemic 
 several times among the pupils attending the schools.^ In 
 the garrison of Besancon, 10 men became affected with goitre 
 in 1840, and 77 more from 1842 to 1853 ; in the summer of 
 1863 the malady broke out among the troops more widely.^^ 
 
 ^ Valentin, in SImonin's 'Reclierch. topogr.,' 411. 
 
 - Cheron, 'Mem. cle med. milit.,' 1822, xii, 79. 
 
 ^ ' Diet, ties scienc. med.' (en 60 voll.), xviii, 549. 
 
 '' Fodere, ' Journ. complem. des sc. med.,' 1829. 
 
 * Hansen, ' Mem. de med. milit.,' 1864, Jan. 
 
 ** Gonget, ib., iSfi^, Sept., 180. 
 
 7 See: Chambe, ' Gaz. med. de Strasb.,' 1864, Nr. ir ; Lanel, ' Mem. dc med. 
 milit.,' 1859, July, 2 ; Tellier, ib., i860, July 5 ; Muller, il>., 187 1, March, 244. 
 
 s Viry ct Richaud, ' Gaz. liebd. de med.,' 1 881, 457, 480. 
 
 ^ Guy ton, 'Journ. des conn, med.-thir.,' 1S52, 386. 
 
 1" Gerard, 'Mem. de med. milit.,' 185.S, xii, 241, 1854, xiii, 152; Artigue, ib.^ 
 xiii, I ; Saillard, 'Essai sur le goitre epidemique,' Par., 1865.
 
 158 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 At St. Etienne it became epidemic in 1864 among tlie 
 soldiers' children;^ in 1873 an epidemic sprang uj? among* 
 the troops^, affecting 280 out of a total strength of 1400;^ 
 and 38 additional cases occurred tlie next year.^ 
 
 These epidemics have been observed, especially often at 
 Clermont-Ferrand and at Brian9on. At the former place in 
 1822, 50 of the seminary pujjils became affected within a few- 
 days ;* in the garrison many cases occurred year after year 
 from 1843 to 1846 (as well as mumps in the latter year), and 
 again in 1848 and 1850-52 ; in i860 there was a consider- 
 able epidemic there, and in the garrison of the adjoining 
 town of Riora at the same time ; and this happened again in 
 1862 and in 1880.^ The number of cases in each year 
 ranged from 40 to 80. From Brian9on we have accounts of 
 goitre being epidemic in the garrison in 1812, i8ig, 1826 
 (134 cases), 1841, 1842-50, 1857-60 (cases especially nume- 
 rous in the latter part of this period), and in 1863.^ In 
 1863, the malady was prevalent at one and the same time in 
 the garrisons of Montdauphin and EmbrunJ The last 
 French epidemic that I have to mention was in the garrison 
 •of Annecy (Thonon) in 1866, when 60 cases occurred among 
 582 men.^ 
 
 Out of France the epidemic occm-rence of the malady 
 after this fashion appears to have been observed very rarely. 
 For the year 1820 there is an account from Silberberg 
 (Silesia) of an ou.tbreak en masse in a battalion lately arrived, 
 so that only 70 out of 380 men escaped having the dis- 
 
 ^ Brisson, 'Mem. de mecl, milifc.,' 1864, Oct. 
 
 - Michaud, ' Gaz. med. do Paris,' 1874, 17, 67. 
 
 ' Utz, ' Mem. de med. milit.,' 1876, May, 209. 
 
 ■1 Nivet, ' Documents sur les epidemies qui out regne dans rarrondissemeut de 
 Clermont-Ferrand de 1849 — 1864,' Par., 1865. 
 
 5 See: Nivet, 1. c, and 'Revue mod.-chir.,' 1852, Dec. ; Fleury, 'Gaz. med. de 
 Paris,' 1861, 510 J Morelle, 'Mem. do med. milit.,' 1862, Dec; Halbron, ib., 
 1864, Feb.; Thibaud, 'Du goitre eiiidemique,' Par., 1867; Chouet, ' Mem. de 
 med. milit.,' 1881, July, 353. 
 
 ^ Haberkorn, ' Essai sur le goitre epldem. considere dans I'armee,' Strasb. ; 
 1864; Chevalier, ' Mem. de med. milit.,' 1830, xxix, 323 ; Gerard, 1. c, Collin, ib., 
 1853, xii, 261 and 1861, July, i ; Lariviere, ib., 1859, July, 7 ; Pastoret, ib., i, 
 Rozan, ib., 1863, x, 343. 
 
 ' Rozan, I.e.; Hcdoin, ib., 1864, June. 
 
 8 Worbe, ib., 1867, Feb., 104, Oct., 273, Nov., 369.
 
 ENDEMIC GOITEE AND CRETINISM. 159 
 
 ease.^ It was epidemic among tlie pupils of tlie Pauline 
 Charity at Stuttgart in 1824 and 1833, 16 children out of 
 39 being affected in the former year, and 39 out of 47 in the 
 latter." In the Russian campaign against Turkestan in 
 1877, there were 245 cases of goitre among the 2753 troops 
 who captured and held the town of Kokaun, and it became 
 necessary to alter the location of tho garrison.^ Sigaud* 
 gives an account of the sudden appearance of goitre among 
 Brazilian recruits in Rio-Urubu (Goyaz) ; so severe was this 
 outbreak that the recruits took to flight in terror and 
 hastened to their homes in the province of Para. 
 
 All these so-called epidemics of goitre have the following 
 peculiarities in common : — (i) Excepting the cases at Nancy 
 and Paris, they occurred exclusively in regions where goitre 
 was endemic ; (2) the malady was always limited to detached 
 premises (particularly barracks, and, next to them, semi- 
 naries or boarding-houses), while no notable increase of 
 goitre showed itself among the population of the place out- 
 side these institutions -^ (3) in the epidemics among the 
 military, it has very often happened that only one barrack, 
 or one section of the troops, has been affected, all the rest 
 remaining exempt ; and (4) the malady has affected mostly 
 those of the troops who had just come to the particular gar- 
 rison, chiefly the younger soldiers, almost exclusively the 
 common soldiers, rarely the sergeants or corporals, very rarely 
 and indeed quite exceptionally the officers. 
 
 ' Hancke, in 'Hufeland's Journ, der Hcilkde,' 1838, May, Bd. 86, Ileft 5, 77, 
 
 ^ ' Reuss, ' Wiirttemb. med. Correspondzbl.,' 1836, vi, 168. 
 
 3 V. Seidlitz, in ' Virchow's Arch.,' Bd. 86, 168. 
 
 ^ L.c.,85. 
 
 * The single exception to this is the small epidemic of 1833, In the Pauline 
 Charity at Stuttgart, when several cases of goitre were observed .simultane- 
 ously outside the institution, but in the same part of the town in which the latter 
 was situated.
 
 160 GEOGRArHIOAL AND HISTOEICAL rATHOLOGY. 
 
 § 42. Independent op Climate^ Season^ or Weather. 
 
 Of all the diseases that are met with in wide diifusion 
 over the globe none appear to bo, in their endemic occur- 
 rence, so independent of geographical position or of climatic 
 influences as goitre and cretinism ; while none, at the same 
 time, are more intimately bound up with conditions of the 
 soil. Both diseases occur with equal frequency in all 
 latitudes, from the equator (Soudan, South America) to the 
 arctic zone (Hudson's Bay Territory), in regions with a mean 
 annual temperature of 85° Fahr. and upwards (Abyssinia, 
 and other negro countries), and with one of 38° Fahr. and 
 below it (Faluh in Sweden, Fort Kent in Maine, Irkutsk) ; 
 and if many observers^ have laid special stress on high 
 degrees of atmospheric moisture as an essential condition of 
 endemic goitre and cretinism, it has also to be taken into 
 account that there are other regions counting among the 
 chief seats of these maladies, such as Ladak, the province of 
 Mendoza in the Argentine Republic, the Brazilian provinces 
 of Minas Geraes and Goyaz, and Peru, where the atmosphere 
 is an absolutely dry one. 
 
 In discussing the question of the dependence of goitre upon condi- 
 tions of climate, on the basis of his experiences in the Andes of New- 
 Granada, Humboldt says : " Goitre is prevalent not only in the lower 
 and the upper basins of the Rio Magdalena {i.e. from Neyvato the con- 
 fluence of the Magdalena and Cauca), but also vipon the mountain- 
 ridges of Bogota, 6000 feet above the bed of the river. The first of 
 those three regions is a dense forest, while the second and third consist 
 o£ ground that is almost entirely barren ; the first and the third are both 
 alike moist, and the second is dry ; and whereas the second and third 
 are swept by the strongest winds, the atmosphere in the first is stag- 
 nant. Over the whole valley of the Magdalena the thermometer stands 
 at 22° to 23° C. (71° to 73° Fahr.) throughout the year, while, on the 
 plateau, it ranges between 4° and 17° C. (39° and 62° Fahr.) ; so that the 
 climate of the one region is distinguished by its high and steady tem- 
 
 * Ackermann, p. 83, for Switzerland.; Wcnzel, p. 95, for the Salzburg Alps; 
 Rosch, ' Untersuchungen,' p. 218, for Wiirteinberg ; Vogt, for Lower Franconia ; 
 Marsden, for Sumatra, and others, Fodere, who at one time entertained this 
 helief (in ' Traito,' Germ. Transl., jip. 44, 140), subsequently held it to bo 
 erroneous. "At the present day," he says, "having h:id a larger experiene^e, I 
 no longer venture to assert that humidity is the only cause of cretinism and 
 goitre " (' Traite de med. legale ').
 
 ENDEMIC GOITRE AND CRETINISM. 161 
 
 perature, and of the otlier by its low temperature and great variations. 
 It is precisely in the upper valley of the river (above Honda), -where 
 di'ougbts and high winds prevail, that we find goitre to be much more 
 common than on the banks of the river somewhat below Honda, where 
 the inhabitants are continually subject to a damp and stagnant atmo- 
 sphere." Restrepo had already written to the same effect concerning 
 the seats of the disease in the Andes of South America. Subsequent 
 experiences there led Boussingault and Foote to the same result, as the 
 observations of Grange and Maffci in the Alps had done for them. 
 
 " II n'est pas nccessaire," says Saint-Lager,^ " d'aller jusqu'en Nou- 
 velle- Grenade pour trouver des exemples analogues : quiconque a par- 
 couru les Alpes et les Pyrenees, a vvi des vallees voisines I'une de 
 I'autre, ayant meme direction, memes altitudes, meme tempei-ature et 
 humidite, et presentant d'etonnants contrastes sous le rapport de la 
 sante de leurs habitants." " With such facts as these," says Bi-amley,* 
 referring to his observations in the Himalaya, " the reader will readily 
 perceive the utter futility of the opinion that any one state of climate 
 can be assigned as the universal cause of the disease . . . for the facts 
 I have stated show, that it appears under all states and conditions of 
 the atmosphere and every variety of climate." 
 
 A few observers^ relying on their own observations^ bave 
 laid special stress on tbe influence of season or weatber on 
 tbe development of tbe so-called epidemics of goitre 3 
 tbey bave pointed out that these epidemics bad occurred, or 
 at least reached their height, uniformly in tbe summer 
 season, and tbey bave accordingly applied to such cases tbe 
 name of " goitre estival."^ But this is a view that also 
 lacks confirmation when we come to sum up tbe various 
 experiences ; many epidemics of goitre bave appeared and 
 run their course at other seasons as well, and in fact it is 
 impossible to show even a preponderance of tbe malady just 
 at tbe time of high temperatui'e. 
 
 Of 24 epidemics of goitre in France, for which I find the period of 
 occurrence given with some accuracy, the respective seasons were as 
 follows : 
 
 5 in winter 6 in summer 
 
 I „ winter and spring 3 » summer and autumn 
 
 7 ,, spring ^ " autumn 
 
 I „ spring and summer 
 The epidemic of goitre in 1877 among the Russian troops at Kokaua 
 happened in the month of February. The epidemic of 1820 in Silbei- 
 
 1 ' Etudes,' p. 138. ' L. c, p. 224. ^ Nivet, * Gaz. des hopit.,' 1852. 
 
 VOL. II. 11
 
 162 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 berg originated in spring ; on tlie setting in of fine wcatlier, the number 
 of cases increased very slowly, but in tlie cold and wet autumn follow- 
 ing, it rose so considerably that loo new cases came under observation 
 between the 17th and 20th November, and in December there were 
 only 70 men, in a battalion 380 strong, who had escaped the disease. 
 
 § 43. Influence of Locality. 
 
 All tlie more marked and unambiguous is the connexion 
 that may be traced between endemic goitre and cretinism and 
 the locality, or, in other words, between them and the soil 
 or what the soil carries and contains. However widely the 
 two diseases (and goitre in particular) are spread over the 
 globe, and however large the tracts of country overrun by 
 them, it is always and everywhere only a few spots, often 
 narrowly circumscribed, which form the seat of the endemic ; 
 outside these, even in the most immediate neighbourhood, the 
 immunity is complete. The report of the Sardinian Commis- 
 sion brings out in the clearest terms this mode of incidence 
 for the localities of Piedmont which are affected by goitre 
 and cretinism ; and equally so the statements of Rosch for 
 Wiii'temberg and of Maffei for Salzburg. The latter have 
 been recently substantiated by Klebs, who points out that the 
 disease cannot be dependent on atmospheric influences (sun- 
 light, air, and the like), inasmuch as it is always limited to 
 particular spots, the surrounding country remaining completely 
 free from it. In the Hungarian countries of Pesth, Raab 
 and Wieselburg, goitre and cretinism are found, according to 
 Glatter, in the districts on the right bank of the Danube ; 
 only an occasional case occurs on the left bank, while the 
 more remote regions of even the right bank are free from 
 both diseases. In the neighbourhood of Passau, there are 
 only sporadic cases of goitre and cretinism, while in the 
 Austrian village of Engelhardszell eighteen miles off, the 
 cases amount to 10 per cent, of the population.^ In Middle 
 and Lower Franconia cretinism is met with at scattered points 
 only." In the quondam Duchy of Nassau it is only the town 
 of Herborn and a few villages in the lofty Westerwald that 
 form the endemic seats of goitre ; in all other parts of the 
 
 ' Friedrich, * Bayr. arztl. IntelligcnzLl.,' 1855, ^J"- 28,352. 
 ' Majer, 1. c.
 
 ENDEMIC GOITRE AND CRETINISM. 163 
 
 country tlie disease is a rare phenomenon.^ In tlie small 
 section of the arrondissement of Rouen which is affected by- 
 endemic goitre, there are 49 villages situated close together, 
 and of these only 25 are subject to the disease, the remaining 
 24 being completely free from it.^ In Bedfordshire, goitre 
 is endemic in a single village, Ridgemont, while all the 
 country round is exempt.^ 
 
 Incontrovertible proof of the influence of locality upon the 
 production of goitre is furnished by the fact that healthy 
 persons coming into goitrous spots from non-goitrous places 
 not unfrequently contract the disease after a longer or shorter 
 stay, and sometimes after a very short stay ; secondly, by 
 the fact that a change of locality has been found to be the 
 most certain means of overcoming the disease or preventing 
 its farther development ; and thirdly, that in regions Avhere 
 goitre is endemic, the animals also are affected by it, especially 
 the domestic animals such as dogs, cats, goats, sheep, pigs, 
 horses and mules.* As regards the first point, I may call 
 attention to the fact already mentioned that, when goitre has 
 broken out as an epidemic among the military, the troops to 
 suffer have been chiefly those that have come into a goitrous 
 locality from a non-goitrous. There are, besides, other 
 references to persons previously healthy falling ill with it 
 under the same circumstances, such as those by Erlenmeyer"" 
 for the Rhine country, Glatter for Hungary, and Wilson 
 for the Punjaub. Observations as to the good effect 
 of a change of locality on the course of the disease 
 have been published by Guyon^ from Santiago (Chili), 
 Mendoza (Argentine Republic), and Switzerland, by Wother- 
 spoon from Fort Kent, and by Greenhow from Oudh.'' Von 
 
 1 V. Franque, 1. c, 621, 623, 625, 627. ^ Vingtrinier, 1. c. 
 
 Blower, 1. c. 
 
 4 This fact was known to Pliny, who saj's (1. c.) : " Guttur homlni tan turn et 
 sulbus intumescit, aquarum quae potantur pleurumque vitio." Instances of 
 the occurrence of goitre in animals are reported from all goitrous localities : by 
 Keyssler, Fodere and Saint-Lager (Piedmont), Baillarger (especially in mules) 
 and Anzouy (Pyrenees), Moretin (Jura), Saint Lager (Lyonnais), Gucrdan (Haden), 
 Eosch (Wiirtemberg), Mittermayer (Pinzgau), Gmclin (Lena Valley, Irkutsk), 
 Bramley, Greenhow, McClelland, Campbell and Fayrer (India), Barton and 
 Wotherspoon (United States). 
 
 * ' Archiv,' 1. c. ^ ' Gaz. raed. do Paris,' 1862, p. 345. 
 
 ' L. c, 441 : " That change of locality is beneficial or the contrary to goitrous
 
 164 GEOGRAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 Seidlitz informs us that wlien the number of cases among the 
 Russian troops in Kokaun (Turkestan) reached such a height 
 as to cause anxiety, the best results followed the removal of 
 the whole military contingent to the neighbouring town of 
 Margelan. 
 
 § 44. Influence op Altitude and Conpigueation. 
 
 The question now arises, What are those conditions of soil, 
 common to all centres of goitre and cretinism, which can be 
 brought into direct or indirect relation with the pathogenesis ? 
 A glance at the area of distribution of both diseases shows 
 that their endemic occurrence is not by any means dependent 
 as a universal rule upon a certain elevation and configuration 
 of the ground ; although it is true that they are mostly endemic 
 in mountainous districts (most of all in high mountain ranges 
 such as the Alps, the Himalaya and the Cordillera), while 
 they are rare on table-lands, extremely rare on low levels, 
 and never found hitherto on coast margins.^ 
 
 Saussure,^ on the strength of his observations in the Swiss 
 and Savoy Alps, was of opinion that the two diseases find their 
 upper limit at a height of 1000 metres (3300 feet) ; while 
 Demme and Maffei^ thought that they could make out 
 a corresponding inferior limit at about 300 metres (1000 feet) ; 
 so that, on either side of that zone, goitre and cretinism 
 would occur only sporadically. But these fixed limits have 
 a purely local value ; for the general distribution of the 
 disease, they cannot be applied at all. That the downward 
 limit (reckoning to the sea-level) is a vanishing one, 
 may be concluded from the prevalence of goitre in the 
 northern plain of France (Departments of the Aisne and Oise), 
 in various parts of England (Norfolk, Somerset and other 
 
 tumours, appears to be a proof that they depend, to some extent at least, on local 
 causes. In England, in America, in Switzerland, and in India, it has been remarked 
 that goitres decrease, and even disappear sometimes, on the patient's changing 
 his residence." 
 
 ^ See Hutchinson, * Med. Times and Gaz.,' 1855, Oct. This circumstance is 
 most noticeable in those countries where goitre is widely prevalent in the plains- 
 situated at the foot of mountain slopes, although it leaves the proper coast 
 region entirely free, as in Brazil (Rendu). 
 
 2 L. c, ii, 487. 3 L. c, p. 147.
 
 ENDEMIC GOITRE AND CRETINISM. 165 
 
 counties), and along the great lakes of North America 
 (Michigan, Lower Canada) ; while the limit upwards which 
 Saussure has fixed depends, as the Sardinian Commission^ have 
 pointed out and Maffei's data for the Salzburg Alps con- 
 firmed, upon the fact that the greater part of the cultivated 
 land and the larger number of human habitations do not 
 reach beyond the altitude named. As a matter of fact both 
 diseases are found at still higher elevations : in the Hautes 
 Alpes at 2060 metres or 6750 feet (St. Veran), in Savoy at 
 1566 metres (Albiez-le-Vieux, where there are 90 goitx-ous or 
 cretinous persons in a population of 1000), in the Pyrenees 
 at 13 16 (Bareges), in Val Tellina at 1300 (according to 
 Strambio), in Sondrio at 1700 (Livigno), even in Baden at 
 1000 (Hammereisenbach), in the Himalaya at 2000 (in Ladak 
 and Nepaul up to 4000), and in the Cordillera of New 
 Granada at from 3000 to 4000 metres (10,000 to 13,000 
 feet) . 
 
 Goitre and cretinism, accordingly, cannot be shown to be 
 dependent for their endemic prevalence upon elevation of the 
 ground. And there is just as little truth in the other doctrine 
 founded by Saussure,^ and formerly in somewhat general cur- 
 rency, according to which deeply cleft valleys, receiving little 
 sunshine or wind, and with a damp air or marshy soil, form by 
 far the greatest if not the only seats of endemic goitre and 
 cretinism. The goitrous and cretinous districts of the Pied- 
 montese and Lombard Alps extend far into the plain of Upper 
 Italy; in Switzerland we find both diseases on the low ground of 
 Malters (Lucerne) which, as Troxler says,^ is neither narrower 
 nor deeper than hundreds of other localities where there is 
 no goitre or cretinism, and, again, in the wide and exposed 
 valley of the Aar ; while the occurrence of cretinism at 
 
 1 L. c.,p. 173. 
 
 * L. c, ii, 390, 480. Saussurc's contcutiou is tliat, whereas tlie inhabitants of 
 the upper part of a valley appeared to bo perfectly healthy, be began to find 
 the first traces of cretinism when he came to hamlets in deeper situations, the 
 Jiumber of cases rising proportionately as he descended towards the bottom of the 
 valley. Beyond the point where the valley began to open on to the level, the 
 malady became rarer, and on the plain itself, as well as in the open and wind- 
 swept valleys, it vanished altogether ; although the conditions of living, as he 
 adds, were exactly the same for the whole population of the valley. 
 
 3 L.c.,p.43.
 
 166 GEOGEAPHIOAL AND HISTORICAL PATHOLOGY. 
 
 Langenargen on tlie Lake of Constance furnishes us with a 
 classical instance of tlie disease having its seat in an open 
 plain. In the Lyonnais goitre occurs equally on the plain 
 and in the valleys, in Alsace and the Palatinate it is prevalent 
 on the level expanse of the Rhine valley, in Lower and Middle 
 Franconia we find it (along with cretinism) not in valleys 
 but on the slopes of the Steigerwald, in Thuringia it is in 
 mountainous and in level districts equally (according to Hehm 
 and Kirchhoff), in Upper and Lower Austria on the great plain 
 of the Danube, in Salzburg on the low grounds of the Enns and 
 Traun, and in Styria on the broad plain of the Mur (the 
 Bichfeld).^ One of the most important goitrous regions of 
 India, as we have seen, is the plain of the Terai joining on 
 to the slopes of the Himalaya. In Northern China, the 
 endemic of goitre is by no means confined to the moun- 
 tainous regions, but extends over the level country as well -^ 
 and the same is true of the western parts of the Soudan.^ 
 On the western slope of the Cordillera of Mexico, the focus 
 of disease goes as far down as the bottom of the basin -^ and 
 in like manner, goitre extends from the eastern slopes of 
 these mountains far into the plains of the southern provinces 
 of Brazil and into those of the Argentine Republic. 
 
 § 45. Relation to the Geology and Mineralogy op 
 
 THE Locality. 
 
 A special interest attaches to the question whether any 
 connexion can be made out between the endemic occurrence 
 
 1 Kostl, who lays most stress for the pathogenesis upon the valleys being shut 
 in, finds examples of this in the valley of the Mur. Between Predlitz and 
 Murau, where the valley is 400 to 500 paces wide, there is one cretin to about fif- 
 teen inhabitants ; from Murau to Schleifling, where the valley becomes four times 
 as wide, cretinism becomes three times less common ; from Schleifling onwards, 
 as it narrows again, the malady almost doubles ; and as the valley widens 
 somewhat from Unzmarli to Judenburg, the disease once more becomes less 
 frequent. So far so good. But now the valley opens out from Judenburg down 
 to the level of Eichf eld, where one would expect cretinism to vanish ; but here, 
 we are told, the conditions favorable to cretinism are so strongly developed that 
 the number of cases at certain spots is from 5 to 10 per cent, of the whole 
 population. 
 
 * Dudgeon, 1. c. : " It is found also on the plains and in our large cities." 
 ^ Quintin, 1. c. ^ Matthieu de Fossey.
 
 ENDEMIC GOITRE AND CRETINISM. 167 
 
 of goitre and cretinism and the geological or mineralogical 
 character of the soil. This is a question "which has been 
 discussed with more or less of keenness by nearly all the 
 more recent observers, although as yet they have come to no 
 conclusion that is at all satisfactory. The difficulty attend- 
 ing the solution of the problem lies essentially in the fact 
 that there is a want of exhaustive and thorough information 
 as to the conditions of soil in the individual circumscribed 
 localities which are the seats of goitre and cretinism ; as 
 well as in the fact that, in forming our opinion, we should 
 require to know not merely the upper layer of soil but also 
 the character of the bottom, which is often very different from 
 the surface ; and, further, in the fact which has been quite 
 rightly dwelt upon by Schwalbe,^ that some localities contain 
 minerals either in the form of ore-deposits or of lodes, or to 
 the extent of a mere impregnation, and that these impart to 
 the soil a geological character which may escape observation 
 for a long time. While paying the fullest tribute to the 
 thoroughness of the inquiries directed upon this question by 
 McClelland,^ Billiet,^ Grange,* Saint Lager, Garrigou,^ and 
 others, we can hardly regard the results that they have 
 arrived at as conclusive ; for, apart from the discrepancies 
 among themselves, they cannot always be brought into 
 harmony with the conclusions of observers in other parts of 
 the world; and as the latter have often been superficial in their 
 determination of the geological conditions, we are without 
 the means of deciding critically wherein the contradictious 
 and discrepancies lie, and how they are to be reconciled. I 
 think it well to introduce the* following table with that 
 remark, so that the reader may have a correct appreciation 
 of the trustworthiness of the conclusions drawn from it. 
 
 ' ' Correspondbl. des Thiiring. aiztl. Veroins.' 
 
 2 ' Sketch of tlie Medical Topograpliy, or Climate and Soils of Beugal and the 
 N. W. Provinces,' Lond., 1859. 
 
 3 ' Annal. med.-psychol.,' 1854, April, 1855, Jan. 
 
 ■» 'Gaz. med. de Paris,' 1848, 820, 1849, 972, 1850, 554, 1851, 103; 'Arch, 
 gen. denied.,' 1850, Jan., 108, Oct., 243. 
 
 5 'Bull, de I'Acad. dc med.,' 1868, xxxiii, 915 ; ' Gaz. hebd. de med,,' 1874, 
 270, 284.
 
 168 
 
 GEOGRAPniCAL AND IIISTOETCAL TATHOLOGY. 
 
 Tabular Survey of Endemic Goitre and Gretioiism as occurring 
 on the several Geological Formations} 
 
 Geological Formatiou. 
 
 Oldest and Eruptive 
 
 Rocks (Gneiss, 
 
 Mica- Slate and 
 
 jClay-Slate, Granite, 
 
 Syenite) 
 
 Silurian and 
 Devonian (transi- 
 tion, Grey-wacke) 
 
 A star (*) before the name of a locality denotes both 
 goitre and cretinism as endemic ; places hot so 
 designated have goitre only. 
 
 i 
 
 Coal 
 
 Permian 
 
 1 
 
 *Piedniont (valley of Aosta, Tarentaise, Upper 
 Savoy)— *Val Tellina (valley of the Adda) — 
 *Woriean Alps (Upper and Lower Austria, 
 Styria) — *Switzerland (Bernese Oberland, 
 Vallais, Grisons) — *Transylvania (circle 
 of Kronstadt) — *Sudetic Mountains — *Erz 
 gebirge (Annaberg and other places) — *Harz 
 (Lautenthal) — *Baden (Neustadt)— Nassau — 
 Sweden (Faluh)— Finland — Alabama — We"w 
 Granada (Pamplona, Socorro). 
 *Norican Alps (Salzburg, Tyrol, Styria) — 
 *Pyrenees — Vosges — Sudetie Mountains — 
 Harz (Lerbach, Clausthal) — Siberia (basin of 
 the Lena) — *Hinialaya (Kumaon, &c.) — Hud- 
 son's Bay Territory (shores of the Elk and 
 Peace Rivers) — New Granada (on the moun- 
 tain ridge between Villata and Muzo)- — Brazil 
 (Prov. of Goyaz, especially the western slopes 
 of the Sierra Geral). 
 England (Derby, Nottingham, Yoi'kshire, Cum- 
 berland) — Silesia — Pennsylvania (Pittsburg, 
 &c.). 
 *Val Tellina (valley of the Lire) — *Maritime 
 Alps — I-yonnais (Rhone) — Hesse (especially 
 valley of Neckar) — Thuringia— New Gra- 
 nada (eastern slopes of the Cordillera). 
 ^^Norican Alps (Styria, Tyrol) — *Black Forest 
 (eastern division) — *IjOwer Franconia (slopes 
 of the Spessart, valley of the Main) — *Thur 
 ingia ^Schmalkalden, &c.) — India (plain of 
 Hindostan (Terai) on the slope of the Hima- 
 laya) — New Granada (valleys of Suarez 
 Chicamocha, Surata, &c.) — Peru— Chili. 
 *'Wurteniburg (region between Rottweil and 
 Mergentheim) — *Sigmaringen (in a side 
 valley of the Neckar) — *Baden (Neudenau, m 
 the .Taxtthal) — Hesse — *Ijower Franconia 
 (Erlabrunn, valley of the Main) — Thuringia 
 — New Granada (province of Socorro). 
 *Savoy (valley of the Isere) — *Hautes-Alpes — 
 *Basses-Alpes — *Wurtemberg (chief seat of 
 the disease in the circle of the Neckar and 
 Jaxt) — *Ijower Franconia (westei-n slope of 
 the Steigerwald, Sulzheim, Geroldshofen, 
 &c.). 
 
 1 This table, it need hardly be said, makes no claim to completeness ; I have, 
 for the most part limited it to the larger centres of disease. 
 
 Variegated 
 Sandstone 
 
 < 
 
 E-i 
 
 Limestone 
 
 Keuper
 
 ENDEMIC GOITRE AND CRETINISM. 
 
 169 
 
 Goologrical Formation. 
 
 Lias 
 
 Jura 
 
 1-3 
 
 Chalk 
 
 Tertiaiy 
 
 Sedimentary 
 
 Volcanic (trap) 
 
 A star (*) before the name of a locality denotes both 
 goitre and cretinism as endemic; places not so 
 designated have goitre only. 
 
 ^Piedmont (valleys of the Stura, Varaita, &c.) 
 —Switzerland (Aigle, Ormonds, and other 
 places in the Canton Vaud) —France (various 
 localities) — Yorkshire (at a few places). 
 
 *Korican Alps — *Savoy — *Daupliine — 
 *Hautes-Alpes— Department of the Meurthe 
 (Oolite formation) — Yorkshire (Upper and 
 Middle Oolite). 
 
 Seine-Inferieure— England (Norfolk, Bucking- 
 hamshire, Hampshire). 
 
 *Switzerland (Bern, on the nagelfluh, several 
 localities in the Canton St. Gall) — *France 
 (Dauphinc, Basses-Alpes, &c.) — Lower 
 Austria — Baden — *Wurtemlburg (Langen- 
 argen). 
 
 Italy (plain of the Po in Lombardy) — France 
 (Bresse) — *Plainof the Rhine (Alsace, Pala- 
 tinate) — Hungary (banks of the Danube and 
 Drave, in the County of Baranya) — Argentine 
 Republic (eastern basin). 
 
 *Piedniont (a few places in Asti and Acqui) — 
 *Franee (Upper Auvergne) — India (Chota, 
 Nagpore, &c., probably on basalt) — Java — 
 Mexico (Colima) — .Azores. 
 
 Altliougli this survey is far from an exhaustive one, it 
 serves to furnish evidence of several facts. The first of 
 these, ah^eady pointed out by Boussingault, by the Sardinian 
 Commission, by Lebert, Grange, Niepce, and others, is that 
 no geological formation precludes the occurrence of goitre 
 and cretinism. The second is that the two diseases occur 
 much more frequently (although not exclusively, as Eschricht^ 
 thinks) on the older formations (including the Trias) than on 
 the newer. The third is that they occur only on those sedi- 
 mentary formations which are composed of the detritus of 
 older rocks, as, for example, in the plains of the Rhine aud 
 of Lombardy, and in the valleys of the Arve and Doria.^ 
 " Dans la province de Savoye-Propre," says the Sardinian 
 Commission with reference to the last-mentioned fact,^ " le 
 cretinisme endemiquc so rencontre sculcment sur la rivo 
 
 1 ' Verhandl. der Wiirzb. phys.-med. GcscUsch.,' 1854, iv, 141. 
 * See Saint-Lager, ' Etudes,' 443. ^ P. 67.
 
 170 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 gauche de Tlsere^ qui fait suite aux Millieres^ de la province 
 de Haute-Savoye. Les cretins cessent aussitot, qu'on 
 arrive sur les terrains de calcaire cretace on jurassique. Mon- 
 seigneur Billiet, arclieveque de Chambery, dans les ren- 
 seignements par lui fournis a la commission, assura que 
 parmi les 140 paroisses situees dans ce dernier terrain, 7 
 seulement presentent des traces de cretinisme ; encore ces 
 communes se trouvent-elles sur un terrain tertiaire forme de 
 detritus des Alpes et sur une molasse argileuse." 
 
 Garbiglietti and Ferraris make similar statements for other 
 parts of Piedmont. Eosch, after sketching the distribution 
 of goitre and cretinism in Wiirtemberg on the variegated 
 sandstone, muschelkalk, and keuper, goes on to say : 
 " Between the keuper and the Jurassic limestone, formiog 
 the main chain of the mountain, there is a narrow zone of 
 Liassic limestone and Liassic slate at the foot of the Alp, also 
 running from south-west to north-east. On that, as well as 
 on the whole Jurassic formation, goitre and cretinism are 
 nowhere endemic," — a fact which had been pointed out before 
 by Riedle as regards goitre, when he proved from the 
 recruiting lists that, in 1000 conscripts examined, tb ere were 
 130 to 155 goitrous among those from the communes on 
 the Trias, but only 2 to 3 per 1000 from localities on 
 the Alp. 
 
 After what has been pointed out already as to local 
 delimitations of the foci of disease, often within very narrow 
 bounds, and as to restriction to particular villages (the 
 adjoining localities being entirely exempt) and as to the immu- 
 nity of certain points in the midst of a large area of the disease 
 although the geological formation is everywhere absolutely the 
 same, it hardly needs more evidence to show that the geolog- 
 ical character of the formation in and hy itself can by no means 
 determine the occurrence of goitre and cretinism. It is 
 remarked by Boussingault that in the mountain ridges which 
 run along the coast of Vene^iuela, one encounters granite, 
 gneiss, mica-slate, talc or clay-slate, and that the same 
 formations enter into the soil of the plain of Caracas and the 
 valleys of the Aragua and Tuy. Now, whereas goitre is very 
 rare throughout the whole province of Caracas, the malady 
 occurs in general diffusion in the provinces of Pamplona,
 
 ENDEMIC GOITRE AND CRETINISM. 171 
 
 Bucaramonga, Giron and others. Throughout a great part 
 of New Granada we find syenite and porphyraceous green- 
 sand in such localities as Montuosa Baxa^ Cacota de Balesco, 
 and Laxas, where goitre is endemic ; v.'hereas in the province 
 of Antioquia and over a large part of the upper valley of the 
 Cauca, which belong to the same formation (oldest eruptive 
 rock), the disease does not occur. Boussingault found many 
 villages much affected by goitre (Villata, La Palma, Copes el 
 Peiion, Pacho, and others) on a belt of clay-slate running 
 northwards from Villata towards Muzo ; whereas, on a 
 second belt of the same formation in the Eastern Cordillera, 
 forming the water-shed between the valley of the Magdalena 
 and that of the Cauca, not a single case of goitre is to be 
 met with. There are the same discrepancies in the distribu- 
 tion of goitre in New Granada on the red sandstone, the- 
 bunt-sandstone, and other formations. 
 
 § 46. Influence of Wet Soil. 
 
 If, then, there bo some causal connexion between 
 the endemic occurrence of goitro and cretinism and tho 
 nature of tho soil, and that connexion do not dej)eud on the 
 geological formation, then the determining factor must lie 
 either in the 'physical characters of the soil or in its chemical 
 constitution or mineralogical characters. 
 
 In regard to the former of these, many observers have 
 laid special stress upon the copious saturation or swamping 
 of the soil ; and it has been specially remarked by some that, 
 where goitre and cretinism occur upon the oldest eruptive 
 formations (the Primary rocks) or upon the older formations 
 generally, the explanation is partly in the fact that the kind 
 of cleavage of the ground peculiar to these formations leads 
 to the production of deeply-cleft, winding, and therefore very 
 damp valleys, such as have been shown by experience to be 
 the chief seats of the disease. It will appear from what has 
 been said of the occurrence of the disease in wide and open 
 valleys and on plains, that this latter argument carries only a 
 certain amount of weight. But those other facts which would 
 1 Especially Garbiglietti, ' Gioin. dtlle sc. med. di Torino,' 1845, Giuguo.
 
 172 GEOGRAPHiOAL AND HISTORICAL PATHOLOGY. 
 
 -make the distribution of the disease to depend upon damp- 
 ness of the ground in general have not the significance that 
 has been often ascribed to them, inasmuch as there are just 
 as many and just as trustworthy observations going to show 
 that goitre and cretinism are indigenous and fully developed 
 even on the driest of soils. 
 
 In the Cordilleras of New Granada Humboldt found that both dis- 
 eases were as common in valleys with a dry soil as with a wet, and that 
 certain wooded districts characterised by heat and moisture, such as 
 the province of Antioquia, the banks of the Orinoco, Cassaquiri, and 
 Rio Negro enjoyed complete immunity from the disease. Roulin 
 and Boussingault have expressed a similar opinion, the former stating 
 emphatically' that among the Cordilleras goitre is prevalent in districts 
 which lie quite exposed and count among the driest spots on the globe 
 (" qui sont les plus scches du monde "). Referring to the distribution 
 of goiti-e in North America, Barton^ points out that the malady has its 
 seat principally in damp valleys and on swampy river banks ; on the 
 other hand, Denny observes that Pittsburg, which is affected by 
 endemic goitre, stands upon a perfectly dry plateau, the vicinity of the 
 town being quite free from marsh. One of the most considerable centres 
 of goitre and cretinism in the Rhone valley is the district of Aigle, 
 notwithstanding that it is free from marsh, moderately dry, exposed to 
 the sun all the year, and well swept by winds.^ " In the Alpine 
 valleys," says Troxler,* speaking generally, " and in other valleys 
 where cretinism occurs, there are almost no proper marshes but 
 only occasional collections of water, producing no important con- 
 sequences ; on the other hand, in the marshiest of regions 
 
 cretinous lesions have not been discovered even by the most careful 
 observers." Wenzel,' Streinz, Hofer, Ozlberger, and various others who 
 have discussed the question with reference to the diseases as they occur 
 • in the Norican Alps, lay special stress upon the dampness of the soil in 
 the goitrous centres. Maffei also takes that factor to be not irrelevant, 
 adding, however: '' " but I know very well that even the suniest, brightest, 
 and driest situation may not preclude the development of cretinism ;" 
 and in order to show how little a marshy soil can determine the occur- 
 rence of the disease, he points to the marshes and moors of low coun- 
 tries, and to the shores of lakes and great rivers, which are quite exempt 
 from goitre and ci'etinism. Schaussberger, who treats of the endemic 
 goitre of Upper and Lower Austria, observes that while many villages, 
 such as Seissenheim, Krum-Nussbaum, and Gross-PiJchlarn ai'C swarm- 
 ing with cretinous and goitrous persons, there are other villages in their 
 
 * *Gaz. med. de Paris,' 1845, 690. 
 
 * L. c, 91. 3 Lebert, ' Archiv,' 1. c. 
 
 * 'Schweiz. Archiv der Med.,' 181 7, Heft 3, 49. 
 ^ L.c, p. 96. « L. c.,p. 154.
 
 ENDEMIC GOITEE AND CRETINISM. 173 
 
 immediate neiglibourliood and with the same low and damp situation 
 wliicli are affected but little or not all, such as Ascliacli, Ottensheim, 
 Tbbs, and particularly Mai'bacb, wliicli is only some ten minutes' distance 
 from Krum-Nussbaum, and is in all other respects similarly placed with 
 it. The same discrepancies come out on comparing the conditions of 
 soil in those localities of Wiirtemberg which are subject to goitre and 
 cretinism. "While Kerner, Diirr, Rampold/ and others, emphasise the 
 dampness of the soil as an essential part of the causation, it is observed 
 by Rosch," who agrees with them generally, that " the valleys of the 
 Alb, which are often very narrow and deep, especially the Donauthal 
 and the Brenzthal, are damp, full of mists and marshy in places, as, for 
 example, the fine stretch of the Donauthal from Miihlheim through 
 Tuttlingen to Sigmaringen, and yet goitre is very rai-e there and the 
 cretinous degeneration does not occur at all." Faber's opinion is to the 
 same effect.^ The centres of goitre and cretinism in Middle Franconia 
 (Iphofen, Einersheim, &c.,) lie high and exposed on a dry plain bounded 
 by the Steigerwald.'' While special stress is laid by Tourdes,^ Hen-- 
 mann,^ and ohters on the marshy character of the Rhine valley as a 
 cause of its endemic goitre and cretinism, Miiller '' on the other hand 
 has shown by his observations that the valley of the Neckar in Hesse, 
 which is also- a seat of goitre and cretinism, is distinguished by the- 
 absolute dryness of its soil. Again, Lettsom would regard the wetness 
 of the soil in Derbyshire as helping materially to produce the endemic 
 of goitre there ; while we have to note, on the other hand, from Rum- 
 sey's observations on goitre ai'ound Beaconsfield (Bucks), that the 
 town itself is free from the malady althovigh its situation is more damp 
 than the adjoining valleys which are affected with goitre. 
 
 It cannot be denied that a wet or marshy soil is anything 
 but a matter of indifference to the well-being of the resi- 
 dents upon it, or that the state of health does experience a 
 change for the better when that evil is overcome, or, in other 
 words, when the soil is dried by drainage, the making of 
 regular water-courses, and the like. And we are indeed 
 justified in associating with that hygienic progress the 
 decrease of goitre and cretinism which has been experienced 
 in the valleys of Savoy ,^ in the Pyrenees,^ in the valley of 
 the Ehine in Alsace,^° in the Jaxtthal in Wiirtemberg,^^ and 
 
 ^ ' Wiirttemberg. mcd. Corrcspondenzbl.,' 18.35, v. 159. 
 
 " L.c, 218. ^ L. c, 221. 
 
 * Hoffmann, ' Einiges iiber den Cretinismus u. s. w.,' Wiirzb., 1841. 
 
 s L.c, 53. 
 
 « ' Blatter fur gericbtl. Med.,' 1882, 147. 
 
 7 ' Bad. med. Annal.,' 1839, v- 89. 
 
 8 Fodere, p. 190; ' Ileport of the Sardin. Commission,' p.''20o; Dnbini, l.c. 
 
 » Bouliniere, 1. c. '" Tourdcs, Herrmann, 11. cc. " Kcincr, 1. c.
 
 174 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 at other places where such improvements in the soil have been 
 carried out. But it is clear that we are here concerned^ not 
 with obviating a specific factor of disease, but with a general 
 elevation of the state of health of the residents and with their 
 increased power to resist morbific influences. 
 
 § 47. Connexion with Limestone, and with Magnesia in 
 
 pakticular. 
 
 According to the oldest and most general view of the 
 origin of goitre, accepted by most observers down to those of 
 the present day, the cause of the disease is to be found in the 
 habitual use of water rich in certain mineral constituents. 
 And, inasmuch as the presence of mineral substances in the 
 water depends on the ground from which it springs or 
 over which it flows, and as, by experience, the suspected 
 " goitre-springs " arc found to be particularly those with 
 carbonate of lime or gypsum dissolved in somewhat large 
 quantities, it was natural to conjecture that goitre and 
 cretinism must be associated as endemics with a limestone 
 soil — a conjecture which the accurate examination of soils at 
 an early period of the inquiry tended to strengthen. 
 
 Boussingaulfc was perhaps tlie first to call attention to tliis significance 
 of a limestone soil — in the Cordilleras of New Granada. Then came Sens- 
 burg, Hofi'mann, and Stahl, who pointed out the association of the two 
 diseases with gypsum, marl, and other limestone-bearing soils in Lower 
 Franconia. Riedle made out that goitre and cretinism in Wiirtemberg 
 were found mostly on the muschelkalk and keuper, and next in order 
 on the Jurassic limestone and molasse — a fact which was subsequently 
 confirmed by Rampold, by Heyfelder for a side-valley of the Neckar in 
 Sigmaringen, by Diirr for the circle of the Jaxt, and by Rosch for 
 the circle of the Black Foi'cst. Falck showed that in Hesse both 
 •diseases occurred mostly on muschelkalk, stratified limestone and 
 zechstein, whereas the localities with lias, oolite, basalt, and clay were 
 exempt from them ; thus of 93 villages in which goitre and cretinism 
 were endemic, 84 were upon zechstein and muschelkalk, 3 on primitive 
 rock, 3 on clay, 2 on molasse, and i on trap. The same results were 
 come to by Guerdan for Neudenau (Baden), both diseases being pre- 
 valent on muschelkalk ; and by Maff"ei, in part at least, with reference 
 to the distribution of these maladies in the Norican Alps. 
 
 The first thorough inquiry into the circumstances in ques-
 
 ENDEMIC GOITRE AND CRETINISM. 175 
 
 tion was instituted by McClelland in the province of 
 Kumaon on the slope of the Himalaya. His results were as 
 follows : 
 
 In 91 villages situated on granite and gneiss, hornblende slate and 
 mica slate, clay slate, green sandstone, granitine, and silicious sand- 
 stone, having an aggregate population of 5383, there were 29 goitrous 
 persons and no cretins ; whereas in 35 villages on Alpine limestone {i.e. 
 Jurassic limestone and zechstein), having an aggregate population of 
 1 1 60, 390 cases of goitre were found and 34 of cretinism. 
 
 These results were afterwards confirmed by Thorel for 
 Mekong and Cochin China. '' A mesure que les montagnes 
 de calcaire deviennent plus nombreuses/' he says, '' les 
 cas de goitre sont egalement d'une extreme frequence. 
 H sufiit, pour que le nombre des goitreux augmente, qu'il 
 y ait pres des villes et des villages, des montagnes de 
 marbre." 
 
 In the meantime Billiet^ had been making inquiries in the 
 same manner as McClelland, into the relation between goitre 
 and cretinism and the various kinds of soil in the Diocese of 
 Chambery (Savoy) ; and he satisfied himself that, of 169 
 villages, 127 were free from the diseases in question, while 42 
 formed endemic seats of the same. Further, he made out 
 that the cases were occasional on the alluvium of the Rhone 
 and on older diluvial formations, that the number of cases 
 rose on coming nearer to the argillaceous limestone soil which 
 runs from Montmelian to Chamousset, and that the endemic 
 reached its height on the limestone, magnesia, and gypsum 
 of the valley of the Maurienne, where the cases amounted to 
 10 per cent, of the population. While the whole of the 127 
 villages on Jurassic and neocomian rock enjoy an absolute 
 immunity, the disease begins to appear in endemic form 
 on argillaceous limestone and slate, and most of all upon 
 soil which bears talc-slate, micaceous slate and gypsum. 
 That it is here the state of soil only that is the deter- 
 mining factor is inferred by Billiet from the fact that all the 
 valleys in the diocese, both those subject to the diseases and 
 those exempt from them, are absolutely alike in all other 
 
 1 L. c, 172. 
 
 * 'Mem. acad. de Savoye,' 1847; 'Aniial. mctl.-psycliol.,' 1854, April, 185 
 
 Jan.
 
 176 GEOai?ArHIOAL AND niSTORIOAL TATHOLOGY. 
 
 circumstances — as regards the form of tlie valleys, tlieir 
 steepness, tlieir planting, their exposure to the sun, their 
 hydrology, and tlieir buiklings, and as regards the well-being 
 of their inhabitants. 
 
 While each of these two authorities had directed his 
 inquiries exclusively upon one small area. Grange^ extended 
 his investigations on the subject over a wide territory, study- 
 ing the problem in the Pyrenees, the Vosges, and in the 
 Alps of Piedmont and Switzerland. He came to the con- 
 clusion (which Zambroni" had come to long before him) that 
 it was in no way an aifair of the whole mass of limestone 
 rock, but exclusively of the magnesia in it, the maximum 
 amount of the disease being found on a soil of dolomite or 
 magnesian limestone. 
 
 Grange's first observations were made in tlie valley of the Isere; 
 both there and in the dihivial plain of Grenoble, in the valleys of the 
 Vosges, Jura, and Pyrenees abounding in dolomite, on the molasse 
 (nagelfluh) of Western Switzerland, in the departments of the Oise, 
 Aisne, and Somme, in a few districts of Dauphinc, and in the depart- 
 ments of Haut-Rhin and Bas-Rhin, it was the abundance of magnesia 
 in the soil that appeared to determine the occurrence of goitre and 
 cretinism. However various the elevation, the configuration and the 
 formations of these regions might be, one unvarying factor in them 
 all was the presence of magnesia in the rock, whether it occurred in the 
 form of magnesia-containing silicates (as particularly in gneiss and 
 granite and in horablende-rocks) or in the form of dolomite ; and it was 
 the absence, or the somewhat scanty or infrequent occuri'ence of mag- 
 nesia in the younger Jurassic rocks, in the chalk, and in the Tertiary 
 formations that explained the immunity of localities in whose soil these 
 predominated. 
 
 These conclusions oE Grange on the relations of a parti- 
 cular quality of soil to endemic goitre and cretinism are in 
 agreement, not only with earlier observations as to the pre- 
 valence of both diseases on the Trias (muschelkalk, keuper, 
 and zechstein), and on the transition limestone of Lower and 
 Middle Franconia, Wiirtemberg, Sigmaringen, Baden, the 
 Norican Alps, and India ; but they have been confirmed also 
 
 1 'Compt. rend.,' 1848, ii, 358 ; 1849, "' 695 ; 1850, i, 518, ii, 58 ; ' Annal. de 
 chimie et de phys.,' xxiv, 364; 'Arch. gen. de nied.,' 1850, Jan., 108. 
 
 * In the paper hrought out by Mongez (' Revue med.,' 1825, iv, 139), on the 
 occasion of the discussion at the Academic des Sciences upon the memoir drawn 
 up by Roulin relating to the distribution of goitre in New Granada.
 
 ENDEMIC GOITIiE AND CllETlNISM. 177 
 
 by mauy recent observations at tlie most diverse points witbin 
 tbe distribution-area of tbe two diseases — by Morel^ and 
 Aucelon for tbe Vosges, by Allaire and Richon for tbe vicinity 
 of Diedenboffen and IMetz^ by Gaudiu for the department of 
 Nievre, by Auzouy and Garrigou for the Pyrenees, by 
 Vircbow and Vogt for Lower Frauconia, by Majer and 
 Riidel for Middle Fraucouia, by E-ohrig for tbe village of 
 Auracb (Waldeck), by Gray for Bhootan, by Greenbow for 
 Oudb, and by Tschudi for Brazil (especially the pi'ovince of 
 Minas Geraes from Oui'o Preto upwards, witb its " itacolumit " 
 or magnesian-quartz soil). 
 
 Lower Franconia, as Yircliow points out, belongs to the Trias, except- 
 ing its northern and western part ; the larger part of the Spessarfc rests 
 on variegated sandstone, the declivities of the valley of the Main yield 
 muschelkalk, and the Steigerwald, a range extending in all directions 
 throughout the Franconian Highlands, consists of keuper. Goitre and 
 cretinism in this region are endemic upon muschelkalk ; on the other 
 hand, both diseases are entirely absent from the interior of the Spessart 
 where the variegated sandstone is most abundant, beginning to 
 show endemically at the edges of that formation, where muschelkalk 
 overlies the sandstone, as well as on a belt of it abounding in salt 
 springs. At the highest points of the Steigerwald, the upper members 
 of the keuper predominate (sandstone mixed with argilaceous strata) ; 
 at the foot of the range and in the plain, extensive layers of dolomite 
 iire exposed, among which gypsum crops out. Thus the area of disease 
 is here limited to localities where muschelkalk, dolomite or gypsum in 
 keuper-marl are found, or where strata of limestone and zechstein occur 
 side by side with variegated sandstone.^ 
 
 Tbe theory developed by Grange and supported, as we 
 have seen, on many sides, has not been permitted to go un- 
 challenged. Thus it has been contested by Saint Lager, 
 whose very comprehensive study of the geological charac- 
 ters of soils over the whole globe (so far as they are known) 
 has led him to the opinion that goitre and cretinism are 
 indigenous only in regions with metal-yielding rock, that 
 their endemic occurrence depends essentially upon the pre- 
 sence of sulphuret of iron or of copper pyrites, and that 
 
 1 In 'Congres scient.,' Nancy, 1S51 ; 'Annal. mcd.-psycliol.,' 1854, avril; 
 •Traite des degenerations phys., &c.,' Par., 1857; ' Arch. gen. de med.,* 1864, 
 fevr., 173; 1865, juill, g. 
 
 * I may note that doloinitic rock is predominant also iu the Western Soudan, 
 where Quintin has found goitre to be endemic. 
 
 VOL. II. 12
 
 178 GEOGEAPHICAL AND HISTORICAL PATHOLOGY. 
 
 their prevalence on soils containing magnesia is explained 
 by the fact that that rock is especially liable to contain sul- 
 phuret of iron. This view has lately found support in the 
 inquiries of Lebour on the distribution of goitre in England.^ 
 But against it the objection has been raised by Grarrigou 
 that there is not a trace of endemic goitre in those very dis- 
 tricts of France where sulphuret of iron occurs in largest 
 quantity — in the canton of Ax (Dept. Arriege) and in the 
 canton of Alais (Dept. Gard) ; while the disease is endemic 
 in many parts of the country where not a trace of sulphuret 
 of iron (or other metal) can be discovered in the soil. 
 There is still another circumstance that I must call atten- 
 tion to as being not without significance for the question 
 in hand : I mean the fact commented on by Thomson and 
 others that goitre is wanting in New Zealand notwithstand- 
 ing that in the northern island, in which almost the whole 
 native population reside, largo masses of magnesian limestone 
 lie exposed. 
 
 Thus the results of inquiries instituted to discover the con- 
 nexion between goitre and cretinism and the mineralogical 
 character of the soil, do not justify us in coming to a 
 definite conclusion. At the same time, the theory developed 
 by Grange is noteworthy in the highest degree. But it still 
 remains not altogether clear what is precisely the connexion 
 between quality of soil and the development of the disease ; 
 at all events the doctrine deduced from these facts of some 
 goitre-producing property in magnesian drinking-water is, 
 us we shall see, a highly unlikely one. 
 
 § 48. Differences op Liability accokdinq to Kace. 
 
 With regard to the liability of various races and nation- 
 alities to goitre and cretinism, the statements of the several 
 authorities are very conflicting. 
 
 Thus Greenliow and Barton state tbat tliey Lad not seen a single case 
 of goitre among tlie white residents ; whereas, according to the experi- 
 ences of Wilson and Fayrer, the disease is equally common among all 
 races. For Nicaragua, the accounts of Bernhard and Guzman agree 
 
 » 'Med. Times and Gaz.,' 1881, Oct., 492.
 
 ENDEMIC GOITRE AND CKETINISM. 179 
 
 that goitre is most frequent among the Indians and more rarely met 
 with among those of mixed blood. In New Granada it would appear, 
 from Humboldt and Roulin, that the disease seldom occurs among the 
 Indians, but, as Roulin adds, it is common among the negroes and the 
 whites. In like manner Smith found goitre most frequent in Peru 
 among the whites and the negroes, but rare among the mestizzos and 
 Indians ; while Tschudi found it in Brazil equally common in negroes, 
 mulattoes, and whites. 
 
 Wlietlier tliese differences, such as tliey are, in the amount 
 of the disease in a mixed population, are attributable to 
 racial distinctions, appears very doubtful ; at all events, the 
 above facts, as well as the fact that goitre is endemic among 
 the Indians of North America (Barton), among the Malay 
 population of Sumatra, Java, and Ceylon, among the Mongols 
 in Ladak and China, and among the Arabs in Algiers and 
 Morocco, make it undoubted that no race or nationality 
 enjoys an immunity from goitre. But it is worthy of the 
 fullest attention that, although goitre is widely spread in the 
 Western Hemisphere, cretinism occurs much more rarely 
 there than it does in the Eastern, or than it does on the soil 
 of Europe in particular. 
 
 § 49- Neglect of Hygiene a peedisposing Cause. 
 
 Few diseases would seem to offer so favorable an oppor- 
 tunity for etiological research as goitre and cretinism. The 
 delimitation of the morbid areas, for the most part within 
 narrow bounds, might make it appear an easy matter to arrive 
 at a knowledge of the physical or chemical influences peculiar 
 to those particular localities as contrasted with others adjoin- 
 ing them, — influences such as could be brought into direct 
 relation with the production of the disease or could be desig- 
 nated as its proper cause. And, indeed, the first observers 
 thought that they had speedily and conclusively solved the 
 problem. But the farther the inquiry proceeded and the 
 larger became the number of places at which observations 
 were made, the more marked were the differences of opinion 
 that showed themselves among the observers, and the greater 
 was the accumulation of diverse theories. An impartial
 
 180 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 estimate at tlie present day requires us to admit that the 
 cause of endemic goitre and cretinism is still enveloped in 
 obscurity. I think I may be excused from recounting all the 
 opinions that have passed current on this subject ; and in the 
 sequel I shall confine myself to a summary discussion of such 
 theories as continue to the present day to have some import- 
 ance assigned to them, or have been recently the subject 
 of discussion. 
 
 The earliest observers were chiefly impressed with the 
 fact that the centres of goitre and cretinism were to be found 
 in deeply cleft, narrow, and damp valleys, little open to the 
 sun or little swept by the wind, and they concluded that the 
 essential cause of the disease was furnished by that kind of 
 yalloy-formation, and by the high degree of atmospheric 
 moisture, associated with high temperature and deficient sun- 
 light, dependent thereon. This view was first put forward 
 by Ackermann,^ Fodere,^ and the brothers Wenzel,^ and it 
 found defenders subsequently, although in a less exclusive 
 fashion, in Berchtold-Beaupre (for Freiburg in Switzerland), 
 Guista (for the Val d'Aosta), Pilz (for the Ennsthal), and 
 others. When speaking of the relations that might be traced 
 between these diseases and states of atmosphere and soil, I 
 showed the untenability of this doctrine (subsequently 
 abandoned by Fodere himself), although I did not question 
 the injurious influence on the health of the population of these 
 factors in general, or their importance as predisposing causes. 
 It is in the same sense, it seems to me, that we have to 
 judge of a second class of etiological factors, to which a 
 preponderant importance, especially for cretinism, has been 
 attached by certain observers, viz. the noxious effects due to 
 social misery, insufficient food, drwikenness, filth, overcrowded 
 and ill-ventilated dwellings, and neglect of body and mind. 
 The good results which have followed improved conditions 
 of living among the inhabitants of 2:)articular places in Switzer- 
 land, Piedmont, Germany, and France (Vosges, Puy-de-D6me) 
 in limiting the extent and severity of cretinism, do not per- 
 mit us to doubt that there are in social defects, just as in 
 the already mentioned atmospheric and telluric influences, 
 certain factors favorable to the production of the disease, 
 
 1 L. c, 83. ' L. c, 44, 140. 3 L. c, 95.
 
 ENDEMIC GOITRE AND CRETINISM. 181 
 
 the obviating of wliicli is one of tlie most important and most 
 pi'ofitable of hygienic tasks. ^ But there are certain facts which 
 make it clear that we are not therein concerned with a specific 
 cause of disease. These are : — that many localities which are 
 quite exempt from goitre and ci-etinism present the same 
 social conditions among their inhabitants as the places afflicted 
 by those diseases, or even social conditions that are worse ; 
 that the populous centres of Europe, Asia and America, 
 where all those noxious influences are in the aggregate 
 developed most, are precisely the places where goitre and 
 cretinism do not occur, or occur in sporadic cases only ; that 
 in many of the tracts of country afflicted with these diseases, 
 the inhabitants are in the enjoyment of comparative comfort, 
 goitre and cretinism where they are endemic being by no 
 means exclusively the attributes of poverty and misery. 
 
 " Je ne crois pas necessaire," says Boussingaulfc, " de refuter ropinion 
 qui attribue le goitre a I'ivTOgnerie, a la malproprete, a I'usage d'alimens 
 grossiers ; sans doute que les auteurs d'line semblable opinion n'avaient 
 pas eii I'occasion de sejourner dans iin pays oii le goitre est commun ; 
 autrement ils auraient pu observer cette maladie cliez les individus les 
 plus sobres et dans la classe aisee de la societc." To tbe same purport 
 is tbe statement of Saint-Lager witb reference to tbe occurrence of 
 cretinism even amidst comfortable circumstances : "J'ai ete fort 
 surpris, apres avoir hi tout ce qu'oii a ecrit au sujet de I'influence 
 qu'exercent siir la production du cretinisme la misere, la salete et la 
 mauvaise nourriture, de trouver en Suisse, en Savoie, en Dauphinc et en 
 Picmont des cretins dans les villes et les villages les mieux batis, dans 
 les demeures les plus i^ropres et chez les pavticuliers les plus aises. II 
 est bien entendu, que je parle ici de I'aisance reelle et non de la ricbesse, 
 qui n'empecbe pas certains individus de vivre a la fa9on des miscrables." 
 After quoting a large number of observations which he bad made on 
 this point, be goes on to say: "La noblesse de Sion, de Sierra et 
 d'Aoste a eu des cretins : ne pouvant citer des noms, par egard pour les 
 families, je me borne a, affirmer que j'ai vu des cretins au sein des 
 families jouissant de la plus grande aisance." It bad been remarked 
 previously by Fodcre that cretinism occurred " equally in palaces and 
 
 1 " La miseria non o direttamente causa di cretinismo, ma ne e un elemento 
 favoritore, iucubatore "— says Lombroso (1. c, p. 14) J ai"^ Herrmann (1. c, 153) 
 sums up bis experiences of tbe influence of an injurious hygiene in producing 
 the cretinism of the phiin of the Rhine in Hesse, with these words : " I am 
 convinced that the social and domestic defects which have been mentioned are 
 to be taken merely as unfavorable or complicating plicnomena and by no means 
 as causes operating independently for the production of cretinism." 
 
 » 'Etudes; p. 173. ^ L. c, 72.
 
 182 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 in thatched cabins;" and we have the same kind of testimony — in the 
 ■writings of Troxler and Lebert for Switzerland, of Hoffmann for Lower 
 Franconia, of Riidel for Middle Franconia, and of Hermann for the 
 Hessian plain of the Rhine, — that the malady is indigenous in localities 
 where the fertility of the soil, the earning power of the inhabitants, 
 and the comforts of living compare favorably with those of neighbour- 
 ing communes which are quite exempt from the disease. That goitre 
 is independent of these etiological factors is testified to not only by 
 Boussingault, but also by Grange, Tourdes (for Alsace), Yingti-inier 
 (for the department of the Seine inferieure), Berkowski (for Perm), 
 and others. The opinion also that the epidemic outbreaks of goitre 
 in French garrisons were specially connected with hygienic defects 
 (overcrowding and filth in the barracks, unsuitable food, &c.) — a view 
 adopted by several French military surgeons— has found no support in 
 the experiences of Gouget, Viry and Richard, Fleury and Saillart. In 
 order to dispose of this theory as absolutely untenable it is only neces- 
 sary to add that the disease has been observed to occur in animals.^ 
 
 § 50. Theory op Increased Vascular Pressure within 
 
 THE Thyroid. 
 
 Anotlier theoiy, wliicL. applies especially to goitre, sets out 
 witli tlie assumption that, in tlie development of that disease 
 we are concerned exclusively with a hyjjersemia of the thyroid 
 gland, produced in a purely mechanical ivay, and continuing 
 for a long period or recurring from time to time, and that the 
 occasion of it is furnished, sometimes by pressure in the 
 cervical vessels or in the thyroid directly (as a result of long- 
 continued extension or strain of the neck in certain attitudes 
 of body), and sometimes in resp)iratory and circulatory disorders, 
 which cause either a fluxion to and over-distension of the 
 highly vascular gland, or congestive hypereemia in it as a 
 kind of safety-valve to the venous congestion of the intra- 
 cranial organs. The occasion of these circulatory and respi- 
 ratory disorders, according to the views of observers, may 
 be either a chill (or the effect of cold air on the heated body, 
 especially on the neck, or of a draught of cold water under 
 the same circumstances), or it may be severe bodily strain 
 such as climbing mountains, carrying heavy burdens (particu- 
 larly on the head), and violent exertions, especially if they 
 be put forth at great elevations or in a rarefied atmosphere. 
 
 * Vide supra, § 43.
 
 ENDEMIC aOITRE AND CRETINISM. 183 
 
 Halm points out^ that goitre wliich was at one time of 
 general occurrence among the female population of Luzarches, 
 has disappeared almost entirely in recent times with the 
 decline of the lace-making industry. His explanation of the 
 fact is that the workwomen^ who found employment at this 
 industry from their early youth, were obliged to sit at their 
 work with the neck thrown forwards, so that pressure was 
 exerted on the cervical vessels and on the thyroid. Brunet^ 
 supports this opinion of the origin of goitre in general, on 
 the ground of his observations in the department of Cote 
 d'Or. On the other hand, Nivet, Halbron, Collin, Michaud, 
 Utz, Chouet, and other French military surgeons, explain the 
 epidemic outbreaks of goitre among the troops for the most 
 part according to the second of the two ways mentioned : that 
 is to say, as due to chills and strains of body, to which the 
 soldiers are exposed in the course of their military exercises. 
 Wilson's^ experiences in the Punjaub led him to a similar 
 explanation of the cause of the goitre endemic there : 
 
 '^ Active occupation, necessarily so much more severe in 
 hilly districts, seems to influence the production of this 
 disease to a great extent, as is shown by its so frequent 
 occurrence in those who lead a laborious life, or pursue active 
 duties in a constrained position. . . . The effects of violent 
 exercise upon the circulation and blood-vessels generally are 
 well known, and it is only necessary, on this point, to refer 
 to the relation of the thyroid gland to the large vessels of 
 tlie heart, its remarkably large supply from them, and its 
 dense capillary structure and consequent ready liability to 
 enlargement from the dilatation of its vessels under the 
 conditions produced by violent and prolonged exercise." 
 
 This circumstance tells especially at the higher elevations, 
 and that is the explanation, Wilson adds, why the male sex, 
 being exposed to these bodily strains in a higher degree 
 than the female, are more often affected with goitre in 
 mountainous regions than the latter, who, in their turn, are 
 more often affected in the plains. Chabrand is of opinion that 
 even cretinism is referable to the same etiological factor — 
 
 1 'Compt. rend.,' 1869, Ixix, No. 16. 
 
 ■■' lb,, 1869, Ixix, Nr. 18. 
 
 ^ *Med. Times and Gaz.,' 1874, Dec, 693.
 
 184 GEOGEAPHIOAL AND HISTORICAL PATHOLOGY. 
 
 " a des perturbations profondes et frequentes de la respira- 
 tion et de la circulation," these being due to the injurious 
 influences above mentioned_, to "passage brusque etfrequem- 
 ment renouvcle d'une temperature froide a une temperature 
 tres-eleve, et vice-versa, efforts, travail excessif, Ac" ^ 
 
 It cannot be contested a 2^'^iori that a hyperoemic swel- 
 ling of the thyroid with dilatation of the vessels and other 
 changes of the organ (hypertrophy and the like) subse- 
 quently ensuing, or, in other words, the formation of a 
 goitre in the manner indicated, may take place and most 
 probably does take place as a matter of fact ; or, at least, that 
 a predisposing cause for the production of goitre is thereby 
 furnished. But an explanation, after any rational fashion, of 
 the endemic occurrence of that disease, and of cretinism 
 as well, cannot be found therein ; and even for the epidemic 
 outbreaks of goitre among soldiers particularly in French 
 garrisons, and in boarding-houses, seminaries, and the like, 
 the explanation does not seem to apply. All speculation as 
 to the causes of endemic goitre and cretinism must be 
 regarded as absolutely misdirected, which leaves out of sight 
 the fact that both diseases have the marked character of 
 local maladies and of local maladies confined within quite 
 narrow circuits, and which seeks, in disregard of this fact,, 
 to find the disease-factors in such influences as are, so to 
 speak, of a cosmopolitan kind. If this theory really pos- 
 sessed the general significance which observers have ascribed 
 to it, then the diffusion of endemic goitre over the globe 
 must needs be infinitely wider than as a matter of fact it is ; 
 the epidemic occurrence of goitre — and this is the punctiwi 
 saliens of the question — would not be limited to those regions 
 where the malady is endemic for general reasons, but the same 
 phenomenon would necessarily present itself in other regions 
 as well, especially if they be mountainous, where there are 
 the same entirely commonplace influences at work, such as 
 catching chill, drinking cold water when the body is heated, 
 over-exertion, and the like. 
 
 Several of tlie Frencli practitioners liave fully admitted tlie trutli of 
 tills. Thus, Gonget, Avriting of tlie epidemic of goitre at Colmar in 
 1863, says that tlie troops previous to tlieir arrival liad gone tbrougk 
 
 * *Du goitre et du cretinisme endumiques,' Paris, 1864.
 
 ENDEMIC GOITEE AND CRETINISM. 185- 
 
 severe military exercises and liad remained quite liealtliy all the wLile.tlio 
 cases of goitre having occurred among them suhsequentlj, or at a time 
 when they were performing light garrison duty and were well lodged 
 and fed. With reference to this theory, Viry and Richard state: 
 "Noussommes conduits a reconnaitre, que la multijjlicite des causes, 
 auxqnelles on a tour a tour rai->porte Tapparition du goitre cpidcmique 
 masque en realite unc grande incertitude touchanfc Tetiologie vraie de- 
 cette maladie." 
 
 There need be no question, as we have ah^eady remarked, 
 that those factors which briug about enduring or frequently 
 recurring hyperasmius of the thyroid, may furnish a predis- 
 posing cause of goitre-formation ; and it is probably to this 
 that we must refer the predominance of the disease in goitrous 
 districts among the female j^opulation, in Avhom experience 
 shows that the hypereemic swelling of the thyroid stands in 
 some connexion, which we cannot for the present defiuo 
 more closely, with physiological processes in the organs of 
 generation (menstruation, pregnancy, childbed). 
 
 The larger number of aiithorities, who make any mention at all of the 
 proportions of goitre in the male and female sex, confine themselves to 
 stating that the disease occurs " preponderantly " or "almost exclu- 
 sively " among women (Inglis, Addison, Bayers, and others for various 
 parts of England, v. Franque for Nassau, Tourdes for Alsace, Mahue 
 for the department of the Aisne, Challan for Kabylia, Bennet for 
 Ceylon, Barton, Smith, Lane, and others for various parts of North 
 America, and Duplouy for Chili). Expressed in figures we find the 
 proportion given by Morel for Serccourt and by Manson for Nottingham 
 to be I man to ii women, and by Hallin for Faluh to be i to I2"3. 
 The statistical data of the French Commission are not of much use, 
 inasmuch as they relate to departments as a whole ; according to them, 
 the proportion for the whole of France is i male to 2*5 females, i to 2 
 for the departments most severely afl^ected (Savoy, Hautes-Ali^es, &c.), 
 and I to 3 for those more slightly aifected. Whether we may conclude 
 from this that a higher prevalence in the male sex depends on the 
 endemic intensity, I do not attempt to decide. 
 
 For the incidence of cretinism these differences in the twa 
 sexes are not discoverable, or at least the figures are too 
 untrustworthy to warrant a definite conclusion. It seems as 
 if the male sex were affected rather more.
 
 186 GEOGRAPHICAL AND HISTOETCAL PATHOLOGY. 
 
 § 51. How FAE CAUSED BY THE DeINKING-WaTER. 
 
 In the doctrine of the causes of disease, there is hardly 
 any idea that has taken so deep a root, both in the popular 
 belief and in the convictions of medical observers, as that goitre 
 and cretinism are caused by the use of drinlcing -water from 
 particular sources. This opinion is founded on the following 
 experiences gathered from various parts of the globe : (1) 
 that at places where the diseases in question are endemic, 
 only those persons become the subjects of them who draw 
 their supply of drinking-water from some particular spring, 
 while those who get their water from other springs escape ; 
 (2) that goitre and cretinism have appeared as an endemic in 
 villages after the opening of new water-supplies, the endemic 
 reaching just as far as the water from such sources was 
 used ; and (3) that the endemics of goitre and cretinism 
 have diminished in extent and finally died out after the 
 suspected water-supply had been abandoned (or closed) and 
 pains been taken to pi-ovide channels for another and innocu- 
 ous drinking water. 
 
 The belief in the power of certain wells — " goitre wells " 
 or ^'goitre springs'' — to bring on goitre (and cretinism), 
 goes as far back as our first information about goitre itself.^ 
 This idea took more definite shape when the belief arose, 
 following in the wake of opinions expressed by Paracelsus 
 and other practitioners and natural philosophers of the 
 1 6th century, that the property of goitre-wells to induce 
 the disease was to be explained through their contamination 
 by mineral matters ; and since that time a very lai'ge 
 number of observations have been brought together which 
 bave afforded grounds for believing that the origin of the 
 disease is related in one or more of the above-mentioned 
 ways to particular wells or springs. 
 
 Thus Boussingault writes from New Granada that a 
 medical practitioner of Socorro, a town where goitre occurs 
 in almost every house, obtained the supply of water for 
 himself and his household from a rain-water cistern, and 
 that every member of his numerous family kept free of the 
 * See the notes to the opening paragraphs of this chapter.
 
 ENDEMIC GOITRE AND CRETINISM. 187 
 
 \ 
 
 malady. Boussingault knew of another family in the highly 
 goitrous town of Mariquita who had protected themselves 
 from the disease hy avoiding all drinking-water that had 
 not been boiled. In St. Jean-de-Maurienne, according 
 to Mottard, those of the inhabitants escape goitre and 
 cretinism who avoid the suspected water from the well oi: 
 Bourieux and obtain their supply from a large rain-water 
 cistern that they have had erected. Morotiu tells us that, 
 some twenty years ago, a hamlet in the commune of Blegny 
 (near Salins in the Jura) used to be much afflicted with 
 goitre, but after the opening of a new spring the disease 
 decreased very considerably ; and the same thing had been 
 observed in the village of Allevard (Dept. Iscre). Bergeret^ 
 remarks that at Saxon in the Yallais, goitre and cretinism 
 had been very widely prevalent previous to 1835, but had 
 almost entirely disappeared since that date coincidently with 
 the giving up of the old water-supply and the opening of a 
 new well. Conversely, Chatin mentions the development of 
 an endemic of goitre in the villages of Fully and Saillon 
 (Vallais) subsequent to the opening of a new water-supply ; 
 and the same thing is recorded by Aguilhon for the canton 
 of Vertaizon (Puy-de-l^ome). Coindet and other Geneva 
 practitioners have found that goitre had become strikingly 
 less there since the town has been provided with water from 
 the Rhone in pipes, and that the disease occurs only in those 
 individuals who use the well-water which everyone used at 
 one time, pi'eferring it for its freshness. Germain ^ points 
 out that the villages of Saint-Michel, Mornoz and Aiglc- 
 Pierre, near Salins in the Jura and situated on one side of 
 the town, are much aifected with goitre, whereas, in the 
 communes of Pretin and Arsures on the other side of 
 the town, only sporadic cases occur, the two groups of 
 villages differing solely in respect that they get their drink- 
 ing-water from different sources. The same observer men- 
 tions the extinction of endemic goitre in the small town of 
 Nozeroy (Arrond. Poligny, Department Jura) on the opening 
 of a new well. Reid^ informs us that the English residents 
 
 1 *Compt. rend.,' 1873, vol. 77, No. 13, p. 15- 
 * ' Bullet, de I'Acad. de med.,' 1849, xv, 193. 
 
 2 Quoted by Saiat-Lagcr, ' Etudes,' p. 194.
 
 188 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 in Purneali protect tliemselves from the generally prevalent 
 goitre by avoiding tlie water of the Coonee brook which 
 flows past the town and by sending for water to the Ganges, 
 three days' journey distant. In the report of the French 
 Commission we find the following fact given : — In the town 
 of Bozel (Tarentaise) there wei^e counted in 1848 some 900 
 goitrous persons and log cretins in a population of 1472, 
 while the village of St. Bon standing 800 metres higher was 
 quite free from both diseases ; but a water-pipe having been 
 carried from that village to Bozel and this water having 
 come into general use, the endemic decreased so remarkably 
 that in 1864 there were only 39 goitres and 58 cretins^ and 
 no new cases were occurring. 
 
 Observations of the same kind are given by Fradenek ^ for 
 Carinthia, There are some particularly striking statements 
 as to goitres induced in Frenchmen and Italians, who 
 purposely drank the water of " goitre wells,' ^ so as to 
 escape military service. Observations to that eifect, said to 
 be well authenticated, are given by Saint-Lager ^ for Savoy ; 
 and Lombroso,^ speaking- of Lombardy, says : *' A Cavecurta 
 vi ha la, ' fonte del gozzo,' ove sogliono audare i giovauni all' 
 epoca della coscrizione onde acquistare in quindici giorni 
 quel diffetto che li sottrae dal servizio." 
 
 Noteworthy as these and many other observations are, 
 there are not wanting others which serve to place in a some- 
 what questionable light the conclusions as to the patho- 
 genesis that have been drawn therefrom. As we have 
 already seeu,^ goitre and cretinism have appeared as a new 
 thing in some localities, just as they have disappeared from 
 others on improvement of the hygienic conditions, without 
 any obvious change whatsoever occurring in the drinking- 
 water. Again, it has been pointed out by many observers 
 that, of a number of villages all in one neighbourhood, some 
 are afflicted with goitre and cretinism, while others, drawing- 
 their water-supply from the same source as the former, 
 enjoy an absolute immunity from these diseases ; this has 
 been observed by Rosch in Wiirtemberg, Riidel and others 
 in Middle Franconia, Schaussberger in Upper and Lower 
 Austria, Meyr in the circle of Kronstadt (Transylvania), 
 ^ L. c, p. 456 S. * P. T91. 3 p ,6^ 4 Siij>ra, pp. 153, iSo.
 
 ENDEMIC GOITEE AND CRETINISM. 189 
 
 Maffei in tlie Salzburg Alps, Miral-Jeudy, in Clermont- 
 Ferrand (Puy- de-Dome), Evans in Tirlioot, Bramley in 
 Nepaul, and Humboldt in New Granada. It has been 
 shown also by Gouget, Morelle, Fleury, Viry and Eichard, 
 Muller and Michaud, that the epidemic outbreaks of goitre 
 in French garrisons cannot be brought into any casual con- 
 nexion with the water, inasmuch as those of the troops who 
 were the victims of the epidemic obtained their drinkiug-water 
 from the same spring that supplied the unaifected barracks 
 as well as the civil population, none of the latter haviug* had 
 any part whatsoever in any of these epidemics. 
 
 There are, indeed, explanations offered by way of resolv- 
 ing these contradictions in what I may call the drinking- 
 water theory, or by way of weakening the force of the 
 objections that have been brought against it. Saint-Lager 
 in particular has with much skill endeavoured to prove that, 
 in those cases where decrease or extinction of endemic 
 goitre and cretinism has been achieved through improved 
 hygienic conditions, there has probably been some change 
 at the same time in the particular substances contained in 
 the drinking-water; and that the unequal distribution of 
 the malady in the various places deriving their water- 
 supply from one source, is to be explained by the fact that 
 the same stream may contain different kinds of mineral 
 substances at various stages of its com'se, owing to washings 
 of the soil or other additions. However, this does not by 
 any means serve to reconcile the contradictions ; and although 
 one should hesitate, in view of the many positive facts, to 
 give up the drinking-water theory of the production of 
 goitre and cretinism as absolutely untenable, yet a certain 
 scepticism in this question is called for, all the more so 
 that no one has hitherto succeeded in detecting in the sus- 
 pected " goitre wells ■" or "■ goitre springs ^' any one uniform 
 thing either of mineral or organic nature, common to them 
 all and occurring in them only. 
 
 It was formerly held by some observers, and it is still a 
 popular belief in" certain mountainous parts of South America 
 (New Granada, Chili^ and Peru), that goitre is a conse- 
 quence of drinlcing snoiv-ivater or glacier-water, being caused, 
 1 Duplouy refers to it as the belief still universally current in Santiago.
 
 190 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 as Boussingault^ and others" have assumed, by the small 
 amount of atmospheric air in the water.^ This doctrine, already 
 overthrown by Fodere,* requires no further refutation when 
 we consider that the disease occui-s at innumerable points of 
 the globe, where there cannot be the remotest thought of 
 drinking-water of that kind, and that the use of distilled 
 water, even for a considerable period, has been shown to bo 
 quite unattended with hai-m. 
 
 The most popular of all these doctrines has been that 
 which makes the peculiar property of causing goitre and 
 cretinism to depend upon the abundance of lime salts {carbo- 
 nate and sulphate of lime, hut particularly of magnesia) in the 
 drhiJcing- water. The fact that water rich in lime and mag- 
 nesia is exceptionally often drunk in regions where goitre 
 and cretinism are endemic, will not be contested, inasmuch 
 as we have seen that those diseases occur, if not exclusively, 
 yet for the most part upon limestone and dolomite soil ; but 
 it is by no means proved that the partaking of water of that 
 kind is actually the cause of these diseases. On the other 
 hand, there are facts, both positive and negative, which tell 
 against any dependence of the pathogenesis on that factor. 
 
 Referring to the amount of lime in the drinking-water of 
 localities inWiirtemberg, both those affected by goitre and cre- 
 tinism and those exempt from them, Rosch^ has the following : 
 '' Many of the streams, particularly in districts and localities 
 where goitre and cretinism are endemic, contain as much 
 gypsum as cold water can dissolve or retain in solution. 
 Notwithstanding this, goitre and the cretinous degeneration 
 do not exist at every place where the water contains gypsum ; 
 for example, they do not occur, or they occur only to an 
 insignificant extent, at Gaildorf, Murrhardt, Botenheim, and 
 other villages. At Tiibingen the constituents of the water 
 
 ^ He became convinced afterwards tliat the theory was untenable. 
 
 ^ Rendu, writing of Brazil, says that this opinion is still held by Dr. Faivre. 
 
 3 Somewhat allied to this opinion is the doctrine given out by Rozan (* Mem. 
 de med. milit.,' 1863, x, 357), according to his experiences in Brian9on, and 
 adopted by Lombard (' Etude sur le goitre et le cretinisme endemiques,' Geneve, 
 1874), to the effect that respiration in rarefied air, or in other words, a lesser 
 amount of oxygen in the air, is a cause of goitre. The rapidity of the respira- 
 tions, as we know, is in proportion to the amount of oxygen in the air. 
 
 ^ L. c, p. 26. 5 L c., p. 213.
 
 ENDEMIC GOITRE AND CRETINISM. 191 
 
 are almost the same in all the wells, and yet goitre and cre- 
 tinism occur only in the lower part of the town belonging to 
 the Ammerthal. On the other hand, goitre (along with 
 cretinism) is found at a number of places where the water 
 contains either no gypsum or the merest trace of it, as in the 
 Glatthal, the Nagoldthal, and on the Lake of Constance, 
 precisely as it is found where there is gypsum in the water.'* 
 The same conclusion has been come to by Maffei^ as i-egards 
 the condition of the drinking-water in the Salzburg Alps. 
 Klebs also, who formerly^ laid particular stress on gypsum in 
 the drinking-water as a cause of goitre and cretinism, was 
 obliged afterwards^ to admit that the water in the Salzburg 
 centres of goitre and cretinism was almost free from mineral 
 constituents. Rossknecht observes that the water supply of 
 the very goitrous commune of Hammeroisenbach in Baden 
 comes out of granite and is absolutely free from saline ingre- 
 dients ; and Weber* points out that in Mannheim, where the 
 water is rich in lime, the goitrous are 0*77 per cent, whereas 
 in Heidelberg, where the amount of lime is very small, they 
 are 5*72 per cent. In the valley of the Neckar in Hesse, 
 where the two diseases ar6 endemic, we learn from Miiller 
 that the water used for culinary purposes is chemically 
 almost pure, whereas in the side valleys which use the same 
 water, neither goitre nor cretinism is met with. According 
 to Herberger, the drinking-water of Rheinzabern in the 
 Palatinate, where goitre and cretinism are endemic, contains 
 mere traces of lime and magnesia. In the village of Ridge- 
 mont in Bedfordshire, goitre is endemic although the water 
 is free from lime, whereas in localities adjoining where the 
 water is rich in lime, the malady does not occur.^ Goitre is 
 endemic also at Bolton (Lancashire) notwithstanding the 
 absence of lime in the water.^ In Switzerland, as Amsler 
 shows, goitre is much commoner in localities Avhere the water 
 is poor in lime than in those where the amount of lime is 
 great. The same fact had previously been demonstrated by 
 Zschokke in connexion with the distribution of the disease 
 among the villages in the valley of the Aar, and wo have 
 
 ^ L. c, p. 1 6o. 
 
 » ' Arch, fiir exper. Pathol.,' 1874, ii, 8r. ^ ' Studien, «S;c.' 
 
 ■» L. c, p. .31. ^ Blower, 1. e. ^ Black, 1. c.
 
 192 GEOGUArniCAL AND HISTORICAL PATHOLOGY. 
 
 corresponding observations on tlie goitre and cretinism of 
 the Canton Vallais. In tlie Champagne, where the water 
 drunk is much impregnated with lime, endemic goitre is un- 
 known^. The three wells in Chambery, which are considered 
 to be most under suspicion, contain only traces of sulphate 
 o£ lime and magnesia." At St. Jean, St. Sulpice, St. Eemy, 
 and other places in the Lower Maurienne, which ai'e the 
 head-quarters of the endemic of goitre and cretinism there, 
 the drinking-water is much purer, that is to say, freer from 
 minei'al matters, than in the Upper Maurienne where neither 
 goitrous persons nor cretins exist.^ How slight an influence 
 the abundance of lime in the water has upon the occurrence 
 of goitre in Italy is shown by Sormani,* in the fact that 
 Bologna, Florence, Leghorn, and Rome, where the water in 
 general use is hard, have goitre only as a rarity, and in the 
 other fact vouched for by Professor Taramelli, that in Vicenza 
 and the Abruzzi, being the provinces of Italy where lime most 
 abounds, the malady occurs only to the very smallest extent. 
 In many parts of North America, which are or have been 
 affected with goitre, such as Bennington, (Verm.) Pittsburg, 
 and Fort Dayton, the drinking-water, as Barton informs us, 
 does not contain lime, whereas lime-salts predominate in the 
 watei- of many parts of Pennsylvania where the disease has 
 never been endemic. 
 
 As regards magnesia, none of it has been found by Niepce 
 in the drinking-water of Bourg d'Allevard, Sassenage and 
 other places near Grenoble, or in the water used in many of 
 the goitrous villages of the Hautes-Alpes and Basses-Alpes. 
 In the commune of Coise there are two wells, one of which 
 is looked upon as causing goitre and the other as curing it ; 
 analysis of the water in each of them gives the following 
 results : 
 
 No. 1. No. 2. 
 
 Carbonate of lime . o"i66 . o"68o 
 
 Sulphate of lime . o"049 
 Chloride of calcium . o'oop 
 Chloride of magnesium o'ooo 
 
 ' Rotinet, ' Gaz. des h6plt.,' 1863, Jiin 
 * Boiijetiu, * Gi 
 2 Podere, 1. c, 
 ■* L. c, p. 164 
 
 0"027 
 0"028 
 
 P- 15- 
 
 * Boiijetm, * Gaz. med. de Paris,' 1851, p. 135. 
 2 Podere, 1. c, p. 27.
 
 ENDEMIC GOITRE AND CRETINISM. 193 
 
 Chevalier has shown that the water in Aosta, Villard, 
 (Tarentaise) and Valnaveys is free from magnesia, whereas 
 that substance is contained in the water of the Graisivaudan 
 valley, which is free from cretinism. Maumene says^ that 
 at RUeims, where goitre used to be endemic, there is not a 
 trace of magnesia to be found in the soil or in the well-water. 
 Dejean has examined the drinking-water from localities in 
 the Jura where goitre is endemic, and has found that the 
 amount of magnesia is least in the Canton Voiteur, which is 
 actually the most goitrous region in the department. Agree- 
 ing herewith is the observation of Moretin that magnesia is 
 found everywhere in the water of the Seille, equally at 
 goitrous localities and at those where the malady does not 
 occur, while there is no definite relationship discoverable 
 between the amount of magnesia in the water and the amount 
 of the disease at each place. In like manner Tourdes" found 
 magnesia in the drinking-water of a few goitrous and 
 cretinous villages of Lower Alsace, but the same constituent 
 showed itself also in the drinking-water of other places in 
 the department, where the maladies were either on the 
 decline or were quite unknown. In the town of Rodez (Dept. 
 Aveyron), where neither goitre nor cretinism occurs, there is 
 five times as much magnesia in the water as at the goitrous 
 and cretinous spots in the valley of the Isere -^ also in 
 Noyon, where the water used is very rich, in magnesia, 
 there is no endemic goitre.* Demortain has examined the 
 water at several goitrous spots in the plain of Lombardy, 
 and found it to be absolutely free from magnesia.^ In 
 Faluh, the single locality of Sweden where goitre is endemic, 
 a kind of drinking-water is used which has not its like in 
 the whole country for chemical purity.^ In the districts of 
 the Punjaub which are subject to goitre and cretinism, the 
 drinking-water has so little of mineral ingredients that it 
 may be described as absolutely pure.'' On the other hand 
 both diseases are unknown on the western littoral of Mexico 
 (Guaymas and Mazatlan), although the water used there 
 contains magnesia.^ 
 
 ' ' L'Institut,' 1850, No. 870, p. 282. ' L. c, p. 18. 
 
 3 Bloudeau, as quoted by Morutiii, p. 42. * Guilbert, 1. c. 
 
 ^ ' Gaz. hebd. de mod.,' 1859, p. 709. « Berg., 1. c, p. 47. 
 
 7 Wilson, 1. c. .8 Lucas, 1. c. 
 
 VOL. II. 13
 
 194 GEOGEAPniCAL AND HISTOEIOAL PATHOLOGY. 
 
 Allied to the theories here discussed (and shown to be un- 
 tenable) which assert the origin of goitre and cretinism from 
 the use of drinking-water peculiarly rich in lime or magnesia, 
 there are certain other views^ belonging to the same order, 
 which have been put forward recently. Such is the conjecture 
 of Schwalbe^ that a deficiency of chlorides in the water, especially 
 of common salt, causes goitre and cretinism. This conjecture is 
 supported by the observation of Euleuberg^ that in the 
 villages of the Coblenz circle where goitre is endemic the 
 water is strikingly poor in chlorides, while in the villages 
 exempt from the malady the chlorides in the water are abun- 
 dant j it is supported also by Demortain's statement that 
 a notable absence of chlorides is found to exist in the 
 drinking-water of the goitrous districts of Lombardy, and by 
 the analysis of waters in some other centres of the malady. 
 Apart from the objection justly taken by Virchow,^ that it 
 is scarcely credible " that an active, nay even an irritative 
 process can be induced by the mere absence of a substance 
 rather than by some positive substance or combination,''^ it is 
 further impossible to understand how any secret power to call 
 forth such effects can reside in the common salt of drinking- 
 water, present for the most part in merely minimal quan- 
 tities, when every day we introduce into the organism enor- 
 mous quantities of salt with all our food — such a power 
 as must be able, if we are to trust the accounts of the wilful 
 production of goitre by drinking the water of '' goitre-wells,'^ 
 to produce its effects within the space of a fortnight. 
 
 Saint-Lager's conjecture, based upon his opinion that goitre 
 and cretinism occur only in those regions where there are 
 metals in the soil, is to the effect that tlte presence of metallic 
 substances in the drinh'ing-ivater,'i)articularly sulphate of i^-on, 
 is the cause of the disease. In somewhat the same sense 
 McClelland had already propounded the question whether 
 perhaps the presence of copper in the soil might not impart 
 goitre-producing proijerties to the water. Low also has 
 recently called attention to the fact that the drinking water 
 in all the goitrous localities of Yorkshire is distinguished by 
 its large amount of iron and alum. 
 
 L. c, p. 31. - ' Arcliiv fiir geineinscliaftl. Arbeiten,' i860, iv, 347. 
 
 ^ ' Geschwiilste,' iii, p. 59.
 
 ENDEMIC GOITRE AND CRETINISM. 195 
 
 Saint-Lager speaks witli the reserve characteristic of an impartial 
 inquirer : " Let us take care," lie says at the end of his discussion,' " not 
 to go too far; the sulphate of iron is for the present only an accused 
 party, until such time as culpability can be proved of it in a conclusive 
 manner." His experiments with sulphate of iron given to dogs have 
 miscarried through accidental causes. Still more dubious is McClel- 
 land's expression of opinion : 
 
 " The noxious principle in the waters of Alpine limestone," he says,^ 
 " is a subtle combination [of various minerals] derived perhaps from 
 the strata of the rock which are called by miners ' copper slate.' 
 They are so distinguished from the quantity of metals which they con- 
 tain, particularly the ores of copper. In describing the locality of the 
 springs, which supply those villages where the inhabitants suffer most 
 from goitre, they may be said to be generally derived from the strata in 
 question, or, at least, from the lower beds of limestone near the junction 
 where it rests on clay slate. But whether there be any other strata," 
 he adds,^ " capable of yielding this peculiar contagion than those we 
 have described, and whether the water is the only medium by which it 
 is conveyed, are points which still remain to be determined." 
 
 Tlie objections to the theory, as we liave already soeri; 
 (p, 178), are, on tlie one hand, that goitre is endemic in 
 localities where not a trace of iron pyrites can be detected 
 in the soil, while the malady does not occur in other regions 
 whose soil is unusually rich in that mineral ; and, on the 
 other hand, that the long-continued therapeutic use of salts 
 of iron, including sulphate of iron in mineral waters, has 
 never, so far as we know, been followed by the development 
 of goitre. It ought not to be difficult to vex'ify the hypo- 
 thesis put forward by Saint-Lager by means of experiments 
 on such animals as are otherwise prone to goitre, and possibly 
 also by observations in medical practice. 
 
 I have to mention in conclusion the view of Maumene* 
 according to which fluorine gives rise to goitre. His con- 
 clusion was derived from the general diffusion of that element 
 in the soil of goitrous regions (especially in the Pyrenees 
 where he had. travelled). To test it he experimented on a 
 cat, which he plied with fluoride of potassium for five months ; 
 towards the end of that period a swelling developed in the 
 neck, but the cat then made its escape, and when it was re- 
 
 1 ' Etudes,' p. 454. 
 
 ' 'Sketches of the Med. Topogr., ic, of Bengal,' Lend., 1859, P* 9^- 
 
 3 lb., no. 
 
 ■4 ' Compt. reud.,' 1866, fevr. 19 (' Arcli. ge'u. de med.,' 1866, avril, 497).
 
 196 GEOGRAPHICAL AND HISTOEIOAL PATHOLOGY. 
 
 captured three years after, tlie tumour, whicli was still there, 
 was found on dissection by Professor Gaillet of Rheims to 
 have nothing to do with goitre. Saint-Lager's experiments 
 on animals with fluoric acid have resulted negatively.^ 
 
 § 52. Theory op Deficiency op Iodine in the Aik and 
 
 Watee. 
 
 A short-lived opinion was that advocated by Chatin " 
 (before him by Prevost and Maffoni,^ and after him by Mar- 
 chand* and Fourcoult)^ to the effect that the cause of goitre 
 and cretinism lay in the absence of iodine in the drinhing- 
 ■water and in the air. Chatin pointed to his numerous 
 inquiries which showed that wherever the amount of iodine 
 was relatively large, as in the basins of the Seine, Yonne and 
 other rivers, the two diseases were unknown ; that they both 
 became prominent with a smaller amount of iodine, as in the 
 Rhone valley ; and that this inverse ratio obtained with even 
 greater force in the valley of the Isere, and most of all in 
 the very intense goitrous and cretinous localities of Taren- 
 taise and Maurienne. Against this theory there is first of 
 all the fact, admitted by Chatin himself, that in mountainous 
 regions the quantity of iodine is inversely as the height of the 
 place, while the greatest prevalence of goitre and cretinism 
 occurs at the more deeply situated spots, decreasing in pro- 
 portion as we ascend. The inquiries made by Dejean, 
 Germain, and Moretin into the amount of iodine in the water 
 of various places in the Jura have resulted in showing that 
 it is nearly zero everywhere, whether in the villages with 
 endemic goitre or in those without it. Niepce has been able 
 to make out the presence of iodine sometimes in considerable 
 quantity, in the air, the water, and the vegetation of the plain 
 of the Po, in several localities of the department of Saone- 
 Loire, in a few villages of the Val d'Aosta, and in the valley 
 
 1 ']Efcudes,'p. 457. 
 
 2 'Compt. rend.,' 1850-52; ' Gaz. des hSpit.,' 1852, Nr. 4 ff; 'Couipt. rend.,' 
 
 1853. 1,652. 
 
 3 ' Atti deir aead. mcd.-chir. di Torino,' 1846, ii, 453. 
 •• ' Compt. rend.,' 1850, 11,495. 
 
 * lb., uS5r, ii, 518,
 
 ENDEMIC GOITRE AND CEETINISM. 197 
 
 of the Isere, all of wliicli are subject to endemic goitre and in 
 part also to cretinism. Bebert^ found a not inconsiderable 
 amount of iodine in several springs in tlie valley of the Mauri- 
 enne^ corresponding to localities where goitre and cretinism 
 were very widely prevalent. Casaseca" affiinns that in Cuba 
 there is not a trace of iodine discoverable either in the air or in 
 the water, and yet that island, like most of the Antilles, is 
 quite free from goitre. Saint-Lager''^ mentions a very noto- 
 rious " goitre-well '^ at Beaulieu in the department of the 
 Oise, which contains a large amount of iodine as well as of 
 iron ; and he adds the remark that the springs most impreg- 
 nated with iodine are those that come from a soil particu- 
 larly rich in vegetable detritus and peat, and that these are 
 just the springs most notorious for their goitre-producing 
 properties. The only other point that I shall advert to is 
 that the theory of Chatin would not so much serve to 
 explain the cause of goitre and cretinism, but rather serve, 
 if it be well-grounded, to show that the actual disease- 
 factor itself widely spread over the globe, is only prevented 
 from becoming potent because it is neutralised within the 
 human body by the iodine introduced (in the most minimal 
 quantities) into the organism along with air and food. It 
 would then remain a question, and a very doubtful one, 
 whether iodine has a prophylactic power against goitre, as 
 well as a curative. 
 
 § 53. A Paik of Infective Diseases due to a Morbid 
 
 Poison. 
 
 The absence of results to all these inquiries about the 
 genesis of goitre and cretinism — inquiries which have extended 
 to every influence perceptible to the senses that could be 
 brought into the consideration of the question befoi'e us — 
 warrants, I will not say compels the conclusion that in those 
 diseases we have to do with a specific agent, a veritable mor- 
 hid poison, and that endemic goitre and cretinism have to he 
 reckoned among the infective diseases. This doctrine finds a 
 certain support in two things : on the one hand the fluctuations 
 
 ' Quoted by Vingtriuicr, p. 28. 
 
 * 'Coinpt. rend.,' 1853, ii, .^48; ^ L. c, p. 240.
 
 198 GEOaRAPHIOAL AND HISTOEICAL PATHOLOGY. 
 
 in tlie amount of the sickness, wliicli we have liad frequently 
 occasion to notice, and for which there is no sufficient ex- 
 planation to be found in the states of the atmosphere or of 
 the soil or of hygiene ; on the other hand, the epidemic 
 outbreaks of goitre, for which the theoiy of infection, as 
 Saillard, Viry and Richard, Thibaud and other French 
 military surgeons have recognised and said, is hitherto the 
 only one that aifords an explanation, and an explanation 
 that accords most nearly with the facts of the case. 
 
 Humboldt was the first, so far as I know, to express 
 this opinion as to the nature and the cause of goitre and 
 cretinism, the hypothesis having subsequently received the 
 adhesion of Vest,^ Bramley,^ Troxler,^ Gugger,* Schauss- 
 berger,^ Virchow,^ Moretin,'^ Vingtrinier,^ Morel,® Berkowski,^° 
 Koberle,'^^ the French Commission, Nivet,^^ and myself (in 
 the first edition of this work). As to the nature of this goitrous 
 and cretinous virus, and its means of conveyance, it is im- 
 possible to form a well-grounded opinion. Its existence and 
 development would appear to depend upon certain definite 
 kinds of soil, such as a soil containing dolomite rock, and it 
 would appear to. occur principally in water, perhaps associated 
 also in some circumstances with plants or suspended in 
 the air. Whether its nature is organic or inorganic is a 
 question that evades our answering. At all events it has 
 nothing in common with malaria, as Tourdes, Fayrer, Ance- 
 lon,-"^ and others would seem to say, inasmuch as goitre and 
 cretinism are endemic, and endemic even to a very consider- 
 able extent, in places that enjoy the driest of situations and 
 
 ^ ' Salzturg. raed.-chir. Ztg.,' 1. c, and in Fradenek, 1. c. 
 
 ■■' ' Calcutta Transact./ 1. c. 
 
 3 ' Der Cretinismus, &c.,' 1836. * 
 
 * ' Oest. raed. Jalirb.,' 1839, Nste. Folge, xix, 85. 
 
 * 'Oest. med. Wocheuschr.,' 1842, 1091. 
 
 8 ' Verhandl. der Wiirzb. Gesellscli./ 1852, ii, 268, and ' Gesamraelte Abhandl.,' 
 958, 968. 
 
 7 L. c, 57. 
 
 8 L. c, 18, 39. 
 
 ^ ' Annal. med.-psychol.,' 1854, Oct., and 'Arch. gen. de med.,' 1864, 173, 
 10 L. c. 
 
 " ' Essai sur le cretinisnie,' Strasb., 1863. 
 '2 'Gaz. hebd. de med.,' 1874, 55. 
 » lb., 1857, 62.
 
 ENDEMIC GOITRE AND CRETINISM. 199 
 
 are most free from all marshy exhalations ; while on the other 
 hand, there are large malarious tracts of low country, espe- 
 cially along the course of great rivers, and not a few of them 
 in closest proximity to goitrous and cretinous spots, which 
 are perfectly free from both of these maladies. Klebs, who 
 had at one time^ characterised the doctrine of the infective 
 nature of endemic goitre and cretinism as a " theory of 
 mystery " is now of opinion^ that he has found the morbid 
 poison in the form of minute animal or vegetable structures, 
 called by him ^^naviculas" from their shape; these he has 
 detected in the well-wa^er of several goitrous and cretinous 
 districts of Salzburg. Whether the " navicul^ " do not 
 involve an even dai'ker mystery must remain at least a ques- 
 tion. Riidel has been unable to find these " naviculse '^ in 
 suspected wells which he examined. 
 
 § 54. Relation op Cretinism to Goitre op the Parents. 
 
 To conclude these inquiries I have still to justify an as- 
 sumption with which I set out, the assumption, namely, that 
 goitre and cretinism, heing a 23air of disease-types closely related 
 in their pathology and etiology, are to be regarded as different 
 expressions of a single niorhid process. This idea is fully 
 borne out not only in the territorial distribution of the two 
 diseases alongside each other, nor only in the fact that by 
 far the most of cretins (three-fourths of them at least) are 
 at the same time goitrous, but above all in the fact which I 
 now come to, that cretinism arises hereditarily or con- 
 genitally where the parents are goitrous. No doubt we find 
 large regions of goitre in which cretinism does not occur 
 or occurs only sporadically ; but, as Virchow very justly 
 remarks, " at every place where there is cretinism associated 
 with conditions of the locality, goitre also is endemic ; . . 
 . . and we cannot but trace both diseases to the same kind 
 of influence, goitre being regarded as the result of a feebler 
 working of the noxious power, and cretinism the issue of a 
 stronger working.'' Almost all observers, both old and new, 
 
 1 « Arch, fiir exper. Tathol.,' 1. c. 
 
 2 ' Studien liber die Vcrbreitung des Cretinismus,' 1877.
 
 200 
 
 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 including Fodere, Iphofen^ Eoscli^ Marchant, Tourdes, 
 Morel, Niepce, Boucliardat, and the French Commission have 
 adopted this view.^ The opinion of Ackermann, Maffei, and 
 the Sardinian Commission, of Ferrus, Moretin, and Koberle, 
 that the endemic prevalence of the two diseases beside each 
 other is no more than an accidental coincidence, is one that 
 we are perfectly warranted in rejecting as baseless.^ 
 
 The most decisive evidence in this question is the fact 
 that hy far the larger number of cretins are the offspring of 
 goitrous parents,^ whether the latter had been at the same 
 time affected with cretinism or uot.^ 
 
 Tlie following figures are derived from inquiries into the inheritance 
 of cretinism made by the Sai-dinian Commission.' Of 4899 cretins, there 
 were 1631 in which neither parent suffered from goitre or cretinism, 
 the parents of the remaining 3268 having been affected as follows : 
 
 
 Goitre. 
 
 Cretiuism. Goitre and cretinism. 
 
 Uncertain. 
 
 Fathers . 
 Mothers . 
 
 962 
 
 1281 
 
 51 106 
 
 43 66 
 
 396 
 
 363 
 
 2243 
 
 94 
 
 172 759 
 
 According to these figures, the proportion of cretins whose parents 
 (not reckoning the 759 uncei'tain cases) were notoriously the subjects 
 of goitre, or of cretinism, or of both, was 51 per cent., and those 
 whose parents suffered from goitre only were about 50 per cent. ; but 
 
 ' " To discover tbe causes of goitre," says Marchanfc (' Observ. des Pyrenees ,* 
 Paris, 1842), " is also to discover the causes of cretiuism." Morel says : " Goitre 
 is the first stage ou the road leading to cretinism ;" and the opinion of Niepce is . 
 to the like effect : " Goitre is the first degree of a degeneration of which cre- 
 tinism is the final result." 
 
 ^ The weight attaching to these dissentient opinions may be estimated from the 
 following statement by the Sardinian Commission (p. 43) : " Si Ton considere, 
 qu'il se trouve des cretins entierement prives du goitre, que le degre du cretiu- 
 isme n'est pas toujours en raison directe de son volume, qu'enfin on rencontre des 
 individus portant un goitre volumineux sans presenter le moindre indice de 
 cretinisme, il est permis de conclure que le goitre n6 constitue pas un symptome 
 essentiel, mais qu'il forme une concomitance purement accidentelle de cette triste 
 degeneration." 
 
 ' " This heredity," says Tourdes, " is one of the clearest proofs of the com- 
 munity of type which characterises the two affections." 
 
 * The marriage of persons suffering frotti cretinism is on the whole very rare, 
 and those unions in which there is cretinism on one side are mostly unfruitful. 
 
 * L. c, p. 162-3,
 
 ENDEMIC GOITRE AND CEETTNISM. 
 
 201 
 
 tLere is no doubt tliat tlie proportion is even greater, as tlie statistics 
 of tlie following autliorities tend to sliow : 
 
 Tahle showing the Goitrous Parentage of Cretins. 
 
 Total number 
 of cretins. 
 
 Goitrous 
 parentage. 
 
 Authority. 
 
 5S 
 20 
 
 75 
 12 
 
 161 
 
 35 
 
 42 
 
 14 
 
 52 
 
 9 
 
 147 
 30 
 
 Marchant. 
 
 Anzouy. 
 
 Roque. 
 
 Billiet. 
 
 Fabre. 
 
 Mcncstrel. 
 
 361 
 
 294 =: 8 r4 j)er cent. 
 
 Fodere was tlio first to recognise this causal connexion 
 between goitre of the parent and a cretinous malady in the 
 offspring ; and the fact has received a large amount of con- 
 firmation, besides the statistical support already mentioned, 
 in the experiences of Roulin, Tourdes, Grange/ Morel,^ 
 Garrigou, McClelland/ Kostl/ the French Commission and 
 others, the conclusion being expressed in the words of Fabre/ 
 "le goitre est le pere du cretinisme." The fact that in many 
 regions goitre and cretinism are prevalent together, while in 
 others goitre only is endemic, indicates that the ^^ parental " 
 power of goitre is dependent on still other influences exerted 
 on the foetus by the progenitors, whereby the development 
 of the former is modified or a disposition to cretinism induced. 
 It is extremely doubtful whether cretinism ever arises spon- 
 taneously, that is to say, without a congenital predisposition, 
 and merely from the intensified action of those influences which 
 suffice in a lesser degree to produce goitre. In the whole of 
 the extensive literature of cretinism there is not a single case 
 to be found in which a child born of parents free from goitre 
 or cretinism, and in a locality exempt from them, has become 
 cretinous on being brought in infancy or youth to live in a 
 cretinous region. Niepce and several others absolutely deny 
 the possibility of such an occurrence, adhering to the dictum 
 of Morel : " on devient goitreux et Ton nait cretin." That 
 
 1 'Compt. rend.,' 1849, ii, 696. 
 
 2 'Arch. gen. de iiicd.,' 1864, 173, 1865, juill., 5. 
 
 3 'Topography, &c.' 118. ' L. c, 107. 
 
 L. c, 257.
 
 202 GEOGRAPniOAL AND HISTORICAL PATHOLOGY. 
 
 there may be a conveyance of tlie endemic morbid poison to 
 the offspring from healthy parents is shown by the observa- 
 tion that in cretinous regions children become cretinous by 
 no means uufrequently when the parents are subject to neither 
 goitre nor cretinism. The most interesting of these cases 
 are those in which healthy parents have migrated from 
 localities free from goitre and cretinism into cretinous centres, 
 cretinism ajDpearing among the offspring born to them there 
 although they themselves had not become goitrous. A case of 
 that kind is recorded by Virchow^ on the information of Dr. 
 Schierlinger of Reichenhall : " an official transferred thither 
 whose previous children had been healthy, had ' Fexe ' born 
 to him during his residence in Reichenhall, while the children 
 born after he was transferred back were healthy as before.'^ 
 Another case is given by Morel, that of a man travelling a 
 stud-horse, who came with his wife to Rozieres-aux- Salines, 
 one of the chief seats of cretinism in the department of 
 the Meurthe, and there had a cretinous child born to him, 
 although his former children had been healthy. On the 
 other hand the observation has never been made that goitrous 
 parents migrating from an endemic region of cretinism into 
 a healthy region, have there had cretinous children. In 
 the majority of cases the first traces of the inherited disposi- 
 tion are observable in the child at the second or third year, 
 and perhaps never so late as the fourth year. But, that 
 ■cretinism may exist even at birth, follows from a case given 
 by Yirchow,^ and from the following statement of the Sar- 
 dinian Commission :^ '' Le cretinisme ne se comporte pas 
 toujours comme les haaladies hereditaires ; quelquefois en 
 effet ce n'est plus seulement la disposition au cretinisme, qui 
 se transmet des parents aux enfants, mais bien le vrai 
 cretinisme.^' 
 
 Cretinism having once appeared in a family may propagate 
 itself through several generations, of which fact there are 
 numerous instances. There is very nearly unanimity among 
 observers that goitre is transmitted hy heredity ; and it can 
 hardly be doubted, also, according to the statements of 
 Rosch and others, that goitre is sometimes, although rarely 
 congenital. 
 
 ' L. c, li, 267. ' L. c, p. 260. ^ L. c, p. 194.
 
 CHAPTER V. 
 
 ERGOTISM. 
 
 § 55. Historical Notices op Ergotism. 
 
 Under the name of " saint's fire '^ {ignis sacer, ignis 8. 
 Antonii) the niedia)val chroniclers have described a kind 
 of epidemic disease, observed mostly in France, which was 
 characterised by intense pain and gangrenous destruction of 
 the skin, the gangrene extending not unfrequeiltly to the 
 other soft parts and to the bones,, and thereby leading to 
 loss of the extremities. In many of the epidemics the mor- 
 tality was frightful. There is no longer any doubt, after the 
 inquiries by E,ead,^ by the Commission appointed by the 
 Medical Society of Paris" (which consisted of Jussieu, Paulet, 
 Saillant, and Tessier), by Sprengel,^ and by Fuchs,* that n 
 all these epidemics of '' saint's fire " we have to do with 
 Ergotismus gangrosnosus {Brandscuche) . The chroniclers of the 
 period had applied the term in a somewhat special sense, 
 whereas the practitioners of the Roman Empire, the Arabians 
 and the media)val practitioners had included under the 
 general notion of " ignis sacer '^ a variety of diseases, 
 (anthrax, malignant erysipelas, &c.), distinguished by intense 
 burning and ulcerous or gangrenous destruction of skin. Wo 
 may conjecture that ergotism was included under that head, 
 inasmuch as the statements of Pliny, Galen, and other 
 authors of antiquity lead us to infer that malignant diseases 
 due to the partaking of damaged or unwholesome grain had 
 been by no means rare. 
 
 ' ' Traite du seigle ergote,' Strasb., i??'- 
 
 * 'Mem. do la soc. roy. do mod. do Paris,' Annoe 1776, Paris, 1779, p. 260. 
 
 ^ 'Opuscula academica,' Lips., 1844, p. 89. 
 
 ^ In ' Heckcr's wissenschaftl. Aniial. der Heilkundo,' 1834, xxviii, r.
 
 204 
 
 GEOGEAFHICAL AND HISTORICAL PATHOLOGY. 
 
 The following passage of Galen,' in wliicli Le draws attention to the 
 poisonous properties of moulds growing on corn, is especially deserving 
 of attention : 
 
 "Edulia vero prava intelligo, turn quae ex natura talia sunt . . . 
 atque etiam quae bona sunt ex natura, sed ob putredinem quandam 
 praedictis aequale aut majus saepenumero vitium acceperunt, ut hor- 
 deum ac triticum et aliae omnes fruges frumentariae, partim ob tera- 
 poris Idngitudinem ad putridam dispositionem deductae, partim situ 
 quodam repletae, quia prave repositae sunt, jwrtim ex 'prima generatione 
 a rubigine (vtt' ipvalfStjc) vitiatae. Tales igitur cibos etiam nunc plerique 
 comedere coacti prae fame, alii febribus putridis ac pestilentibus niortui 
 sunt, alii pustulis scabiosis et leprosis correpti." 
 
 We have no means of judging whether the convulsive form 
 of ergotism {KriehelkranJvheit, raphania) had occurred in 
 ancient and medigeval times, along with or independently of 
 the gangrenous form. Of that disease our first accounts 
 date from the sixteenth century, and it is noteworthy that 
 they come from countries which have been less frequently the 
 subject of gangrenous ergotism, and not from France where 
 the latter form of disease has been most prevalent from the 
 earliest times down to the most recent. In a few epidemics, 
 however, both forms of the malady have been observed 
 together. As a basis for my sketch of the geographical and 
 historical relations of the disease I prefix the following 
 chronological table of all the more considerable epidemics of 
 ergotism known to me, omitting those in which merely 
 isolated cases are spoken to : 
 
 OJironological Table of Epidemics of Ergotism. 
 
 Year. 
 
 591 
 
 857 
 
 945 
 993-4 
 
 *France (Limoges) ... 
 *Germany (Rhinel.j... 
 
 *France (Paris) 
 
 *France (Perigord. 
 Angoumois, Li- 
 mousin) 
 
 Authority. 
 
 Gregor Tur., Hist. -Franc, x, 30. 
 Annal. Xant. in Pertz, Monum., ii. 
 
 230- 
 Frodoardi, Chron., ib., iii, 389. 
 Radulphi, Hist., ib., vii, 61, Bouquet, 
 
 Collect., X, 147, 318, 361, Mezeray, 
 
 Hist., ii, 5. 
 
 ' 'De differentiis febrmm,' lib. i, cap. iv, ed. Kiihn, vii, 285. 
 
 2 Where a star (*) is prefixed, the epidemic is ergotismus gangra3nosus ; the 
 absence of a star indicates raphania or convulsive ergotism. A cipher (") indi- 
 cates that both forms occurred together.
 
 ERGOTISM. 
 
 205 
 
 Year. 
 
 996 
 
 999 
 
 1039 
 
 1041-2 
 
 1085 
 
 1089 
 
 1089 
 
 1092 
 
 1094-5 
 
 1099 
 1 109 
 
 mo 
 
 1 125 
 
 1 1 28-9 
 
 1140-1 
 
 1151 
 1180 
 1205 
 
 1214-5 
 
 » 
 1230 
 1236 
 
 1254 
 1256 
 
 1347 
 
 1373 
 1460 
 
 i486 
 
 1565 
 1 The 
 
 Country. 
 
 *France (Lorraine) . . . 
 
 *Spain (Leon) 
 
 *France 
 
 *rrance 
 
 *France (Lori'aine) ... 
 
 *France (Lorraine, 
 Dauphine) 
 
 ■)*Netherlands(Flan 
 
 ) ders) 
 
 *France 
 
 *Netlierlands (Flan- 
 ders) 
 
 *France (Dauphine) . . . 
 
 *France (Orleans, 
 
 Chartres,Dauphine) 
 
 *England 
 
 Authority. 
 
 *France 
 
 *Germany (Silesia) ... 
 
 *France (very widely 
 spread) 
 
 *Netherlands (espe- 
 cially Utreclit) 
 
 *Germany 
 
 *England 
 
 *France (Paris and 
 
 other places) 
 *France (very widely 
 
 spread) 
 *France (Lorraine) ... 
 
 *Spain 
 
 *France .™ 
 
 Calmet,Hist. de Lorraine, ii,Praef. xi. 
 Villalba, Epidemiol., i, 40. 
 Radulphi, Hist., 1. c. 
 Hugo, Chron. in Pertz, Monum., viii, 
 
 403 ; Bouquet, xi, 145. 
 Konigshofen, Ohron., 302 ; Bouquet, 
 
 xii, 465. 
 Sigberti, Chron. in Pertz, vi, 366; 
 
 Bouquet, siii, 159, xiv, 141. 
 
 > Chron. van Vlaendern, i, 114, 567. 
 
 Bouquet, xii, 427, xiii, 260. 
 Chron., i, 118, 119. 
 
 Chron. Ursperg., 177. 
 Bouquet, xii, 690, 708, xv, 148. 
 
 Short, On the Air, Weather, &c., 108 
 
 (untrustworthy). 
 Chron. Ursperg., 206. 
 Henschel, Med. in Schlesien, Bresl., 
 
 1837, 38 (untrustworthy). 
 Bouquet, xii, 283, 780, xiii, 269, 328, 
 
 495. 582, xiv, 1 8, 234. 
 Chron. van Yland., i, 175. 
 
 Accord, to Ozanam (very untrust- 
 
 woi'thy). 
 Short, 1. c, 115. 
 Bouquet, xii, 55S, xiii, 27, 501, 582, 
 
 xiv, 20. 
 lb., xiii, 275. 
 
 *France 
 
 *Spain 
 
 *Majorca 
 
 *France (Poitou) 
 
 *France (Marseilles) 
 *Spain . (Salamanca, 
 
 &c!) 
 
 *France (Bretagne) . . . 
 
 *Fr;ince 
 
 *Sicily (Trapani, Pa- 
 lermo) 
 
 *Germany (very gene- 
 ral) 
 
 *Spain 
 
 Villalba, i, 47. 
 
 Annal. Elnonens. in Pertz, Monum., 
 V, 16. 
 
 I YiUaiba, i, 53-57- 
 
 lb., 58. 
 
 Fuchs, 77, §49- , .,, . .. 
 
 Foderc, Le?. sur les epidemics, ii, 45. 
 
 Villalba, i, 62. 
 
 Chron. Briocense, in Fuchs, 78, §53. 
 Mem. de la soc. de mod., 270, 274. 
 lb., 274, and Renzi, Sul clavismo 
 
 cancr., Napoli, 1841. 
 Fabricius, Annal. urbis Misnione 
 
 and var. other chron.' 
 Villalba, i, 178 (untrustworthy). 
 
 disease is here referred to under tlie ntinie of Seharbock (scurvy .
 
 20G 
 
 GEOGliAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Year. 
 
 1581 
 
 1587 
 
 1590 
 
 1592 
 
 1595.6 
 
 1600 
 
 1630 
 
 1648-9 
 
 1650 
 
 j> 
 
 1660 
 1664 
 1670 
 
 1672 
 
 1674 
 
 j> 
 
 1675 
 
 5J 
 
 1676 
 
 5» 
 
 1687 
 1693 
 1694 
 1699 
 1700 
 
 Country. 
 
 Germany (Limebiirg) 
 
 Germany (Sudetic 
 Mountains) 
 
 *Spain 
 
 Germany (Silesia) .. 
 
 Germany (Westpha 
 lia, Rhine, Bruns- 
 wick, Hanover, Hoi 
 stein,Saxony, Hesse, 
 Breisgau, &c.) 
 
 Holland (Gelders, 
 
 Fi'iesland, &c.) 
 
 Germany (Upper 
 
 Hesse) 
 
 *rrance (Sologne) ... 
 
 Germany 
 
 Voigtland) 
 
 (Saxon 
 
 Authority. 
 
 *France (Guyenne, 
 
 Sologne, Gatinois, 
 
 Perault) 
 *Switzerland (Bern, 
 
 Zuricb, Lucerne) 
 1 *France (Sologne, 
 i &c.) 
 *rrance (Guyenne, 
 
 Sologne, &c.) 
 Germany (Westphalia) 
 
 *France (Montargis) 
 
 *S wit zer land (Bern 
 Lucerne, Zurich) 
 
 *France (Gatinoife) ... 
 
 Germany (West- 
 
 phalia, Voigtland) 
 
 *France 
 
 *Switzerland 
 
 England 
 
 Germany (Hesse. 
 
 Westph alia, Cologne ) 
 
 Germany (Black 
 
 Foi'est) 
 
 *France (Orleans, 
 Sologne) 
 
 " Germany (Harz) 
 
 Rousseus, Miscell. in Schenck, Obs. 
 
 med. lib., vi, Fft. 1665, 830. 
 Schwenckfeld, Theriotroph. Silesiae. 
 
 Lignic, 1C05, 334. 
 Villalba, i, 208 (after Fragoso). 
 Schwenckfeld, 1. c. 
 Bericht von der Krampfsucht.,Marb., 
 
 1597, a Bra in Foresti, Observ. xx, 
 
 Lugd. Bat., 1595, 414 ; Wier, Obs. 
 
 med., ii, § I ; 0pp. Amstelod., 1660, 
 
 946. 
 A Bra, 1. c. 
 
 Horst, Opjp. Norimb., 1660, ii, 422. 
 
 Thullier, Journ. des S^av., 1676, iv, 
 
 79. 
 Leisner,Trakt. von der Krampfsucht. 
 
 Plauen,i676; Buddaeus, Cons. med. 
 
 von der Krampfsucht. Budiss., 
 
 1717; Hoffmann, Med. rat. syst., 
 
 t. ii, p. ii, cap. ix, § 15. 
 Thuillier, I. c. 
 
 Lange, Descr. morbi ex esu clavor. 
 secal., &c., Luz., 17 17. 
 
 ] Thuillier, 1. 1 
 
 lb 
 
 c. 
 
 Heusinger, Rech. de pathol. com- 
 
 paree ii, 546 (after Diez). 
 Dodart, Philos. Transact., 1676, Nr. 
 
 130, 758. 
 Lange, 1. c, ad 1650. 
 
 Leisner, Hoffmann, 11. cc. 
 
 f Lange, 1. c. 
 
 Birch, Philos. Transact. 
 
 Act. med. BeroL, ii; Ann. vi, 50. 
 
 Wepfer, Obs. de affect, capitis, obs. 
 
 120, Scaph., 1727, 556. _ 
 Heusinger, 1. c. (after Diez). 
 
 Brunner, Ephem. Acad. Leoj). Dec. 
 iii, Ann. ii, Obs. 224. 
 Germany (Thuringia) Hoyer, ib., Ann. ix et x, Obs. 93.
 
 ERGOTISM. 
 
 207 
 
 Year. 
 
 1703 
 
 1709 
 1710 
 
 1716-7 
 
 1722-3 
 
 1736-7 
 1741 
 
 1745 
 1746-7 
 
 1747 
 1749 
 
 a 
 1750 
 1754 
 
 1756-7 
 1764 
 
 Country. 
 
 Germany 
 Silesia) 
 
 (Hanover, 
 
 *France (Sologne, 
 Dauphine) 
 
 "Switzerland (Lucerne) 
 
 *France (Orleannais, 
 Danphine, Langiie- 
 doc) 
 
 *Italy (Cremona) 
 
 Russia (Baltic Pro- 
 vinces) 
 
 Germany (Silesia, 
 Saxony, Lansitz, 
 Sleswig, Holstein) 
 
 Switzerland (general) 
 Germany (Silesia, 
 
 Priegnitz, Pomer- 
 
 ania) 
 Russia (Moscow, Nov 
 
 gorod) 
 Germany (Silesia, 
 
 Bohemia) 
 Germany (Branden 
 
 burg, Westphalia, 
 
 and other places in 
 
 North Germany) 
 
 Sweden (Elfsborg) 
 Sweden (Lund) 
 
 Authority. 
 
 *France (Sologne, Ar- 
 tois, Flanders, Bor- 
 deaux) 
 
 France (Bethune) ... 
 " France (Flanders) . . . 
 
 Germany (Potsdam) 
 
 Sweden (Smaland, 
 
 Blekinge) 
 Germany (Rhenish 
 
 provinces) 
 *France (Artois, 
 
 Arras, Douay) 
 
 HoflFmann, 1. c. ; Taube, Gesch. der 
 Kriebelkrankheit, &c., Gott., 1782, 
 31 ; Burghart, Med. Siles. Satyras, 
 iii, 26. 
 
 Dodart, 1. c. 
 
 Lange, 1. c. 
 
 Noel, Hist, de I'Acad. des Sc, 17 10, 
 80. 
 
 De Renzi, 1. c. (after Ginanni). 
 Ilmoni, Nord. Sjukd. Hist., iii, 15. 
 
 Bresl. Samml., 17 17, 87, 397, Act. 
 med. Berol., ii, Ann. vi, 50 ; Wedel, 
 Diss, de morbo spasm, epid., Jen., 
 1717 ; 'Waldschmidt,Diss. de morbo 
 epid. convuls., Kil., 1717. 
 
 Bresl. Samml., 1717,87. 
 
 Vater, Diss, de morbo spasm, j^opul., 
 Silesiae, Wittbg. ; 1223; Act. med. 
 Berolin, 1. c, 54. 
 
 Schober, in Bresl. Samml., 1723, 39. 
 
 Burghardt, Med. Siles. Satyr., i, 44, 
 iii, 26 ; Scrinci, ib., iv, 35. 
 
 Bergen, Diss, de morbo epid. spasm, 
 conv., Fcft., 1742; Briickmann, 
 Commerc. litter., Norimb., i743. 
 hebd. 7 ; Hofmeyer, Von der Krie- 
 belkr. u. s. w.,Berl., 1742 ; Leiden- 
 frost, Diss, de morbo convuls. epid., 
 &c., Duisb., 1 77 1. 
 
 Rosenblad, Act. med. Suec, i, Sect, 
 ii, 9. 
 
 Rosenstein, Diss, de morbo spasm, 
 convuls. epid., Lond., Goth., 1749. 
 
 Du Hamel, Hist, de I'Acad. des Sc, 
 1748, 528; Salerne, Mem. de I'Acad. 
 des Sc, ii, 155; Raulin, Observ., 
 320. 
 
 Tissot, Gesamm. Schriften, v, 687. 
 
 Bouchet, Journ. de med., 1762, xvii, 
 327. 
 
 Cothenius, in Schreber, Samml. verm. 
 Schriften, i, 413- 
 
 Linne, Amoenitates acad., vi, 430. 
 
 Leidenfrost, 1. c, ad 1741- 
 Tissot, ]. c, Read, 1. c, 82.
 
 208 
 
 GEOGRAPHICAL AND [[ISTORIOAL PATHOLOGY. 
 
 Year. 
 
 1765-6 
 1770-I 
 
 1785 
 
 •1785-7 
 1789 
 
 1793 
 1794 
 
 1795 
 1801 
 
 1804 
 
 1804 
 1805 
 
 1813-4 
 
 1 816 
 
 1819 
 
 Sweden (Smaland) .. 
 
 Germany (widely dif 
 fused, especiully in 
 northern districts) 
 
 *France (Solognc, 
 Maine, Tours, An- 
 jou, and other 
 places) 
 
 Sweden (Blekinge, 
 Kronoberg, Chris 
 tianstad) 
 
 Italy (Tuscany) 
 
 Russia (Kieff j 
 
 Italy (Turin). 
 
 Italy (Foggia, Capita- 
 
 nata) 
 Germany (Stolberg) . . . 
 
 Italy (Milan) 
 
 Germany (Treves) ... 
 
 Russia (Minsk, Podo- 
 lia, Ukraine, Volhy- 
 nia, Jekaterinoslav) 
 
 Sweden 
 
 Poland 
 
 Germany (Prussia, 
 Brandenburg) 
 
 *France (Dpt. Saone- 
 Loire, Allier, Isere, 
 Cote-d'Or, Lyon) 
 
 *France (Lyon, Dpt, 
 Isere, Drome) 
 
 Russia (Yiatka) 
 
 Authority. 
 
 Wahlin, Abhdl. der Schwed. Akad., 
 xxxiii, 18. 
 
 Taube, 1. c. ; Leidenfrost, 1. c. ; Wich- 
 mann, Beitr. zur Gesch. der Krie- 
 belkr., Lpz., 1771, Nachricht von 
 der Kriebelkr., &c., Zelle, 1771, 
 Bericht, die Kriebelkr. betr. 
 Kopnb., 1772; Steffens, Hannov. 
 Mag., 177 1, Nr. 50,51 ; Tode, Med.- 
 Chii-. Bibl., i, 150; Marcard, Von 
 einer der Kriebelkr. ahnlichen 
 Krampfsucht., Hamb., 1772. 
 
 Tissot, 1. c., 725 ; Read, 1. c, 83; 
 Vetillart, Mem. sur une espece de 
 poison, connu sous le nom d'Ergot, 
 &c.. Tours, 1770. 
 
 Ref. in Weckoskrift for Lakare, vii, 
 61, 207, viii, 85. 
 
 De Renzi, 1. c, 54 (after Giovanelli). 
 Frank, Pi-ax. med. univ. praec, ii, 
 
 vol. i, sect, ii, 205. 
 Moscati, Nuovo giorn. delle piu 
 
 recente Letter med., 1795, ix, 117. 
 De Renzi, 1. c, 61. 
 
 Kortum, Beiti*. zur Arzeneiwiss., 
 
 Gott., 1795, 145. 
 Moscati, 1. c. ; Corradi, Annal. delle 
 
 epid. in Italia, iv, 461. 
 Burckhardt, Allgem. med. Annal., 
 
 1802, Correspondzbl., 186. 
 Frank, 1. c. 
 
 ■) PhilippoflP, Med. Ztg. RussL, 1845, 
 
 > .388. 
 
 Lorinser, Vers, und Beobacht., Berl., 
 1824. 
 
 Courhaut, Tr. de I'ergot du seigle, 
 Ohallons sur Seine, 1827 ; Boucher, 
 Deseffets du s. e.,Par., 1840 ; Jan- 
 sou, Melanges de chirurg., Lyon, 
 1844, 379 ; Marmy et Quesnois, 
 Topogr. med. du Dpt. du Rhone, 
 Lyon, 1866, 184. 
 
 Oompt. rend, de la soc. de med. de 
 Lyon, 1818, 37; Fraufois, Journ. 
 gen. de med., Iviii, 72; Lecompte, 
 Gaz. de Sante, 1817, Jan. ; Cour- 
 haut, 1. c. 
 
 Frank, 1. c.
 
 ERGOTISM, 
 
 209 
 
 Year. 
 1821 
 
 1824 
 1825 
 
 1829 
 
 1831-2 
 
 1832 
 1835-6 
 
 1837 
 1840-4 
 
 1844 
 
 » 
 
 1845-6 
 
 1848 
 I85I 
 
 I85I-2 
 
 1852-3 
 1854-5 
 
 1855-6 
 
 Country. 
 
 Germany (Boliemia) 
 
 Russia (Dimaburg) 
 
 United States (New 
 York) 
 
 Germany (Circle of 
 Bunzlav, Bohemia) 
 
 Germany (Circle of 
 Schweinitz, Merse- 
 burg, Circle of Luc- 
 kau, Potsdam) 
 
 Germany (Branns- 
 
 dorf, Saxony) 
 Russia (Novgorod) . 
 
 Russia (around Lake 
 
 Onega) 
 Finland (very widely 
 
 diifused) 
 
 Sweden (Kalmar).... 
 Russia (Novgorod) , 
 Germany (Circle of 
 Elbogen, Bohemia) 
 "Belgium (St. Bern 
 hard, Namur, Ghent) 
 Sweden (Nerike) ... 
 Norway (Smaalenene) 
 
 Sweden (Kopparberg, 
 
 Jonkoping) 
 Russia (Govern 
 
 Minsk.) 
 Germany (at various 
 
 places around 
 
 Prague) 
 *Prance (Dpts. Isei'e, 
 
 Loire, Haute-Loire 
 
 Ardcche, Rhone) 
 *Germany (Briinn) .., 
 
 Germany (Nassau, 
 Brunswick, Wal 
 deck, Hesse, &c.) 
 
 Authority. 
 
 VOL. IT. 
 
 Witterungs- und Krankheits-Con- 
 
 stitution in Bohmen, 182T, Frag., 
 
 1824. 
 Tassukowitsch, Bull, des sc. mod., 
 
 xvi, 40. 
 Ref. in New York Med. and Phys. 
 
 Journ., 1825, V, 493. 
 
 Ref. in Oest. med. Jahrb., Nst. F., v, 
 197. 
 
 Wagner, in Hufel. Journ., Bd. 73, 
 Heft 4, 74, Heft 5. 6, 75, Heft 3, 
 Sanitiitsber. der Prov., Branden- 
 burg, 1831, 65! Burdach, in Cas- 
 per's Wochenschr., 1834, 724; 
 Schramm, ib., 1833, 377. 
 
 Ref. in Radius' Cholera-Ztg., 1832, 
 Nr. 119, 364. 
 
 Bardowski, Med.-Ztg., 1850, Nr. 22, 
 
 Schrenck, Reise in die Tundren der 
 
 Samojeden, i, 19. 
 Hartman, Finsk. Liik. Sfillsk. Handl., 
 
 i, Nr. I ; Ilmoni, ib , iii, Nr. i ; 
 
 Sj)oof, Om forgiftninger med. secale 
 
 cornutum, &c., Helsingfors, 1872, 
 
 Ekman, Hygiea, 1845, Oct. 
 
 Bardowski, 1. c. 
 
 Ref. in Prag. med. Viertelj., 1845, ii, 
 
 197. 
 Bull, de I'Acad. de mod. de Belg., v, 
 
 410. 
 Levin, Hygiea. 
 Ref. in Norsk Mag. for Laegevi- 
 
 densk, 1851, v, 847. 
 Sveriges Sundh. Beriittelse, 1851, 156, 
 
 1852, 21. 
 Ref. in Med. Ztg. Russl., 1853, 158. 
 
 Hussa, Prag. med. Yiortelj., 1846, ii, 
 Analect. 38. 
 
 Barrier, Gaz. med. de Lyon, 1S55, 
 Nr. 10. 
 
 Helm, Woch. der Gescllsch. derWien. 
 
 Aerzte, 1856, 165, 1S6, 197. 
 Franque, Nass. med. Jahrb., 1S56, 
 
 xiv, 336 ; Kahler, Corrospdzbl. f. 
 
 Psychiatric, I S55, Nov. ; Pockels, 
 
 Ii
 
 210 
 
 GEOGRAPHICAL AND IIISTORTCAL PATHOLOGY 
 
 Year. 
 
 Country. 
 
 Authority. 
 
 
 
 Deutscb. Klin., 1857, Nr. i, 2; 
 
 
 
 Heusinger, Studien liber den Ergo- 
 
 
 
 tismus, Marb., 18,1^6, 20. 
 
 1857 
 
 Hungary (East of'Meyr, Wocliensclir. d. Gesellsch. der 
 
 
 Transylvania) 
 
 VVien, A., 1861, 377. 
 
 1862 
 
 Finland (widespread) 
 
 Spoof, 1. c. 
 
 1867 
 
 Germany (especially 
 
 Flinzer, Viertelj. f. gericbtl. Med., 
 
 
 in Chemnitz) 
 
 1868, viii, 360. 
 
 1867-8 
 
 Sweden (Kronobergs- 
 
 Sveriges Sundb. Berattelse, 1867, 33, 
 
 
 Ifin) 
 
 1868, 39. 
 
 1879 
 
 Germany (Circle of 
 
 Siemens, Arcb. fiir Psycbiatr., 1880, 
 
 
 Frankenberg, Hesse) 
 
 xi, 108. 
 
 » 
 
 Russia (Novgorod) . . . 
 
 Swiatlowski, Petersb. med. Wocb., 
 1880, Nr. 29. 
 
 § 56. Two Forms of Ergotism distinct in Time and Place. 
 
 Witliout doubt this table of all tlie epidemics of ergotism 
 that have come to my knowledge represents the history of the 
 disease very imperfectly ', and that holds good not only for 
 the mediseval history of the gangrenous disease, but even 
 more for the history of the convulsive form {Kriehelhrmihheit) , 
 of which we have no accounts at all until the sixteenth cen- 
 tury. Still, from the accounts that have come down to us, 
 we may draw certain general conclusions as to the history and 
 geography of the disease, which will throw some interesting 
 light on the pathogenesis. 
 
 The most noteworthy of all the facts are : that the gangre- 
 nous form of sickness and the convulsive [Kriehelkrankheit) 
 have at all times had almost entirely distinct areas of distri- 
 bution, each disease appearing time after time in its own 
 territory as a wide-spread epidemic ; that certain of the 
 greater of these epidemics have coincided in time in the 
 various countries; and that both forms of ergotism have 
 occurred much more frequently and have been much more 
 widely diffused in former centuries than in recent years. 
 
 Of 38 epidemics of gangrenous ergotism recorded between tbc end of 
 tbe sixth century and the end of the fifteenth, 22 happened in France,
 
 ERGOTISM. 211 
 
 5 in Spain, 4 in tlie Netherlands (Flanders), 4 in Germany (3 doubtful), 
 2 in England (botli doubtful), and i in Italy. From tbe beginning of 
 the sixteenth century down to the year 1880, there have been 25 
 epidemics of ergotismus gangrsenosus chronicled, i8 of these belong- 
 ing to France, 3 to Switzerland, 2 to Spain, and i each to Italy and 
 Germany. Apart from the 5 doubtful epidemics, there are thus 58 in 
 all, of which 40 have occurred in France, 7 in Spain, 4 in the Nether- 
 lands, 3 in Switzerland, and 2 each in Italy and Germany. As far as 
 the data enable us to decide, there have been thirteen more considerable 
 epidemics of gangrenous ergotism in France — in the years 993-4, 1094- 
 5, 1109, 1128-29, "51. 1214-15, 1650, 1670, 1709-10, 1747, 1770-71, 1813- 
 14, and 1854-55; in Switzerland there have been two (1650 and 1674), 
 and in Germany one (i486). 
 
 Of epidemics of ergotismus convulsivus {KriebeUranTcheit) we have 
 accounts of 62 in all between the years 158 1 and 1879, ^^ which 29 per- 
 tain to Germany, 11 to Russia, 10 to Sweden, 4 to Italy, 2 to Finland, 
 and I ea'ch to the Netherlands, England, Switzerland, Norway, Hun- 
 gary, and New York. Of these 62 epidemics, there have been only 8, so 
 far as we can gather, of any considerable extent, namely, 5 in Germany 
 (1595-9^. 1716-17, 1741, 1770-71, and 1855-56), 2 in Finland (1840-44 and 
 1862-63), I in Switzerland (1716-17), and i in Russia (1804). 
 
 The chief coincidences have been the gangrenous epidemics in France 
 and Switzerland in 1650, the convulsive epidemics in Germany and 
 Switzerland in 17 16-17, ^^^ the gangrenous epidemic of France with the 
 convulsive epidemic of Germany in 1770-71. 
 
 § 57. Geographical Distribution of Ergotism. 
 
 Not less noteworthy for the history o£ ergotism is its com- 
 paratively small area of distribution, not merely in respect 
 of the surface of the globe generally, but even within the 
 particular regions from which the accounts of it come to us. 
 From North America, excepting a small epidemic of the con- 
 vulsive form limited to a few persons in one of the New 
 York city prisons, I have not been able to find any accounts 
 of ergotism, although I have searched carefully in the very 
 copious medico-topographical and epidemiographical litera- 
 ture of the United States. Nor have I found any certain 
 indication of ergotism in the medical intelligence from 
 Central America, the West Indies, South America, Africa, 
 Asia, AiLstralia, and Oceania. The disease would thus appear 
 to be confined exclusively to Europe, and within that conti-
 
 212 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 nent to certain regions^ and witliin tliese again to certain- 
 definite circles. 
 
 Amon^g the European countries that have been subject to 
 ergotism, the first place has to be assigned, according to the 
 data, to France, Germany, Russia, and Sweden ; from all 
 other parts of Europe, the accounts of epidemics of ergotism 
 are but few. 
 
 In France the disease (in the gangrenous form) has been 
 observed most frequently in the upper and lower basins of 
 the Loire (provinces of Orleannais, especially in the Sologne, 
 Touraine, Poitou, Anjou, and Maine), and in the basin of the 
 Rhone (provinces of Lyonnais, Dauphine, Languedoc, and 
 Burgundy). Of forty-seven epidemics whose area is some- 
 what accurately given, i6 pertained to the first of these regions 
 and 13 to the second; next come 8 epidemics in the south- 
 west (Angoumois and Guyenne), 7 in the north (Lorraine, 
 Picardy, Artois, and Flanders), 2 in the Isle de France, and 
 I in Brittany. Of the ig epidemics which have occurred in 
 more or less wide diffusion over France from the beginning 
 of the seventeenth century to the present time, 9 belong to 
 the seventeenth century, 7 to the eighteenth, and only 3 (of 
 any importance) to the nineteenth. In Germany there has 
 been since the sixteenth century only one epidemic of the 
 gangrenous form, a small one in 1^55-56 among railway 
 navvies near Briinn ; but of Kriehelhrankheit there have been 
 57 epidemics, of which 11 date from the sixteenth century, 
 10 from the seventeenth, 21 from the eighteenth, and 15 
 from the nineteenth, the only instance of its general diffusion 
 in recent times having occurred in 1855-56. Of these 57 
 epidemics, 23 occurred in the north-east of Germany 
 (Prussia, Silesia, Brandenburg, Pomerania, Saxony, and 
 Thuringia), 23 in the north-west (Holstein, Schleswig, 
 Brunswick, Hanover, Westphalia, and Rhenish Prussia), 
 while there were only 8 in the south-west (Hesse, Nassau, 
 and Baden), and only 5 in Bohemia, From the central 
 regions of South Germany (Wilrtemberg, Bavaria, &c.) there 
 is not a single reference to ergotism known. In Russia, 
 ergotism in the form of Kriehclliranhheit has been especially 
 frequent, having occurred at some places such as Novgorod 
 (according to Bardowski) in the character of an endemic.
 
 EKGOTISM. 213 
 
 'The epidemiogx'apliical accounts of it from that country for the 
 period between 1710 and 1879 are certainly not more than 
 twelve. It is stated, however, in a paper by Swiat- 
 lowski that KriehelTcranhheit was prevalent from 1832 to 
 1864 in the governments of Vladimir, Yolhynia, Grodno, 
 Jekaterinoslav, the Don Steppe, Kaluga, Kioff, Minsk, 
 Mohileif, Moscow, Novgorod, Petersburg, Simbirsk, Smo- 
 lensk, Tauria, Tver, Tomsk, Tula, Charkoff, Tscheruigoff, 
 Jaroslav, and more especially in Viatka, Kasan, and Kos- 
 troma — so that hardly any part of this vast empire would 
 seem to have escaped. In Sweden the first occurrence of 
 Kriehelkrankheit appears to have been in 1745; from that 
 date down to 1867 there are ten epidemics of it mentioned 
 in the epidemiographical records of the country, which were 
 all confined to the south excepting the epidemic of 1844 in 
 Nerike (Orebrolan) and that of 1851 in Kopparberg. In 
 Finland there were two very severe epidemics in 1840-44 
 and 1862-63 j fo^ Norway I find mention of only one small 
 epidemic in 1851. 
 
 Ergotism does not appear to have been observed during 
 the present century in any other countries of Europe, ex- 
 cepting Transylvania (in the south-eastern portion of which 
 there was a somewhat extensive epidemic of ergotismus con- 
 vulsivus in 1857), and Jjelgium, where the disease occurred in 
 a few localities to a slight«extent in 1845-46. In Switzerland 
 the gangrenous form of the disease occurred in the seven- 
 te^ith century three times (1650, 1674, and 1676), and in 
 the eighteenth century twice in the convulsive form (1709 
 and 17 16). From England and the Netherlands we have no 
 information whatsoever as to ergotism during the last three 
 centuries. In Italy the disease had occurred in former 
 times, but only in occasional and very limited epidemics ; 
 Moscati says that it was almost unknown in Northern Italy, 
 and De Renzi^ observes that the only accounts of it in. that 
 country relate to those epidemics which are mentioned by 
 him (and are given in the chronological table). In Spavi 
 also it does not appear that the malady has recurred during 
 the last three centuries. 
 
 1 ' Storia della medicina in Itulia,' Napol., 1848, v, 763.
 
 214 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 § 58. Conditions favorable to the geowth op Ergot 
 
 ON Rye. 
 
 There is no doubt that ergotism is due to the somewhat free 
 use of corn contaminated with the ergot-parasite, that is to say, 
 of articles of food prepared from the corn ; and it appears to 
 be equally certain, that although the same parasite grows 
 upon various other graminaceous plants, yet it is only when 
 it occurs on rye, and perhaps also on the bromus-grass,^ that 
 it possesses the poisonous property. We find evidence of 
 this, apart from experiment, in the fact that the disease has 
 occurred most frequently, and to the extent of an epidemic, 
 under circumstances which are known from experience to be 
 most favorable to the thriving of the corn-parasite, as, for 
 example, after a damp season, particularly in years where a 
 hot and dry summer has followed a very rainy spring, or 
 where the corn has grown in the shade, or in localities where 
 the bottom is sandy, cold" or marshy, or where the grain is 
 ill-formed ; and we shall probably not err if we seek to find 
 the reason of the comparatively rare occurrence of ergotism 
 in recent times in the more careful cultivation of the soil, in 
 the improved food-supply due to better ways and means' of 
 communication, and in the general cultivation of the potato. 
 
 The influence of the above-mentioned weather- conditions on the pro- 
 duction of the disease, or, in other words, ou the morbific causation, has 
 been apparent in a very large number of eiDidemics. Facts pointing 
 that way were observed in Flanders in 1094-95, France and Switzerland 
 in 1650, 1674, and 1676, France in 17 10, Saxony and the Lausitz in 
 1 7 16, Pomerania, Silesia, and the Priegnitz in 1723, Silesia and 
 Bohemia in 1735-37, Brandenburg and Westphalia in 1741, Sweden 
 in 1745, 1754, 1765, and 1785, Lille in 1749, North Germany in 1770-71, 
 the circles of Schweinitz and Luckau in 1831-32, Finland in 1840-41, 
 Belgium in 1845-46, the north-west of Germany in 1855-56, and 
 Transylvania in 1857. The significance of a marshy soil for these 
 occurrences comes out very definitely in the almost endemic prevalence 
 of the disease on the marshy banks of the Loire, particularly in the 
 Sologne and Blaisois. Another noteworthy fact, observed in 1 749 in 
 
 ' Heusinger makes out a particularly good case for this as regards the epidemic 
 of 1855-6 in Upper Hesse. 
 
 ^ Observations to that eifect were made iu 1770 in Schleswig and Liineburg, 
 in 1840 in Finland, and in 1844 in Sweden
 
 ERGOTISM. 215 
 
 the neiglibourhood of Lille, is that the disease was much more widely 
 spread on the marshy ground to the south of the town than on the dry 
 ground on its northern side. The influence of the cultivation of the soil 
 on the occurrence of ergot is shown in the fact given by Riva/ that since 
 a principle of rotation was introduced into the rice fields of Northern 
 Italy, the fields being worked-at one time under irrigation and another 
 time di-y, the crop of rye grown on the fields that had been watered 
 abounds in ergot. 
 
 § 59. Mostly a Disease op the Poorer Peasantry and op 
 
 Children in particular. 
 
 However sound may be tlie general conclusions arrived at 
 as to the origin of ergotism^ there still remain some problems 
 in tlie history of this disease, the solution of which is for the 
 present not entirely satisfactory. 
 
 The first noteworthy thing is that ergotism has occurred 
 almost exclusively among the country 'population, so much so 
 that some practitioners have thought themselves justified in 
 calling the disease '' morbus ruralis.'^ Next we have a fact 
 ascertained in all epidemics of ergotism, that the disease has 
 been prevalent mostly if not exclusively among the poorer- class 
 of people, and has attained its widest distribution when prices 
 have been high owing to failure of crops or to other cala- 
 mities, or when there has been actual famine.^ In tlie same 
 connexion we may take the fact sometimes observed, that 
 ergotism may confine itself exclusively to places exceptionally 
 ill off in hygienic respects — to prisons, foundling hospitals, 
 orphanages, and the like. Instances have occurred at 
 Turin in 1789 and Milan in 1795, both times in orphanages 
 (Moscati), in the prison of Treves in 180 1-2, in a prison 
 at New York in 1825, in a children's institute at Brauns- 
 dorf (Saxony) in 1832, and in the prisons of St. Bernard, 
 Namur, and Ghent in 1845-46. Finally, it has happened 
 not unfrequently that the age of childhood has furnished 
 the largest contingent of the sick, as in Stolberg in 1794, 
 
 ' ' Influenza delle rizaje,' Novara, 1847, P- 3.v 
 
 - Examples of tbis are furnished, by the epidemics of 1581 in Liineburg, 1695 
 in the Harz, 1741 and 1770-1 in North Germany and in France, 1804-5 '" Sweden 
 and Poland, 1831-2 in the circle of Schweinitz, 1835 ^^^ following years ia 
 Novgorod, 1848 in Nerike (Sweden), and 1854-5 iu several parts of France.
 
 216 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 in the circle of Luckau in 1831-32, Sweden in 1754, 
 Beaurepaire (Dauphine) in 1816, Upper Hesse in 1855-56, 
 and in tlie epidemics already mentioned as occurring at 
 Turin, Milan, and Braunsdorf in 1789, 1795, and 1832. 
 All these facts are to be explained, in my view, by the 
 influence which unfavorable hygiene and diet exert upon 
 the individual, inasmuch as they lower his power of resis- 
 tance to noxious things, and thereby increase his predis- 
 position to fall into sickness ; and for the remarkably 
 frequent incidence of the disease in childhood a corresponding 
 reason may be found in the well-known liability of that 
 particular time of life to be aifected by narcotic poisons. 
 
 But it is not so easy to explain how it is that poisoning by 
 ergot has led to gangrenous disease in some regions (France 
 and Spain), and in other regions (Germany and Russia) 
 just as uniformly to convulsive ergotism [Kfiehelhrankheit) ; 
 and why it has happened that only on the rarest occasions 
 the two forms of disease have occurred together. It is 
 highly improbable that this variation in the type of the 
 disease depends on the quantity of poison consumed ; it is 
 much more reasonable to conjecture that we have here to do 
 with a qualitative difference in the toxic principle of the 
 ergot parasite, a difference which would appear to be essen- 
 tially bound up with the soil on which the epiphyte thrives.
 
 CHAPTER VI. 
 
 PELLAGRA AND ALLIED DISEASES. 
 § 60. Symptoms and Morbid Anatomy op Pellagra. 
 
 Under the name of " pellagra," corresponding to the 
 Spanish mal de la rosa or 7nal roxo, a peculiar disease has 
 come to knowledge, very distinctively characterised by a 
 series of morbid conditions in the skin and the mucous' mem- 
 brane of the digestive tract, and "by symptoms referable to 
 the cerebro-spiual system. It showed itself first about the 
 middle of last century in several parts of Spain and Upper 
 Italy ; it came afterwards to Central Italy, and since the 
 beginning of the present century it has broken out in some 
 of the south-western departments of France, and more 
 recently in Eoumania and Corfu. A prominent place among 
 the endemic maladies of those regions has been accorded to 
 it, not only on account of its considerable diffusion at many 
 places therein, but also by reason of its injurious influence 
 on the working power of the population. 
 
 Clinical history. — The onset of the disease' is usually deuoted by a 
 sense of weakness and disinclination for tlie individual's ordinary 
 avocation. He complains at the same time of headache, giddiness, 
 singing in the ears, and an acute feeling of burning issuing from the 
 back, spreading over the extremities and locating itself particularly in 
 the hands and feet. The tongue is coated, the epigastric region, and 
 sometimes the lower part of the abdomen also, are tense and painful, 
 and the stools not unfrequently loose. These phenomena occur in most 
 cases in the beginning of spring ; and along with them there bi-eaks out, 
 on those parts of the body which are ordinarily bare and exposed to the 
 sun (the back of the hands, the face, also the feet in those who go bare- 
 
 ' The writings quoted in the sequel are given at the end of the chapter, 
 arranged alphabetically according to tlie authors' names.
 
 218 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 footed, and more rarely the back and chest), an exanthem of irregular 
 formation, bright red or dark red, and sometimes even livid, having the 
 type of erythema or erysipelas, and vanishing completely on pressure. 
 The skin looks to be somewhat swollen at the atfected places, and the 
 patient complains of a feeling of tightness, uneasiness or burning, 
 which becomes particularly acute under the action of the sun's rays. 
 After lasting three or four months, that is to say, until July or August, 
 these symptoms decline, the skin remaining somewhat dark-coloured 
 and remarkably rough and dry for a certain time longer; and therewith 
 the morbid process appears to have come to an end. Next spring, 
 however, the whole series of phenomena recurs, and now, or it may be 
 not until the third onset, the disease assumes a more severe character. 
 The general feeling of weakness is now so great that the patient keeps 
 on his feet with difficulty, being unable, accordingly, to pursue his 
 occupation; he loses weight, the pains in the head and back become 
 very acute, and drooping of the upper eyelid, dilatation of the pupil, 
 amblyopia, diplopia, and other disorders of vision follow. (In 50 
 patients with pellagra, the ophthalmoscopic examination of the fundus 
 of the eye showed the condition to be normal in 10 only, in 29 
 there was cloudiness or greyish discoloration of the retina, in 23 
 there was atrophy of the arterial retinal vessels, in 2 there was 
 dilatation of the retinal veins, in 4 atrophy of the papilla, and in 
 3 redness of it.') The exanthem now spreads over larger areas and 
 looks darker coloured, the skin thickens and cracks, the tongue 
 becomes red and dry (the patient comjilaining of burning in the mouth 
 and pain on swallowing), the coated gums bleed readily, the diarrhoea 
 increases, and most of all the symptoms referable to the cerebro-spinal 
 affection show a marked aggravation. Besides pains in the head and 
 back, tonic and clonic spasms occur in the upper and lower extremities, 
 being sometimes confined to one side; there is also delirium, or a 
 succession of typhoid symptoms under which the patient quickly 
 succumbs. In another and commoner class of cases, a mental disorder 
 gradually sets in, less frequently in the form of mania than of melan- 
 cholia, with a peculiar tendency to suicide, especially by drowning 
 (hydromania). Other noteworthy signs are : that the extensors get into 
 a state of paresis,^ so that the limbs are in the position of semi-flexion 
 owing to the preponderance of the flexors, and remain fixed when an 
 attempt is made to move them; that the electi-o-muscular irritability of 
 the extensors is diminished ; and that there is anassthesia or lowering of 
 the cutaneous sensibility under the application of the induced current. 
 As the disease advances, it may sometimes be observed that the area of 
 cardiac dulness is diminished, the cardiac impulse feeble, and the 
 heart-sounds less audible. In severe cases the urine is often alkaline, 
 and the specific gravity reduced, it may be as low as 1005 ; but albumen 
 
 * Lombroso (ii, 65), after the researches cf Plarer, Manfredi, and Forlanini. 
 
 ' Accurate inquiries into these motor and sensory disorders were first made by 
 Lombroso ; they are given at p. 71 of the second of his works quoted in the list 
 at the end of the chapter.
 
 :^LLAaRA. 219 
 
 is rarely present. The downward progress of the patient continues, the 
 extremities and the bladder become paralysed, mental power is lost even 
 to the degree of imbecility, and death — if it have not been anticipated 
 by suicide — is ushered in by rapid wasting, colliquative and ill-smelling 
 sweats, profuse diarrhoea and dropsy. A favorable issue of the disease is 
 only to be looked for if there had been no more than one preceding attack, 
 or attacks of the slighter kind if more than one, and the patient then 
 placed under better conditions of living or withdrawn from the morbific 
 influences. When the malady has reached a more advanced stage of 
 development, the prognosis is very gloomy ; and even in the best cases 
 there will always be some disorders remaining behind, especially in 
 the sphere of the nervous system. The duration of the disease is 
 exceedingly variable ; it may extend to ten or fifteen years or more, and 
 even when it has lasted as long as that, it may still be short of its full 
 development. 
 
 Morbid anatomy. — The following ax*e the most noteworthy points in 
 the morbid anatomy as compiled by Lombroso' from 66 necropsies 
 made by himself. In 29 cases the pia mater and arachnoid were 
 opaque and thickened (purulent deposit in 4, and ecchymoses under 
 the arachnoid in 5), in 24 cases there was cedema of the brain, in 1 1 
 atrophy of the brain, especially the cerebral cortex, in 33 rottenness of 
 the heart-muscle and yellowish-brown discoloration, in 19 (out of 
 26 examined) the heart under weight, in 16 brown atrophy of the 
 liver, in 40 the spleen atrophied, in 21 fatty degeneration of the 
 kidneys, and in 31 cirrhotic atrophy of the same. There was also 
 that attenuation of the muscular coat of the intestine which all 
 previous observers had noted, with hyperasmia of the mucous mem- 
 brane and ulceration of the rectum; in 18 (out of 42 where it was 
 looked for) there was fragility of the ribs, the other fiat bones being 
 normal, and the individuals not in a state of marasmus nor aged, 
 and in 21 (out of 44 examined) the voluntary 'muscles were 
 atrophied. From the microscopic examination of the organs most 
 implicated, which was carried on with the assistance of Professor 
 Bizzozero, the following were the chief conclusions : of 33 hearts, 
 brown atrophy of the muscle in 27 (always with splitting of the fibres 
 or formation of lacunae in them), and fatty degeneration in 5 ; of 
 kidneys from 28 cases, fatty degeneration of the tubular epithelium 
 and sclerosis of connective tissue in 18; of 27 livers, fatty infiltration 
 of the acini in 12 ; in 10 brains, pigmentation or fatty degenera- 
 tion of the outer coat of the capillaries, and in 3 brains calcare- 
 ous deposit in the same; deep pigmentation of the sympathetic 
 ganglion-cells in 8 cases out of 12. According to the post- 
 mortem examinations, the anatomical changes characteristic of the 
 morbid process may be referred to four classes: (1) hyperajmias and 
 inflammatory processes leading to exudation, hypertrophy and the like, 
 as shown in the brain-membranes, the liver, the spleen, the kidneys 
 
 ^ L. c, p. 117.
 
 220 GEOGllAl'IUCAL AND IIIST^IUCAL PATHOLOGY. 
 
 and the lowei- part of tlie intestinal canal ; (2) atrophy and marasmus 
 especially apt to occur in the heart, lungs, liver, spleen, intestine and 
 kidneys, these being the thoracic and abdominal organs supplied by the* 
 vagus and sympathetic nerves ; (3) fatty degeneration ; and (4) pig- 
 mentary changes — a special characteristic of the moi'bid process. 
 
 Lombroso's' inference from clinical observations and the post-mortem 
 condition is that pellagra is lyrimarihj a toxic effect on the sympathetic 
 nervous system, the structural and functional disorders being dependent 
 thereon. Dejerine, who has lately investigated the morbid changes in 
 the cutaneous nerves in pellagra, regards the skin affection as also 
 •' d'origine trophique." 
 
 § 6l. HjSTOEY and PfJESENT DISTRIBUTION. 
 
 Bpain. — The earliest information about pellagra comes 
 from Spain. In that country, according to Casal/ it had 
 been observed as an endemic since 1735 in the Asturian dis- 
 trict of Oviedo, comprising about a twentieth part of the 
 whole province, while it was quite unknown throughout all 
 other parts of Asturias, including Santillaua in the immediate 
 neighbourhood, as well as in th'e frontier districts of Gralicia 
 and Leon. Concerning the later history of this disease in 
 Spain, the facts known to me are very incomplete and not 
 altogether trustworthy ; at all events the subsequent 
 diffusion of the malady has been somewhat extensive, espe- 
 cially in .the northern provinces of the country. At the 
 instigation of the Italian consul-general in Barcelona, the 
 Academy of Medicine of that city instituted in 1879 a minute 
 inquiry into the present condition of the disease in Spain, the 
 following being the conclusions^ (which may be accepted in 
 part only) : Asturias is to the present day one of the chief 
 centres of the mal de la rasa, the disease being located espe- 
 cially in the communes of Regueras, Llanera, Corbera, and 
 Careiio. It is met with also, to no inconsiderable extent, in 
 
 * L. c, p. 97. 
 
 " Ciisal's treatise was first printed in 1762, although its contents were known 
 before to Thiery, who had brought the description of the mal de la rosa under the 
 notice of the profession in Prance (' Journal dc mod.,' 1755, ii, 337). 
 
 3 This report is given in the official publication oi the Italian Government, 
 *La Pellagra,' Roma, 1880, p. 387.
 
 • PELLAGRA. 221 
 
 Loiver Arragon and Burfjos, as well as in tlie province of Guada- 
 lajara, where it is so prevalent in several of the fifty villages 
 between Colmenar di Osoja and Vasouciia on the one side 
 and between Sadices and Brihuega on the other, that the 
 number of the sick may amount to 2 per cent, of the popu- 
 lation. Information to the same effect comes from several 
 parts of the province of Cuenca, from the district on the 
 frontiers of Navarra and Arragon ( San guesa), from the Ebro 
 valley in the province of Zaragoza, from the level banks of 
 the Douro and Tormes in the province of Zamora, and from 
 Galicia. That the disease occurs in many other parts of 
 Spain is shown by the statistics of pellagrous persons 
 received into the hospital of Madrid; of these 10 came from 
 the Madrid province, 5 from Toledo, 3 from Seville, 2 
 from Lugo, and one each from the provinces of Granada, 
 Orense, Oviedo, Ciudad Real, Guipuzona, Avila, Palencia, 
 Guadalajara, Valladolid, and Segovia. According to the same 
 report, there has been a considerable abatement of recent 
 years, if not in the number of patients, yet in the severity of 
 type of the disease. 
 
 J^ftZ?/.— Shortly after it began in Spain, pellagra made its 
 appearance in Italy — in Lomhardy and Ve^ietia. Even pre- 
 vious to 1 730, occasional cases had been seen^ in the vicinity 
 of Sesto Calende (on Lago Maggiore) ; but from that date the 
 cases became more numerous, the malady breaking out simul- 
 taneously in the districts of Milan,^ Brescia,^ Bergamo,^ and 
 Lodi,^ and shortly after in country around Como,^ Cremona,''^ 
 Mantua,^ and Pavia ; ^ so that towards the end of the century 
 its area extended over nearly the whole of Lombardy.^^ In 
 Venetian territory, it showed itself first at Udine,^^ and we 
 have information of it a little later in date from the pro- 
 vinces of Belluno^^ and Padua,^^ and then from Verona ;^* so 
 that the Venetian kingdom was also affected by it over a 
 
 ^ Terzaghi. 
 
 2 Frapolli, Zanetti, Glierardiui, Albera, Strambio. 
 
 3 Balaj-diui, Menis, Mottoni, 'Kelazionc' ^ Faclicris, Chiappa. 
 
 5 Villa. " Comolli, Tassani, II. 
 
 ' Cerioli, Tassani, I, Robolotti, Cappi. * Sacchi, Lombroso, I. 
 
 9 Ilildenbrand, Cambieri. '" Jansen, Cerri, Balardiiii. 
 
 1^ Pujati, Romano. ''^ Odoardi, Zecchinelli, Pcrtilc. 
 
 13 Fanzago. " Agostini.
 
 222 GEOGEAPHICAL AND HISTOlilOAL PATHOLOGY. 
 
 wide area before the end of last century or the beginning of 
 the present.^ In Piedmont and Ligurid it is of more recent 
 origin ; our first information of its occurrence in them dates 
 from the last ten years of the eighteenth century, when 
 it was seen at Castellalfero^ and in the territory of 
 Massa / since 1820-30, it has attained to general diffusion 
 in these regions, especially in the provinces of Ivrea, 
 Saluzzo, and Alessandria, but nowhere to the same extent as 
 in Venetia and Lombardy,'* The Genoese littoral has con- 
 tinued free from it down to the present day.^ In Tuscany 
 it was known as early as 1785, it showed itself afterwards in 
 1797-98 around Mugello, reappearing there to a greater 
 extent in 1 809, and in the Romagna Toscana / in more recent 
 years it has established endemic centres in the upper valley 
 of the Arno, in Volterrano, around Lucca and Pisa, and 
 among the hills near Florence.'^ The same period at which 
 the disease was first seen in Tuscany furnishes us with the 
 earliest accounts of its occurrence in the JEmilia ; we hear 
 of it at Reggio^ in 1782, in the vicinity of Bologna^ and in 
 the district of Parma'^ at the beginning of the century, while 
 its appearance in Ferrara^^ and Modena^^ was somewhat later, 
 and its more considerable outbreak not until recent times. 
 The same applies also to the development of the disease in 
 the Marches (mostly in the province of Urbino-Pesaro) ,^^ and 
 in Umhria ;^* but in these, as well as around Rome,^^ it has 
 never attained the same importance as in Northern Italy. 
 The southern provinces of Italy (the Abruzzi, Campania, 
 Apulia, Basilicata, and Calabria), as well as Sicily and 
 Sardinia, have hitherto enjoyed immunity from the 
 disease. , 
 
 • ' Soler, Facen, Festler, Llberali. 
 
 * De Rolandis, I. ' Boerio. 
 
 * Fontaiia, De Rolandis, II, Ferraris, Ramati, Garbiglietti, Maffoni, Girin, 
 Vacca, I. 
 
 5 Morelli. « Vignoli. 
 
 7 Chiarugi, Cipriani, Vignoli, Morelli, Bartolozzi. 
 
 8 (Rosa.) 
 
 ^ Calori, Favini, Paolini, Leonard!, Brugnoli. 
 '" Gucrrcschi, Thomasini. ii Gambicri, Bcnuati. 
 
 '2 Martinelli, Maragliano, Vacca, II. '» Girolami, Frigcrio, Michetti. 
 
 " Adriani. . is Parini.
 
 PELLAGEA. 
 
 223 
 
 The following table gives the amount of pellagra in the 
 several divisions and provinces of Italy in 1879 :^ 
 
 Divisions and provinces. 
 
 LOMBAEDY , 
 
 Pavia 
 
 Milau 
 
 Como , 
 
 Sonclrio 
 
 Bergamo 
 
 Brescia 
 
 Cremona 
 
 Mantua 
 
 Venetia 
 
 Verona 
 
 Viconza 
 
 Belluno 
 
 Udine 
 
 Treviso 
 
 Venice 
 
 Padua 
 
 llovigo 
 
 Piedmont 
 
 Cuneo 
 
 Turin 
 
 Alessandria 
 
 Novara 
 
 LiGUEIA 
 
 Porto Maurizio ... 
 
 Genoa 
 
 Massa and Carrara 
 
 .Emilia 
 
 Piacenza 
 
 Parma ...• 
 
 Eeggio 
 
 Modena 
 
 Ferrara 
 
 Bologna 
 
 Ravenna 
 
 Forli 
 
 Population. 
 
 Urban and 
 rural. 
 
 3,653,941 
 
 477.887 
 1,070,098 
 
 51.^.677 
 n8,8.:;S 
 
 389,406 
 468,906 
 .Si.l,T43 
 301,089 
 
 2,812,022 
 388,489 
 .S9.3.250 
 190,491 
 509,447 
 382,410 
 346,8.^1 
 386,762 
 214,322 
 
 3,077,200 
 
 6.S3.90.? 
 
 1,021,630 
 
 728,941 
 
 672,726 
 
 1,056,669 
 130,000 
 755.428 
 171,241 
 
 2,193,440 
 
 2.>o,7i.i 
 270,456 
 
 250.570 
 28 1, 593 
 228,931 
 
 455.190 
 229,866 
 246,121 
 
 Rural 
 
 alone. 
 
 1,284,670 
 172,758 
 322,320 
 161,964 
 
 57-274 
 153,418 
 187,278 
 116,728 
 112,930 
 
 977,346 
 125,722 
 146,788 
 
 66,090 
 189,054 
 152,186 
 
 77.878 
 143,024 
 
 76,604 
 
 1,147,808 
 277,886 
 .155,688 
 308,570 
 205,664 
 
 310,552 
 
 54.904 
 
 193,166 
 
 62,482 
 
 791,408 
 
 83,968 
 
 109,436 
 
 95.564 
 100,158 
 
 65,946 
 157,846 
 
 8.1.836 
 
 94.654 
 
 Nuinl)cr 
 
 of cases of 
 
 pellagra. 
 
 40,838 
 
 800 
 10,380 
 
 618 
 
 39 
 7,122 
 
 14,989 
 
 S.23S 
 
 1.655 
 
 29,386 
 
 2,391 
 3,400 
 1,400 
 4,000 
 4,902 
 2,696 
 8,207 
 2,840 
 
 1,692 
 
 34 
 1,042 
 
 403 
 213 
 
 148 
 
 27 
 121 
 
 18,728 
 4.326 
 
 5.013 
 920 
 
 1,500 
 
 3,650 
 
 2,574 
 145 
 600 
 
 Proportion of ciiscs of 
 
 pellagra per lOOO 
 
 inliabitauts. 
 
 Urban and 
 rural. 
 
 11-2 
 
 1-7 
 
 9-8 
 
 I'2 
 
 0-3 
 
 i8-3 
 
 317 
 167 
 
 10-5 
 6-2 
 8-1 
 7-4 
 7-9 
 
 12-8 
 
 7-8 
 2r2 
 
 133 
 
 0-6 
 
 0-05 
 
 ro 
 
 06 
 
 0-3 
 
 0-14 
 
 o'oo4 
 o'07 
 
 8-53 
 
 18-75 
 
 18-53 
 
 3-68 
 
 "5 '33 
 
 15-43 
 
 5 "63 
 
 ©•64 
 
 2-45 
 
 Rural 
 alone. 
 
 31-70 
 
 4'63 
 32-20 
 3-8 1 
 0-68 
 46-42 
 80-03 
 4484 
 14-65 
 
 30-52 
 19-01 
 23:16 
 2'i-i8 
 21-15 
 32-21 
 34-61 
 57-38 
 37-07 
 
 1-47 
 
 0*I2 
 2-93 
 
 I '3 1 
 
 1-03 
 
 0-47 
 
 0-14 
 193 
 
 23-66 
 
 51-51 
 
 45-80 
 
 962 
 
 14-97 
 
 55-34 
 
 16-30 
 
 1-72 
 
 6-33 
 
 1 I have taken the figures from the official publication ' La Pellagra in Italia,' 
 Boma, 1880. The calculation of the number of oases in proportion to the urban 
 and rural population has a special interest ; for it .shows us that pellagra is met 
 with almost exclusively in the latter class of the population, while, in coiitra.st, 
 it is absent among: the inhabitants of the towns.
 
 224 
 
 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Divisions iind provinces. 
 
 Tuscany 
 Lucca ... 
 
 Pisa 
 
 Leghorn 
 Florence 
 Arezzo ... 
 Siena ... 
 Grosseto 
 
 IMaeches and Umbeia 
 
 Pes.aro 
 
 Aiicona 
 
 Macerata 
 
 Ascoli Piceno 
 Perugia 
 
 iROME 
 
 Population. 
 
 Ur1)aii and 
 rurul. 
 
 2,048,537 
 292,651 
 280,406 
 120,000 
 79f'>447 
 
 2 1 0,000 
 1 10,000 
 
 1,498,284 
 222,765 
 
 271..S97 
 244,646 
 209,476 
 550,000 
 
 849,125 
 
 Uural 
 alone. 
 
 691,694 
 
 1 00,660 
 
 90,.^ 1 2 
 
 9,908 
 
 228,494 
 
 1 18,042 
 
 95.248 
 
 49,030 
 
 619,534 
 91,688 
 88,092 
 
 10.^.774 
 85,798 
 
 250,182 
 
 581,939 
 
 TCumber 
 
 of cases of 
 
 pellagra. 
 
 4,382 
 2,500 
 
 22 
 
 560 
 1,300 
 
 2,155 
 
 1,000 
 
 300 
 
 225 
 40 
 
 590 
 
 76 
 
 Proportion of cases of 
 
 pellagra per loOO 
 
 inhabitants. 
 
 Urban and 
 rural. 
 
 2-17 
 
 8-56 
 
 o-o8 
 
 5-86 
 
 1-44 
 
 4*49 
 
 I'lO 
 
 o'09 
 
 0'02 
 
 108 
 
 0-09 
 
 Rural 
 alone. 
 
 6-33 
 
 24-83 
 
 0'24 
 
 2-45 
 
 1 I'OI 
 
 3-47 
 1090 
 
 3 "4° 
 2-17 
 0*46 
 2*36 
 
 0-25 
 
 According to this table tlie tei-ritorios tliat suffer most are 
 Lombardy, Yenetia, and tlie -Emilia : in Lombardy chiefly 
 the provinces of Brescia_, Bergamo, Cremona, and Milan ; in 
 Venetia the provinces of Padua and Rovigo ; and in the 
 -Emilia the provinces of Ferrara, Piacenza, and Parma. 
 When we follow the distribution of the disease into the 
 several districts of these provinces, we find the largest 
 number of cases in the district of Verolanuova (Brescia), 
 being 59'6 per 1000 of the whole population; and next in 
 order in Badia (prov. Rovigo) with 54*6 per 1000, Con- 
 selve (Padua) with 50*2, Chiari (Brescia) and Campo San 
 Piero (Padua) with 42*9, Borgo San Domino (Parma) with 
 3 1 "7, Brescia district with 31*2, Lodi (prov. of Milan), and 
 Treviglio (Bergamo) Avith 27*5, Asiago (Vicenza) with 24*7, 
 Este (Padua) with 23-5, Cento (Ferrara) 23*0, and the dis- 
 tricts of Cremona and Piacenza with 22*5 per 1000. 
 
 Another noteworthy fact is that, in proportion as the area 
 of pellagra has extended into Central Italy, the number of 
 cases in the earlier seats of the disease has increased.^ 
 Thus, to mention only a few instances, the number of 
 
 ^ The only considerable exception to this rule is the province of Cuneo (Pied- 
 mont), where the number of pellagra cases was 294 in 1847, but only 34 in 1879.
 
 PELLAGEA. 225 
 
 pellagrous persons iu Lombardy in 1839 was 20,282 ; in 1856 
 it liad risen to 38,777, and in 1879 it had readied tlio figure 
 of 40,838. In Piedmont, an enumeration in 1847 showed the 
 number to be 987, while in 1879 it was 1692. In Venetia, 
 20,000 cases of pellagra were known between 1853 and 1856, 
 whereas in 1879 the number was 29,386. As an instance of 
 the way in which this increase has affected the several pro- 
 vinces, we may take the case of the pi^ovince of Vicenza, 
 where there were only 1380 pellagrous subjects in 1853-55, 
 but 2974 in i860, and 3400 in 1879. 
 
 France. — Besides those of Spain and Italy, the endemic 
 seats^ of pellagra are a few districts in the south-west of 
 France, as well as Roumania and the island of Corfu. The 
 first intelligence of pellagra in France" dates from 1829, in 
 which year Hameau published an account of cases observed by 
 himself since 18 18 around Teste-de-Buche and in the plain of 
 Arcachon, as well as of the subsequent increase and general 
 diffusion of the malady in the coast-region of the Gironde. 
 His facts were afterwards confirmed by Gintrac ; but this 
 observer, as well as others,^ brought forward evidence at the 
 same time that the endemic focus of pellagra was by no 
 means confined to that part of Gascony which lies between the 
 left bank of the Garonne, its tributary the Cn'on and the coast, 
 but that it covered a large area in the department of Luiides 
 as well, its extent being indeed greater in the latter than in 
 the former.^ Smaller centres of pellagra, of more recent 
 origin, are met with in the departments of Hautes-Pyrenees 
 
 ' The statements as to the occurrence of pellagi-a in Hungary and the Banat, 
 in Egypt, and in Algiers, are based upon quite untrustworthy information. 
 Pruner's description (1. c, p. 1 79) of the cases which he saw in Egypt (a brownish 
 exanthem, paresis of the upper extremities, and muscular atrophy), does not by 
 any means correspond to pellagra; and as regards Do Bucherie's account (' De la 
 Pellagrej &c.,' Strasb., 1858), in which mention is made of the disease occurring 
 in Coustantine, we have the testimony of both Armand (' Med. et hyg. des pays 
 chauds,' Paris, p. 428) and Bertheraud (as quoted by Pietra Santa, in ' Journ. 
 d'hyg.,' 1880, Dec, p. 619) that pellagra has never been seen in Algiers, unless a 
 very doubtful case of Armand's be regarded as such. 
 
 ' Roussel gives a complete history of ihe disease in France down to the year 
 
 1845. 
 
 3 Marchand, Hiard, Sorbets, Balhadere, Bouchard, Lavielle, Lalesque. 
 
 ^ In the arrondissoment of Dax (Dept. Lnndes) the disease, according to 
 Lavielle, has decreased of late. 
 
 YOL. TI. 15
 
 226 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 and Basses-Pyrenees,^ in tlie valley of Vernet {Pyrenees 
 orient.),^ and in tlie plain of Lauragais — in tlie arrondissements 
 of Villefranclie {IJaiit-Garonne)^ and Castlenaudary {Aude)'*'. 
 At all these points, however, and especially at the last 
 named, tlie amount of the disease is very little. Observa- 
 tions on sporadic cases of pellagra come to us from some 
 other parts of France — from Par is, ^ the departments of 
 Seine-Oise,^ Marne^ Allier^ Maine-Jjoire,^ lUe-et-Vilaine)^ 
 and from Bouen}^ I shall specially recur to these when I 
 come to speak of the etiology of the disease. 
 
 Roumania. — Caillat, who was the first to mention the 
 occurrence of the disease in Roumania, says that it had not 
 been seen there previous to 1846, a statement which v. 
 Theodori confirms, to this extent at least, that his father, who 
 acted as physician to the first hospital in Roumania, assigned 
 the outbreak of the malady to the year 1833, although 
 it was not until 1846 that the first pellagra patients were 
 admitted into the hospital. At the present day, the disease 
 is somewhat widely spread throughout that country, more in 
 Moldavia than in Wallachia,^^ in which latter Felix saw the 
 first cases in 1859-61 at the village of Muscel in the district 
 of Campulungu. The attention of the profession was first 
 drawn to the occurrence of pellagra in Roumania by the 
 work of V. Theodori ; since then there have been numerous 
 writings on the disease in that country,^^ from which it 
 appears that its head-quarters are the districts of Ott 
 (Slatina), Arges (Pitesti), Dimbovitza, Prahova, Buzen, 
 Neamtzu (Piatra), Succava (Folticeni), and Dorohoi. We 
 learn from Felix that the disease since 1878 has declined in 
 some districts and increased in others ; he estimates the 
 number of pellagrous persons in Roumania at 4500, or not 
 quite I per 1000 of the whole population. 
 
 Corfu. — In Corfu, according to Typaldos, the first cases of 
 pellagra, were seen in 1839, but it is only since 1856 that 
 the disease has taken on the character of an endemic. At 
 
 ' Bataille, Nogues, Laurens, Balhadei'e. '^ Courtz. ^ Cales. 
 
 * Roussilhe. ^ Roussel (II), Yilleaiin. '^ Giberfc. 
 
 7 Landouzy, Collard. s Bougiere. ^ Fabre, Billod. '" Id. 
 
 " Leudet. '- See Champouillon, Scheiber, Klelu, Felix. 
 
 ^^ A. list of all the papers on pellagra in Roumania (most of tliem in tbe 
 Roumanian language) is given by Felix (pp. 27—29).
 
 PELLAGRA. 227 
 
 the date of Hs writing (1867) it was prevalent in 27 out of 
 the 117 rural communes iu the island, but only to a mode- 
 rate extent, the number of cases representing about 3*2 per 
 1000 of the population. 
 
 § 62. A Recent Disease or the Peasantry, limited to a pew 
 
 Regions. 
 
 There are two points in the history of pellagra which give 
 the inquiry into the origin of the malady a definite direction 
 from the outset. One is the fact that pellagra has appeared 
 within comparatively recent times as a disease hitherto un- 
 known ; the other is that it is limited to an exceedingly 
 narrow area. As regards the first point, we have not only 
 the unanimous opinion of those who observed and have 
 described the first outbreak of the malady in Spain, Italy, 
 France, Roumania, and Corfu ; but we have also the circum- 
 stance that in the earlier medical records of the countries 
 which subsequently became and continue to be affected with 
 pellagra — particularly in the medico-topographical accounts 
 by Italian physicians of the seventeenth century who gave 
 special attention to prevailing diseases, and above all in the 
 classical work of Ramazzini on the diseases of the labourinsf 
 class — we do not find the slightest reference which could be 
 taken as bearing even remotely on pellagra.^ In respect to 
 the second point it is noteworthy that the localities where 
 the disease is endemic are situated within a zone extending 
 from 42° to 46° N., and that within these narrow limits of dis- 
 tribution, it is always and everywhere dixnong i\\o rural popu- 
 lation only that the endemic foci of the disease exist, the 
 cases of pellagra that come to notice among the residents in 
 towns being at no place or at no time more than sporadic. 
 
 " Su tutti i diversi punti di lontanissime parti terraquee," Lussana 
 and Frua^ observe by way of summary, " nelle Asturie spagnuole, nelle 
 
 ' Mottoni points out that iu the very carefully kept death-registers of the towns 
 of Chiari and Rudiano, which were among the most intense centres of pellagra 
 shortly after it broke out, there is not a single death entered during the sixty 
 years preceding that outbreak, iu which the description of the cause of death 
 points even remotely to pellagra. 
 
 ' (II), 1. c, p. 67.
 
 228 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Lande francesi, nell' Insubria lorabarda, sul Veneto, nel Piemonte, nella 
 media Italia — le prime e consuete vittime della pellagra si mostrarono 
 sempre gli abitatori delle campagne e piu propriamente i coltivatore 
 dei campi." Frank' says : " Tria solum numeramus pellagrae in 
 incolis urbium exempla;" and be calls attention to tbe remark of Cerri 
 tbat many of tbe cases of pellagra seen in towns are in country people 
 wbo bave migrated tbitber witb tbe disease already on tbem. Anotber 
 telling piece of evidence for tbe prevalence of tbe disease among tbe 
 rural population is furnisbed by tbe statistical returns of sickness and 
 mortality.'^ Of 1955 persons wbo died of pellagra in Lombardy from 
 1848 to 1859, tbe number of covmtry people "^^^ ^^53 (Lombroso) ; tbe 
 wbole of tbe 150 pellagrous lunatics in tbe asylum at Modena were from- 
 tbe country; among 148 insane patients witb pellagra, Salerio found 
 only 9 wbo were not peasants, and even tbese were mostly born of 
 country parents ; of 561 pellagra-lunatics treated by Yigna, 493 were 
 villagers.^ Tbe propoi'tion bas been found to be tbe same in tbe more 
 recent outbreak of tbe disease in Corfu (according to Typaldos) and in 
 Roumania (according to Klein). 
 
 "Le petit nombre de cas de vraie Pellagi-e," says Felix witb reference 
 to Roumania " observes dans quelques villes, s'explique par le fait, que 
 les habitants des quartiers excentriques de ces villes sont des agricul- 
 teurs qui vivent dans les memes conditions que les paysans." 
 
 These facts, then, warrant us in concluding as regards the 
 source and character of the actual and material disease-agent, 
 that its origin is somewhat recent ; that it must have deve- 
 loped from time to time in the several pellagrous regions out 
 of causes acting locally ; and, accordingly, that all those 
 noxious influences arising from general conditions of climate, 
 weather, and soil — influences which have been felt not only 
 at all times in the localities in question, but have been 
 equally active, and are still as active, at other points of the 
 globe that are exempt — can be concerned in the production 
 of pellagra only in so far as the development of the specific 
 cause of the disease is more or less dependent upon them. 
 This is a point to which I shall return. 
 
 * L. c, p. 284. 
 
 * See the above-quoted statistics of pellagra for the Italian provinces subject 
 to tbe malady, in which the proportions of sickness among the combined urban 
 and rural population and the rural alone are given side by side. 
 
 ' See Parola, ' Saggio di climatologia e di geographia nosologica dell' Italia/" 
 Torino, 1881, p. 754-5.
 
 PELLAGRA. 229 
 
 § 63. Not distinctively caused by Poor Living. 
 
 These are factors in tlie etiology whose influence is merely 
 an indirect one ; and along with them I feel bound to include 
 the noxious effects of wretched living, particularly the much- 
 blamed inadequacy of the food to the severe labour, the 
 miserable dwellings, and the other things associated with 
 penury. I feel bound to consider those factors also as in- 
 direct ; although, as we shall see, there is another way of 
 interpreting the fact (to which all observers bear witness), 
 that pellagra is associated almost exclusively with the ijoorestof 
 the rural population, as well as the other fact attested by many 
 that amelioration in the manner of living, and particularly 
 an improved diet, exerts a favorable influence upon the sick. 
 At all events the opinion held by many observers^ that 
 pellagra is the direct consequence of poverty, misery, and 
 deficient food, or that it is a " morbus miserise,^' must be 
 decidedly rejected as untenable. 
 
 The misery of living is as old as the human race, and it 
 is no greater in Northern or Central Italy, in the northern 
 provinces of Spain, or in the south-western departments of 
 France, than in many other parts of these countries, or than 
 in Russia, Ireland, Upper Silesia, and Galicia, which have 
 never been aflQicted with pellagra. The outbreaks of the 
 disease in Spain, France, Roumania and Corfu were preceded 
 by no noticeable social change of any kind, such as would 
 have caused an increase in the difficulties of living within 
 the affected districts, and so given rise to the development of 
 the disease. Still less can this be alleged of Northern Italy 
 where, about the middle of last century or at the very time 
 when pellagra was beginning to show itself, the social con- 
 dition of the agricultural community was exceedingly good, 
 while the populations of the States of the Church, who 
 escaped the disease, were groaning under all the stress of mis- 
 government. Objection had been already taken by Zecchinclli 
 
 ' Meuis (I, 138), MugiiR, Verga, Gemma, for Lombardy ; de Rolandis, 
 SrafEoni, for Piedmont; Morelli, for Tuscany; Bennati, for Ferrara ; Cazeuave, 
 Courty (1. c, 696), Marchand (' Docum.,' 214), Gintrac (II), Bouchard, Monribot 
 (\. c, 25), Laurens, for France ; Scheiber, for Roumania.
 
 230 GEOGEAPHICAL AND HISTORICAL PATHOLOGY. 
 
 and other of the earliest observers of the disease to the notion 
 that want and misery were essential causes of pellagra, and the 
 same view was afterwards expressed by Frank^ and others. In 
 the year 1830, when the disease was widely diffused through 
 the provinces of Brescia, Cremona, and Bergamo, there were 
 only two pellagrous persons known in the Val Tellina, 
 " sebbene grande e non minore al certo che altrove vi sia la 
 miseria e il mal nutrimento nei contadiui " as Balardini 
 adds j^ and in the year 1879 the official returns gave the 
 number of pellagra cases in the whole of Sondrio, a province 
 not specially favoured by nature, at thirty-nine only, while 
 in the other provinces of Lombardy the cases were reckoned 
 by thousands. 
 
 § 64. Evidence that it is due to Damaged Maize. 
 
 The specific noxious thing on which pellagra depends 
 must consist in some factor which is common property to the 
 affected districts only, and which did not begin to make 
 itself felt until the period from whence our first information 
 about pellagra comes. Starting from these perfectly reason- 
 able premisses, the earliest observers of the disease in Spain 
 and Italy, as well as those of a later date in France, adopted 
 the opinion that the production of the malady was directly 
 caused by the use of maize as food ; and at the present day 
 that is the doctrine, based on a large experience and on 
 many experiments, which is held, if not without dissent, yet 
 by the great majority of observers and investigators, among 
 whom there are differences of opinion only in so far as 
 relate to the conditions under which a diet of maize becomes 
 a cause of the disease. I accept this theory in the sense of 
 those who take pellagra to he a toxic 'process, resembling ergo- 
 tism, and caused by a morbid condition of maize ; and in the 
 paragraphs that follow I have put together the arguments 
 which have been adduced, or which can bo adduced, for and 
 against that view. 
 
 (1) Pellagra is endemic only in countries where maize is 
 
 * L. c, p. 289. 
 
 ' ' Topogr. statist.-med. della provincia di Sondrio,' Milano, 1834, p. 65.
 
 PELLAGRA. 231 
 
 cultivated, and wtere it constitutes a chief article of diet for 
 the mass of the peasantry, particularly in the form of 
 porridge — the polenta of the Italians, the cruchade of the 
 Gascons, and the mamaliga of the Eoumanians. On the 
 other hand, in districts lying within the pellagra-areas or 
 directly adjoining them, in which maize, in the above form, 
 is used only exceptionally and does not constitute a material 
 part of the food of the people, the malady is observed rarely 
 or not at all. As regards the first point in this contention, 
 there cannot be a single doubt entertained when we examine 
 the pellagra-area ; the second argument rests upon an exten- 
 sive experience gathered from the various places within that 
 area. Attention had already been drawn by Strambio to the 
 fact that in the districts of Lombardy which formed the 
 chief seats of the malady, most of the cases occurred in those 
 villages where poleuta of maize constituted the food of the 
 inhabitants more or less exclusively. It was afterwards 
 pointed out by Balardini that in Brescia and Bergamo, the 
 head-quarters of the disease, polenta was consumed to so 
 great an extent that the local production of maize did not 
 suffice for the demand, large quantities of the corn having to 
 be imported from adjoining provinces ; while in those dis- 
 tricts of the country where other cereals, 7nore especially 
 rice, took the place of maize, the amount of pellagra was 
 very slight. It had been observed by Vallenzaska^ that, in 
 some parts of the severely affected Venetian province of 
 Belluno, where the potato had been introduced and had 
 replaced maize as an article of diet, pellagra had diminished 
 considerably. The statement was confirmed by Fertile, who 
 added more generally that the disease was most severe in the 
 lower parts of the province where the diet was almost exclu- 
 sively polenta, whereas in the upper parts, where the inhabi- 
 tants were better off and used other kinds of food as well, it 
 was much less common. To the same effect we read in the 
 official report of 1879 :^ 
 
 *' La causa d'una relativa immuuita nel Cadore e nell' 
 Agordino viene spiegata del modo alquanto diverse d'alimen- 
 tazione di quegli alpigiani ai quali la richezza del boschi 
 
 ' 'Delia Falcadiiia,' Vencz., 1842, p. 190. 
 * 'La pellagra,' p. 146.
 
 232 GEOGRAPHICAL AND HISTORICAL PATHOLOGV'. 
 
 rende meno disgraziatia la vita, potendo essi, oltre della 
 polenta, cibai'si di patate, d'orzo, fugioli e latticini in piu 
 larghe proporzioni degli altri villici della provincia." 
 
 In the province of Novara (Piedmont), the chief seat of 
 the disease is the district of Canavese, where polenta is the 
 staple food ; but in those parts of Piedmont (Biella, Varallo, 
 Pallanza, Domodossola,^) where the diet consists of polenta 
 made from sound maize, and of chestnuts, wh eaten bread, 
 and potatoes as well, pellagra is either not seen at all, or it 
 occurs in sporadic cases only. The same holds good for the 
 country round Genoa and for the Liguriau coast. From the 
 report of the Sardinian Pellagra Commission, which was far 
 from being committed to the maize theory, we learn that 
 522 out of 626 pellagrous persons, or 83 per cent., lived on 
 polenta alone, the rest having used other articles of food as 
 well. Vignoli states that the frequency of the disease in 
 the various affected districts of Tuscany is directly propor- 
 tionate to the extent in which polenta has become the staple 
 food ; it had been previously shown by Chiarugi that the 
 disease, on its first breaking out in Mugello and vicinity, had 
 attacked only those villages where the people lived almost 
 exclusively on maize, sparing those where wheaten flour, 
 rye, or chestnuts entered into the diet. In like manner, for 
 Roumania, Felix observes that there is little or no pellagra 
 in those districts where the food is mainly other kinds of 
 cereals and fish. Lastly I shall mention the fact dwelt upon 
 by Chiappa, that pellagra is hardly known in great domains, 
 cliateaus,and the like occupied by rich proprietors, or in towns, 
 where polenta is always more of a dainty than an article of diet. 
 (2) There is not a single fact to prove, or even to hint, 
 that pellagra had been seen in any part of Europe before 
 the introduction of maize ; nowhere in that continent did 
 pellagra show itself until maize became a staple food of the 
 people. Evidence of this is furnished on comparing the date 
 of the outbreak of pellagra with that of the introduction of 
 maize cultivation into Europe. The plant, which is a native 
 of the Western Hemisphere, is said to have been brought by 
 Columbus to Spain, but it was not until after the first quarter 
 of the sixteenth century that it was grown there to any 
 
 1 lb., p. 47.
 
 PELLAGRA. 233 
 
 extent. Tlie date of the introduction of maize into Italy 
 falls about the middle of the sixteenth centui-y ; although it 
 was not from Spain that it was brought but from Turkey 
 (hence the colloquial Italian name " grano turco "), into 
 which the plant had been introduced by the Spaniards shortly 
 before. It is^ however^ from the middle of the seventeenth 
 century that we have to date the general cultivation of maize 
 in Italy, and it was not until the beginning of the present 
 century that it began in France. It was introduced into 
 Koumania and recommended to the people for cultivation by 
 Niclaus Maurocordato in 1710.^ 
 
 (3) A change in the diet, the interdicting of maize alto- 
 gether and the providing of other kinds of food instead of it, 
 has in many cases effected a complete cure where the malady 
 was in its early stage. It had been asserted by Casal that 
 the first thing wanted to overcome pellagra was to change 
 the food, and particularly to exclude maize from it ; if 
 adopted at the beginning of the disease this was tho best 
 means of getting rid of it. Cerri, at the instigation of the 
 authorities in Milan, submitted ten Avell-marked cases of 
 pellagra to a suitable diet of meat and bread (excluding 
 polenta), and in the course of a year he thereby effected a 
 perfect cure. Similar observations have been published l)y 
 Brierre de Boismont, Roussel, and others. 
 
 § 65. Not dependent on the Low Nuteitive Value of a 
 
 Maize Diet. 
 
 Against these arguments adduced in favour of the disease 
 being caused by living- on maize, a number of objections 
 have been raised. More particularly it has been contended 
 that the maize-zone, corresponding to those regions of the 
 globe where maize is not merely cultivated, but also used as a 
 material part of the people's food, extends very widely 
 throughout the Eastern and Western Hemispheres, whereas 
 pellagra is confined to only a few comparatively small 
 districts of Europe ; that even in these the disease did not 
 appear until many years after the growing of maize had 
 begun, the grain having been previously used by the people 
 
 ^ Theodori, p. 54.
 
 234 
 
 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 as food without harm ; and, lastly, that sporadic cases of 
 pellagra have been observed in various parts of France 
 where maize is not a general article of food, and in parti- 
 cular had not entered into the habitual diet of the persous 
 affected. Leaving the last of these arguments for future 
 discussion, a certain weight attaches to the first two only in 
 so far as they controvert the opinion held by many authori- 
 ties,^ that the essential cause of pellagra is an exclusive or 
 at least a 2^feponderant diet of maize as such, hy reason of its 
 small nutritive value, and more 'particularly of tlie small 
 amount of nitrogen that it contains. This theory will be 
 seen to be quite untenable when we consider : (i) that, 
 although insufficient food may certainly induce chronic 
 inanition and marasmus, yet the perfectly well-marked 
 morbid state which is distinctive of pellagra is never deve- 
 loped under that influence ; (2) that those who fall ill of 
 pellagra not unfrequently have the look of being well 
 nourished at the beginning of the malady, the wasting which 
 occurs in its subsequent course being the effect of organic 
 disease and particularly of the intestinal affection / and (3) 
 that large bodies of people who live solely on rice or pota- 
 toes remain quite free from pellagra although these articles 
 of food are far behind maize in nutritive value, as the following 
 analysis shows : 
 
 Table of Comparative Nutritive Values. 
 
 
 Is'itrugcnous niiitters. 
 
 Caibo-liydratcs. 
 
 Salts. 
 
 Water. 
 
 Wheat 
 
 186 
 100 
 
 78 
 17-9 
 
 655 
 744 
 781 
 
 2'5 
 
 17-2 
 
 i6'9 
 
 30 
 
 97 
 
 140 
 
 139 
 
 •37 
 
 755 
 
 Maize 
 
 Rice 
 
 Potatoes 
 
 If, then, there be some direct causal connexion between 
 the use of maize as food and the production of pellagra, it 
 must be a question of certain qualities of this nutritive 
 
 * Fanzago, Strambio, Verga, Paoliui, Fesller, Vignol, Morelli, Lusannae Frua, 
 Leonai'di, Bonfiglia, and others. 
 
 * See Soimani, p. 250.
 
 PELLAGRA. 235 
 
 substance wliich are not proper to its nature, but acquired 
 by it under particular conditions, that is to say, a question 
 ol: the grain having undergone a change through decomposi- 
 tion or disease. It had been conjectured by several of the 
 earliest observers of pellagra, by Casal, Frapolli, Gherandini, 
 and others, that the use of damaged maize {mais guasto) 
 was at the root of the disease ; and the attention of investi- 
 gators was afterwards directed to the nature of this decom- 
 position in the grain, — to the circumstances under which it 
 took place, the kind of change which the corn underwent, 
 and the connexion between grain thus altered and the 
 pathogenesis. And if these inquiries have not yet led to a 
 final solution of the question, yet the experimental evidence 
 has shown with a high degree of probability, that certain 
 toxic siihstances, rcjyrcsentiv g the 'projper cause of the malady^ 
 are developed in the course of the decomposition of Indian corn,, 
 and possihly tinder the influence of epiphytes on the corn. 
 
 § 66. Due to Maize Cultivated and Harvested under 
 Unfavorable Circumstances. 
 
 Maize requires, for its full flourishing, a climate approxi- 
 mating to that of tiTipical or sub-tropical regions, and a 
 strong loose soil, sand with loam being the best. The 
 farther any locality is from these climatic and geological 
 characters, the more imperfectly does the Indian corn ripen 
 and the more readily does it undergo decomposition, the 
 latter being particularly apt to occur when the grain is 
 gathered and stored while it is still in a damp state. 
 Roussel, Bataillo, Michclacci, and others have pointed out 
 that pellagra is quite unknown in those latitudes where the 
 climate as a rule makes it possible for the crop to ripen ta 
 the full, as in the countries where maize is indigenous, and 
 in others such as India and Neai'cr Asia; that the geo- 
 graphical distribution of this disease falls precisely within 
 those latitudes where the crop is less thriving from want of the 
 conditions above mentioned, the grain often failing to come to 
 full maturity ; but that even there, with certain precautions 
 and careful management of the crop, it may be prevented
 
 236 GEOOxRAPHIOAL AND HISTORICAL PATHOLOGY. 
 
 from spoiling, and that in this lies the explanation of the fact 
 that many regions in temperate latitudes, where maize is 
 ^rown and enters largely into the food of the people, are 
 happily free from pellagra. 
 
 This origin of pellagra, from consumption of maize which 
 had been cut before it was quite ripe, gathered before it was 
 dry, stored in its damp state, and consequently become 
 putrid, is the explanation that we meet with in Balardini, 
 Facen, Assandri, Triberti, Tassani, Liberali, Girin, Fertile, 
 ■Cambieri, the whole profession in Roumania, and the larger 
 number of the more recent observers in general. It is re- 
 marked by Tassani that the districts in the province of Cre- 
 mona which suffer most from pellagra are those in which the 
 maize chiefly used is the so-called quarantin maize {zea mays 
 2:)raccox), or, in other words, the smallest variety of the 
 plant. The late sowing, the lateness of the autumnal ripening 
 and the consequent immature harvesting, the gathering of the 
 corn in its wet state in damp weather, the bad storage (bad 
 because this kind of maize is destined for the food of the 
 poorer classes, and not for the market, like the large kind 
 of autumnal or August maize), — all these things contribute in 
 a marked degree to its rapid decomposition. Scheiber, who 
 is himself an opponent of the maize theory of pellagra, calls 
 attention to the fact that the Wallack peasantry of Tran- 
 sylvania who are free from pellagra notwithstanding their 
 addiction to a diet of maize-polenta, had long ago learned 
 from their Saxon neighbours a better way of tilling their 
 fields and an improved husbandry of their crops of corn, so 
 that they allow the maize to ripen as much as possible and 
 then dry it on the ground and in barns ; whereas the Wal- 
 lack peasantry of Roumania, who are subject to pellagra, do 
 not permit the corn to become ripe enough, and shoot it 
 into pits where it becomes musty or spoilt.^ Typaldos gives 
 the following interesting information relating to the outbreak 
 of pellagra in Corfu : The maize grown on the island usually 
 thrives remarkably well, and supplies a good kind of suste- 
 nance ; however, since about thirty years ago — the account 
 dates from 1866, and the first appearance of pellagra in 
 
 ^ Theodoii (I. c, p. 55) and Felix (1. c, p. 23) confirm this statement, particu- 
 larly as regards the unripe state in which the maize is harvested in Koumauia.
 
 PELLAGRA. 237" 
 
 Corfu from 1839 — vine-planting has extended very raucli in 
 the island, almost displacing the cultivation of maize in some 
 districts, so that large quantities of that grain have had to 
 be imported from neighbouring countries to make good the 
 deficiency, especially from Albania, Greece, Southern Italy, 
 and the Danubian Provinces. The maize from the former 
 gi'oup of countries is as good as that grown in Corfu, but 
 the Roumanian maize is very often damaged and mouldy, 
 partly in consequence of the long sea-transit ; and Typaldos 
 has satisfied himself that it is precisely this Roumanian pro- 
 duct which constitutes the great bulk of the maize consumed 
 in Corfu, and that a large part of the grain comes iuto 
 market in a very damaged state. 
 
 § 67. A Bad Maize Harvest is followed by an Increase 
 
 OP Pellagra. 
 
 Further support to this doctrine is given by the collected 
 experience as to the influences above mentioned of states of 
 the lueather and the soil upon the goodness or badness of the 
 maize crop and upon the amount of the sickness. In Italy 
 it has been often observed, and not unfrequently at various 
 points, that a remarkable increase occurs in the number of 
 those attacked by pellagra — a sort of pellagra epidemic — 
 whenever there has been a bad harvest in consequence of 
 unpropitious weather, when the maize corn has been mal- 
 formed, gathered half ripe owing to the peasantry being 
 short of food, and stored or used in its wet state. Earlier 
 authorities had already noticed these fluctuations in the 
 amount of the disease from year to year,^ and a series of 
 observations has actually proved that those exacerbation- 
 periods of pellagra had a remarkably close correspondence 
 with the years noted for bad harvests and famine. Chiappa, 
 Hildenbrand, Menis, De Rolandis, and others adduce in this 
 connexion the experiences of 1755^ 1801, 18 15- 17, 1822-23, 
 1829-30, and 1838. Tassani remarks that in 1830 those 
 
 I Among others Cerri (' Giornale,' 1. c), who observed a remarlcahle increase of 
 the malady in Somma (province of Milan) in 1878, contrasting with its relatively 
 small amount in 1876 and 1877.
 
 238 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 villages in tlie Cremona district suffered from pellagra most 
 iu whicli the corn turned out to be of particularly bad quality, 
 and that the same thing had been observed there in 1838 as 
 well as at more recent periods. In Piedmont, as Girin and 
 others inform us, pellagra is always most frequent in dear 
 years, when the peasant does not wait for the full ripening of 
 the maize, and an inferior kind of flour is made from the pre- 
 maturely harvested crop ; and the experience is the same 
 from Ferrara in 1853-54, from Mantua^ in 1873 (after heavy 
 floods), and from the Modoua~ district in 1874, when the 
 peasantry were obliged to live on bad polenta after the total 
 failure of the crops the year before. 
 
 Besides being dependent on the weather, the thriving of 
 the maize crop depends on the above-mentioned conditions of 
 soil. We find accordingly that pellagra is particularly 
 common in localities with a poor soil of sand, marsh, or 
 clay, little adapted for growing maize, and upon which the 
 grain is all the more likely to go wrong ; of this we have 
 information by Hammer from Lombardy, by Girin from the 
 district of Canavese (Piedmont), and by Marchand from the 
 department of Landes. Felix points out that in Eoumania 
 the people suffer most in the mountainous districts, where 
 the maize ripens with greatest difiiculty, and that the number 
 of cases is in proportion to the goodness or badness of the 
 yield of corn. 
 
 §.68. The Pellagra- Poison : Expeeimental Evidence. 
 
 As the conviction steadily gains ground that it is not a 
 •diet of maize as such, but of damaged maize, that furnishes 
 the cause of pellagra, the question necessarily forces itself 
 upon us. What is the decomposition-change in the maize with 
 which the pathogenic effect is bound up, or what is it in 
 spoiled maize that constitutes the proper 'pellagra-'poison ? 
 The conjecture had already been thrown out by Sette that it 
 is an affair of a toxic parasitic mould, as in ergotism ; and 
 that idea has been taken up and followed out by Balardini. 
 On musty maize the latter found a greenish-coloured mould, 
 ' See Parola, 1. c, p, 753. * Martiiielli, Maragliano.
 
 PELLAGRA. 239 
 
 to wliicli lie gave the name of " verderame ;'' it was recog- 
 nised by Cesati as belonging to the genus S]3orisorium and 
 named Sporisorium ma'idis. Toxic experiments which Balar- 
 dini made upon men and animals with maize so affected 
 gave results which seemed to justify that conjecture as to 
 the origin of pellagra. Fowls which were fed on such 
 maize became thin, lost their feathers, became affected in 
 their power of movement, and died with still other nervous 
 symptoms. In the human subject there occurred burning 
 in the throat, digestive troubles, and diarrhoea. Although 
 Rezzi, as reporter of the commission appointed by the 
 Istituto Lombardo to test the discovery of Balardini, gave an 
 unfavorable verdict, chiefly on the ground that the verderame 
 was very often found on maize in many other regions, such 
 as Southern Italy, which were quite free from pellagra ; yet 
 Balardini's theory was adopted by Roussel and Costallat, 
 while Tardieu^ gave a favorable opinion on it in name of the 
 Commission of Inquiry nominated by the French Minister of 
 Agriculture. 
 
 The question seemed thus to be settled, when Lombroso 
 made it the subject of exact investigation anew. Ho con- 
 firmed the result of Balardini's toxicological experiments 
 with decomposed maize, and indeed, in his experiments on 
 the human subject, the characteristic phenomena of pellagra 
 in the skin and nervous system came out more decidedly than 
 in those made by Balardini. In fowls he observed diarrhoea, 
 casting of their feathers, and death ; in rats, wasting, 
 choreiform movements, contractures, and a fatal issue as in 
 fowls ; in healthy men, after a prolonged course of a tincture 
 prepared from mais gnasto, loss of appetite, vomiting, diar- 
 rhoea, desquamation of the cuticle, giddiness, dilatation of 
 the pupil and mal-nutrition. 
 
 But at the same time he proved that the view of Balar- 
 dini, according to which the verderame was the proper toxic 
 principle, must have been based on an error, inasmuch as 
 that fungus is generally speaking very rare ; so rare, indeed, 
 that he did not succeed in finding it upon maize in the 
 course of a journey through the whole of Lombardy, while 
 
 ^ His report is reprinted in Costallat's paper. 
 
 - In papet-s (II) and (III) under his name in the list at tlie end of the chapter.
 
 240 GEOGHAPHICAL AND HISTORICAL PATHOLOGY. 
 
 two of tlie foremost botanists in Italy who made a searcli for 
 it, discovered it on only a few grains of corn now and then. 
 It is probable, as Lombroso conjectures, that Balardini had 
 confounded the Sporisorium with Penicillium glaucum, which 
 is certainly very common on musty maize, although Lombroso's 
 experiments with it prove it to be perfectly harmless. 
 
 In view of these facts, both positive and negative, Lom- 
 broso considered himself justified in concluding that the 
 toxic principle was not pi'esent in maize-corn in the form of 
 a parasitic mould, but that certain substances were deve- 
 loped in the parenchyma of the decomposing corn, which had 
 a specifically toxic action as above, and were the proper cause 
 of pellagra. Further inquiries inade by him, in conjunction 
 with Dupre, Brugnatelli, and Erba,^ on these decomposition- 
 products formed in maize, have shown that the chief thing' is 
 the occurrence of a fatty oil (maize-oil), and an extractive 
 substance (named by Lombroso '^ pellagroze'in '' and by Erba 
 " maizina ") which are never found in sound maize ; that the 
 decomposition-products can be artificially produced in the 
 corn when it is exposed to fermentation ; that these matters 
 are much more powerfully toxic when produced in the hot 
 season than when obtained in cold weather ; and that their 
 effect upon the animal body is to induce a series of pheno- 
 mena which do not indeed bear the perfect impress of the 
 pellagrous group of symptoms, but are yet a decided expres- 
 sion of some severe cerebro-spinal affection, and reveal 
 many analogies with the phenomena observed in pellagra. 
 
 In forming a judgment on these admirable studies of 
 Lombroso, there are two things to be kept in mind : firstly 
 that the toxicological experiments were made on the lower 
 animals, which react to poisons in a different way from man, 
 and differently, too, in their own several classes ; and 
 secondly, that they deal with acute poisoning, whereas 
 pellagra is a disease depending upon a chronic toxic effect. 
 
 There have naturally not been wanting objectors to the 
 discoveries of Lombroso and to his theory of the genesis of 
 pellagra — a.mong them Gemma, Bellini, Lussana (III and IV), 
 
 ^ These inquiries will be found in Lombroso's papers (IV), (V), (VI), and 
 (VII).
 
 PELLAGRA. 241 
 
 'Ciotto, and Bonfigli -^ Biffi also, tlie reporter of a Commission 
 of Inquiry appointed by the Institute Lombard©, has spoken 
 very doubtfully of them. On the other hand, the experi- 
 mental results obtained by Tizzoni and the Roumanian 
 physicians (Felix) entirely agree with those of Lombroso. 
 But more especially Cortez, working at the instigation of 
 Husemann and in association with him, has carried out a 
 considerable number of very exactly planned experiments 
 with the toxic substances obtained from maize by Lombroso 
 and Erba, which confirm Lombroso's conclusions in almost 
 every point ; so that there cannot be the slightest doubt as to 
 the trustworthiness of the latter. At the same time it must 
 remain an open question how far the formation of these toxic 
 substances in decomposed or fermenting maize is dependent 
 on the presence of the lower organisms which are always 
 found to coexist. 
 
 § 69. Affinities to Ergotism. 
 
 If, then, the question of the cause of pellagra has been 
 settled by the labours of Lombroso, not perhaps altogether 
 finally, but, in my opinion, very nearly settled, the theory 
 expounded in the foregoing sections will receive additional 
 ^nd very material support from the similarity which pellagra 
 shows to other analogous toxic diseases and p articular I ij to 
 ergotism. Strambio, Jansen, Hildenbrand, and other of the 
 older observers, as well as Rayer among the recent, have 
 called attention to that resemblance. Of special weight in 
 this regard is the declaration of Hebra :" " I have seen a 
 large number of cases of pellagra. The type of the disease 
 has unquestionably the closest resemblance to other toxic 
 •conditions induced by decomposed vegetable matters ; only 
 the effect is slower (but not the less profound on that 
 account), and the course more protracted. One is involun- 
 itarily reminded of ergotism.^' 
 
 1 In au article (' Gaz. nied. Lombard.,' 1880, No. 47) directed against Lussaua 
 and Ciotto, Lombroso points out the want of judgment with which their toxico- 
 logical experiments liad boon devised. 
 
 ^ In the ' Handb. der spec, rathol.' (edited by Virchow), III, i, 205, note 2. 
 
 VOL. II. 16
 
 242 GEOGEAPHIOAL AND HISTORICAL PATHOLOGY. 
 
 § 70. Objections to the Maize-Theoey answered. 
 
 Against this theory of the origin of pellagra from tlie con- 
 sumption of decomposed maize, there have been two objec- 
 tions raised which call for a brief discussion. The first of 
 these is, that maize is grown and used as a popular article 
 of food • in many localities which are not better adapted for 
 its cultivation than the pellagrous districts themselves, and 
 yet the disease does not occur in them. The second objec- 
 tion is that in many parts of France, as we have seen 
 (p. 234), sporadic cases of pellagra have been observed, which 
 cannot be brought even remotely into connexion with 
 poisoning by maize. 
 
 As regards the first point, special stress has been laid on 
 the fact that maize is largely cultivated and used as food in 
 Burgundy, in the Bresse, and in Franche-Comte, while 
 pellagra is quite unknown in these provinces. It has been 
 shown, however, by Kous^el and Costallat that the newly 
 gathered maize in all these localities is thoroughly dried, or 
 rather scorched, before it is stored or put to use, and that any 
 decomposition of the corn is thereby prevented. The same 
 practice is observed, as I have had frequent opportunities of 
 satisfying myself, also in Southern Italy, where moreover, 
 polenta of maize figures to a much smaller extent than in 
 Northern Italy. Salas, in his interesting work on pellagra, 
 informs us that in Mexico, as well as in America generally,, 
 the maize is shelled out directly after harvesting, and the 
 corn is then thoroughly dried in the sun. No doubt damaged 
 maize sometimes occurs even there, especially towards the 
 end of winter ; but it is usually made into food for the 
 horses, or mixed in small quantities with sound maize by the 
 poorer class of people, and in that case always subjected 
 before being cooked to certain processes which render it 
 harmless. 
 
 Fseudo-peUagra. — The second objection is substantially 
 met by the argument that most of the cases of so-called 
 *' sporadic pellagra " clearly rest on errors of diagnosis. 
 Eoussel has called them '' unites factices,'^ or arbitrarily made- 
 up groups of symptoms in which nervous and psychical
 
 PELLACIRA. 243 
 
 affections arc included witli disorders of the digestive organs 
 and with morbid appearances in the skin, and the name of 
 '' pellagra^' given to them. Billed went so far as to assert 
 that it is a mental disorder that we have to do with mainly 
 in pellagra, and that when affections of the digestive organs 
 and of the skin are added thereto, we have " pellagra " com- 
 plete ; others snch as Hardy,^ have confounded pellagra 
 with alcoholism ; so that Tardieu was perfectly justified in 
 declaring that there never had been such confusion of ideas 
 among French physicians as on the subject of pellagra. 
 Moreover, these authorities must admit, as regards the cases 
 of " sporadic pellagra,'^ that there was never more than a 
 resemblance between them and the endemic disease ; and 
 Roussel, accordingly, found it necessary to speak of them as 
 '^ pseudo-pellagra." This is the judicial standpoint assumed 
 by nearly all the more recent observers, such as Chaussit, 
 Vernois, Pellizari, Brierre de Boismont (II), and various 
 others ; Dejeanne, who has made a very full collection of all 
 the observations relating to this matter, and subjected them 
 to a thorough scrutiny, says that " these are maladies differ- 
 ing widely among themselves, and all of them very different 
 from endemic pellagra not only in the etiology, but also in 
 the nature and concatenation of the symptoms.^' 
 
 It should not be denied, however, that sporadic cases 
 occur by no means exceptionally outside the foci of pellagra, 
 just as undoubted sporadic cases of lepi'osy have been seen 
 outside the leprous centres. The question had already been 
 put by Bouchut^ in this connexion, whether other kinds 
 of grain as well, such as oats, may not under certain circum- 
 stances suffer changes like those of maize, and thereby give 
 rise to pellagra in localities where maize is not grown or not 
 used as food. To the like effect Husemanu says -^ " There 
 is absolutely no reason why a similar toxic principle should 
 not develop in any other substance, which approximates to the 
 grains of Zea Mais in chemical composition, although it may 
 not be actually derived from that plant. It is no remote 
 possibility that a process of decomposition may be set up \\\ 
 the flour of other kinds of grain under the influence of dcli- 
 
 1 ' Traite de pcllasro,' Paris, 1866. 
 
 " ' Arch. gen. de med.,' 1867, Nov., p. 503. ^ L. c, p. 27:.
 
 244 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 nite external conditions, leading to the formation of peculiar 
 matters wliose gradual introduction into the organism 
 would produce phenomena either identical with those of 
 pellagra or presenting at least close analogies thereto.'' It is 
 remarkable, moreover, that sporadic cases of pellagra have 
 never occurred, or at least never been observed hitherto 
 out of France. 
 
 §71. Not Contagious ; doubtfully Hereditary. 
 
 The view held by some of the first observers of pellagra, 
 that the disease spreads by way of contagion, is opposed in 
 the most decided manner by all the later investigators both 
 on positive and on negative grounds. The almost absolute 
 immunity which the urban population enjoy from pellagra, 
 notwithstanding their active inteixourse with the inhabitants 
 of the surrounding country, should be sufiicient of itself to 
 decide the question in a negative sense.^ While there is unani- 
 mity as to non-contagiousness, there is also a positive agree- 
 ment among the greater number*^ of observers that pellagra is 
 transmitted by heredity, although the views diverge on. the 
 point whether we have to do with inheriting the disease itself, 
 that is to say, with a congenital dyscrasia — " si nasce pella- 
 grosi," says the Piedmontese Commission — or with an inherited 
 specific predisposition, such as scrofula is, or finally with a 
 state of congenital feebleness referable to the deteriorated 
 health of the parents, and serving to increase the suscepti- 
 bility of the individual to the specific influences by lowering 
 his general power of withstanding influences from without. 
 The occurrence of the disease among infants at the breast 
 might have been taken as favouring the first mentioned 
 kind of conveyance, were it not that we learn from several 
 authorities, such as Lussana and Frua, that even sucklings 
 are fed Avith polenta. 
 
 The great discrepancies among the data to hand do not permit us to 
 decide how much significance for the spread of the disease attaches to 
 this factor. The Piedmontese Commission found only 189 cases out of 
 927, or 20 per cent., clearly hereditary ; according to Lombroso, heredity 
 could be j)roved for only 74 in 472 cases or about 16 per cent. ; Mara- 
 
 ' See ' La pellagra,' pp. 344 — 51. 
 
 - Felix (1. c, p. 17) denies tbe hereditary transmission of the disease.
 
 PELLAGRA. 245 
 
 gliano found heredity pronounced in 26 out of 150 cases observed by 
 himself, or 22 per cent. On the other hand, an examination of 815 
 pellagrous inmates of lunatic asylums showed that 415 of them, or 
 nearly 50 per cent., came of pellagrous parents. Boudin has ascertained 
 that in 657 married couples, with 740 pellagrous children, both husband 
 and wife were pellagrous in 15 per cent., the husband only in 24 per 
 cent., the wife only in 27 per cent., while in 18 per cent, both parents 
 were healthy, and had several pellagrous children, and in 16 per cent., 
 the parents were healthy with only one child pellagrous. 
 
 This question naturally cannot be decided for certain unless 
 we were to ascertain how many of the pellagra patients who 
 had been born of pellagrous parents, were withdrawn from 
 the pathogenic influences at birth, and developed the disease 
 although kept remote from them ; but I do not find any 
 figures of that kind in the reports to hand. 
 
 List op Authorities on Pellagea. 
 
 Adriani, La pellagra nella provincia dell' Umbrio. Perugia, 1S80. 
 Agostini, Aunal. univ. di uied., 1874, Decbr., 478. Albera, Trattato teor.- 
 prat. della malattia . . . volgarmente detta Pellagra. Varese, 1781. 
 
 Balardini, Della pellagra, etc. Milano, 1845. Balhadere, De la pellagra. 
 Par., 1859. Bartolozzi, Sulla pellagra in Valdinievole. Pescia, 1877. Bataille, 
 Kevue thcrap. du Midi, 1853, JuiH- Bellini, Gaz. med. Lombard, 1S73. 
 Nr. 26. Bennati, Eaccogliton med., 1880, Decbr., 473. Biffi, Relazione 
 della commissione, etc. Milano, 1875 ; abso in Gaz. med. Lombard, 1875, 
 Nr. 21, 22. Billed, Annal. med.-psychoL, 1855 ! ^^*^ Arcb. gen. de med., 
 1858, March, 257. Boerio, Istoria della pellagra. Torino, 1817. Bonfigli, 
 II Raccoglitore med., 1879, 30, Gennaio, 10, Avrile, 1881, 30 Avrile, seq. 
 Bouchard, Recherch. nouvell. siir la pellagre. Par., 1862. Boudin, Annal. 
 d'hyg., 1 86 1, Jan v. Bougiere, Gaz. des bopit., 1844, Nr. 79. Brierre de 
 Boismont (I), Arch. gen. de med., 1830, Decbr. (II) Annal. med.-psychol., 
 1866, viii, 161. Bnignoli, Melattie popol. nel Bologuese. Bologna, 1878. 
 
 Caillat, Union med., 1854, Avril. Calderini, Annal. univ., 1844. Cales, 
 Bull. gen. de therap., 1S45, Mai. Calori, Scoperta dell' origine della 
 pellagra, etc. Bologna, 1824. Cambieri, Gaz. med. Lombard, 1869, Nr. 
 28. Cappi, Annali univ. di med., 18S0. Giugno, 514. Casal, Historia 
 natural medica del principado de Asturias, segnido de la descvipcion de la 
 enfermedad conocida per el vulgo cun el nomhre de nial de la rosa. Madr., 
 1762. Cazenave, Gaz. des bopit., 1852, Nr. 74, 293. Cerioli, Annal. univ. 
 di med., 1820. Gennaio, 22. Cerri (I), Giorn. della piii recente litter. 
 med.-chir., 1792, ii, 175, iii, 200. (II), Annal. univ. di med., 1S19. Agosto, 
 188. Cliampouillon, Mem. de med. milit., 1868, Mars, 191. Chaussit, 
 Annal. des malad. de la peau, 1S51, Jan v. Chiappa, Annali univ. di med., 
 1833, Gennaio. Chiarugi, Saggio di ricerche nella pellagra. Firenze, 1814-
 
 246 GKOGrvAPlITCAL AND HISTORICAL TATHOLOGY. 
 
 Ciotto cf. Lussaiia (IV). Cipriani, Gaz. med. de Paris, 1846, 982. Collard, 
 Do la pcllagre sporad. dans lo Dpt. de la Marne. Par., i860. Comolli, 
 Gaz. nied. di Milano, 1848, 305. Covtez, Ein Beitrag zur Wirkung der 
 Faulnissstoffe. Gott., 1878. See also Husemann. Costallat, Etiologie et 
 propliylaxie de la pellagre, etc. Paris, i860. Courty, Gaz. med de Paris, 
 1850, Nr. 28, 32, 34. 
 
 Dejcaunc, De qiielques pseudo-pellagres. Par., 1871. Dejerine, Compt. 
 rend., 1881, torn. 93, N. 2, p. 91. 
 
 Fabre, De la pellagre . . . a I'asyle d'alienes de St. Gemmes. Montp., 
 1868. Facen, Memorialo dcllamed. contemporanea, 1842, Septbr. ; and Gaz. 
 med. Lombard, 1869, Nr. 18. Facheris, Delle uaalattie del dipartimento del 
 Serio, a. c. Pellagra. Bergamo, 1804. Fanzago, Memor. sopra la pellagra 
 del territorio Padovano. Pad., 1789. Parini, Memor. della soc. med.-cbir. 
 di Bologna, 1839, ii, Nr. 2. Felix, Sur la propbylaxie de la pellagre. 
 Geneve, 1882. Ferraris, Giorn. della soc. med.-cbir. di Torino, 1839, ii, 
 395. Festler, Giorn. per servire ai progr. della patol., 1844 (Memor. sopra 
 la pellagra. Venez., 1844). Fontaua, Ilopert. med.-cbir. di Torino, 1833, 
 289, 1826, 337. Frank, Prax. med. univ. praecepta., part i, vol. iii, sect, ii, 
 263. Frapolli, Animadversiones in morbum vulgo Pellagra dictum. Medio- 
 lani, 1771. Frigerio, Cenni stat. del manicomio Pesarese. Pesaro, 1874. 
 
 Gambieri, Relazione sul Manicomio di Ferrara. Ferr., 1865. Garbiglietti, 
 Atti deir acad. med.-cbir. di Torino, ii, 386. Gemina, Gaz. med. Lombard, 
 i87i,Nr. 41, Gemma, Annal. univ. di med. 1873, Luglio e Agosto 249 
 and Gaz. med. Lombard, 1873, Nr. 18, 19, 38, 1874, Nr. 7, 8, Gberardini, 
 Descrizione della pellagra. Mikno, 1780. Germ, transl. Lemgo, 1792. Gibert, 
 Gaz. med. de Paris, 1853, 504. Gintrac (I), Journ. de med. de Bordeaux, 
 1836, Juin; (II), ib, 1863. Aoiit, Spt. Girin, Journ. de med. de Lyon, 
 1848, Janv. Girolami, Sulla pellagra nella prov. di Urbino e Pesaro. 1853. 
 Guerrescbi, Atti della soc. med.-cbir. di Parma, 181 4, xiv. 
 
 Hameau (I), Journ. de med. de Bordeaux,. 1829, Mai, and Bull, de I'Acad. 
 de med., 1832, ii, 7 ; (II), Bull, de I'Acad., 1851, No. 26 and Eevue med., 
 1852, Mai, 539. Hammer, in Iluf eland's Journ. der Ileilk., 1840, Mai, 94. 
 Hiard, Gaz. des hopit., 1858, Nr. 91, 362. lliklenbrand, Annal. scbol. clin. 
 med. Ticinensis. Pap., 1826, i, 100. Ilusemaun, Arcb. fiir experim. Patho- 
 logic, 1878, ix, 226. See also Cortez. 
 
 Jansen, De pellagra diss. Leyd., 1788. 
 
 Klein, Memorabilien, 1872, Nr. 10. 
 
 Lalesque, Mem. sur la pellagre landaise, etc. Bord., 1847. Landouzy, 
 Bull, de I'Acad., 1852. xvii, 629, and Union med., i860, Nr. 31, 32, 1861, 
 Nr. 17. Laurens, l^tiologie et traitement de la pellagre. Par., 1866. 
 Lavielle, Topogr. mod. du canton de Dax. Par., 1879, 113. Leonardi, 
 Raccoglitore medico, 1873, xxiv, 321. Leudet, Gaz. med. de Paris, 1867, 3 19, 
 339, 399. Liberal!, Giorn. per servire ai progr. della patol., 1S47, Luglio. 
 Lombroso (I), La pellagra nella provincia di Mantova. Roma, 1878; (II), 
 Studi clin. ed esperimentali nella natura . . . della pellagra. Milano, 
 1870; (III), Esperienze per lo studio . , . della pellagra. Milano, 
 1869; (IV), Indagine cbimiche, fisiologicbe e terapeuticbe sul mais guasto. 
 Milano, 1872 ; (V), Gaz. med. Lombard, 1875, No. 38, and Ri vista clin di
 
 PELLAGRA. 247 
 
 Bologna, 1S75, Decbr., 368 ; (VI), Lo Sperimentale, 1876, Septbr., 353, seq. 
 (VII), Rivista cliii. di Bologna, 1878, Genuaio, 8, seq. (VIII), Gaz. med. 
 Lombard, 18S0, Nr. 47. Laussana (I), Gaz. med. Lombard, 1853, Nr. 7, seq. 
 (II), Lussana c Frua, Sulla pellagra. Milano, 1856. (Ill), Gaz. med. 
 Lombard, 1875, Nr. 33. (IV), Lussana e Giotto, Gaz. med. Lombard, 
 1880, Nr. I ff. 
 
 Maffoni, Atti dell' acad. med.-cbir. di Torino, ii, 453. Maragliano, Giorn. 
 della societa ital. d'igiene 1S79, i, 149, 245. Marchand, Gaz. med. de Paris, 
 1843, 484, and Documents pour servir a 1' etude de la pellagre des Landes. 
 Par., 1847. Martinelli, Union med., 1878, Nr. 50. Menis, Saggio di 
 topogr. stat.-med. della provincia di Brescia. Bresc, 1837, i, 135. Miche- 
 lacci, Delia pellagra. Milano, 1S70. Michetti, II manicomio di S. Bene- 
 detto in Pesaro. Pcsaro, 1878. Monribot, De la pellagra. Paris, 1865, 
 Morelli, La pellagra, etc. Firenze, 1855. Mottoni, Gaz. med. di Milano, 
 1848, Nr. 40 fli. Mugna, Aunal. univ. di med., 1846, Septbr. 
 
 Nogues, Journ. de med. de Toulouse, 1862, Decbr. 
 
 Odoardi, Di una specie particolare scorbuto. Diss. Venez., 1776. 
 
 La pellagra in Italia. Eoma, 1880 (Official Report by tbe Ministero di 
 Agricoltura). Paolini, Annal. des malad. de la peau, 1852, Septbr. Pelli- 
 zari, Annal. univ., 1866, Febr. Fertile, Gaz. med. di Milano, 1848, 416. 
 Porta, Effemeride delle sc. med., 1840, Septbr. Pujat quoted by Odoardi. 
 
 Eamati, Sulla pellagra nel Novarese. Tor., 1843. Relazione sulla 
 pellagra nella provincia di Brescia. Bresc, 1879. Robolotti, Delia pellagra 
 cremonese. Padova, 1865. De Rolandis (I), Ilepert. med.-cbir. di Torino, 
 1822, 227. (II), ib., 1823, 505. Romano, Studi special! sulla pellagra nel 
 Friuli. Milano, 18S0. (Rosa) De epidemicis et contag. morbis acroasis. 
 Neap., 1788, 172, note 86. Roussel (I), De la pellagre ... en France. Paris, 
 1845. (II), Revue med., 1842, Jull., 5, 1843, Jull., 342 ; (III), Arch. gen. de 
 racd., 1866, Janv., Fcvr. Roussilhe, Journ. de med. de Bordeaux, 1845, Mai. 
 
 Sacchi, Pellagra nella provincia di Mantova. Firenze, 1878. Salas, 
 Dissert, sur la pellagre. Par., 1863. Scheiber, Viertelj. fiir Dermatologie, 
 1875, ii, 417. Sette, Giorn. crit. di. med. analitica, 1823, iv, Fasc. vi. Soler, 
 Osserv. teor.-prat. cbe f ormano la storia di una particolare malattia. Venez., 
 1 79 1. Sorbets, Gaz. des bopit., 1858, Nr. 97, 387. Strambio, De pellagra 
 observationes, 3, Vols. Mediol., 1786 — 89. German ed. Leipz., 1796. 
 
 Tassani (I), Gaz. med. di Milano, 1847, ^73 5 (II)> Notizie igien. della 
 provincia di Como. Milano, 1865. Terzagbi in a letter to Frank, 1. c, 
 26^. V. Theodori, De pellagra diss. Berol., 18^8. Tizzoni, Ri vista clin. di 
 Bologna, 1876. Agosto, 234. Tommasini, Gaz. di Parma, 18 14, Settembr. 
 Typaldos, Essai sur la pellagre observee a Corfou. Athen, 1867. 
 
 Vacca (I), Osserv. sopra la pellagra del Contado Massese. Modena, 1862 ; 
 (II), Sulla pellagra nella prov. di Modena. Modena, 1879. Verga, Gaz. 
 med. Lombard, 1848, Nr. 49. Vernois, Annal. d'hyg., 1866, Octbr., 428. 
 Vignoli, Gaz. med. federativa, 1850, Nr. 21. Villa, Giornale fisico-med. del 
 Brugnatelli, 1795, iv. 
 
 Willemin, Arch. gen. de med., 1847, March, 347, Mai, 36. 
 
 Zanetti, Acta acad. Leopold, 1778, vi, obs. 24. Zecchinelli, Annal. univ. 
 di med., 1818, Decbr.
 
 248 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Aerodijma {mal des ineds el des mains, ery theme epldemique) 
 
 § 72. Clinical Characters, Historical Odtbreaks. 
 
 Under tliese and other names tlie French physicians have 
 described a disease which appeared in epidemic form in 1828 
 and 1829 at several places in France, being very widely dif- 
 fused in Paris. It shows so many striking analogies with 
 ergotism, and even more with pellagra, that it may find a 
 place in the meantime along with these toxic diseases, 
 although there is still much that is doubtful as to its essen- 
 tial nature and its causes.^ 
 
 Syviptoms. — The onset of the disease is usually marked by signs of 
 more or less intense irritation of the gastric and intestinal mucous 
 membrane, a feeling of weight in the stomach, sickness and vomiting, 
 and by loose or even dysenteric stools which continue in many cases 
 until near the end of the attack and serve to reduce the patient greatly. 
 With these symptoms, there are usually associated redness and puflBness 
 of the conjunctiva, and an cedematous swelling of the face, which is for 
 the most part very transitory. After a few days (five to twelve) formi- 
 cation comes on, and flying pains in the hands and feet like the pricking 
 of needles, often very acute, or intense burning in the soles of the feet ; 
 hypersesthesia exists over large areas of the skin, which increases with the 
 external heat and makes even the slightest pressure lanbearable. After 
 these phenomena of morbidly increased sensibility have passed off, or 
 in some cases, from the very first, the patients suffer from anaesthesia, 
 especially in the soles of the feet, like the ansesthesia of tabes dorsalis. 
 Associated with the development of these nervous symptoms there is 
 usually an outbreak of an erythematous or erysipelas-like exanthem, 
 which spreads mostly over the hands and feet, but not unfrequently 
 over a large part of the extremities and even over some parts of the- 
 trunk; the skin at these spots becomes gradually thickened and wrinkled,, 
 
 1 Bayle, 'Revue med.,' 1828, iv, 445 ; Chardon, ib., 1830, iii, 51, 374; Cayol, 
 ib., ii, 48; Chomel, ib., iii, 485; Genest, 'Arch. gen. de med.,' 1828, xviii, 232, 
 1829, xix, 63, 357 J Longueville, ib., 1828, xviii, 310; Villeneuve, ib., 122, 311;. 
 Hervez, ' Journ. gen. de med.,' 1828, cv, 15; Fran^-ois, ib., 360; Montault, ib., 
 cvi, 170; Prus, ib., 385 ; Kuhn, ' Bullet, des. sc. med.,' 1828, xv, 252 ; Sedillot,. 
 •Gaz. med. de Paris,' 1833, 266; Audral, ' Gaz. des hopit.,' 1833, Septbr. ;. 
 Clairat, ' Consider, sur la malad. epidemique, &e.,' Par., 1829 ; Miramond, ' Diss, 
 sur raffection epidem., &c.,' Par., 1829 ; Rue, ' Essai sur la maladie (jui a regne 
 epid^iniquement, &c.,' Par., 1829; Ratier, 'Cliuique des hopit.,' 1828, '20, 
 Novbr.
 
 ACRODTNIA. 249" 
 
 and at length discoloured to a dark brown or black In consequence of an 
 abundant deposit of pigment, the discoloration being greatest in the 
 region of the nipples, over the lower part of the abdomen, on the neck 
 and in the folds of the axilla, elbow, groin and ham. In cases of a 
 severe type paroxysmal seizures of cramp, or evidences of paresis of the 
 extremities, will occur in the subsequent progress; the limbs are kept 
 continually bent in a state of tonic spasm, or there is inability to grasp 
 and hold objects or to walk straight. If these nervous attacks should 
 have persisted for some time, the aflfected limbs waste and there occurs- 
 cfidema of the thighs and legs, and sometimes even general anasarca- 
 The disease runs its course without fever ; it lasts from a few weeks to 
 several months, relapses contributing materially to its long duration- 
 It was only rarely, in the case of old and enfeebled persons, that it ended 
 fatally, and then mostly in consequence of long-continued diarrhoea. 
 Recovery was always slow and there was always weakness present for 
 some time after, and a feeling of stiffness in the limbs tbat had been 
 affected. Post-mortem examination did not throw the faintest light on 
 the nature and seat of the disease; the most careful naked-eye exami- 
 nation of the spinal cord and nervous system in general was absolutely 
 fruitless; " I'acrodynie," said Andi'al, "est une de ces maladies qtie- 
 I'anatomie pathologique ne pent eelairer en aucune maniere." 
 
 History. — Acrodynia showed itself first in the winter of 
 1827-28 at Paris, Avhere it was scattered over tlie whole city 
 in isolated cases, but was most abundant in the Quartier Hotel 
 de Ville and in the Eue Petits Augustins. Towards spring- 
 the number of cases increased, — so considerably, indeed, that 
 they numbered 40,000 by the end of summer. Meanwhile 
 news had come of its prevalence at Meavix, Troyes, St. Ger- 
 main-en-Laye, Noyon, and other towns in France. During 
 the autumn and winter following the cases again became 
 sporadic, but in the spring of 1829 the disease resumed its 
 epidemic character in Paris, and broke out simultaneously 
 at Coulommiers, Soisy-sous-Etiolles, Montmirail, and other 
 places, continuing to be prevalent until the approach of 
 autumn and dying out entirely in the winter. 
 
 All observers were agreed that acrodynia was a disease 
 quite unknown in France previous to its appearance there in 
 1828 ; and, in so far as we have any published epidemio- 
 graphical information from former centuries or from the first 
 part of the present, or in so far as such is known to me, I must 
 not only confirm that opinion, but, in agreement with Andral 
 who spoke of acrodynia as " une maladie inconnue jusque la- 
 dans le monde," T must say further that there are absolutely
 
 250 GEOGEAPHICAL AND HISTOIIICAL PATHOLOGY. 
 
 no prior observations ou the disease, be tliey descriptions or 
 mere indications, in tlio literature of medicine generally.^ 
 tSubsecpient to 1830, accounts of sporadic cases of acrodynia 
 Avere pubb'slied from various parts of France/ wliicli show, 
 however, very material deviations from the type of the 
 disease as deduced from the epidemic of 1828-30. It is only 
 the isolated cases seen by BarudeP in 1859 among the troops 
 in Lyons that bear the perfect impress of acrodynia, and 
 perhaps also the case observed by Roucher* at Setif 
 (Algiers) in a French soldier, who had, in addition to other 
 characteristic symptoms, the burning very well marked in the 
 soles of the feet and afterwards in the thighs. We may 
 also include with these the small epidemic which occurred in 
 1874 in a regiment at the camp of Satory near Versailles, 
 described by Bodros^ (who had fourteen cases under his own 
 notice in two months), although the gastric symptoms were 
 less marked, and the hypersesthesia, cramps, and dropsical 
 phenomena entirely wanting. 
 
 Of recent years epidemics of acrodynia have been observed 
 also in other parts of the world — in several Belgian prison«s 
 in 1846, among the French troops at the seat of war in the 
 East in 1854 {Orimea and Constantino'ple) , and among 
 Mexican and French (Algerian) soldiers in Mexico in 1866. 
 
 In Belgium the epidemic of the disease occurred in 
 December, 1845, ^-'ut it had been preceded, according to 
 Vleminckx,^ by sporadic cases during 1844 and 1845 in the 
 
 ' The atcouiit by S;iuto Nicoletti of a disease observed in a number of soldiers 
 at Padua in 1806, the same disease, accordinfi^ to this authority, from which 
 S. Marino and Savigliano had suffered in 1762, and Iiad been described by 
 Ozunam (' Ilist. med. des malad. epideui.,' 18.^5, iv, 242) under the name of 
 " Pedionalgie," does not in any way point to acrodynia (see also Corradi, ' Auual. 
 <lelle opidemie occorse in Italia,' iv, 582). The same remark applies to 
 McGregor's account of a disease of tlie feet observed among the English troops 
 in Spain in 1812 and 1813 (' Med.-Chlr. Transact.,' 1815, vi, 38r). 
 
 * Raimbert ('Revue med.-chir.,' 1848, Mai); Cheveriat (' Gaz. des Lopit./ 
 ^850, 71), and Beau (ib., 1862, 302), for Paris; Saucerotte (ib., 716) for Lune- 
 ville; Ganiez (ib., 1878, 226), for Darsey (Vosgcs). 
 
 ^ ' Mem. de med. milit.,' 1861, i, 367. ^ ' Union med.,' 1866, Novbr., 409. 
 
 * ' Mein. de med. milit.,' 1875, Sejitbr. and Octbr., 428. 
 
 ^ 'Bull, de I'Acad. do med. de Belgique,' 1846, v, 410, on the information of 
 Tosquinet and Stanquez for Brussels, Chamberlain for Namur, and Mareska for 
 •Ghent. See also the account by de Maeyer in the ' Anual. de la soc. de med. 
 <l' An vers,' 1846, p. 443.
 
 ACRODYNIA. 251 
 
 St. Bernard House of Correction at Brussels^ which institu- 
 tion, along- witli the prisons of Ghent and Namur, formed 
 the chief seat of the epidemic. The type of disease, except 
 as reg'ards the disorders of digestion which were the excep- 
 tion in this epidemic also, corresponded perfectly to the 
 description given by the French physicians ; in one case 
 gangrene of the lower extremities was observed, and in ano- 
 ther gangrene of the scrotum. In the prison at Brussels the 
 disease assumed a particularly severe form, thirty-three dying 
 out of the 288 persons attacked by it ; it may be inferred, 
 however, from the narrative, that it was complicated with 
 typhoid in many cases. In the cases observed in the Army 
 of the East, estimated by Tholozan^ who reported upon them 
 at 500 to 600, the symptoms of intestinal disorder were less 
 marked than in the first French epidemic ; rarer also were 
 the conjunctivitis and the affection of the skin, while oedema, 
 which always preceded thenervous symptoms, was uniformly 
 present. The epidemic in Mexico, according to Laveran,^ 
 was confined exclusively to a division of Mex^ican franc-tireurs 
 and to a battalion of Algerian tirailleurs, the disease 
 running its course with exactly the same symptoms as at 
 Paris in 1829. 
 
 § 73. Affinities of Acrodynia with Ergotism and 
 Pellagra : the Food Suspected. 
 
 The French practitioners who witnessed the epidemic of 
 of 1828-29 were almost unanimous in recognising a similarity 
 hetween tlie phenomena of acrodynia and those of ergotism and 
 j)ellagra ; and some of them, such as Ratier and Kuhn, 
 expressed their conviction that the disease was a toxic pro- 
 .cess, just as in those two diseases. Neither did the Belgian 
 physicians overlook that correspondence in the symptomato- 
 logy, Stanquez declaring that the malady vividly recalled 
 raphania. It would appear that subsequent observers of 
 acrodynia had been impressed with the same view, for they 
 gave special attention, in their search after the cause, to the 
 
 ' ' Gaz. med. de Paris,' 1861, p. 647, seq. 
 * ' Mem. de med. milit.,' 1876, p. 119.
 
 252 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 quality of the food served out to those who fell ill, particu- 
 larly the flour and bread. Although the inquiries directed 
 to that point led only to negative results both in the 
 first and in all subsequent epidemics ; yet the possibility is 
 not excluded of acrodynia being a poisoning by the food 
 similar to that which occurs in the toxic diseases already 
 mentioned. Stanquez, after assuring- us that the most 
 careful examination of the flour used in the House of Cor- 
 rection at Brussels did not reveal the slightest trace of 
 decomposition in it, goes on to remark : " Ce qui est incon- 
 testable, c'est qu'il y a intoxication."^ 
 
 It is a noteworthy fact, moreover, that the disease in the 
 epidemic of 1828-29 was prevalent almost exclusively among 
 the poorer classes, particularly in garrisons, hospices, prisons, 
 and such like confined places, the inmates of which were 
 subject to a uniform diet, and in which the disease no sooner 
 appeared in one case than it spread to the whole, or nearly 
 the whole of them. Thus in the Caserne de FOursine 300 
 men of a battalion were seized with acrodynia at once ; in 
 the Caserne de Faubourg du Temple not one soldier escaped 
 it ; in the Marie Therese Hospice thirty-six out of the forty 
 inmates fell ill. In Belgium the epidemic was strictly 
 limited to prisons, and in Brussels the interesting observa- 
 tion was made that all those convicts escaped who were at 
 work outside the House of Correction, that is to say, in the 
 open air. In the Crimean War and in Mexico, the malady 
 occurred among certain divisions of the troops only, a cir- 
 cumstance which would seem to make quite untenable 
 Laveran's notion that it was the hardships of the service 
 which properly caused the disease. There is, accordingly, 
 some obscurity still hanging over the cause of acrodynia, and 
 I shall not venture to say whether it may not be dispelled in 
 the end by the discovery of something toxically injurious in 
 the food. 
 
 ' The attempt made by some autliorities to identify acrodynia with dengue is 
 quite mistaken. Also the opinion expressed by Le Koy de Mericourt (' Bull, de 
 I'Acad. de med.,' 1865-6, xxxi, c,^) that the Paris epidemic of 1828-9 ^'^s an 
 affair of trichinosis I take to be groundless ; not merely the whole train of 
 symptoms, but the mode of spreading in acrodynia, tells decidedly against that 
 view.
 
 COLOMBIAN MAIZE DISEASE. 2oS 
 
 Pelade or the Colombian Make-Disease. 
 
 § 74. Toxic Effects of Ergot op Maize on Men and 
 
 Animals. 
 
 Accordiug to Eoulin,^ there occurs in Colombia, particulai'ly 
 in the provinces of Neyva and Mariquita, a disease of maize 
 caused by the ergot mould — mais peladero — by reason of 
 which the corn acquires properties injurious to health. In 
 man, as a consequence of using the diseased grain, the hair 
 comes out — an occurrence all the more remarkable that bald- 
 ness in those parts is rare even in old men — and sometimes 
 the teeth get loose and fall out ; but there ai'e never the ner- 
 vous or gangrenous incidents peculiar to ergotism. Animals, 
 such as pigs and mules, suffer in the same way from eating 
 ergotised maize ; but in these there have been noticed also 
 paresis and wasting of the hind legs. Fowls fed on mais 
 peladero lay eggs without shells, the explanation of this, 
 in Eoulin's opinion, being that the egg is expelled by the 
 tetanic contraction of the oviduct before the calcai'eous 
 envelope has had time to get deposited round it. Pelade, he 
 says, never occurs in Peru or in Mexico ; and that statement 
 is confirmed, as regards the latter country, by Celle.^ There 
 have been no accounts of this disease from Colombia^ more 
 recently. 
 
 In connexion with the effects of the ergot-parasite of maize, Hesel- 
 bach's'' observation is worth noticing, that eleven cows cast their calves 
 after eating diseased maize — he speaks of Ustilago maidis, but it was 
 probably ergot of maize — and that abortion occurred in two pregnant 
 bitches to which he gave the diseased coi*n pulverised. Estachy* also 
 has recently published observations on the power of ergot of maize to 
 bring on labour. 
 
 ^ ' Journ. de chimie med.,' 1829, v, 608 ; * Transact, med.,* 1830, i, 420. 
 
 ^ ' Hygiene prat, des pays cliands,' Paris, 1848, p. 173. 
 
 3 Husemann having had bis attention called to Roulin's paper in the course of 
 his inquiries on the effects of decomposed maize (' Arch, fiir experiment. Pathol.,' 
 1878, ix, 276), sent to Santa Fe de Bogota for information about pelade, but 
 he has learned nothing hitherto. 
 
 * ' Magazin der Thierheilkde.,' i860, p. 211. 
 
 ^ ' Bull. gen. de therap.,' 1877, xciii, 85.
 
 CHAPTER Vn. 
 
 MILK SICKNESS AND THE TREMBLES 
 
 (Sick Stomach, Swamp Sickness, oe Milk Disease). 
 
 § 75. ''The Trembles/' an Enzootic Disease of Cattle 
 IN THE United States. 
 
 In some parts of the United States a disease occnrs among 
 herbivorous mammals^ mostly among cattle and less fre- 
 quently among sheej), horses and deci% to which the colloquial 
 name of "the trembles" has been given in consequence of 
 the characteristic symptom of a kind of paralytic weakness 
 and spasm-like trembling in the movements of the body.^ 
 
 Symptoms of " the trembles." — It has been noticed in the more slightly 
 affected animals that, besides refusing their food they had difficvilty in 
 moving, and were easily made to tremble, the trembling being con- 
 siderably aggravated when the animal's movements became more 
 vigorous. At a more advanced stage of the malady, the weakness 
 reached such a degree tbat the animal could not keep on its feet, the 
 
 ^ I subjoin iiii alphabetical list of all the papers on this subject known to me : — 
 Carson, ib., 1880, Octbr., 299; Coleman, ' Philad. Journ. of Med. and Phys. Sc.,' 
 1822, Aug., 322; Crookshauk, ib., 1826, Aug., 252; Crooks, ' Phihid. Med. and 
 Surg. Eeporter,' 1873, July 22; Drake, ' Notices concerning Cincinnati,' Cine, 
 18 10; Forry, ' The Climate of the U.S. and its Endemic Influences, &c.,' New York, 
 1842 ; GnifP, ' Amcr. Journ. of Med. Sc.,' 1 841, April, 351 (the leading authority); 
 Haines, ' Philad. Journ. of Med. and Phys. Sc.,' 1822, Aug., 331; Haller, in 
 •Transact, of the Illinois State Med. Soc.,' 1856 ; Lea, ' Philad. Journ. of Med. 
 and Phys. Sc.,' 182 1, May, 50; Lewis, 'Transylvania Journ. of Med.,' 1829, 
 May, 24r; M'Call, 'Amer. Mod. Eecorder,' 1823, vi, 254; Minturu, 'Med. 
 Times and Gaz.,' 1857, April, 420; Ref. (I), in 'Transylv. Journ. of Mcd.,'Ji829, 
 Febr., 145; lief. (II), in 'Transact, of the Kentucky State Med. Soc.,' 1868; 
 Hef. (Ill), in 'Philad. Med. and Surg. Reporter,' 1870, July, 102; Seaton, 
 « Philad. Med. Examiner,' 1842, Nr. 10; Shelton, ' Transylvania Journ. of Med.,' 
 1836, April; Simpson, 'On Milk Sickness,' Lexington, 1839; Smith, 'Boston 
 Med. and Surg. Journ.,' 1868, Jan., 471; Sutton, in 'Transact, of the Amer. 
 Med. Assoc.,' 1858, xi ; Wright, 'Amcr. Med. Recorder,' 1828, Apr., 401; 
 Yandell, ' Transylvania Journ. of Med.,' 1S28, Aug., 309.
 
 MILK SICKNESS AND THK TKEMHLES. 255 
 
 ■whole body trembling violently, and tLc head tossing from side to side 
 continually ; sometimes the beast would be thrown down in a heap 
 by well-marked convulsions, never to rise again. The muscles are kept 
 rigid, those of the belly being contracted to the utmost; not unfre- 
 quently there is vomiting, the animal emits a peculiarly fetid breath, 
 the eyes are dull and blood-shot, and death occurs, in most cases after a 
 few hours of illness, with symptoms of extreme dyspnoea. If an animal 
 severely affected attempts any violent exertion, such as running fast, 
 it collapses suddenly and expires in a few minutes. On examining 
 the carcasses of animals that had been killed',^ Graff found the cerebral 
 sinuses very much distended, the veins of the brain-membranes choked 
 with dark fluid blood, the pia mater clouded and covered with a more 
 or less copious purulent exudation, and the brain remarkably soft. 
 There were also traces of inflammation in the spinal membranes, the 
 cord itself being very vascular. The stomach and intestines were 
 extremely contracted, the mucous membrane of the stomach and small 
 gut injected ; lungs, liver, spleen and kidneys full of blood, the spleen 
 sometimes swollen to twice its volume, and, like the liver, remarkably 
 soft; the blood dark and perfectly fluid, without a trace of clot any- 
 where. 
 
 Geograijldcal area. — This disease is mostly found in the 
 Prairie States of Nortli America {Indiana, Illinois, Ohio and 
 Missouri), and in tlie more western of the Central States' 
 {Tennessee, Kentuchj and Virginia). Sporadically, it has 
 been seen also in Alabama, Georgia, and South Carolina ; 
 but in North Carolina, where it used to be prevalent espe- 
 cially along the course of the Yadkin, it has now completel}' 
 disappeared before the thorough tillage of the soil. 
 
 § 7G. HisTorjcA.L Notices op the Tbemules. 
 
 The earliest information of the occurrence of the trembles 
 dates from the beginning of last century. The French mis- 
 sionary bishop Hennepin, who at that time penetrated along 
 the rivers far into the western parts of North America, makes 
 mention of the disease; but, the first precise accounts of it 
 come down to us from the time when European colonization 
 began to reach the Western States, general attention having 
 
 ' The examination related to carnivorous animals which Graft' Lad poisoned 
 with tlie flesli of cows dead of tlie trembles. According to tlic brief notes given 
 by him and McCall similar changes would appear to have been found in tlie 
 cattle primarily diseased.
 
 2b6 GEOGKAPHICAL AND HISTORICAL PATHOLOGY. 
 
 been directed to tlie disease by tlie frightful devastation that 
 it made among the herds of the first settlers. To escape from 
 this plague among their cattle, whole communities broke up 
 before they had well acquired a firm footing in a locality ; 
 many fruitful tracts of country stood long unoccupied on 
 K^ccount of it ; aud although the malady has become con- 
 siderably less common in more recent times, it is still pre- 
 valent in a destructive form among the herds of cattle in 
 many regions, such as Monroe County, Eastern Tennessee, 
 (according to Carson) . Not unf requently, it breaks out as an 
 epizootic, extending to many herds in some years and in 
 other years only to a few. 
 
 § 77. Nature of the Localities where the Trembles 
 
 break out. 
 
 Although this disease of cattle is found at all seaso7is and 
 under every kind of weather, it is particularly common in 
 summer and autumn, more widely spread in hot and dry 
 weather than in damp, and most prevalent, accordingly, in 
 years of drought.'^ Again, it has an unmistakable connexion 
 with certain localities, or with pasturages of a certain kind. 
 The experience of all affected districts goes to show that the 
 cattle do not take the disease unless when they graze on 
 particular ground, usually within a small area, closely circum- 
 scribed and situated in a deep valley or in the hollow of a 
 meadow. They remain well so long as they are kept away 
 from such spots ; the fencing of these places, accordingly, 
 gives perfect protection to the herd, and if the animals break 
 through the fence, the consequence is that new cases of the 
 disease occur among them. At many places it has been 
 remarked that the disease has occurred among the cattle of 
 some one farm only, all the other animals in the neighbour- 
 hood keeping perfectly free from it. Forry observes that 
 nowhere and at no time has the focus of disease been known 
 to enlarge its boundaries beyond the originally infected spot, 
 that these centres of the enzootic have often undergone con- 
 traction but never expansion, that the malady has never 
 
 1 Crookshank, Lea, McCall, Coleman, Minturn, Yandell, Haller, Thompson (in 
 Ilaller), Simpson, Shelton, &c.
 
 IIILK-SICKNESS AND THE TKEMBLES. 257 
 
 broken out in new districts^ but only in tliose where it Lad 
 existed from the first. Usually, as we have said_, these foci 
 of the disease are very limited in area ; it is only exceptionally 
 that they extend over large tracts of country, as on prairies 
 like tliose of Indiana, where the enzootic occurs for nearly 
 a hundred miles continuously on a narrow strip along the 
 banks of the Wabash. 
 
 § ,78. PooE OK Fallow Land tavorable to the Trembles. 
 
 It is impossible to decide, so far as inquiries have gone 
 hitherto, whether certain peculiarities of soil are to any 
 extent accountable for this clinging of the disease to par- 
 ticular points. The dampness or dryness of the ground 
 has no significance in this matter;^ it would appear to be 
 of greater importance that the land should be arahle or 
 cultivated. Graff observes that there is something peculiar 
 in the character of the enzootic districts in Edgar County, 
 Indiana ; that they lie rather higher than other ground in the 
 neighbourhood, being situate on ridges ; that their soil is in 
 general poor, and their growth of wood sparse and stunted, 
 such localities presenting now and then the appearance of a 
 heath j on the other hand, the disease never occurs in localities 
 where there is a luxuriant growth of grass. All observers" 
 agree that animals catch the complaint only in ranges of 
 woodland or on land that has not been tilled, that regular 
 tillage affords a sure protection against the malady, the 
 cattle on well-tended meadows never taking it, and that 
 allowing the soil to lapse into an uncultivated state is not 
 unfrequently followed by reappearance of the old noxious 
 property in the pasture. 
 
 § 79. The Trembles probably dub to a Toxic Substance 
 
 IN the Pasture. 
 
 There can be no question that in this disease of cattle 
 we have to do with a toxic effect, and that the poison must 
 
 ^ Coleman, Simpson, YandeU. 
 
 - Dixou (quoted by Lea), Coleman, Lewis, Simpson. 
 
 VOL. II. 17
 
 258 GEOGEAPinCAL AND HISTORICAL PATHOLOGY. 
 
 be in the soil, or rather the iiroduce of the soil. But no 
 certain proof has been given as yet of the nature of this 
 poison. The conjecture thrown out by some observers that 
 it is 'poisoning hy miasma which underlies the disease, is quite 
 untenable ; at least we should have to regard it as something 
 new in the history of miasmata if they can be kept within 
 bounds by a fence. There is equally little likelihood in the 
 notion^ that some m,ineral ijoison, such as cobalt, may exist 
 in the springs at which the cattle drink, having soaked out 
 from the soil, and that this is the true cause of the malady. 
 Against that assumption there is the fact that the symptoms 
 are not in the least like those of arsenical poisoning ; and 
 we have further to bear in mind that the water from the 
 presumably poisoned sources has often been drunk by men, 
 especially by the cattle tenders, without any injurious effects 
 ever following ; while lastly there is a complete refutation 
 of it in the results of Graff's exact inquiries, according to 
 which no metallic substances are to be found in the suspected 
 springs beyond a small amount of iron and a trace of copper, 
 and certainly no trace of arsenic or salts of arsenic, which 
 metal he had also sought in vain for in the soil of the 
 diseased spots.^ The most likely and most rational theory 
 is that the disease is due to some vegetable ])oisoning ; 
 at all events, there is nothing opposed to this in any- 
 thing that we know of its distribution, its way of breaking 
 out and disappearing again under the circumstances above 
 mentioned, or of its symptoms. But the decisive proof of 
 this — the detection of the plant which contains the poisonous 
 principle — is not yet forthcoming, despite the most careful 
 search. 
 
 Some observers^ are inclined to the opinion that it is an affair of 
 poisoning by one of the numerous toxic umbelli£era3 which grow in such 
 enormous quantities in the uncultivated parts of the Western States ; 
 others'* believe that the malady is a consequence of eating a species of 
 Rhus {Bhus toxicodendron, the poison-oak). An opinion has lately 
 
 1 Adopted by Shclton, Croolcshank, Seaton aud Haller. 
 
 2 All the more recent observers pronounce against this notion of the trembles 
 being caused by metallic poisoning. 
 
 ' Eef. I in the list above given. 
 
 * Drake, Owen (quoted by Sutton), aud otlicrs,
 
 MILK-SICKNESS AND THE TREMBLES. 259 
 
 been expressed' that tlie poisoning is caused Ly a fungus belonging 
 to the class of ConiomyceteSj whicli tlie animals consume witb their 
 fodder. 
 
 § 80. "MlLK-SlCKNESS " IN MaN COEEESPONDING TO THE 
 
 Trembles in Cattle. 
 
 In all those regions where the cattle-disease known as 
 "the trembles" is indigenous, a disease occurs in the human 
 subject which perfectly resembles that malady in its sym- 
 ptoms, or, in other words, it has the same character of being 
 a toxic state induced by a powerful vegetable poison. 
 
 Syvqytoms of the " milh-sichiess." — The disease begins usually with 
 pains in the head and liuibs, a genei'al feeling of weakness, disorders of 
 digestion, and a peculiar fcetor of the breath ; along with these sym- 
 ptoms there are anxiety, restlessness, great irritability, not unfrequently 
 some slight confusion of ideas and an eager condition, while the move- 
 ments are unsteady and tremulous, and the skin cold and wrinkled. 
 Then, after a shivering fit and a hot fit following it, the patient vomits a 
 soapy or greenish -yellow substance, not unfrequently bloody mucus, and, 
 in the worst cases, blood presenting the appearance of cofi"ee-grounds ; 
 the vomiting is attended by a feeling of oppression or burning pain in the 
 region of the stomach, and of intense thirst and a desire to slake it by 
 cold water. At the same time the bowels are constipated, in most cases 
 completely, and the constipation is difiicult to move. The pains in the 
 neck and limbs increase, the tongue becomes dry and red, and often 
 swollen to such an extent that it completely fills the month, beiug marked 
 by the impressions of the teeth and too large to be protruded by the 
 patient. The pulse, which was at first full, becomes small and quick, and 
 the urine is much diminished or quite suppressed. The trembling limbs 
 are cold and covered with clammy sweat, the patient passes into delirium 
 or coma, from which he does not eventually emerge, hiccup comes on, the 
 eyes become bloodshot, the pupils dilated, not unfrequently the motions 
 are involuntary and of a cadaveric fcetor, the pulse becomes thready 
 and intermittent, and death closes the scene. When the issue is to be 
 favorable, of which the indication is copious evacuation of the bowels, 
 the urine gradually returns, the vomiting ceases, and the patient passes 
 into a convalescent state which often lasts for months. In many cases 
 the disease runs its course with moderately severe symptoms, such as 
 violent tremblings on the smallest physical exertion, and a remarkable 
 degree of stiffness in the joints, which lasts a long time. 
 
 Morbid anatomy. — Gratf succeeded only once in getting a 2iost-mortcni 
 examination in this disease. The case waa that of a woman who died 
 
 1 Ref. III.
 
 260 GEOGEAPHICAL AND HISTORICAL PATHOLOGY. 
 
 on the fourtli day, severe metrorrhagia having come on; the gastric 
 and intestinal mucous membrane was injected in places, and the intestine 
 remarkably contracted in its lumen ; there were typical signs of cerebral 
 meningitis, the brain was soft and very hypersemic, with much serum 
 in the ventricles ; the liver also was hypera;mic. Blood which had been 
 drawn from a vein on the third day of the disease coagulated slowly, 
 the clot being small, soft and gelatinous, and the serum stained red, 
 apparently through extensive decomposition of the red corpuscles.^ 
 
 This disease occurs^ as we have seen, in tlie very same 
 regions where the above described disease of cattle is endemic, 
 and it was so common in the first years of the century that 
 several hundred persons died of it annually. From time to 
 time it assumes an epidemic character, in correspondence 
 with the epizootic, as in Falmouth/ Kentucky in 1854 and 
 1856, and most recently in 1867 in Kenton/ Ohio, when 
 there were fifty cases and seven deaths. 
 
 § 81. Evidence op Poisoning by the Milk or Meat. 
 
 The special interest of this disease for our inquiry lies in 
 the question of its relation to the disease in cattle. The 
 similarity of the symptoms as a whole in the two processes 
 warrants us in assuming that they are connected in their causa- 
 tion, either in such wise that both of them proceed from one 
 and the same cause, or that the disease in the human subject 
 depends upon sickness in the animals, that is to say, upon a 
 transmission from the latter to the former. While each of 
 these theories has its supporters, by far the larger number 
 of observers incline to the view that the disease in man is 
 solely the consequence of using as food the milk {and the 
 ■products -prepared from it) or tJie flesh of the diseased animals; 
 and hence the name of "milk-sickness'^ by which the disease 
 is colloquially designated. Numerous observations by Lewis, 
 McCall, Yandell, Crooks and others lend material support 
 to this doctrine ; not less in its favour is the fact that carni- 
 vorous mammals and birds, such as the dog, fox, wolf, buzzard, 
 
 ' Graff explains that the anatomical conditiou was not perfectly ascertained 
 for the reason that he was obliged to make the examiuatiou by caudle light iu 
 the open air. 
 
 ' Sutton. 3 Smith.
 
 MILK-SICKNESS AND THE TREMBLES. 261 
 
 and vulture^ which had fed on the flesh of cattle dead of the 
 trembles^ succumb. Most decisive of all, however, we may 
 reckon the toxicological experiments which Graif made on 
 dogs and other animals with the milk and flesh of cows that 
 were killed by the disease ; assuming that no mistakes of a 
 gross kind have been committed, there can be hardly any 
 doubt that these experiments have established the fact of 
 transmission. 
 
 Graff's inquiries into the physical, chemical and toxic 
 properties of the flesh and tnilh of cows dead of the disease have 
 yielded the following results : In appearance and taste, the 
 flesh differs in no respects from healthy meat ; it goes putrid, 
 however, rather sooner. Pickling it, smoking it, or treating 
 it with various acids and alkalies did not destroy its virulent 
 properties ; somewhat prolonged boiling with galls, and 
 subsequent careful sousing of the flesh, destroyed its toxic 
 character in so far that only slight symptoms of poisoning 
 ensued in the experiments on animals, after the administration 
 of large quantities of it. Further, the poison proved to be 
 completely insoluble in water. The milk, as well as butter 
 and cheese made from it, showed no dift'ereuces in its physical 
 qualities (smell, taste and appearance) from that yielded by 
 healthy cows. The following experiment by Graff affords 
 an approximate measure of the time during which the 
 elimination of the absorbed poison may go on in the sick 
 animal : A cow slightly affected was brought into a shed, 
 where she was kept perfectly quiet and properly fed ; for 
 eight days after her milk was still found to be poisonous, 
 but in another week she was well and the milk had lost its 
 virulent properties. The elimination of the poison ceased, 
 accordingly, from eight to fourteen days after the seizure, 
 and, in Graff's opinion, the restitutio ad integrum was not 
 gradual but sudden. 
 
 § 82. Other Explanations op Milk- Sickness. Similar 
 Observations at Malta. 
 
 Against this theory of the origin of the disease in man, 
 a number of objections have been raised, which may be
 
 262 GEOGRAnilOAL AND HISTORICAL PATHOLOGY. 
 
 summarised as follows : (i) Milk-sickness occurs more fre- 
 quently in adults than in children^ although the consumption 
 of milk by the latter is the greater ; (2) not everyone who 
 had drunk of the suspected milk or eaten of the suspected 
 flesh takes the disease ; (3) cases of so-called milk-sickness 
 have occurred where no evidence of poisoning could be 
 adduced. 
 
 If these objections cannot bo summarily dismissed, yet 
 the trustworthiness of the observations from which they 
 proceed is not so perfectly assured that they can invalidate the 
 force of the facts already given. Still less can that evidence 
 be said to be weakened by the notion which refers the cause 
 of the disease to the injliience of malaria — an influence 
 assumed as affecting men and animals alike.^ This notion, be- 
 gotten of the malaria craze, rests upon the entirely erroneous 
 assumption that the disease occurs especially on damp or 
 marshy, that is to say, malarious soil ; and it takes so little 
 account of the symptoms and of all the experience collected 
 to prove the narrow limitation of the disease to particular 
 spots, that Yandell is perfectly right in describing it as 
 '' absolutely paradoxical." 
 
 A satisfactory solution of the whole question is only to 
 be got, naturally, by discovering the source of poisoning, 
 which has so persistently eluded every search hitherto. In 
 favour of the possibility of animals conveying the poison to 
 men, or in other words, of diseases being induced by the milk 
 of animals (cows and goats), there are collateral observations 
 relating to a series of cases of cholera-like sickness, which 
 originated in all probability, if not certainly, in the same 
 way. The older observations of that kind are those of 
 Ollivier," Bonorden^ and Chevalier.* Of special interest is 
 Mackay^s^ account of the occurrence of cholera-like cases 
 in Malta, after the consumption of poisoned milk. These 
 cases would seem to form a slight pendant to the milk-sick- 
 ness of the United States. On board a ship of war in the 
 
 1 Sutton (as reported by Barbour). The same opiuion was formerly expressed 
 by Lea, Thompson (quoted by Haller), and Wright. 
 - ' Journ. gen. de med.,' 1827, ci, 255. 
 ' 'Rust's Magazin fiir die Heilkdc.,' 1828, xxvii, 193. 
 
 * ' AnnaL d'hyg./ 1846, xxxv, 138. 
 
 * 'Edinb. Med. Journ.,' 1862, March, 825.
 
 MILK-SIOKNESS AND THE TEEMBLES. 2G3 
 
 quarantine harbour of Yaletta, eleven officers took ill suddenly 
 with choleraic symptoms, and the one thing common to them 
 all was that they had partaken of milk which had been 
 brought on board; in following- up the inquiry into the source 
 and quality of the suspected milk, Mackay learned that it was 
 a fact well known in Malta that cows which fed on a certain 
 plant, called by the natives " tenaowta ^' became ill, and that 
 their milk, when consumed by men, had the unwholesome 
 effects above described. He was told by botanists that the 
 poisoning of the animals was induced by a species of the 
 Euphorbiacefe.
 
 CHAPTER VIII. 
 "ENDEMIC COLIC." 
 
 § 8^. Definition of the Subject. 
 
 Under siicli names as colic of Poitou, colic of Madrid^, 
 Devonshire colic, colica intertropical colica vegetabilis, 
 colique seclie, and dry bellyaclie, — names derived from, the 
 locality, from the supposed cause or from the most promi- 
 nent symptom, — several diseases have been described in the 
 course of the last hundred years as occurring at various parts 
 of the globe cndemically or epidemically ; they correspond 
 perfectly with lead-colic in the symptoms, although their 
 origin from lead-poisoning was long contested, and is con- 
 tested for some of them at the present day. The interest in 
 the subject has become all the more lively from the fact that 
 a malady has established itself in the French navy since fifty 
 years ago, which in its development presents the symptoms 
 of lead-colic, but in the opinion of many observers owes its 
 origin to other causes of a climatic or miasmatic nature. 
 The discussion of that question has recalled attention to the 
 alleged endemic prevalence of the same form of disease in 
 the tropics ; and it has been attempted to show from these 
 tropical observations as well ihat there exists a hind of 
 disease the same as or exactly similar to lead-colic, whose origin- 
 depends on an etiological factor other than lead-poisoning . 
 In order to elucidate this subject, which is as interesting 
 historically as it is in the way of practice, I have in the 
 first place put together in the sequel the facts ascertained as 
 to the epidemic or endemic occurrence of colics of that kind ; 
 secondly, I have discussed the question of the " endemic 
 colic of the tropics ;" and finally, I have inquired into the 
 subject of colic on board ship.
 
 ENDEMIC COLIC. 2G5 
 
 § 84. Historical Outbreaks mostly proved to be Lead- Colic. 
 
 The earliest reference^ to an epidemic of what was after- 
 wards called '^ colica vegetabilis " occurs iu a sixteenth cen- 
 tury notice by CEtheeus/ according to which a severe form of 
 colic — well-marked lead-colic, from the description of it — 
 had been prevalent in several parts of France, Burgundy, 
 Asturias, and Rhtetia, the cause of it being ascribed to the 
 drinking of certain strong wines, especially such as had been 
 subjected to artificial treatment ("ex artificiosa conditura 
 sulphuris.")^ Then follows the first account of "^"^ colic of 
 Poitou " {colica Pictonuni) by Citesius,'* who plg,ces the 
 beginning of the epidemic in the year 1572 ; later informa- 
 tion on this disease from the seventeenth and eighteenth 
 centuries puts it beyond all doubt that it was an affair of 
 poisoning by wine contaminated Avith lead, the same being 
 the case with the colic mentioned by Bonte^ as having been 
 prevalent in Normandy in the middle of last century. 
 
 Bontc distinguislied two forms of tlio disease, tbe one dependiBg on 
 lead-poisoning and tlie otlier " coliqnevcgetale." From the more recent 
 account by Vasse it appears that lead-colic is somewhat common in 
 Normandy where cider containing lead is drunk, the " colique vege- 
 tale " on the other hand consisting in an intense irritation of the 
 stomach due to perry, which has no toxic ingredients. 
 
 * The toxic propei-ties of load and the symptoms ensuing after poisoning hy 
 that metal were known to the Greek and Iloinan physicians, as appears from tlie 
 statement in Dioscorides (' De materia med.,' v, cap. 103; ' De venenis,' cap. 22, 
 ed. Kiihn, i, 769, ii, 32); Celsus (lib. v, cap. 27, § 15); Galen (' De antidotis,' ii, 
 cap. 7, ed. Kiihn, xiv, 144) ; Paulus Aegineta (lib. v, cap. 59, 62) ; Aetius 
 (' Teti-abibl.,' iv, sermo i, cap. 45), and Actnarius (' Method, med.,' v, cap. 12). 
 In speaking of colic Paulus (lib. iii, cap. 43) mentions an epidemic of it that 
 had occurred in the first half of the seventli century, iu many parts of the IJoman 
 Empire, the symptoms of which may perhaps be taken as pointing to lead-colic 
 (" plerisque in morbum comitialem, aliis ad artuum resolutionem, servato scnsu, 
 quibusdam ad ambo delapsus contigit "). 
 
 ^ In Schenck's 'Observ. med.,' lib. iii, obs. 184, Fraukf., 1600, p. 650. 
 
 ^ It is undoubtedly to this disease, or to the one mentioned by Citesius, that 
 Riviere's account of " colica; biliosa; species qua; in piiralysin degenerat," relates 
 — evidently lead-colic from the description of it. Like all his contemporaries^ 
 he finds himself quite at a loss to explain the true cause of it. 
 
 * ' De novo et populari apud Pictones dolore colico-biiioso,' 0pp., Par., 1639. 
 
 * ' Journ. de med.,' 1761, xv, 399, 1762, xvi, 300; 1764, xx, 15.
 
 206 GEOGBAPHIOAL AND IIISTOEICAL PATllOLOGY. 
 
 A disease perfectly the same as tlie colic of Poitou was 
 observed at the time in some parts of tlie Netherlands, 
 and in Devonshire. It was sliown on careful inquiry tliat here 
 again it was not dietetic substances of a vegetable nature 
 that caused the disease, as had been supposed, but poisoning 
 by lead ; which fact having been recognised and the mischief 
 removed, the disease came to an end. 
 
 It was proved by Troncliin^ that the poisoning in Holland was due to 
 the water-pipes having been lined with lead. In Devonshire, as 
 Huxham" informs ns, the blame was laid on the immoderate drinking 
 of the cider for which the county is famous; until at length Baker ,^ 
 Alcock/ and others brought forward proof that it was not the cider 
 itself which was at fault, but the contamination of it with lead fi'om the 
 leaden vessels in which it was made. 
 
 At a more recent date the " colic of Madrid " attracted 
 
 especial notice, owing to the writings on it by French 
 
 physicians, who, although not denying the identity of the 
 
 disease with lead-colic, were strongly opposed to the notion 
 
 that lead-poisoning was at the bottom of it. 
 
 It had been stated by Hernandez^ and afterwards by Luzuriaga,^ the 
 latter having the Academy of Medicine in Madrid with him, that the 
 cases of colic resembling lead-colic were as a matter of fact colic due to 
 lead, Luzuriaga pointing out that the poor in Madrid and many other 
 IDarts of Spain used badly glazed vessels in which to keep their food, 
 that the glazing, which contained lead, underwent decomposition, and 
 that the food was contaminated by the lead thus set free. Lai'rey'' 
 rejected this view as erroneous ; he assumed instead that the extreme 
 fluctuations of temperature common on the table-land of Castile were 
 the true cause of the disease, a theory which was afterwards adopted by 
 Faure,'^ although the latter was obliged to admit the perfect similarity 
 of the disease with lead-colic. 
 
 In this state of suspense the question remained until at 
 
 length Hisern^ and Cuynat'° produced exact evidence of the 
 
 ^ ' De colica Pietonul^^,' Genev., 1757. 
 - 'Observ. Med.-Pliys.,' Lips., 1784, iii, 54. 
 
 ^ 'Essay concerning the Cause of the Eudemical Colic of Devonsliire,' Lond., 
 1767. 
 '' 'The Endemical Colic of Devonshire, &c.,' Plymouth, 1769. 
 * 'Trat. del dolor cdhco,' Madr., 1737. 
 ^ ' Disert. sobre cl colico de Madrid,' Madr., 1796. 
 7 'Memoires de Chirurgie, &c.,' vol. i, Paris, 1812. 
 
 ' Des fievr. intermitt.,' Paris, 1833, p. 409. 
 
 ' Revue med.,' 1840, Sept., p. 361. 
 
 ■ Mem. de I'Acad. des so. de Lyon,' 1843-4, P- 20. 
 
 8 
 9 
 10 <
 
 ENDEMIC COLIC. 207 
 
 lead-poisoning' wliicli was underlying the disease, Cuynat at 
 the same time showing that the malady was by no means 
 confined to Madrid or New Castile, but was found in many 
 other parts of Spain, — in Catalonia, Andalusia, and wherever 
 there were gross hygienic errors conducive to lead-poisoning, 
 such as conveying drinking water (charged with carbonic 
 acid) in leaden pipes, allowing lead to get into the wine, or 
 keeping articles preserved with vinegar, such as capers, 
 cucumbers and other pickles, in badly glazed vessels. 
 Moreover, as Hisern adds, there can be at least no question 
 of endemic colic in Madrid in recent times, inasmuch as it 
 happened to him in an extensive private and hospital 
 practice to see only seven or eight cases of this " Madrid 
 colic " in the space of nine years. 
 
 The '' dry bellyache " or " bilious colic " of United States 
 'practitioners has had the same fate as the " colique vege- 
 tal e," that is to say, it has turned out to be lead-colic. 
 
 In a letter of Benjamin Franklin* to Yaiighan, dated Philadelphia, 
 July 31st, 1786, he says : " The first thing I remember of this kind was 
 a general discourse in Boston when I was a boy, of a complaint from 
 North Carolina against New England rum, that it poisoned their 
 people, giving them the dry bellyache, with a loss of the use of their 
 limbs. The distilleries being examined on the occasion, it was found 
 that several of them used leaden still-heads and worms, and the 
 physicians were of opinion that the mischief was occasioned by that use 
 of lead. The legislature of Massachusetts thereupon passed an act, 
 prohibiting, under severe penalties, the use of such still-heads and 
 worms thereafter." 
 
 The same was the case, no doubt, with the " bilious colic " that was 
 prevalent and grew into an epidemic at Woodsborough in 1821; 
 Staley- says of it that it perfectly resembled lead-colic, but it was not 
 to be attributed to lead-poisoning because " there was only a small 
 quantity of lead in the mills employed to extract the juice of the sugar 
 canes;" the amount of lead accordingly in the rum could be but slight, 
 and the disease was rather of a malarious nature. 
 
 Of the remai-kable epidemics of " bilious colic " at New Orleans in 
 the summers of 1849 ^^^ 1850 we have an interesting account by 
 Tenner,^ from which it appears that the case was one of wholesale 
 poisoning by soda-water containing lead ; perhaps also the driuking- 
 
 ^ The letter is quoted iu Hunter's * Observations on the Disease of the Army 
 in Jamaica,' 2ncl ed.. Lend., 1796, p. 211. 
 •^ ' Amer. Med. Recorder,' 1873, vi, 231. 
 ^ ' Southern Med. Reports,' 1850, ii, 27, 247.
 
 268 GEoaRAPniCAL and niSTorjCAL rATnoLOGY. 
 
 water was contaminated by the lead pipes wliicli connected tlic Louses 
 witli the iron mains, and together represented a length of some 90,000 
 yai'ds. More recently (1865) there was an outbreak of the same kind of 
 " bilious colic " at a village in Orange County, N.T. ;' an investigation 
 showed that the miller who supplied the village with flour had filled up 
 the holes in his mill-stones with lead, the consequence being that 
 particles of the metal got into the flour and therewith into the bread.^ 
 
 § 85. The ''Dry Bellyache" op the Tkopics. 
 
 While almost everyone has given up the belief in a disease 
 of temperate latitudes identical in all respects with lead-colic, 
 but in its origin dependent on other causes (such as the eating 
 of some vegetable, or food prepared from the same, or the 
 malarial influence) ; the same belief has lasted much longer, 
 and is held by many practitioners even at the present day, 
 as regards the endemic occurrence in the tropics of a ''colique 
 vegetale '^ of that kind, or "colique secho " (dry bellyache), 
 constituting in fact a specific tropical disease. 
 
 The earliest information of endemics of that kind comes 
 from the West Indies. The first to mention them,^ Smith* and 
 Hillary,^ do not touch the question of the origin of the disease; 
 while Moseley,^ who recognised the similarity of the disease 
 to lead-colic, did not admit lead-poisoning as the cause of it. 
 On the other hand, Clark,^ Hunter^ and Turner^ were quite 
 decided that " dry bellyache " was always the consequence 
 of poisoning by lead, particularly by lead-tainted new rum ; 
 
 ' ' Account in the 'Medical News,' Philad., 1866, p. 112. 
 
 ^ Lead colic occurred epidemically uiuler the same circumstances in 1858 and 
 1 86 1 at two villages in the neighbourliood of Chartrcs, according to the accounts 
 by Mannory and Sahnon (' Gaz. med. de Paris,' 1862, p. 208, 1865, pp. 270, 288, 
 302); thequantity of lead used by the miller in 1861 amounted to 20 kilos (44 lbs,); 
 of some 400 persons who fell ill, about twenty died of the poisoning. 
 
 3 Sydeiiliam (' De colica,' in 0pp., Genev., 1736, i, 512) in speaking of colica 
 Pictonum, remarks, " Apud iusulas Caribum uotissima est," although he says 
 nothing of the cause of the disease. 
 
 ^ 'De colica apud incolas Caribenses endemica,' Leid., 171 7. 
 
 ^ ' Observations on the Changes of the Air, and the concomitant Epidemical 
 Diseases in Barbadoes,' 2ud ed., Lond., 1766. 
 
 '' 'Treatise on Tropical Diseases,' Lond., 1787. 
 
 '^ 'Treatise on the Yellow Fever,' Lond., 1797. 
 
 ^ L. c, 183, and ' Med. Transact.,' 1785, iii, 227. 
 
 '■» 'Lond. Med. Gaz.,' 1832, xi, 78.
 
 ENDEMIC COLIC. 269 
 
 they stated, moreover^ in confirmation of Chisbolui/ that 
 there could be no thought of a true endemic prevalence of 
 this colic. In like manner Dutroulau/ who had, like Brassac,^ 
 denied in his earlier papers that lead-poisoning" was the cause 
 of " colique seche,^^ returned subsequently to the view of 
 Corre/ who asserted, from his experiences in Martinique 
 (and at Vera Cruz), that severe cases of colica stercoralis 
 were common there, as they were everywhere, particularly in 
 the tropics (for reasons to be afterwards given), but that he 
 had never seen what is called " colique seclie " under other 
 circumstances than as a consequence of lead-poisoning ; that 
 term, accordingly, as an " entite morbide speciale " should 
 be given up. 
 
 Next to the West Indies, Guiana used to be specially 
 reputed as an important centre of endemic colique suclie, 
 and Legend^ in particular, among more recent writers, has 
 favoured that idea, rejecting altogether tlie notion of lead- 
 poisoning as the cause of the disease and explaining it as a 
 neurosis of the sijmjiathet'tc hroiigJtt on hy chill. Long before 
 bim Rodschied^ had expi-essed the opinion that the existence 
 of '' dry bellyache " as an endemic was not to be thought of ; 
 colics of various kinds, he said, are without doubt somewhat 
 common in Guiana, but among these the so-called dry colic 
 played a comparatively small j^art, the disease known specially 
 by that name having nothing whatever to do with climatic 
 influences but depending on nothing else than poisoning by 
 lead, particularly the lead contained in wine and rum. This 
 explanation was afterwards accepted in every point by 
 Hille^ in Surinam, Blair^ in British Guiana, and Lefcvre^ in 
 Cayenne. 
 
 1 'Manual of the Climate and Diseases of Troiucal Countries, &c.,' Loud., 
 1822, 93. 
 
 '^ 'Arch. gen. de mod.,' 1855, Deccmbre, and ' Traito des malad. des Europoeus 
 dans les pajs chauds,' Par., 1S61, 34. 
 
 ^ ' Consider, pathol. sur les pays chauds,' Montp., 1863. 
 
 •* ' Notes med. rec. a la Vera Cruz, &c.,' Par., 1869, 60. 
 
 5 ' Gaz. des hopit.,' 1834, March, 25; ' Journ. hebdom. de uicd.,' 1835, ^^- .?> 
 13; 'Essai sur la nevralgie du grand sympathique,' Par., 1837, ^^^^ ' Kevue 
 uied.,' 1S3Q, Mai, 239. 
 
 ^ ' Bemerkungcn iiber das Klima . . . von Rio Essequcbo,' Frankf., 1796, 184. 
 
 7 Casper's ' Wocheuschr. der Htilkde.,' 1842, Nr. 6. 
 
 ^ 'Account of the last Yellow Fever Epidemic,' Lond., 1852, 21. 
 
 '■^ Rechcitbes sur les causes de la colique scchc,' Par., 1859, 96, 98.
 
 270 GEOGrvAPHICAL AND HISTORICAL PATHOLOGY. 
 
 According to an account by Chapnis,' there was a remarkable increase 
 of the colique secLe in Cayenne during the years 1858—60, as com- 
 pared with the years immediately i^recedin^: while the number of cases 
 treated for that disease in 1856 and 1857 was 82 and 67 respectively, 
 it rose in 185S to 102 and in 1859 to 201. Of 31 patients treated for 
 colique seche in the first quarter of 1 860, there were 6 for whom lead- 
 poisoning was proved ; for the remaining 25 no evidence was forthcoming, 
 although the possibility of the same cause having been in o^Deration iu 
 these cases also was by no means excluded. 
 
 For other parts of trojncal South Araerica we do not Lear 
 a word about any disease cliaracterised by the symptoms of 
 lead-colic wliicli was not actually due to lead-poisoning. 
 Tlie statements of Thevenot^ and Borville^ as to tlie frequent 
 occurrence of colique seclie iu Senegamhia are contradicted 
 by the later accounts of Lefevre^ aud Villette ;^ most of the 
 cases had been treated in the marine hospitals and belonged 
 therefore to man-of-war crews ; and in every case, as the 
 authorities last named tell us, lead-poisoning could be shown 
 to be the cause of the ^ickncss. The same holds good, 
 according to Monnerot^ and Abclin/ for the disease as it 
 occurs on the Gaboon coast. Nothing is known of colique 
 seche in Algiers, Egypt, Abyssinia, on the East Coast of 
 Africa or in the adjacent islands ; from time to time a case 
 of severe colic comes under observation in the marine 
 hospitals of Mauritius and Reunion, but these also can be 
 always traced to lead-poisoning.^ For India and the East 
 Indies it is the same case; nowhere in these countries is 
 there anything heard of an endemic disease resembling lead- 
 colic, the few cases of colique seche Avhicli are met with at 
 Pondicherry being almost exclusively on board French men- 
 of-war, and most of them, as Huillet^ remarks, traceable to 
 poisoning by lead.^° In the ports of Gochin Gliina, as at all 
 
 1 ' Gaz. hebd. de med./ i860, Nr. 36, 577. 
 
 2 'Traite des malad. des Europeens dans les pays cbauds,' Par., 1840, 232. 
 
 3 'Gaz. des hopit.,' 1858,147. * L. c, 114. 
 5 'Arch, de lued. nav.,' 1866, Fevr., 81, Mars, 178. 
 
 fi 'Consider, sur les malad. eudem. obs. a I'hopital de Gabon,' Montp., i868> 
 p. 36.^ 
 
 ' 'Etudes sur le Gabon,' Paris, 1872, p. 29. 
 
 ® Lefevrc, 1. c, p. 130. 
 
 3 'Arch, de med. nav.,' Janv., 1868, p. 12, 
 
 10 Smith (' Ed. Med. Journ.,' July, 1856), gives an account of an opidcniic of 
 " colic of Poitou " which was so general among the garrison stationed at Newera
 
 ENDEMIC COLIC. 271 
 
 the French naval stations in the tropics^ cases of coliquo 
 scche have been seen occasionally ; and here again they 
 belonged to the crews of men-of-war, and were in every 
 instance traceable to lead-poisoning.^ From China we have 
 information to the same effect by Lagorde/ who expreses 
 his astonishment that anyone should have spoken of colique 
 seche as occurring endomically there ; during a two years' 
 stay in Chinese ports he had seen only one case (lead-poison- 
 ing) on board a French ship-of-war, while no case of the 
 disease among the foreign or native residents had come 
 under his notice. Lastly, we have to give the same account 
 of the colique seche in Taldti, where poisoning by lead in 
 the wine could be proved for all the cases observed by 
 Gallerand -^ and in New Galedonia (Port-de-France) where 
 occasional cases are seen on board the French men-of-war, 
 they are always due to poisoning by lead."* 
 
 § 86. Always caused by Lead. 
 
 It follows from all these facts above adduced that the 
 endemic or epidemic prevalence of '' colica vegetabilis " or 
 " colique seche/' in former centuries had always been an 
 affair of wide-spread lead-colic ; that these occurrences have 
 become less frequent as a more correct view of the origin 
 of the malady has gained ground, and as the progress of 
 public sanitation has diminished the chances of the disease 
 breaking out ; that there have no doubt been ej^idemics of 
 lead-colic from time to time, even within the most recent 
 period ; but that there can be no thought at all of the disease 
 
 Ellia, in Ceylon, that in a force of 87 men there were 142 admissions including 
 the relapses. It caine out on inquiry that the epidemic was due to poisoning Ly 
 lead in the sugar and in the arrack. 
 
 ^ See Richaud, ' Arch, de med. nav.,' 1864, Mai, 351 ; Margaillan, 'fitudc sur 
 I'etiologie saturnine de la colique su'ihc,' Par., 1866; (Jimello, 'Union med.,' 
 1869, Nr. 53, 694. Girard de la Biircerie (' Consider, iiied. s\ir la Cochinchinc, 
 &c.,' Montp., 1868, 42) did not see a single case of colique seclie during a two 
 years' residence in Cochin Cliina. 
 
 2 ' Arch, do med. nav.,' 1864, Mars, 185. 
 
 3 lb., 1865, October, 286. 
 
 "• De Rochas, ' Essai sur la to]iogr do la Nouvelle Caledonic,' Par., 18C0, 
 
 18; acco^mt in 'Arch, de med. nav.,' 1866, Jauv., 21.
 
 272 GEOGEAPHICAL AND HISTORICAL PATHOLOGY. 
 
 being endemic or, more particularly, of tliero being- an endemic 
 -^'colique secbe" of the tropics. Almost all the cases observed 
 in those latitudes, and described under that name, have 
 occurred in ports among the crews of French men-of-war ; and 
 in by far the most of these, it has been shown to be an affair of 
 lead-poisoning. Thus the whole inquiry reduces itself prac- 
 tically to answering the question. What are the circumstances 
 of this much talked-of " coUque shelve " of the French navy, or 
 ihe so-called " shijj colic?" 
 
 <§ 87. The " Colique Seche " op Steamships op the Fkench 
 
 Navy. 
 
 There have been occasional cases of lead colic occurring 
 for a long time past on board ships of every flag, both of 
 the mercantile marine and of the navy. If not in all of these, 
 yet in most of them it has been possible to trace the cause 
 of the sickness to a fresh coat of lead paint on board, or to 
 beverages or preserves contaminated with lead ; sometimes 
 the source of the poisoning has eluded all inquiry, and the 
 disease, as Falck^ appositely says, had a ''^ cryptogenetic'^ 
 origin assigned to it, although its cause was neither mis- 
 understood nor denied. 
 
 Thus BueP speaks of tlie somewhat frequent occurrence formerly of a 
 disease perfectly resembling lead-colic among tlie engine-room staif of 
 the steamshijis plying between Panama and California, remarking that 
 the illness was probably brongbt on by lead in the drinking-water; " the 
 condensed water from tbe boilers," says the report, " was at one time 
 extensively used for drinking and culinary purposes, and a part of the 
 jn'ocess was performed in lead pipes." Lcfevre^ communicates an in- 
 teresting account of an epidemic, with tbe symptoms characteristic of 
 lead-poisoning, on board an Italian merchant ship, in which the source 
 of the poisoning was most probably the lead contained in the glazing 
 of the utensils used for preparing the food. According to the account 
 of Pop/ there was not a single case of colique seche from 1853 to 1857 
 in the Dutch men-of-war on the East Indian Station, and only a few 
 cases in those stationed on the Surinam coast, and in adjoining West 
 
 ' In Vircliow's ' Ilandb. der spec. Pathol.,' ii, Abtli. i, 181. 
 
 " ' Amer. Journ. of Med. Sc.,' 1856, April, 324. 
 
 ^ ' Gaz. med. de Paris,' 1861, 776, 788, 802. 
 
 ■* 'Isederl. TijdscUr. voor Geuecsk.,' iii, 24, 213, 217.
 
 ENDEMIC COLIO. 273 
 
 Indies; bnt in iS66 the disease became epidemic in a sheamsliip of the 
 fleet on tlie naval station at Sumatra, and they did not succeed in making 
 out lead-poisoning to be the cause of the epidemic' 
 
 A remarkable contrast to this state of matters, as "well as 
 to that in the navies of England, Germany, and tlic United 
 States, in which lead-poisoning, so far as we know, has 
 never occnrred on a large scale, is afforded by the French 
 navy, in wliicli ''^ coliqne seclie " has played an important 
 part since the last forty-five years, or since the time when 
 steamships wore introduced, having gone on increasing in 
 proportion as these have displaced sailing ships in the 
 fleet. 
 
 The disease first began to occur moi'e frequently on board French 
 men-of-war, as we learn from the inquiries of Lefcvre,- subsequent to 
 the year 1840; and it was found over the whole of the West Afi-ican 
 station from St. Louis down to Cape St. Paul de Loando, on the 
 Indo-Chinese station (Madagascar, Reunion, and the Moluccas), and 
 on the South Sea station, its occurrence being somewhat later on 
 the West Indian station and on board the ships on the coast of Cayenne 
 and in the River Plate. 
 
 It is admitted on all hands that the colique seche is 
 absolutely the same in its phenomena as lead colic ; but in 
 
 ' Account in ' Arcli. de med. nav.,' 1867, Septbr., 169. 
 
 ' 'Recli. sur les causes de la colique scche, &c.,' Par., 1859 (^^^^ leading work). 
 The earlier accounts? are those of Dutroulau, ' Gaz. med. de Paris,' 1851, 278 ; 
 •Arch. gen. denied.,' 1855, Decbr., 1856, Jauv.; Ponssagrives, ib., 1852, Juni, 
 and ' De la nature et du traitement de la colique nerveuse, &c.,' Par., 1S57; 
 Marion, 'Nouv. Amial. inarifc.,' 1852, Aug.; Letersec, ' Observ. sur la colique 
 nervense, &c.,' Moutp., 1855; Petit, 'Consider, hyg. et med. sur la col. secbe. 
 Sec.,' Par., 185s; Rocbard, ' Union med.,' 1856, Nr. 4, 5; Desjardins, ' Gaz. des 
 hopit.,' 1856, Nr. 16; Lecoq., ib., Nr. 5; St. Pair, ib., 1857, 340; Berville, ib., 
 1858, 147; Peron, * Quelq. reflex, sur la colique secbe,' Par., 1858; Touze, 'Do 
 la colique seche des pays chauds,' Pur., 1858 ; Cbevallier, ' Anual. d'hyg.,' 1859, 
 xi, 95, 296. There are more recent accounts by Lefevre, ' Gaz. mod. de Paris,' 
 1861, 39, and 'Arch, de med. nav.,' 1864, Oct., 302, Nov., 385 ; Luzet, ' Sur les 
 causes et le traitem. de la c. s.,' Strasb., 1861; German, ' De la col. uerv. des 
 pays cbauds,' Par., 1862; Benoit de la Grandiere, ' Relat. med. d'uue traversee 
 de Cochincl<ne en France, &c.,' Par., 1862 ; Vidal, ' La colique seche a, la Guyanc 
 fran9., &c.,' Moutp., 1863; Lagarde, 'Arch, de med. nav.,' [864, Mars, 185; 
 Mondot, 'Etude sur la c. s., &c.,' Montp., 1864; Riehaud, 'Arch, de med. nav./ 
 1864, Mai, 3Sr ; Villette, ib., 1866, Fevr., 81, Mars, 178; FoUet, 'Etude sur la 
 c. s. vegtitale, &c.,' Montp., 1866 ; Morgaillau, 1. c; Dupre, ' De la c. s. des pays 
 chauds,' Par., 1866 ; Borcbard, ' De I'identite de la c. s. des pays chauds et de la 
 col. saturnine,' Par., 1866; Soboul, ' Consider, sur la c. s., &c.,' Moutp., 1S68 ; 
 Roumieu, ' De la c. s. observee en Cochinchiue, &c.,' Montp,, 1869; Maruata, 
 ' De la col. seche, &c.,' Par., 1880. 
 
 VOL. II. 18
 
 274 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 cases where there has been no obvious occasion of lead- 
 poisoning on board the vessels, or where the inquiries that 
 were made have yielded no results, many observers have 
 decidedly refused to admit the saturnine character of the 
 disease, and have either adopted Segond's view of a 
 neurosis of the sympathetic brought on by chill (Rochard, 
 Marion, Chabassu,^ Thil),^ or they have pronounced for a 
 miasmatic origin of the malady (Dutroulau),^ or even for its 
 malarial nature (Fonssagrives, Vidal, Coste,* Herve,^ Rou- 
 mieu). There is still another school who would admit that 
 many cases of the ship colic are indeed cases of lead colic, 
 but that there had been besides these a special kind of 
 colique seche depending on some one of the causes above 
 mentioned. (Thil, Follet, German, Mondot.) This chaos of 
 contradictory and quite untenable opinion has been reduced 
 to order by Lefevre, Director of Naval Sanitary Board at 
 Brest ; in his truly classical work, he has adduced evidence 
 that tlie " colique seche " of the French navy is nothing more 
 than lead colic, and he has had the satisfaction of seeing not 
 only old adherents of the miasmic theory like Dutroulau^ come 
 round to his side, but of gaining the unreserved adhesion of 
 the majority of the French naval surgeons of recent years 
 (Villette, Richaud, Benoit de la Grandiere, Corre, Mar- 
 gaillan, Borchard, Dupre, and others). The regulations 
 drawn up in consequence of this by the Ministry of Marine 
 for the steamships of the navy, warrant us in expecting that 
 the disease will become as rare in the French marine in 
 future years as it was previous to 1840. In the following 
 pages I have put together the facts which serve to explain 
 the exceptional frequency of lead colic in the French navy, 
 particularly in tropical waters and among certain classes of 
 the ships^ companies. 
 
 The chief stress has to be laid on the enormous amount 
 
 ^ ' Union med.,' 1863, Nr. 126, seq. 
 
 ^ ' Remarques sur les principales malad. a la Cochinchine,' Par., 1866, 29. 
 
 ^ " L'atmosphere inarine dcs cotes," he says (' Traite, 72), " seiuble efcre 
 le foyer d'emergence de sa cause, qui frappe de preference les equipages des 
 navires en mouillagc." 
 
 ^ ' Arcli. de nied. uav.,' 1867, Octbr., 299. 
 
 * ' Union nied.,' 1862, Nr. 43. 
 
 6 In the 2nd ed. of his ' Traite,' Par., 1868, 647.
 
 ENDEMIC cone. 275 
 
 of lead used in French men-qf-ivar with steam power, and upon 
 certain applications of it luhich afford quite special opportu- 
 nities for lead-poisoning . In the construction and equip- 
 ment of a French war-steamer of ninety gnns, there are 
 used, according to official returns, no fewer than 13,000 
 kilogrammes of regulation lead, partly in the form of pipes 
 (for conveying water), partly as receptacles, partly as plates 
 to protect the ship^s sides within, and partly as deck fasten- 
 ings, the superficial area of this mass of metal amounting to 
 upwards of 80 square metres (or about 100 square yards). 
 We have to add to that a large quantity of oxide of lead and 
 salts of lead for the making of putty and paint. But most 
 important of all we have the fact that, since 1840 or since 
 the time when the malady began to be more prevalent, the 
 distilling apparatus supplied to the ships has been so ill 
 designed as to have the distilled water (which is known to 
 have a strong affinity for lead) conveyed away in leaden 
 pipes. Another ready source of poisoning has been dis- 
 covered in the so-called " charniers," or large wooden tanks 
 for holding drinking-water, provided round their edges 
 with mouth-pieces communicating with siphon-tubes, through 
 which the sailors and others of the ship's company imbibe 
 the water. These mouth-pieces are mostly made of glass ; 
 but on many of the ships the tubes themselves are made of 
 lead, and that construction, which is open to suspicion in any 
 case, becomes all the more dangerous from the fact that the 
 water, whenever the ship comes into tropical latitudes, is 
 acidulated to make it more refreshing. Lastly, it should 
 not be omitted that the enamel of the drinking cups and 
 cooking utensils on board French men-of-war usually con- 
 tains lead ; and after long use they may easily give rise to 
 poisoning. The following facts given by Lefevre in an 
 open letter^ addressed to Dutroulau will serve to show how 
 cai-eless the French naval authorities have been in that 
 matter : 
 
 " Dans toutes nos possessions equatoriales I'industrie des 
 
 confiseurs, des patissiers, restaurateurs, marchands de vins 
 
 ou de comestibles, destillateurs et fabricants de sucre, 
 
 s'exerce en toute liberte, sans qu'on se preoccupe du choix 
 
 1 ' Gaz. hebdomad, de med.,' i860, p. 438.
 
 276 GEOGEArniCAL AND HISTORICAL PATHOLOGY. 
 
 des substances, qu'ils emploient, tin degre de purete des 
 etamages et de celni des alliages des vases d'etain destines 
 a contenir ou a mesurer les boissons. . . Nous possedous 
 assez de faits recueillis en France^ et particulierement en 
 Espagne, pi^ouvant I'alteration rapide de ces vernis plombi- 
 feres sous Taction des liqueurs et des aliments acides, pour 
 n'avoir ancun doute sur la part quails peuvont avoir dans la 
 production de ces coliques^ qui paraissent endemiques dans 
 certains pays oil elles ne se developpent liabituellemeut, 
 comme vous I'avez observe aux Antilles, que sous la forme 
 sporadique." 
 
 The greater frequency of the disease on hoard ships crtiising 
 in tropical luaters compared ^vitli those stationed in tempe- 
 rate latitudes is explained without the slightest difficulty by 
 the circumstance that a higher temperature is very materi- 
 ally conducive to the development of lead-poisoning. 
 Tanquerel has shown that, of 12 17 cases of lead colic, 454 
 occurred in summer (June — August), 309 in spring (March 
 — May), 251 in autumn (September — November), and 203 in 
 winter (December — February), giving a very considerable 
 preponderance in the warmer months. In complete agree- 
 ment with this is the fact that the maximum amount of the 
 disease in the above-named regions of the temperate zone 
 (France, England, Spain, and the United States) has always 
 fallen in summer ; perhaps also the fact that those emjsloyed 
 in kitchens and engine-rooms, and particularly firemen, have 
 been attacked with the colic vmusually often, so much so 
 that on board the American mail steamers it was known by 
 the name of ''fireman's colic." There is another circum- 
 stance besides, which may serve to explain the prevalence of 
 colic in that particular class of the ship's company — I mean 
 their having to remain constantly in confined and badly 
 ventilated places, where the atmosphere is charged with 
 particles of lead. 
 
 § 88. Eeview op Objections to the Doctrine of Lead 
 Colic on board Steamships. 
 
 To all these proofs, adduced both a priori and a posteriori^ 
 of the origin of " colique seche,"' the opponents of the
 
 ENDEMIC COLIC. 277 
 
 doctrine auswer by two arguments, wliicli require a few 
 words of notice. In the first place tliey say tliat the disease 
 does not occur at all on board the steamships of other 
 navies, such as the English, American, and German, or only 
 rarely as in the Dutch navy. This is easily explained, in 
 my opinion, by the fact that the naval sanitary authorities 
 of those countries have carefully avoided everything in the 
 construction, equipment, and provisioning of their men-of- 
 war, which might give rise to lead-poisoning among the 
 ci'ew ;^ whereas in the French navy there must have been 
 something wrong. And herein lies the great merit of 
 Lefevre in showing what that ''something" was, by means 
 of the exact inquiries already referred to. The second 
 objection is that in many cases of colique seche, it has not 
 been possible to make out any source of lead-poisoning ; 
 while, on the other hand, out of considei'able numbers who 
 were all equally exposed to the suspected influence of lead, 
 some have become ill of colique seche and others have 
 escaped. These facts must be admitted ; but in weighing 
 the second argument we should keep in mind that predis- 
 posing causes play a considerable part in the etiology of 
 lead colic, as of almost every disease. Not to mention the 
 peculiar predisposition residing in the physiological circum- 
 stances of the individual and hardly capable of exact 
 definition, which confers a relative immunity from the action 
 of certain poisons or makes a peculiar liability to the same, 
 it has been shown by Tanquerel, Galtier,^ Chevalier,^ Levy,* 
 and others, that the abuse of spirituous liquors predisposes in 
 
 ^ The distilling apparatus in the French navy is mostly made of tin-plate, 
 which is well known to contain lead. From the experiences gathered in the 
 Prussian navy in this matter, I am able to give the following facts : — A few years 
 ago the distilled water from a distilling apparatus which had been made at the 
 Dantzic dockyard out of tin as an experiment, was examined, and found to con- 
 taiu a large amount of lead. After it had been in use for some time, the lead 
 disappeared from the water, and it was thereupon found that the interior of the 
 apparatus was coated with a greyish substance easily rubbed off, which was un- 
 doubtedly a deposit of lime, gypsum, &c., from the water itself. What had 
 happened was that the lead on the surface of the tin had been dissolved out by 
 the hot water, while the coating, although an uncertain protective, had enabled 
 •the metal to withstand the action of the water subsequently. 
 
 ^ 'Traite de Toxocologie,' Par., 1845, '» ^59- 
 
 ^ 'Annal. d'hyg.,' 1852, Oct., xlviii, 331. 
 
 ■» 'Traite d'hyg. publ.,' ed. ii, Par., 1857, ii, 906.
 
 278 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 an especial way to lead-poisoning ; and herein we must seek 
 to explain tlie fact tLat just as the officers and midshipmen 
 on board ship are much more rarely attacked than the 
 sailors, so, when lead colic is epidemic or endemic on shore, 
 the women and children are much less liable to it than the 
 men. As regards the first argument, relating to the un- 
 explained cases of coliquo seche, we are quite justified in 
 doubting whether the search after the sources of lead- 
 poisoning had been conducted with the necessary circum- 
 spection and care ; " if one is not discouraged,^^ says 
 Borchard, *'by the fruitlessness of a first search, one always 
 ends by finding the toxic metal." 
 
 The much greater frequency of severe cases of colic, 
 especially of colica stercoracea, in the tropics than in tempe- 
 rate latitudes, is explained by the disordered digestion that 
 is so easily brought on in the formei-, particularly in 
 strangers, and by the lesions of the stomach and intestine 
 resulting therefrom. The so-called " colique seche," or, in 
 other words, the disease with symptoms of lead colic, is 
 actually nothing else than a lead colic, and we must 
 accordingly express agreement with Le E,oy de Mericourt 
 when he says :^ 
 
 " II n'y a pas lieu d'admettre dans le cadre nosologique, 
 en dehors des manifestations variees et successives de 
 rintoxication saturnine uue maladie endemique des pays 
 chauds, donnant lieu aux memos symptomes se succedaut 
 dans la meme maniere, qui reconnaiti'ait pour cause une 
 intoxication miasmatique, tellurique ou autres. La colique 
 endemique des pays chauds n'existe pas." 
 
 ^ ' Bull, dc I'Acad. de med. de Paris,' 1876, ii, ser. v, 460.
 
 CHAPTER IX. 
 ANIMAL PARASITES. 
 
 § 8g. The term "parasitic disease" includes all those 
 forms of sickness in which the morbific cause is the 
 residence, permanent or temporary, of living organisms 
 within or upon the human body ; or, to express it otherwise, 
 in which the disorder of health is brought about by animal 
 or vegetable organisms that take up their abode for a time 
 or for the whole of their existence in man's body and find 
 their sustenance there, either preying upon it partly by way of 
 abstracting matters from the tissues of their host which 
 they appropriate to their own uses, partly by acting as 
 mechanical irritants, or inducing disease sometimes by 
 elaborating from materials within their reach, or by ex- 
 creting from their own bodies certain chemical products 
 which exert an injurious or toxic influence on the human 
 organism within or upon which they reside. Of recent years 
 few departments of medicine have grown so much as that 
 of parasitology. Starting from the modest beginnings of 
 the intestinal Helminthinje and a few worms and insects 
 inhabiting the surface of the body, it has in course of time 
 annexed the gi'oup of epiphytes and entophytes as well as a 
 large number of parasites belongiug to the lower orders of 
 the animal kingdom which inhabit the internal organs. 
 But there has also arisen, in the course of studying the 
 infective diseases, a pi-ospect of adding to this department 
 of pathology to an extent that cannot yet be estimated, in 
 adducing evidence that those diseases are of a parasitic nature, 
 or that there occur in them organisms of the lowest rank of 
 organic development — the micrococci and bacilli, so named 
 from their form. The results hitherto arrived at concerning the 
 part played by these parasites in the acute and chronic infec-
 
 280 GEOGGAPHICAL AND HISTOEICAL PATHOLOGY'. 
 
 tions have either been given already, or remain to be given, in 
 treating of eacli of the diseases in its proper place. In the 
 following chapters my purpose is mei-ely to deal with those 
 diseases where the parasitism consists in the presence of 
 more highly organised animal or vegetable forms within 
 particular organs or parts ; and which possess further a special 
 interest for geographical pathology, owing to their wide 
 diffusion over the globe or to their endemicity at particular 
 spots. 
 
 We may take it to be a general truth that parasitism is 
 much more developed, whether we estimate it by the number 
 of the forms under which it occurs or by the frequenc}'' of 
 each individual form, in lower latitudes, that is to say, in 
 tropical and sub- tropical countries, than in the temperate 
 and cold zones. 
 
 " Les vers," says Sigaud,^ " occupent une grande place dans la patlio- 
 logie intevtropicale." Speaking of the frequency of Entlielmintba) in 
 the Nile countries, Pruner^ says : " One seldom opens a cadaver in 
 Egpyt without finding specimens of one or more species." Waring^ 
 says : " No medical officer can have had charge even for a short time of 
 any of the large civil dispensaries in any part of India, without having 
 been struck with the large proportion of ' worm cases ' which come 
 under his observation ;" and the reports from the West Coast of Africa,'' 
 Guiana,^ and the West Indies'' are to the same effect. What is here said 
 of the Enthelmintha; in particular a^jplies still more to the other para- 
 sites, the larger number of which are indigenous to the tropics. 
 
 The explanation of this is partly, no doubt, the influence 
 which climate exerts on the variety and luxuriance of every 
 kind of growth ; partly also the circumstances and habits of 
 living which, as we shall see in speaking of the several forms 
 of disease, are peculiarly favorable to the introduction of 
 parasites into the human body. It is these habits that serve 
 to explain the differences in the amount of parasitic disease 
 among various races and nationalities as well as among* 
 different classes of human society. 
 
 ^ 'Du climat et des maladies du Bresil,' Par., 1844, 425. 
 - 'Die Krankh. dcs Orients.,' Erlang., 1846, 244. 
 2 'Indian Annals of Med. Sc.,' 1859, July, 371. 
 
 ■» Boyle, 'Med. Account of the Western Coast of Africa,' Loud., i8;,i, 402. 
 ^ Rodschied, 'Med. Bemerk. iiber . . . Rio Esscquebo,' Frankf., 1796, 290. 
 6 Levaclier, 'Guide nied. des Antilles,' Par., 1840, 193; Thomson, ' Edinb. 
 Med. and Surg. Jouru.,' 1822, Jan., 43.
 
 TAPEWORM. 281 
 
 I. Cestodes. 
 
 § go. Tj^nia Mediocanellata. 
 
 Among tlie parasites tliat have been longest known and are 
 most widely distribnted belong those of the tapeworm class — 
 Tscnia mediocanellata {T. saginata) and Tseiiia solium ; next 
 to these we have to consider Boihriocephalus and Echino- 
 ■coccus (the larva of Tsenia ccldnococcus whose host is 
 the dog). 
 
 Tcenia mcdiocancUata has its greatest area of distribution 
 in Abyssinia, where, according to the unanimous opinion of 
 observers/ only a few of the natives are exempt from it_, and 
 strangers also soon become infested by it unless they are 
 especially careful about their food and in particular avoid 
 the favourite diet of raw meat. " Men and women^ all and 
 sundry, in this country/' says Courbon, " have the entozoon ; 
 and they take some kousso regularly every two months to 
 prevent the more serious derangements which it might 
 ■cause." In Egypt and Nulla also, it is mostly Tasnia 
 mediocanellata that is met with / and the same is true of the 
 extensive territory, mostly occupied by a Mohammedan 
 population, which extends fi'om the northern coast of Africa 
 (including AlgicrtJ^) , to Senegamhia,'*' and the western 
 Soudan,^ and, on the other side, to Syria^ and ArahiaJ 
 
 1 Aubert-Rochc, 'Annal. cVliyg.,' xxxv, 5; llodgkin, 'Med. Times/ 1844, 
 2^0. 266; Pruuer, 1. c. ; Schiiupor, ' Guz. mcd. de Strasb.,' 1848, Nr. 4; Bilhari!, 
 'Zcitscbr. fur wissenscbaftl. Zoologie,' 1850, iv, 35; Courbon, ' Observ. topogr. et 
 iiied. . . . sur le littoral de la mer rouge,' Par., 1861, 35 ; Currie, 'Brit. Army 
 Reports' for tbe year 1867, ix, 296; Blaue, ' Gaz. bebd. de med.,' 1874, Nr. 22, 
 345 ; Rochard, ' Bull, de I'Acad. de med.,' 1S77, 998. 
 
 - Pruner, BiUiarz, 11. cc. ; Vauvray, ' Arcb. de mcd. uav.,' 1S73, Sept., 161 
 Tutscbeck, 'Oest. med. Wocbenscbr.,' 1846, 1209. 
 
 3 Boudiu, 'Mem. de med. milit.,' 1848, Ixv, 204; Reuard, ib., 1873, Oct., 545 
 Vidal, 'Gaz. med. de Paris,' 1874, Nr. 22, 23; Cauvet, ib., Nr. ^3 i Araould, ib. , 
 .425 ; Henne, 'Mem. dc med. milit.,' 1876, Mai, 238 ; Rochard, 1. c. 
 
 •• Tbaly, ' Arcb. de med. nav., 1867, Sept., 187 ; Leonard, ' Observ. rec. au poste 
 de Sed' Hiou, &c.,' Par., 1869, 62; Corre, ' Bull. gen. de tberap.,' 1877, Fevr., 
 170; Hebert, ' Une annee med. a Dagana,' Par., 18S0, 41 ; Borius, 'Arcb. de 
 aned. nav.,' 1881, Mai, 372. 
 
 * Quintin, ' Extrait d'uu voyage dans le Soudan,' Par., 1869, 49. 
 
 ® Pruner, 1. c. ; Robertson, 'Edinb. Med. and Surg. Journ.,' 1843, April, 247; 
 Guys, ' Statistiquo du Pascbalik d'Alep,' Mai'scille, 1853, 63 ; Rocbard, 1. c. 
 
 ^ Pruner, Courboti, 11. cc.
 
 282 GEOGIIAPHICAL AND HISTOKIOAL TATHOLOGY. 
 
 Of the frequency of the parasite in Algiers we are suffi- 
 ciently assured in the account by Bondin ; during the years 
 1840 — 48 sixty-eight cases of it occurred in an average 
 strength of 1 00^000 men, whei^eas among 250,000 (average) 
 m.en in France during the same period there were onlj^ seven 
 cases, so that the parasite was twenty-three times commoner 
 in Algiers than in the mother country. Subsequent observers 
 (referred to below in the paragraph relating to France) have 
 called attention to the increasing frequency of Ta3uia medio- 
 canellata in the latter since Algerian cattle began to be im- 
 ported. With reference to Senegavihia, Leonard has expressed 
 his astonishment that taenia should be so remarkably common. 
 there, inasmuch as the natives, being Mohammedans, eat no 
 flesb of swine ; but this mystery lias been cleared up by 
 Corre, who points out that raw beef is a favorite article of 
 diet with them, and that the tapeworm is not Taenia solium 
 but T. mediocauellata. It would appear from the statements 
 of Quintin that the circumstances are the same in the Soudan^ 
 where pork is never used, but where beef dried in the sun 
 serves as the food of the negro population. The cliief seats of 
 tlio parasite in Syria, according to Pruner and Guys, are the 
 mountainous regions, and the vicinity of Aleppo ; and in 
 Arabia, according to Pruner, the plateau of Assir. In 
 Jeddah, on the Arabian shore of the Hed Sea, it is said by 
 Courbon to be of rare occurrence. 
 
 A notice by Berenger-Feraud^ throws light on its preva- 
 lence in Senegambia; among 159 patients admitted for 
 tapeworm into the naval hospitals of Toulon and Cher- 
 bourg, the only worm found was Taenia inermis, and of 
 the whole number 102 had acquired the parasite in Sene- 
 gambia. The accounts from various parts of the Went Coast 
 of Africa^ all bear witness to the very frequent occurrence of 
 the tapeworm disease there, and although the species of the 
 parasite is not stated with precision, there can be no doubt 
 that it is mostly Ttenia mediocauellata. This conjecture is 
 made all the more probable by the fact that the same species 
 of tosnia occurs in South Africa (particularly tJte Cape'') ; so 
 
 1 ' Bull, gen. de tla'rap.,' 1882, 15 Aug., 97. 
 
 ^ Boyle, 1. c; Danicll, ' Sketches of the Med. Topogr. . . of the Gulf of Guiuca, 
 Lend., 1849, 53 J Moreira, ' Jornal das sc. mod. de Lisboa,' xv, 121. 
 
 3 Hodgliin, I.e.; Black, 'Ediub. Med. and Surg. Journ.,' 1853, April, 262;
 
 TAPEWORM. 283 
 
 tLat tlie African continent would appear to be its habitat in 
 general. The occurrence of tapeworms among Hottentots 
 who had served in the war in Caffirland is mentioned by 
 Scherzer ; and it would appear that not Tienia solium but 
 T. mediocanellata is meant here, from the fact that the tribes 
 in question avoid the flesh of the pig while they esteem raw 
 beef as a delicacy. 
 
 For India, the available data^ seem to sliow that tapeworm 
 is indigenous principally in certain provinces of Upper India 
 belonging to the Bombay Presidency and the N. W. 
 Provinces, especially in the Deccan and the Punjaub, and to a 
 less extent in Lower Bengal, Madras, and the sovithcrn 
 districts ; but in that country the Hindu race, as we shall see 
 presently, enjoys an almost complete immunity fi-om the 
 parasite, and it is practically the European residents and 
 the flesli-cating Mohammedans who suffer from it. So far 
 as concerns the Mohammedan population we are justified in 
 concluding that it is the Taenia mediocanellata which is found 
 among them ; and the same would appear to bo tlie case for 
 the most part with the Europeans living in India, and partic- 
 ularly for the British troojDs in the Punjaub, among whom 
 tapeworm has been very often observed of late. The use of 
 uncooked flesh, including even beef, by the troops in India 
 had already been indicated by Hoile as the cause of the 
 tapeworm so often found among them. In a more recent 
 paper" attention is drawn to the increase of the disease 
 especially in the Bombay Presidency and in the Punjaub ; 
 and in a subsequent notice relating to the same fact it is 
 stated that " the prevalence of tapeworm in the regiments 
 in the Punjaub has been recently shown to depend upon the 
 consumption of beef infected with the Taenia mediocanellata." 
 The statement of Bernard,* that Tienia solium occurs in 
 
 Scherzer, ' Zcitscbr. der Wiener Aerzte, 1858, 152; Adunis, ' Mccl. Times aucl 
 Gaz.,' 1859, Dee., 549. 
 
 ' Audcrson, ' Ind. Annals of Med. Sc.,' 1852, Oct., 87 ; Hoile, ib., 1857, April, 
 457; Gordon, 'Med. Times and G:iz.,' iHc,(>, Nov., 5r2; 1857, May, 429 ; Adams, 
 1. c. ; Chipperfield, ' Madras Quart. Journ. of Med. Sc.,' 1861, Jan., 78; Waring, 
 1. e. 
 
 ^ 'Med. Times and Gaz.,' 1867, Nov., 57.-;. 
 
 ^ 'Lancet,' 1868, Jan., 59. 
 
 ^ • De I'influeuce du climat de la Cochincl.ine, &c.,' Moutpell., 1867, 50.
 
 284 GEOGEAPHIOAL AND HISTORICAL PATHOLOGY. 
 
 China and Cochin China in consequence of the use of measly- 
 pork^ is confirmed by Beaufils ;^ but the latter agrees with 
 Rochard that Taania mediocanellata is much the more common 
 form." The same is true also of Japan? and other parts of 
 Northern Asia, as well as of the Mongolian race of Bar jutes 
 inhabiting the country around Lalce Baikal} 
 
 Of the somewhat frequent occurrence of Taenia medio- 
 canellata in Europe,^ we have evidence from North Germany^ 
 {East Prussia, Berlin,^ Leipzig, according to Wagner, and a 
 few districts of Tlmringia^), as well as from Wiirtemberg ^ 
 and Vienna. Tn Copenhagen, T. mediocanellata, as com- 
 pared with T. solium, has become a good deal more common 
 of recent years (whereof more in the sequel) ; so that while 
 the proportion of the former to the latter was 53 to 37 down 
 to 1869, it came to be in the ratio of 66 to 19 in the years 
 from 1869 to 1880.^° In England, where attention was 
 long since drawn to the numerous cases of tasnia among 
 fleshers who were known as " beef eaters " jiar excellence, 
 we learn from Welch ^^ that T. mediocanellata is very com- 
 mon. So it is also in the Netherlands, while in BelgimnP 
 ihe Taenia solium is distributed about equally with it. In 
 ■Switzerland ^^ T. mediocanellata appears to be a good deal 
 more prevalent than T. solium; of 199 patients with ta3nia, 
 
 ' 'Arch, de mcd. iiav.,' 1882, Avril, 265. 
 
 - Berenger-Feraud (1. c.) found nothing but Ta3nia iuermis amcng 44 patients 
 invalided home from Cochin China with tapeworm, who were admitted into the 
 naval hosijitals of Toulon and Cherbourg. 
 
 ^ Wernich, ' Deutsche mod. Wochenschr.,' 1878, Nr. 6; Leuckart, ' Parasiteu,' 
 2 Aufl., i, 605, on the authority of Prof. Billz. 
 
 ■• Kaschin, ' Petcrsb. med. Zeitschr.,' 1861, Dec. Almost the whole of a division 
 (500), composed of Barjutes, and quartered in Irkutsk, suffered from ta-nia. lu 
 iSo of them, who died of other diseases and were examined post mortem, he 
 failed to find tapeworms only twice. 
 
 * Compare Knoch, ' Berl. klin. Wochenschr.,' 1864, Nr. 30 ff. 
 
 * Virchow's ' Archiv fiir pathol. Auat.,' 1857, xi, 80. 
 '■ llobinski, 'Berl. klin. Wochenschr.,' 1874, Nr. 37. 
 
 8 V. Conta, 'Zeitschr. fiir Epidermiol.,' 1871, Nr. 10, 11. Among 18 patients 
 with tapeworm at Jena, Gerhardt found T. mediocanellata in 15 and T. solium 
 •in 3. 
 
 '•* Weishaar, Knoch, 1. c. 
 
 '" Krabbe, ' Ugeskr. for Lacger,' 1869, xxlii, Nr. 8 and 18S0, N. R., xii, Nr. 23. 
 
 " 'Journ. of Microscop. Science,' 1875, Jan. 
 
 ^'^ Knoch, 1. c. 
 
 ^•* Zaeslein, ' Correspondenzbl. fiir Schweizer Aerzte,' 1881, Nr. 21.
 
 TAPEWOKM. 285 
 
 1 80 liad T. mediocanellata and only ig T. solium. Indeed, 
 tlie former species seems to have been found in recent times 
 much more often than it used to be ; and in France also, a 
 considerable increase in the cases of T. mediocanellata has 
 been noted of late,^ of which fact an explanation will be 
 given in the sequel. For Italy I find only two notices 
 relating to the question — by Grasse ^ and Marchi ; according 
 to these 16 out of 19 cases in Milan were T. mediocanellata, 
 while in Florence the proportion, of that species to T. solium 
 was 34 to I. 
 
 In the medico-topographical accounts from the Western 
 Hemisphere, there are on the whole very few references tO' 
 the occurrence of tapeworm, and most of them either relate to 
 T. solium or leave the species undetermined. In Mante- 
 gazza's ^ account of the truly endemic prevalence of tape- 
 worm in the Argentine Meiniblic, and especially in Entrc 
 Rios, we read that an explanation should be looked for in 
 the gi-eat liking of the people for partially cooked beef, — 
 the beef -steaks a la Tartare ; so that we may fairly take the 
 parasite in that case to be T. mediocanellata. 
 
 § gi. TiENiA Solium. 
 
 The area of distribution of Tsenia solium extends in like 
 manner over the greater part of the globe, or wherever 
 swine's flesh is used. But that species has been met with 
 much more rarely than T. mediocanellata, particularly of 
 recent times. Moreover many of the earlier notices of T. 
 solium are based upon errors of diagnosis * and relate in 
 reality to the other species. 
 
 1 Vidal, Eochard, 11. cc. ; Decroix, 'Abeille Med.,' 1876, Juin ; Bercnger- 
 Feraud, 1. c. 
 
 2 ' Gaz. med. Lombard.,' 1879, No. 12. 
 
 3 « Lettre med. sulla America meridionale,' Milano, i860, i, 100, 160. 
 
 * The derivation of the adjective " solium," which occurs first in the medical 
 writers of the middle ages, remains a question. At all events, it has nothing to 
 do either with solium, "the throne," and still less with solus, "alone." Professor 
 Krehl, the Orientalist, conjectures (as wo learn from Leuckart, 'Parasiten,' 
 2nd ed., i, 519) that it is a corruption of the Syriac word "schuschl e," meaning 
 " chains " (as in tape-worm or chain-worm), and that from it had come the Arabic 
 word " susl " or " sosl," well known to the media;val physicians. It was the mis-
 
 286 GEOGRAPHICAL AND HISTOTIICAL PATHOLOGY. 
 
 The widest prevalence of T, armata occurs in tlie interior 
 governments of Russia, sucli as Moscow/ as well as in East 
 Prussia, some parts "of Thuringia,^ of Belgium^ and of 
 Sivitzcrland,^ in Roiinnania^ and in TiirJcey (but only to a 
 small extent and naturally only among those of the popula- 
 tion who do not belong to the strictest of Moslems),^ In the 
 Western Hemisphere, it occurs in Newfoundland where 
 Oras ^ assigns the cause of it especially to the use of pork ; 
 it is found also in Mexico, where, as we learn from Seme- 
 leder,^ pork is one of the chief articles of food. It is 
 impossible to make out which of the species of taenia it is 
 that occurs so often in Brazil, especially among the negroes, 
 Sigaud's '"* account making mention of it merely as " ver 
 ^' solitaire." 
 
 Lastly, I shall mention a few regions which have a very 
 remarkable immunity from tapeworm of wliatever species. 
 Among them is Iceland, where, as Finsen ^^ tells us, there is 
 a dislike of pork among the inhabitants, and where flesh of 
 any kind plays a very subordinate part among the articles of 
 food. Another of these regions is Greenland (particularly 
 South Greenland), where tapeworm does not occur at all, so 
 far as Lange's '^ information goes. In Guatemala, according 
 to Bernoulli, ^^ tapeworm is of rare occurrence ; and in 
 
 taken idea of solium being derived from "solus," and of its denoting the occa- 
 sional occurrence of a single parasite in an individual's intestine, that unquestion- 
 ably led to errors of diagnosis, whicli were all the more likely to occur for the 
 reason that practitioners were not generally acquainted with T. saginata until 
 ■quite recent times. In those cases where only one pai-asite was found in an 
 individual, it was thought necessary to assign it to the species of T, armata. 
 Leuekart points out, as Davaine had done befoi'e him, that it is really T. medio- 
 «anellata which seldom occurs in more than a single specimen in a person's 
 intestine, whilst T. solium is mostly found in numbers. 
 
 ' Knoch. 2 y_ Conta, 1. c. •"* Knoch, 1. c. •• Zaeslcin, 1. c. 
 
 ° Leconte, 'Consider, sur la pathol. des provinces du Bas-Danube,' Montp., 
 1869, p. 49. He is explicit in saying that he bad not seen a single case of illness 
 from tapeworm among the numerous Moslems and Jews in Roumania; pork 
 being cheap, the consumption of it was extensive. 
 
 •^ Rigler, ' Die Turkei und deren Bewohner, &c.,' Wien, 1852, ii, 209. 
 
 " 'Qnelques mots sur Miquelon,' Montp., 1867. 
 
 ^ 'Wien. med. Pressc,' 1873, Nr. 34, 
 
 « L. c, 133, 425. 
 
 '" ' Jagttagelser angaaende sygdomsforholdene i Island,' Kjobenh., 1874, 108. 
 " 'Bemaerkn. om Gronlands Sygdorasforhold.,' Kjobenh., 1864, 43. 
 " 'Schweiz. med. Zeitschr.,' 1862, iii, 100.
 
 TAPEWORlt. 287 
 
 Martinique it did not lia^open to Rufz,^ during a practice of 
 many years among ci-eoles and whites, to see a single case of 
 teenia. 
 
 § 92. Distribution op T. Mediocanellata and T. Solium 
 
 COREESrONDS WITH A PorULAR DiET OP BeEP AND PoRK 
 RESPECTIVELY. 
 
 The peculiarities in the geographical distribution of the 
 two species of trenia, the greater frequency of the parasites 
 in one region than another, the differences in their occurrence 
 among the various races and nationalities, the increase or 
 decrease of one or other species from time to time in one 
 and the same place, — all these things are explained without 
 difficulty when we take account of the well-established fact 
 that Ta3nia mediocanellata develops from the cysticercus that 
 occurs in cattle, and Taenia solium from a larva infesting 
 the pig, the occurrence of the one species or the other in 
 man depending accordingly upon the access of the embryos 
 of one bladder-worm or the other to the human intestine. 
 
 The somewhat rare occurrence of T. armata compared 
 with T. saginata in Asia and Africa depends essentially on 
 the fact that the use of pork is much restricted, either on 
 religious grounds, as among orthodox Mohammedans, or from 
 prejudice against it, as in Abyssinia and among the natives 
 of South Africa (as well as in Iceland) ; and that it is mostly 
 among the European residents that it obtains. Again, the 
 immunity enjoyed by particular races, such as the Egyptians, 
 the Hindus, the Malays and others, is a consequence of their 
 almost exclusive vegetable diet, an infection by cysticercus 
 being a rare occurrence. 
 
 In India, says Cliipperfield, tapeworm is, on the whole, rare among 
 nationalities other than the European. Waring's opinion, though less 
 ahsoluto, is to the same effect: "Tapeworm is confined almost exclusive]y 
 to the flesli-eating Mussulman or the omnivorous European soldier." 
 In Travancore, a purely Hindu State, he had not seen a single case of 
 taenia during a six years' residence. Dr. Sperschneider, who served 
 eight years as surgeon to the Nair hrigade (a division of 1800 men 
 composed entirely of pure-caste Nairs or Sudras), had likewise seen no 
 case of taj)eworm ; and the official returns from the Travancore Circar 
 ' 'Arch, (le med. iiav.,' 18C9, Juin, 440.
 
 288 GEOGRAPHICAL AND HISTORTCAL PATHOLOGY. 
 
 during twenty yeai's are to tlie same effect. Of 95 cases o£ taenia which 
 Anderson olDserved in Upper India, 86 occurred in European soldiers, 
 8 in Moslems, and a single case in a Hindu, belonging to one of the 
 lower castes Avhich did not i-estrict itself to a purely vegetable diet. 
 Huilley also states that in Pondicherry he had seen tapeworms only in 
 Europeans. 
 
 We liave already adverted more tlian once to the fact 
 that the tapeworm parasites, and for obvious reasons T. 
 raediocanellata in particular, are especially frequent in those 
 countries where flesh in the raw or half-cooked state is a 
 favourite article of food. In this connexion we may note 
 the fact brought forward by the French observers above 
 mentioned, that Tasnia mediocanellata has become consider- 
 ably more common in France since the abundant importation 
 of beef from Algiers and the use of the same in the raw state 
 as an easily digested and strengthening article of food for 
 patients and convalescents. In like manner Krabbe for 
 Denmark and Zaeslein for Switzerland assign the increased 
 number of cases of tapeworm to the same cause. Lastly, 
 we have to remark that several recent observers (Krabbe, 
 Kiichenmeister,^ and others) have ascertained that there 
 has been a considerable decrease of T, solium dating from 
 the time when the general outbreak of trichinosis in man 
 either led to a restricted use of uncooked pork on account 
 of the danger of infection from it, or brought protection 
 to the public against measly pork through the system of 
 inspection. 
 
 § 93. BoTnEiocErnALus Latus. 
 
 The distribution area of Bothrioccphalus latus is very much 
 smaller than that of T. saginata and T. solium. It appears, 
 indeed, so far as we are warranted in concluding from the 
 facts before us, to be confined practically to a few spots in 
 Europe, such as the coast-regions of Sweden and Finland, 
 the Baltic provinces of Eussia, including St. Petersburg, 
 a few districts in the east of Eussia, and the v>-estern can- 
 tons of Switzerland with the adjoining departments of France. 
 
 1 'Arch, de metl. nav.,' 1868, Few., p. 87. 
 
 ' ' Die Parasiten des Menscben,' 2 Aufl., Leipz., p. 94.
 
 TAPEWORM. 289 
 
 In Sweden it is truly endemic on the coast oE the Gulf of 
 Bothnia^ in Norrbotteu, Westerbotten, Westernorrland and 
 Oefleborg-Ljin ;^ it is rarer on the Baltic coast, but it has 
 been seen in Blekiugs-Liin.^ The district most affected is 
 Norrbotten-Lan, where the number of those suffering from 
 the parasite is estimated at half the population ; in Haparanda 
 there is said to be hardly a household in which one or more 
 persons are not the subjects of it. In Finland^ also, the 
 bothriocephalus occurs mostly on the coast of the Gulf of 
 Bothnia. Of its prevalence in the Baltic provinces, we have 
 information from Moritz/ Erdmann/ Knocli,*^ (who also men- 
 tions it as occurring in the eastern parts of Russia) , Bottcher'^ 
 and Braun.^ In St. Petersburg according to an estimate by 
 Attenhofer^ in 1817, about 15 per cent, of the popula- 
 tion suffered from it. In Stvitzerland, according to the very 
 ■careful inquiries of Zaeslein (1. c.) bothriocephalus is endemic 
 (and remarkably common) only on the shores of the lakes 
 of Bienne, Morat, Neuchatel, and Geneva ; in these localities, 
 according to Zaeslein, the parasite occurs with a frequency 
 that can only be compared to the general prevalence of T. 
 saginata in Abyssinia ; whereas only occasional cases of 
 bothriocephalus are met with on the shores of all the other 
 Swiss lakes. 
 
 In Poland (according to Knoch), in East Prussia and 
 ■on the Pomeranian coast, in Denmark,^^ in Holland and 
 Pelgimn,^^ and about the Italian Lakes (Knoch) we find this 
 parasite in considerable frequency, though much more rarely 
 than in the countries before mentioned. Finally, bothrio- 
 
 ^ Huss, ' Om Sverges cndem. sjukclomar.,' Stockli., 1852, 2 j Berg, ' Bidrag til 
 Sveriges med. Topogr. och 8tatistik.,' ib., 1853, 10, 16, 23, 36, 184; Wistraud, 
 'Ufversigt af helso-ocli sjukvardun i Svcrige 1851-60/ Stockli., 1863, 5. 
 
 - ' Medicinal-Beiattelse lor ar 1866/ 22. 
 
 ^ Wistrand. 
 
 •* "Spec, topogr. med. Dorpatensis,' Dorpat, 1823. 
 
 '' ' Drcsdener Zeitschr. fiir Natur- uud lleilkde.,' 1827, v, 160. 
 
 « ' Berliner klin. Wocliensclir.,' 1864, Nr. 30 ff. 
 
 7 In ' Virchow's Arcli.,' 1864, Bd. 30, 97. 
 
 ^ lb., 1882, Bd. 88, 119, and ' Petcrsb. med. Wochcuschi-.,' 1882, Nr. 16. 
 
 'J 'Med. Topogr. der Hauptstadt St. Petcrsb.,' Ziirich, 181 7, 226. 
 
 •" Krabbe, 11. cc. 
 
 " Boiidin, 'Geogr. ct statist, mi'd.,' i, 337; de Muttos and Israel, ' N. Arch. 
 voor Geueesk.,' ill, 26; Kuotli, 1. c. 
 
 VOL. 11. 19
 
 290 GEOGRAPniCAL AND HISTORICAL PATHOLOGY. 
 
 ceplialus occurs in more casual cases at various points of 
 North and South Germany — -at Hamburg and Berlin, in 
 South Bavaria,^ at Heilbronn/ Ulm/ Biberacli/ and other 
 towns of WLirtemberg,^ — as well as in Brittany^ and Ireland.^ 
 In tbe regions beyond Europe, it would appear to be very 
 rare, or at all events tliere are no sufficiently trustworthy 
 records of it. According to a statement of Balfour's/ 
 bothriocephalus frequently occurs in cbildren sent home from 
 Ceylon to England, and Pop^ speaks of it being found 
 among the crews of ships-of-war on the Dutch East Indian 
 station. The accounts^ of bothriocephalus in South Africa 
 rest most probably on errors of diagnosis, the more likely 
 species being Teenia lata (or saginata). The description^^ of 
 a case of the bothriocephalus in an English officer in 
 Canada is more trustworthy ; and we may credit also 
 Semeleder's^^ statement that the same species occurs along" 
 with Taenia solium in Mexico. 
 
 § 94. Bothriocephalus associated with the Shoees oe 
 
 Seas or Lakes. 
 
 A glance at the distribution-area of bothriocephalus will 
 show us that it is mostly indigenous to the sea-coast and to the 
 shores of laTces and other inland waters. The Swedish 
 practitioners are clear in their statements that it is almost 
 exclusively the inhabitants of the coast who suffer from it,. 
 those dwelling even a few miles inland being nearly exempt. 
 Zaeslein, also, has shown with much exactness that the same 
 holds good for Switzerland. In that country he distinguishes^ 
 
 * Bollinger, ' Bayr. iirztl. Intelligenzblatt,' 1879, Nr, 15, 155. 
 ' Betz, ' Wiirttemb. iiied. Correspondenzbl./ 1850, xxx, 262. 
 3 Majer, ib,, vi, 192. 
 
 ■• Hofer, ib., viii, 308. 
 
 * Boueix, ' Journ. de med.,' Ixxv, 415. 
 
 ^ Fra/.er, ' Dubl. Quart. Jouru.,' 1868, Nov., 324. 
 
 ^ In Boudin, L c. 
 
 ^ 'Nederl. Tijdschr. voor Geneesk.,' 1859, ^''' -^• 
 
 ' Scberzor, Fritsch, 11. cc. 
 
 *" Beared, ' Brit. Med. Journ.,' 1874, Miiy, 649. 
 
 " *Wien. med. rre5SP,' 1873, No. 34.
 
 TAPEWOEM. 291 
 
 four zones of frequency. The first of these^ embracing the 
 villages lying close down to the lakes, is to bo regarded as 
 the proper area of infection. In the second, comprising the 
 country one to four leagues inland from the lakes, the para- 
 site is much rarer ; it no longer occurs, as in the first zone, 
 among all classes equally, but more frequently among the 
 industrial part of the population, and less so among the 
 agricultural, the inhabitants of that zone becoming infected 
 for the most part not at home but during their visits to the 
 lake shore. As regards the third zone, comprising the towns, 
 large and small, at a distance of more than five leagues 
 from a lake, the infection may in most cases be traced 
 with certainty, or at least with probability, to the French 
 Alpine departments, although there are a few places such as 
 Burgdorf and Thun for which the autochthonous occurrence 
 of the parasite cannot be altogether denied. Finally, in the 
 fourth zone, distant from the lakes more than six leagues, 
 bothriocephalus is met with either in mere occasional cases, 
 or not at all. 
 
 This narrow delimitation of the area of bothriocephalus to 
 sea-coasts and the shores of lakes and rivers has given rise 
 to the suggestion that its occurrence is closely connected 
 with Q: fish diet; but it is only lately that the inquiries of 
 Braun have furnished definite evidence on the general 
 question as well as on the mode of invasion of the parasite. 
 In the first place he had an opinion to controvert which 
 Knoch^ had given currency to, that the eggs and embryos of 
 bothriocephalus develop at once into the worms without an 
 intermediate larval stage. He then proceeded to show by 
 experiments on cats, that ^' the asexual bothriocephali found 
 in various organs and tissues (such as the muscles) of the 
 pike and quab, are the immature forms of the Bothriocephalus 
 latus of man, and that these fishes are to be regarded as the 
 intermediate hosts and the sources of infection.^' 
 
 • In ' VJrcbow's Arcliiv,' 1862, 13cl. 74, ^. 453.
 
 292 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 § 95. ECHINOCOCCUS. 
 
 We have accounts of the prevalence of echinococcus from 
 many regions of the Eastern Hetnisphere, but unfortunately 
 these are not such as to afford the means of estimating the 
 relative frequency of that parasite at the various points 
 within its distribution area. In the form of an endemic 
 malady, it occurs, so far as we know at present, in only 
 two countries — in Iceland and in the Australian colony of 
 Victoria. 
 
 Our first trustworthy information as to the endemic of 
 echinococcus in Iceland we owe to Schleisner;^ although it 
 follows from the references of earlier pi'actitioners to *'in- 
 farctus/' " obstructio hepatis " and " heptalgia/^ that the 
 history of the disease in that country goes back to remote 
 times. It was Schleisner, however, who first showed that 
 this disease of the liver depended on the presence of a 
 parasite within the organ, that the same parasite occurs in 
 other parts of the body, and that the malady has a most in- 
 jurious influence upon the health and working capacity of 
 the population. His observations have been subsequently 
 confii'med in part, and in part extended by Eschricht," 
 Krappe,^ Hjaltelin,^ Finseu,^ and Galliot.^ Among 327 
 patients that were under his treatment, Schleisuer found 
 echinococcus fifty-seven times, or in 18 per cent, of 
 the cases ; and he estimates from the twenty years^ observa- 
 tions of Thorstensen, that the parasite infests one-seventh of 
 the whole population of Iceland. Eschricht and Hjaltelin 
 consider that estimate as not excessive, while Krabbe and 
 Finsen would put it much lower. Finsen, whose experiences 
 relate to the northern districts and who does not deny that 
 echinococcus is more common in the south, would make it 
 one-fortieth of the inhabitants, and Galliot thinks that one- 
 
 ' 'Island undersogfc, &c.,' Kjobenh.,' 1849, 4 — 16. 
 
 '^ ' Undersogelser over den i Island endemiskc hydatldesygdom.,' Kjobenh., 1853. 
 
 ^ ' Helmintliol. undersogelser i Danmark og paa Island, &c.,' ib., 1865. 
 
 4 ' Edinb. Med. Jonrn.,' 1867, Aug., 137, and in ' Dobell's Reports,' 1870, 286. 
 
 * 'Ugeskrift for Laeger,' 1867, iii, Nr. 5 — 8, and • J;igttagelser, &c.,' Kjobenh., 
 1874, 65. 
 
 ^ 'Bull. gen. de therap.,' 1879, Aug., 97.
 
 HYDATIDS. 293 
 
 tliirtietli is not too liigb. It is a noteworthy fact tliat here 
 as elsewhere the female sex suffers to a much greater 
 extent than the male. Among 385 cases with echinococcus 
 Schleisner found 212 in women, and Finsen had 132 female 
 patients in a total of i8g. 
 
 The first accounts^ from Victoria date from the year 1S63 ; 
 the number of cases increased so quickly that even in 1867 
 Kichardson" spoke of the hydatid disease as " exceedingly 
 common/' adding that " the affection has become so preva- 
 lent of late years that it may be called a disease of the 
 country/^ and that it was equally common in towns and in 
 rural districts. Those statements are confirmed by later 
 authorities,^ among others by Thomas who gives us a means 
 of estimating the frequency of the malady approximately when 
 he tells us that 307 deaths from echinococcus were officially 
 registered during the ten years from 1867 to 1877 in a popu- 
 lation of about 800,000. 
 
 Besides those two endemic centres, we have accounts of 
 the somewhat frequent occurrence of the parasite in India, a 
 certain proportion of the endemic hepatic abscesses of that 
 country, as Cleghorn* observes, being referable to it. Echino- 
 coccus is found not unfrequently also in Algiers,^ Ecjijpt,^ and 
 Russia,'^ as well as in England and France.^ Of 22 cases of 
 hydatids of the liver in Switzerland, 13 occurred in the north- 
 east of the country, 3 in Basel, 3 in Neuchatel, 2 in Geneva, 
 and I in Bern.^ From many parts of Germany, also, such as 
 Dresden, Rostock, Berlin, Breslau, Jena, &c., we learn^° that 
 echinococcus is not unfrequent ; but these data relate only to 
 
 ^ Hudson, 'Austral. Med. Jouni.,' i860, April j Ralph, ib., July ; Sutherland, 
 'Victoria Med. Record,' 1863, Feb. 
 
 - 'Edinb. Med. .Tourn.,' 1867, Dec, 529. 
 
 3 Notice in 'Brit. Med. Journ.,' 1871, Dec, 783; Bird, 'Med. Times and Gaz.,' 
 1873, Aug., 164; Tliomas, ' Lancet,' 1879, March, 297. 
 
 ■• ' Indian Med. Gaz.,' 187 1, March. 
 
 ^ Vital, ' Gaz. mod. de Paris,' 1874, Nr. 22, 23. 
 
 ^ Bilharz, ' Zeitschr. fiir wisseuchaftl. Zoologie,' 1853, iv, 53; 'Zeitschr. der 
 Wiener Aerzte,' 1858, 447. 
 
 7 Knoch, 'Petersb. med. Zeitschr.,' 1866, x, 245. 
 
 ^ Cobbold, 'Lancet,' 1875, June, 850. 
 
 9 Zaeslein, 1. c, 681. 
 
 '" The references down to 1877 '"^ve been collected by Neisser ('Die Echino- 
 coccen-Kraukheit.,' Berl., 1877, 34).
 
 294 GEOGRAPHICAL AND HISTORICAL TATHOLOGY. 
 
 liospital practice and are available neither for comparison 
 among themselves nor for estimating the proportion of cases 
 in the respective populations. In the Western Ilemisjphere it 
 would appear to be rare ; at all events Osier/ after searching 
 carefully in museum catalogues, journals and proceedings of 
 societies, has found only 6i cases for the whole of North 
 America. Of these Montreal had 3 cases (in 800 sections), 
 and of the whole 61, it was pi'obable that many had occurred 
 in immigrants from other countries. 
 
 § 96. ECHINOCOCCDS THE LaEVA OF A T^NIA INFESTING 
 
 THE Dog. 
 
 The presence of echinococcus in man (and the larger 
 animals) is due, as is well known, to the introduction of 
 the eggs of a tapeworm which infests the dog, the Taenia 
 echinococcus ; the frequency of hydatids among a population 
 w^ould be in proportion, therefore, to the number of the dogs, 
 and to the intimacy of the relations between those animals 
 and their masters' households, or to the careless way in which 
 the members of a family keep company with the dogs. We 
 may thus explain the prevalence of the parasite among the 
 pastoral populations of Iceland and the Australian colony. 
 The number of dogs kept in Iceland is proportionately much 
 larger than anywhere else, and the enormous frequency of 
 echinococcus among the cattle on the island, and even more 
 among the sheep — Iljalteliu says that one-fifth of all the 
 grown sheep have the parasite — affords abundant opportu- 
 nities for the shepherds' dogs to be infected with the bladder- 
 worm. The Iceland cowherds have notoriously little sense 
 of cleanliness, and they are all the more ready to share with 
 their highly treasured dogs not only their dwellings but their 
 platters also, and even their beds, because the risk of infection 
 from the dog is a thing unknown to them. Fui-thcrmore, the 
 dogs have free access to the store-rooms, whose contents they 
 befoul with their dejecta^ ; and it can only be because a few 
 
 1 ' Amer. Journ. of Med. Sc.,' 1882, Oct., 475. 
 
 - The assertion of one writer, that quacks in Iceland use the excrement and 
 uriue of the dog as a medicine for internal administration, is declared by Finseu 
 to be a fable.
 
 DISTOMA H^MATOBIUM. 295 
 
 out of the many thousands of tasnia-eggs entering the 
 human intestine ever reach the mature stage of bladder- 
 wormSj that a very much large number of persons in that 
 country do not suffer from echinococcus. Finsen is explicit in 
 stating that the parasite is hardly met with among the more 
 civilised of the Icelandic population, among families occupying 
 commodious houses and duly practising cleanliness. It is 
 unquestionably the same circumstances that explain the 
 prevalence of echinococcus in Australia, whei'e the population 
 is mostly engaged in cattle rearing, and where the sheep, as 
 Hudson informs us, suffer from echinococcus to the extent 
 of at least 4 or 5 per cent. The first cases treated in the 
 Melbourne Hospital, according to Richardson, were shepherds. 
 ^^ It does not require much imagination," he says, "to 
 follow the course of these embryonic tapeworms eaten by the 
 shepherd's dog. They are matured in the dog, passed as 
 tapeworms over the pasturage of other sheep, the ova are 
 again taken into the stomach and system of the sheep, and 
 circles of propagation are established." It would be of 
 great interest to discover what is the state of matters as 
 regards this disease among other pastoral peoples living, like 
 those spoken of above, in a half civilised state ; and at the same 
 time to obtain more accurate information on the geographical 
 distribution of the Tifiuia echinococcus itself. 
 
 II. Trematodes. 
 
 § 97. DiSTOMA H^MATOBIUM. EnDEMIC H^.MATURIA OP 
 
 Egypt and South Africa. 
 
 The parasitic trematode which was first described byBilharz^ 
 and Clriesinger^ and named by them Distoma hsematohium, has 
 been found hitherto as an endemic cause of sickness at only 
 two points of the globe, both on the African continent, 
 namely, Egypt and the Cape of Good Hope. From the former 
 
 ' ' Zeitscbr. fiir wissenseliaftl. Zoologie,' 1852, iv, 59 ; ' Wieu. med.Woclienschr.,' 
 1856, Nr. 4, 5, and Zcitscbr. der Wiener Aerzte,' i8_,S, 447. 
 " 'Arch. fiir. pliysiol. Ileilkde.,' 1854, xiii, 561.
 
 296 GEOGIiArniCAL AND niSTORlCAL PATHOLOGY. 
 
 of these we have accounts by tlie two observers already 
 named and by Simpson/ Sonsino/ and Damaschino^ ; and 
 for the latter territory the occurrence of the parasite is 
 described by Harley/ Fritsch/ and Batlio.^ It is impossible 
 to decide, for the present, whether the endemic lisematuria 
 of the more central parts of Africa is associated with these 
 parasites, as some travellers^ state, or, as seems to me to be 
 more probable, with Filaria sanguinis.^ 
 
 In Egypt the habitat of the parasite is strictly limited to the 
 coast and to the banks of the Nile within the Delta ; and in 
 those localities it is enormously frequent. Griesinger found 
 it in 117 out of 363 bodies, but he believed that the minor 
 degrees of the malady, and particularly the beginnings of it, 
 had been overlooked by him many times. And Sonsino, 
 who found it in 13 out of 31 bodies, estimates the number of 
 cases of distoma at a much higher ratio even than that. At the 
 Gape its frequency is equally great ; there' also it is strictly 
 confined to the coast territory and to the banks of a few 
 streams for a distance of some ten or twenty miles up from 
 the sea. Its principal seats are the south-eastern districts 
 of Gape Golony about Algoa Bay, particularly Uiten- 
 hage and Port Elizabeth ; the neighbourhood of King 
 William's town and East London in GajJ'raria ; and several 
 places in Natal, on the banks of the Umlasi, the Ungeni 
 (from Port Natal up to Pietermaritzburg), and the Umhloti 
 (Yerulam). 
 
 1 «Brit. Med. Journ.,' 1872,' Sopt., 320. 
 
 2 'Ricerche intorno alia Bilharzia Haematobia, &o.,' Cairo, 1874, and 'Arch, 
 gen. de med.,' 1876, Juin, 652. 
 
 3 'Oaz. hebd. de med.,' 1882, 365. 
 
 * *Mcd.-Cbir. Transact.,' 1864, xlvii, 55; 1865, xlviii, 161; 1869, Hi, 379 > 
 1871, liv, 47- 
 
 5 *Arcb. fiir Anatomie,' 1867, 752. 
 
 6 'Brit. Army Med. Reports,' 1870, xii, 502. 
 
 7 Allen ('Lancet,' 1882, July, p. 51) is of opinion that all the rivers of Africa^ 
 from Egypt to the Cape, contain the parasites. 
 
 * See the section on Filaria sang, hominis.
 
 DISTOMA H^MATOBIUM. 297' 
 
 § 98. Mode op Access op Distoma Haematobium 
 TO THE Human Body. 
 
 Within the human body, as is well known, the parasite is 
 found mostly in the blood of the portal system of veins — in 
 the mesenteric veins — and in the vessels of the urinary blad- 
 der. From the latter it reaches the mucous membrane of the 
 bladder, sometimes also the ureters, and even the pelvis of the 
 kidneys. In these situations it sets up serious local lesions, 
 leading to blood in the urine (one of the forms of Jwsmaturia 
 intertropicalis) , the formation of calculus (uratic and phosphatic 
 deposit around clusters of the parasite's eggs), the endemic 
 prevalence of which in Egypt is essentially due to Distoma 
 hEematobium ; ^ sometimes also, according to Griesinger,. 
 it causes severe intestinal lesions, and in certain not at all 
 rare cases (especially in Egypt where the disease is on the 
 whole more severe than at the Cape") it leads to general 
 cachexia and the death of the patient. 
 
 Opinions are still divided as to the mode in which the 
 parasite invades the human body. The invariable association 
 of the disease with sea-coasts and the shores of river estuaries, 
 contrasting with its absence from the adjoining inland 
 districts where the disease is never seen except in imported 
 cases, renders it highly probable that the eggs or embryos 
 of the parasite either come with the water itself or that they 
 cling to certain aquatic animals (fishes, crustaceans, gastero- 
 pods or other molluscs) which become the media of con- 
 veyance ; they would thus be introduced with the drinking 
 water or by means of plants or vegetables that had been 
 in the water, or by these parasite-bearing" animals ; or they 
 would enter by the skin of persons in the water, or 
 
 1 Pruuer, in speiiking of tlio urolitliiasis coiumon in Egypt (' Krankh. des 
 Orients,' p. 272), had already called attention to the severe lesions of the vesical 
 mucous membrane (which are due to distoma), without knowing their connexion 
 with a parasite, and without adverting to the htematuria. On the other hand, 
 the statement of Renoult (' Journ. gen. de med.,' An. xi, vol. xvii, 366) as to the 
 endemic occurrence of blood in the urine among the French troops during the 
 occupation of the country by Napoleon, would seem to refer to this endemic 
 litematuria. 
 
 - According to Batho (1. c, p. 503) urolithiasis is not found at all frequently 
 except in Port Elizabeth, which is the chief scat of the distoma-diseasc of that region..
 
 293 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 even by the urethra, as has been alleged. Against the latter 
 of these views, maintained by Harley and his informants, 
 there has to be taken into account the striking disparity 
 in the number of cases which may be noticed among pei^sons 
 of different age and sex ; and if the mode of access by the 
 dio-estive organs is on the whole more likely, still the same 
 variations raise many difficulties in the way of that theory 
 also. 
 
 § 99. D. HvEMATOBIUM MOSTLY AFFECTS MaLES AND PRINCIPALLY 
 
 Boys. 
 
 The various races and nationalities would appear to be 
 subject to the disease cseteris imrihus somewhat uniformly. 
 The opinion of Bilharz that it is chiefly the Egyptians (Copts 
 and Fellahs) who suffer from distoma (the negroes very 
 rarely and the Europeans never), and the assertion of Rubidge 
 (in Harley's paper) that the Caffirs enjoy an absolute im- 
 munity from it, have been controverted by Griesinger who 
 has often found the parasites in negroes, by Sonsino who 
 has not unfrequently seen them in Europeans, and by Batho 
 who declares that they are jusb as common in Europeans as 
 in Zulus. It would appear, also, from the numerous cases 
 at the Cape among coolies from Bombay and Madras, that 
 Hindus and Malays are not exempt. 
 
 On the other hand, there is almost complete agreement 
 among observers that the parasite occurs very rarely in the 
 female sea;, the recorded instances of it being mostly in children 
 or young girls. Griesinger has never seen it in women, and 
 Batho says : " Its subjects are invariably of the male sex." 
 Sonsino is the only observer who has seen a few cases in 
 Avomen, one of them being a Turkish woman who had lived 
 a considei'able time in Alexandria. 
 
 As regards the time of life, it is noteworthy that of 17 
 cases specially mentioned by Sonsino, 13 were in children 
 and 2 in youths. On the same point Batho says : " In 
 Natal the hsematuria is very prevalent, largo numbers of 
 boys being affected. At the capital, Pietermaintzburg, it 
 would appear as if the majority of the male youth suffer
 
 NEMATOID WORMS. 299 
 
 from it. It commences to show itself almost invariably 
 before puberty, and never attacks persons of middle or old 
 age. The limits of ago during which its existence is possible 
 are apparently from five years to thirty. I was unable to 
 hear of a single instance m which it commenced at a later 
 age." And a similar opinion is expressed by the authorities 
 for places in Cape Colony (Uitenhage and Port Elizabeth) . 
 
 § 100. D. H^MATOBIUM COMMONEST IN SuMMER. 
 
 With respect to the influence of the season of tJie year 
 upon the amount of the sickness, Griesinger says that he 
 found the parasites in one-half of the bodies that were opened 
 in the months of June, July, and August, but in only one 
 fourth of those opened from September to January. He 
 thiuks that this is not accidental but connected somehow 
 with the food ; it is possible, however, that the fact may be 
 explained by variations in the frequency of the parasites 
 themselves in the several seasons. Without doubt the 
 duration and severity of the sickness depends on the intro- 
 duction of the worm in considerable quantities and over 
 considerable periods ; and, accordingly, the most certain 
 means of cure is to remove the infected person away from 
 the habitat of the parasite. 
 
 III. Nematodes. 
 
 § lOI. ASCARIS LUMBRICOIDES. 
 
 In regard to their diffusion over the whole habitable globe 
 and the frequency of their occurrence, Ascaris lumbricoides, 
 Oxyuris vermicularis and Trichocephalus dispar are a group 
 that hold unquestionably the first place among parasitic 
 worms. The round-worm is a parasite that is indigenous 
 wherever men congregate. While statistics do not enable 
 us to give its relative frequency in various parts of the world 
 with mathematical accuracy ; yet we may infer from the 
 statements of authorities in troincal and siihtropical regions,
 
 300 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 and fi'om the language of astonishment that they use in 
 speaking of its enormous prevalence, that it is much more 
 common with them than in higher latitudes. 
 
 This is the opinion held by Pruner,' Hartmann,^ Vauvray,^ and others 
 for the Nile countries, by Karris'^ and Coui-bon^ for Abyssinia, by Borch- 
 grevink" for Madagascar, by Grenef for Mayotte, by Allan^ for the 
 Seychelles, and for the Mauritius by Dyer,^ who says : " This complaint 
 is nearly universal in the Mauritius . . In the black population in such 
 numbers are the lumbrics produced, that I have frequently been dis- 
 gusted by seeing them crawling from the anus and mouth at the same 
 time. One black literally brought me his hat full, which he assured 
 me he had passed very shortly before." Further, by DanielP" for 
 the West Coast of Africa, Chassaniol" for Senegambia, Pruner, Robert- 
 son'- and Guys'^ for Syria, Pruner for Arabia, Ward and Grant,'* 
 Voigt,'* Waring,'" Day,'' Huillier,'** Auboeuf,"* and others for India, 
 Waitz,2° Heymann,-' and v. Leent"" for the East Indies, Bernard^ 
 and Beaufils-^ for Cochin China, Wilson"^ and Smart"" for China, 
 Friedel"'' and Wernich-'^ for Japan, Bernoulli"^ for Central America^ 
 
 ^ ' Krankh. dos Orients,' 244. 
 
 " ' Naturgesch.-mcd. Skizzen der Nilliinder,' Ecrl., i866. 
 
 •> 'Arch, de ined. iiav.,' 1873, Sept., 161. 
 
 * 'The Highlands of /Ethiopia,' Lond., 1844, ii, 407. 
 
 * ' Observ. topogr. et med., &c.,' Par., 1861, 35. 
 
 * 'Norsk Mug. for Laegevidcusk,' 1872, viii, 240. 
 ' ' Souvenirs med. ... a Mayotte,' Montp., 1866. 
 ^ ' Edinb. Montbl. Journ.,' 1841, Aug., 569. 
 
 9 'Loud. Med. Gaz.,' 1834, March, 866. 
 
 '0 ' Sketch of the Med. Topogr. of the Gulf of Guinea,' Lond., 1849, 55- 
 " ' Arch, de med. nav.,' 1865, Mai, 511. 
 '2 ' Edinb. Med. and Surg. Journ.,' 1843, April, 247, 
 13 'Statist, du Pasclialik d'Alep,' Marseille, 1853, 63. 
 '•• 'Official Papers, &c.,' Pinang, 1830. 
 '^ ' Bibl. for Laeger,' 1834, i, 352. 
 ^^ ' Ind. Annals of Med. Sc.,' 1859, July, 371. 
 '' 'Madras Quart. Journ. of Med, Sc.,' 1862, Jan., 37. 
 18 ' Arch, de med. nav.,' 1868, Fevr., 87. 
 
 " 'Contribut. a I'etude . . . des malad. dans I'lnde,' Par., 1882, 70. 
 '" ' On Diseases incident to Children in Hot Climates,' Bonn, 1843, 263. 
 21 i Wiirzb. pbys. med. Verliandl.,' v, 30. 
 ■•" 'Arch, de med. nav.,' 1867, Sept., 170. 
 23 'De I'influence du climat de la Cocbinchine,' Montp., 1867. 
 ^^ 'Arch, de mod. nav.,' 1882, Avril, 265. 
 -'' 'Med. Notes on China,' Lond., 1846, 193. 
 '" ' Transact, of the Epidemiol. Soc.,' 1862, i, 219. 
 
 ^ 'Beitr. zur Kenntniss des Klimas und der Krankh. Ost- Asians,' Berl., 1863, ^3, 
 28 'Deutsche med. Wochenscbr.,' 1878. 
 ^9 ' Schweiz. med. Zeitschr.,' 1862, iii, 100.
 
 NEMATOID WORMS. 301 
 
 Levacher,' Dazillc^ aud Rufz^ for the West Indies, Rodseliied* and 
 Bajon for Guiana, and by Jobim'" aud Sigaud^ for Brazil. 
 
 From the higliest latitudes also, such as those of New- 
 foimdlancV and Greenland^ we have information of the 
 endemic occurrence of Ascaris lumbricoides. The sinarle 
 exception to the general rule, so far as I know, is Iceland, 
 where this parasite, according to Finseu,^ is rarely met with. 
 
 § 102. Mode op Access op A. Lumbricoides to the Human 
 
 Body. 
 
 There is still some difference of opinion as to the mode of 
 access of Ascaris lumbricoides to the human body. Either 
 the embryo-containing eggs discharged from the human 
 intestine may reach the organism in the food or drink, parti- 
 cularly by means of uncooked field or garden produce, there- 
 after developing to worms, — an alternative which is opposed, 
 no doubt, by the fact that all experiments hitherto to infect 
 men by the introduction of the eggs of ascaris have failed j^" 
 or, as Leukart considers more probable, the transmission 
 takes place through an intermediate host belonging to one of 
 the lower classes of animals. " Considering the frequency 
 and almost universality of the human round- worm, ^' he says,^^ 
 " we may at any rate conjecture that the transmitting agent 
 or agents of it are very generally diffused.'' ^^ 
 
 ^ ' Guide ined. des Antilles,' Pur., 1840, 193. 
 
 ^ ' Observ. sur les maladies des negres,' Par., 1792, i, 106. 
 
 2 'Arch, de med. nav.,' 1869, Juiu, 440. 
 
 ^ ' Mcd.-chir. Bemerk. iiber . . Rio Essequebo,' Fraiikf., 1796, 290. 
 
 * ' Disc, sobre as molestias . . do Rio de Janeiro, <tc.,' Rio, 1835. 
 
 ^ ' Du cllmat et des malad. du Rresil,' Par., 1844, 425. 
 
 ^ Gras, 'Quelques mots sur Miquelou,' Motitp., 1867, 24; and Anderson, in 
 Dobell's 'Report,' 1870, 365. 
 
 '' Lange, ' Beuiaorkn. oui Gronlands sygdomsforhold.,' Kjobenli., 1864, 43. 
 
 ^ ' Jagttagelser aiigaaende sygdomsforboldone i Island,' Kjobeuh., 1874, 108. 
 
 '" Given by Leuckart ('Die menscLlichen Parasiten, &c.,' Lcipz., i8"76, ii, 222). 
 '' lb., p. 229. 
 
 '^ As these lines were going through the press, I read in a paper by Radu 
 (' Wien. mcd. Blatter.,' 1882, No. 45, p. 1386) that he had observed during the 
 general prevalence of ascaris iu Moldavia iu the very I'ainy year 1881, a case
 
 302 GEOGRAPHICAL AND HISTORICAL I'ATHOLOGy. 
 
 § 103. Parasitism of Ascaris probably favoured by climatic 
 
 Heat and Moisture. 
 
 If it be not definitely proved that states of soil and weather, 
 particularly dampness and a higli temperature, increase tlie 
 frequency of the parasites or the prevalence of the malady, 
 yet that becomes highly probable when we consider what is 
 known of the development of ascaris-eggs.' The preference 
 of the parasite for negroes, Indians and other nncivilised 
 peoples, is not an affair of racial or national peculiarity, but 
 of their manner of life, which is peculiarly favorable to the 
 introduction of the ascaris progeny under the circumstances 
 already mentioned. 
 
 § 104. OXYDRIS VeRMICULARIS AND TrICHOCEPHALUS DiSPAR. 
 
 These worms are met with in the same genei-al diffusion 
 over the globe and in the same frequency as Ascaris lumbri- 
 coides. Many of the above-mentioned observers in tropical 
 or subtropical regions adduce evidence of this in their 
 writings, and there are not less numerous reports establishing 
 the same fact for higher latitudes. There are, no doubt, 
 differences in the prevalence of the worms at various points. 
 Thus Finsen says that in Iceland oxyui-is is enormously 
 frequent, contrasting with the very rare occurrence of 
 ascaris ; while, contrariwise, Rufz dwells upon the rarity of 
 oxyuris in Martinique, as compared with the very wide 
 diffusion of ascaris. Virchow^ observes that he used to find 
 
 which went to prove tlmt the i-eprodnction of the rouiid-wonus in the hniuau 
 intestine takes place not merely through eggs reaching it, hut also by the fully-de- 
 veloped young brood being liberated alive from the mother's body. From the 
 patient there was discharged a solid mass of gelatinous and opalescent substance, 
 about the size of a hen's egg (a so-called round-worm's nest), adhering to the worm. 
 On examination, it was found that the head of a young ascaris projected from 
 the middle of the body of this worm ; and when the young one was pulled out a 
 second followed clinging to it, and then a third, and so on to the seventh. With 
 the last there came away a tube about an inch and a half long; the whole brood 
 was enclosed in a thin and almost transparent sheath. 
 
 ' Leuckart, p. 211. 
 
 * ' Archiv fiir pathol. Auat.,' 1857, xi, 81.
 
 TRICHINA SPIRALIS. 303 
 
 triclioceplialus in the course of post-mortem examination more 
 commonly at Wurzburg than at Berlin. According to 
 Krabbe/ the whip- worm is very rare in Copenhagen. But 
 all such data are so isolated, or have been arrived at under 
 such special circumstances, that they have no value for a 
 general conclusion as to the number of cases in various 
 parts of the world. 
 
 According to the inquiries of Leuckart/ there can be no 
 doubt as to the introduction of both these parasites by 
 embryo-containing eggs discharged from the human intestine, 
 and without the intervention of any transmitting medium. 
 
 § 105. Tkichina Spiralis : its Disco very. 
 
 The first trustworthy accounts of the trichina-disease in 
 man reach no farther back than about the year 1 830 ; and 
 even as late as i860 the observations concerning it related to 
 muscle-encapsulated trichina) accidentally found in the course 
 of anatomical examination. 
 
 Apart from a somewhat doubtful case of Tiedemann's^ in 
 
 which large calcareous concretions were found in the muscles 
 
 of a subject, and not reckoniDg f rom the muscle-preparations 
 
 with calcified trichinee which Peacock"* in 1828 deposited in 
 
 the museum of Guy's Hospital, the first case of encapsuled 
 
 trichinae is that recorded by Hilton,^ who spoke of them as. 
 
 " oval bodies, transparent in the middle and opaque at their 
 
 end, altogether about —th of an inch in length." These he 
 
 found in a dissected subject in all the muscles of respiration ; 
 
 '^no organisation," he added, " could be discovered with the 
 
 aid of a microscope ;" and his explanation of them was that 
 
 they were very minute cysticerci. The merit of recognising- 
 
 the parasitic nature of these objects and of accurately 
 
 describing the parasites themselves belongs to Owen*' and 
 
 Harrison.^ 
 
 ' Quoted by Leuckart, p. 466. ^ L. c, pp. .132, 498. 
 
 3 ' Froriep's Notizun,' 1821, i, 64. 
 ■* According to Cobbold, ' Entozoa,' Suppl. i. 
 s 'Med. Gaz.,' 1833, Feb., p. 605. 
 
 ^ ' Lond. and Edin, Thilos. Mag.,' 1835, p. 452, and 'Med. O'az.,' 1835, Apiil, 
 p. 125. 
 
 7 ' Dubl. Journ. of Med. Sc.,' 1835, Sept., p. 185.
 
 ^04 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Owen's discovery was made in a piece of muscle beset witli encapsuled 
 tricliina3, which was brought to him by Paget, then a student at St. 
 Bartholomew's Hospital, whei*e the appearance had several times been 
 pointed out to him by Wormald, the prosector. Paget's conjecture was 
 that the objects in question were entozoa. An examination with the 
 microscope bore out this guess ; Owen succeeded in making out the 
 parasite, its position within the capsule, and its characters ; and it was 
 he that gave it the name of " Trichina spix-alis." 
 
 Harrison gave a demonstration of the parasite in August, 
 1833, in the medical section of the British Association, then in 
 session at Dublin ; and thereafter followed accounts of it by 
 Farre/ of London, Knox/ of Edinburgh, Curling,'^ Bischoff* 
 (Heidelberg), Bow ditch and Wyman*^ (Boston), Svitzer^ 
 (Copenhagen), Bristowe and Rainey'^ (London), and by 
 Turner,** of Edinburgh, who stated that he had found the 
 parasites in from i to 2 per cent, of all the subjects in the 
 dissecting-room during the five years preceding (1855 — 
 i860). Meanwhile Leidy^ had proved the occurrence of the 
 trichina in the pig, and Guret^'' had found it in a cat ; and 
 these discoveries gave rise to the feeding experiments 
 of Herbst,^^ Leuckart,^^ and Virchow,^^ and finally to the 
 distinction made by Virchow,^'^ and simultaneously by 
 Zenker,^^ between muscle-trichinas and intestinal trichiuEe, 
 and to a correct understandiug of the genetic relation 
 between the two. 
 
 The significance of the parasite as a cause of disease in 
 
 1 ' Lond. Med. Gaz.,' 1835, ^ec, 382. 
 
 - 'Edinb. Med. and Sm-g. Joiuu.,' 1836, July, 89, and 'Lond. Med. Gaz.,' 
 1843, Sept., 805. 
 
 3 lb., 1836, Feb., 768. 
 
 ■• ' Med. Annalen,' 1840, vi, 232. 
 
 ^ 'Boston Med. and Surg. Jouru.,' 1841-43. 
 
 ^ 'Froriep's Notizen,' 1847, Nr. 35, 195. 
 
 ^ 'Transact, of the Pathol. Soc.,' 1854, v, 277. 
 
 ^ ' Edhib. Med. Journ.,' i860, Sept. 209. 
 
 * 'Proceed, of the Acad, of Nat. Sc. of Philadelphia,' 1846, Oct., 107, and 
 'Annals and Mag. of Nat. Hist.,' 1847, ^^^' 3S8. 
 
 "• Appendix to part i of his ' Luhrbuch der pathol. Anafc. der Hausthiere,' 
 I3erl., 1849, 144' 
 '1 ' Gott. gclehrt. Anz.,' 1851, Nr. 19; 1852, Nr. 12. 
 
 '* 'Arch, fur Naturgesch.,' 1857, ii, 1S8, and ' Conipt. rend.,' 1859, xlix, 452. 
 " ' Deutsche Klinik,' 1859, 430, iind ' Compt. rend.,' 1859, xlix, 660. 
 " lb., i860, li, 13, and ' Arcb. fur pathol. Auat.,' x86o, Bd. 18, 330, 535. 
 '' lb., s6i.
 
 TRICHINA SPfRALIS. 305 
 
 the human body remained quite obscure until iS6o. No 
 doubt the connexion between the acute muscular pains felt by 
 the patient, and the pi^esenco of parasites found after death 
 had been coirectly indicated by Wood^ in 1835. 
 
 Wood's case was that of a young man, ret. 22, -who was admitted in 
 October, 1834, into the Bristol Infirmary for " acute rheumatism," 
 implicating the trunk and the extremities, and who died a few days after. 
 The 2Mst-mortem examination showed commencing pneumonia and peri- 
 carditis, and the presence in the muscles, especially in the pectoral 
 and deltoid, and in the muscles of the chest and shoulders generally, of 
 what proved to he the entozoa that Owen had described. Wood was 
 unable to make out the nature of these at the time, although he took 
 the microscope to them ; but when he heard of Owen's discovery they 
 became at once clear to him ; and, he adds, " would it not be well to 
 ascertain, if possible, whether in either or all of the cases alluded to in 
 Mr. O.'s paper, there was any symptom of rheumatism or inflammation 
 of any kind in the muscular system ? " 
 
 This idea of Wood's, lioweyer, remained unnoticed. Tlie 
 trichinae, which were afterwards detected so often, were 
 regarded as harmless intruders in the human body, and by 
 some {e.g. Bischoff) as products of spontaneous generation ; 
 until at length Zenker came forward in the beginning of 
 i860 with his pioneering observation of a severe case o£ 
 trichinosis, whereby he proved the connexion between that 
 disease and the eating of trichinous pork, and thus 
 constituted himself, along with Lcuckart and Virchow, the 
 founder of the doctrine of trichina-disease. 
 
 § 106. Earlier Cases op Trichinosis. Present Distribu- 
 tion. 
 
 No sooner did the fact become knoAvn to the profession than 
 numerous accounts began to come in from North Germany 
 of sporadic cases of sickness due to trichinosis as well as 
 of trichinous epidemics. At the same time evidence more 
 or less trustworthy was adduced that the disease had occurred 
 before, although the nature of it had not been recognised. 
 
 Whether the cases of sickness observed by Fehr in 167,-;, in a peasant's 
 family in VViirtemberg, are to be taken for trichina-disease, as some 
 
 ' 'Medical Gazette,' 1835, ^^y> V- ^9°- 
 vol. II. 20
 
 306 GEOGEAPHICAL AND IlISTORIOAL PATHOLOGY. 
 
 Lave believed, api^ears to me very doubtful.^ Still less can I accept the 
 view of Le Roy de Mericourt, according to wliicli tbe disease observed in 
 France, in 1828-29, and designated witli the name of " acrodynia," 
 was trichinosis.- The instance given by Klopsch^ o£ a group of trichi- 
 nosis cases in 1843 is to be accepted, inasmuch as in 1866 living 
 trichina3 could still be detected in the intercostal mviscles of one of the 
 persons originally attacked by the disease. Probably also the epidemic 
 of 1849 at Wegeleben, described by Mosler,"* and taken to be " English 
 sweating sickness," was an aifiiir of trichinosis ; and the same holds for 
 the cases observed at Schwetz in 1858 and reported upon by Meschede.^ 
 The mysterious sickening of a whole company who had dined together 
 at a small town in Hesse in 1845, was fortunately explained'' (and the 
 suspicion of having poisoned them removed from their host), by the dis- 
 covery in 1864 of encapsuled trichiiise in the muscles of one of the 
 members of the company, in an operation upon him by Langenbeck. 
 In the same way TiingSl'' succeeded in proving by a post-mortem exami- 
 nation in 1863 on the body of an individual who had been seized at 
 Hamburg in 185 1 with the same kind of symptoms as several others in 
 his company, that the illness had been a small epidemic of trichinosis. 
 GriepenkerP also showed by siibsequent anatomical examination that 
 the disease which prevailed at Blankenburg, in the Harz, in 1858-60 
 among a battalion of Brunswick Jagers, and was set down as " gastric 
 rheumatic fever," was no other than trichinosis. The following' has 
 been communicated to me by Surgeon- General Dr. Abel, of the German 
 army: In 1S51 at Halberstadt, Quedlinburg, and the village of Hars- 
 leben, situated between those towns, he treated about 150 cases of a 
 remarkable malady which appeared to him at the time to be very 
 mysterious, although when he afterwards came to know the trichina 
 disease he recognised its character. All the cases got well, and he 
 considered the disease to be a peculiar kind of influenza, although he 
 was constrained (according to the symptoms) to locate its seat in the 
 subcutaneous connective tissiie and in the fasciaa. All the doctors who 
 practised in Halberstadt, Quedlinburg, and neighbourhood, assured him, 
 in answer to his questions, that precisely the same disease had been 
 known in that locality for several years, that it had been, moreover, 
 often fatal, and had been taken to be a kind of nervous fever. The 
 town of Wegeleben was indicated as the place where the disease had 
 
 1 ' Miscell. med. phys. acad. nat. cur. Leopold,' 1677, Decas 5, Ann. vi, obs. 191, 
 p. 269. 
 
 ' See p. 252, note. 
 
 ' ' Virchovv's Arch.,' 1866, Ed. T,i„ 609. 
 
 ■* lb., 1S65, Pd. 33, 414. 
 
 * lb., 1864, Bd. 30, 471. 
 
 " Accord, to Liieke, ' Viertelj. fiir gericbtl. Med.,' 1864, Jan. ,'102. 
 
 "> * Vircbow's Arcb.,' 1863, Bd. 28, 391. 
 
 ^ ' Deufcscbe Klinik.,' 1864, No. 17. See also Scbolz, ib.. No. 40. 
 
 ' [Introduced into tbe English edition from the author's MS.]
 
 TRICHINA SPIRALIS. 307 
 
 been seen especially often and in its most fatal form. There had been no 
 post-mortem examinations. It can hardly be doubted that all these cases 
 were cases of trichina-disease ; and the matter is all the more interesting 
 from the fact that the sickness happened in the very district in which 
 the first authenticated epidemics of trichinosis afterwards occurred. 
 The assumption that the outbreak of trichinosis had been caused by the 
 introduction of Chinese swine is quite untenable for the locality above 
 referred to. Besides the indigenous breed, the pigs there for a period 
 of thirty to fifty years have all been importations — in enormous droves 
 — of the Polish breed. 
 
 The publication of Zenker's case was followed by notices 
 of cafees, either sporadic or in groups, by Waldeck^ (Korbach 
 in Waldeck), Wunderlich" (Leipzig), Friedreich^ (Wiirzburg), 
 Sendler^ (Magdeburg), Landois^ (Riigen), and others. Then 
 came accounts of extensive outbreaks of trichinosis as an 
 epidemic in the following places : Calbe-on-the-Saal^in 1862, 
 Plauen^ in 1861-63, Hettstiidt® in 1863-64, the Saal circle^ 
 in 1864 ^'^^ following years, Quedlinburg^" in 1864, Haders- 
 leben^^ (one of the severest epidemics), Zoppot,^^ Liibeck,^^ 
 Konitz^* and Chemnitz,^^ Neudorf^^ (near Breslau) and 
 Weimar,^'^ — all in 1865, Berlin^^ in 1867, Schonebeck in 
 1 868, Erlangen^^ and Heidelberg^° in 1870, Bovenden"^ (near 
 
 1 ' Jaliresb. der GcscUsch. fiir Nntur- und Heilkde. in Dresden/ 1861-62, 50. 
 = 'Arch, der Heilkde.,' 1861, ii, 269. 
 
 2 ' Vircliow's Arch.,' 1862, Bd. 25, 399. 
 "i 'Deutsche Klin.,' 1862, 261. 
 
 5 lb., 1863, Nr. 4, 8. 
 
 8 Simon, ' Preu's. med. Vereins-Ztg.,' 1864, Nr. 38, 39. 
 
 '' Bohler and Konigsdorffer, 'Die Erkenntniss der Trichinenkraukh.,' Plancn, 
 1864, and Sequel, ib., 1865. 
 
 ^ Rnpprecht, ' Die Trichinenkraukh., &c.,' Hettstiidt, 1864. 
 
 9 Puder, ' Die Trichinen in Halle und im Saalkreise,' Halle, 1870. 
 w WolfE, 'Deutsche Klin.,' 1864, Nr. 16, 18. 
 
 '' Kratz, ' Die Trichinenkraukh. in Hadersleben,' Leipz., 1866. 
 12 Benzler, ' P)erl. klin. Wochenschr.,' 1865, 51. 
 ^ Eschenburg, ' Hannov. Ztg. fur pr. Heilkde.,' 1865, 496. 
 1' Wolir. 
 
 15 Giinther and Flintzer, ' Zeitschr. fiir Med., Chir. und Gtburtsh,' 1867, 526. 
 »6 Lebert, ' Gaz. med. de Paris,' 1866, 195 ff. 
 *7 Frommann, in 'Virchow's Arch.,' 1871, Bd. $t„ 501. 
 
 '8 Account in ' Bcrl. klin. Wochenschr.,' 1867, 357, and Hoffmann, ib., 547. 
 '9 Maurer, 'Arch, fiir klin. Med.,' 1871, viii, 368. 
 '0 Friedreich, ib., 1872, is, 459. 
 
 2' Kracmer, ' Deutsche Klin.,' 1872,277, 289, and Seebohm, ' Die Trichiiien- 
 Epidemle zu Bovenden,' Dissert., Gott., 1872.
 
 308 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Gottingen) and Lobau^ (in Saxony) in 1872, Westphalia^ in 
 1877, Hof, Niirnberg, Bamberg, Marktleuten^ and Crails- 
 lieim* — all in 1878, and Barmen^ in 1880. 
 
 By far the larger part of all these notices, and nume- 
 rous other accounts of isolated cases of trichinosis, relate to 
 Northern Germany. The few instances as yet reported from 
 South Gi-ermany are, as we have seen, those from Hesse in 
 1845, Heidelberg and neighbourhood in 1866-70, Erlangen 
 in 1870, and the Franconiau towns above mentioned, together 
 with Crailsheim, in 1878. Doubtless there have been many 
 cases of trichinosis both in North and South Germany, 
 which have not come to the knowledge of practitioners or have 
 been wrongly diagnosed, or have been passed over without 
 mention, particularly of recent years when the interest in 
 the matter has declined and the disease itself has become 
 decidedly less common. But we may still safely assume that 
 trichinosis, particularly in its epidemic form, has occurred, 
 much more rarely in South Germany than in North ; and we 
 may conclude in like manner, from the extremely scanty 
 accounts of the malady that reach us from Austria — small 
 epidemic at Briinn'^ in 1866, sporadic cases at Prague^ in 
 1866, and a.t Vienna^ in 1867 — that trichinosis has been seen 
 but seldom in that country. From Great Britain — where,, 
 as we have seen, the muscle-trichinae were first discovered 
 in the dead body and repeatedly described in subsequent 
 years — there come notices of only two small epidemics of 
 trichinosis, the one in 1871 in the village of Workington* 
 (Cumberland), and the other in 1879 among the boys an 
 board a training-ship in the Thames.^" 
 
 In Denmark trichinse were seen for the first time in the 
 
 1 Kittel, ' Allg. Wicn. med. Ztg.,' 187 1, 254. 
 
 ^ Miiller, ' Deutsche Zeitsclir. fiir pract. Med.,' 1876, Nr. 14, 15. 
 
 ' Bollinger, ' Zeitschr. fiir Thiennedicin,' 1879, v, 13. 
 
 ■• Haeberlein, 'Wiirttbg. med. Correspondenzbl.,' 1879, Nr. 26, 27. 
 
 ^ Strauss, 'Deutsche med. Woehenschr.,' 1880, Nr. 48. 
 
 « Boner, ' Allgem. AVien. med. Ztg.,' 1866, Nr. 6. 
 
 7 Knoll, 'Prager Vierteljahrschr. fiir Heilkde.,' 1866, iii, 144. 
 
 s Peyritsch, ' Wocheuhl. der Gesellsch. der Wiener Aerzte,' 1867, Nr. 34; 
 Flamm, ' Wieu. med. Woehenschr.,' 1867, Nr. 74 ff., 1868, 139, 730. 
 
 » Dickinson, 'Brit. Med. Journ.,' 187 1, April, 446. 
 
 '0 Power, ' Report of Med. Officer of the Local Government Board,' Suppl. for 
 the year 1879, 47.
 
 TRICHINA SPIRALIS. 309 
 
 winter of 1866-67 i^^ three subjects in the dissecting-room 
 at Coj)enhagen, and a case was shortly afterwards diagnosed 
 in that city during life.^ To the same period belong notices 
 of sporadic cases in Denmark/ and two years later there was 
 a case of trichinosis under observation in Fiihneo.^ In 
 Sweden, down to 1873, cases of trichinosis had never been 
 seen in groups_, but only quite casually ; although every year 
 trichinous swine were met with^ and trichiuas frequently 
 found after death in the bodies of persons who had died of 
 other diseases.* The first accounts^ of trichinos in Russia 
 date from 1866; but there was no considerable prevalence 
 of the disease until 1873 at St. Petersburg, 1874 at Moscow 
 and Lodz (Poland), 1878-79 at Riga, and 1879 again at 
 Moscow^ and St. Petersburg.^ For Romnania we have 
 Scheiber's^ statement that encapsuled trichinos had been 
 found after death in a subject at Bukharest ; he adds, that 
 trichinosis would appear to be very rare in that country. 
 In Switzerland, according to the account by Roth,® trichinge 
 were first discovered in two cadavers in i860 by Miescher, 
 and two more cases were found among 19 14 corpses exam- 
 ined anatomically in that town during the period from 1872 
 to 1880. A small epidemic of trichinosis occurred in 
 Switzerland in 1868, at the village of Ravecchia within a 
 mile of Bellinzona in the Canton Ticino.^*^ Concerning the 
 occurrence of the malady in France,^^ Italy, Spain, and 
 Portugal,^^ I know of only occasional notices, and these relate 
 
 ' Krabbe, ' Tidsskrift for Veteriuar.,' 1867, xv, H. 3. 
 
 ' Ring, ' Ugeskrift for Laeger,' 1868, v, Nr. 11 ; Ditlevseu, ib., Nr. 12. 
 
 3 Petersen, ' Hospitalstidende,' 1872, xv, Nr. 5. 
 
 * Axel Key, ' Hygiea,' 1868, xxx, 127, and ' Siuidliets-Colleg. Beriittelse aren 
 1865 — 187.^.' 1 find no further mention of the disease iu the medical reports 
 after this. 
 
 ^ Maydell, 'Petersb. med. Zeitschr.,' 1866, x, 81 ; Krithsen, ib., 161 ; Rudnew, 
 iu ' Virchovv's Arch.,' 1866, Bd. 35, 600. 
 
 ® Knoch, ib., 1876, Bd. 66, 393, and ' Petersb. nied. Wochenschr.,' 1880, Nr. 16. 
 
 7 Kernig, ib., 1880, Nr. i. 
 
 s In ' Virchow's Arch.,' 1872, Bd. 55, 462. 
 
 ^ ' CoiTespondenzbl. fiir Schvveizer Aerzte,' 1880, x, 129. 
 
 1" Zangger, ' Wochenschr. fur Thierheilkde.,' 1869, xiii, 55, and Jauch, ' Aunali 
 univ. di med.,' 1869, Oct., 72. 
 
 1' Cruveilhier, ' Anat. pathol.,' Par., 1842, ii, 64; Delpech, ' Bull, do I'Acad. de 
 med.,' 1866, xxxi, 659. 
 
 '- Silva Amado, ' Bayi\ iirztl. lutelligenzbl.,' 1868, 506.
 
 310 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 almost exclusively to the detection of tlie parasite in the pig 
 or in the human body after death. For Spain, the state- 
 ment is made, a jpropos of the discovery of trichinaa in the 
 indigenous breed of pigs in Barcelona, that epidemics of 
 trichinosis had often been observed before in various parts 
 of the country.^ 
 
 North America would appear to be subject to particularly 
 severe visitations of trichinosis, as might have been almost 
 inferred from the enormously frequent occurrence of the 
 parasite in the American hog. Not to mention the evidence 
 of this furnished by the pork imported into Europe from the 
 United States, we find the fact asserted by American prac- 
 titioners themselves ; as, for instance, by Sutton,^ who says 
 that in the Western States at least 4 per cent, of all the swine 
 are trichinous. Accounts of the trichina-disease among the 
 people on a large scale reach us from New York^ for the 
 year 1864, from Marion (Iowa),* Chicago^ and Springfield*^ 
 1866, New York'^ 1868, Philadelphia^ i86g, a locality in 
 Western Virginia^ in 1870, Michigan^*^ in 1875, and other 
 places. 
 
 In the medical literature relating to Central and South 
 America,^^ as well as the West Indies, there is, so far as I 
 know, not a word said about trichinosis. Also for the 
 countries of Asia and Africa 1 have found but very few 
 references to the disease. One of these is by Wortabet,^" 
 who gives an account of a severe epidemic of trichinosis at 
 the village of El Khiam in the highlands of Syria, not far 
 from the sources of the Jordan, which had been caused by 
 
 1 Quoted by Bollinger in Virchow-Hirsch's ' Jahresber.,' 1879, i, 625. 
 
 2 'Transact, of the Indiana State Med. Soc./ 1875. 
 
 * Jackson, 'Auier. Journ. of Med. Sc.,' 1867, Jan., 101. 
 
 ■J Ristine, ' Med. News,' 1866, iii. 
 
 5 Smith, 'Chicago Med. Journ.,' j866, 161. 
 
 ^ Report in 'Lancet,' 1867, April, 501. 
 
 7 Buck, 'New York Med. Record,' 1869, March 7. 
 
 8 Stockton Hough, 'Amer. Journ. of Med. So.,' 1869, April, 565; 1870, Jan., 
 282. 
 
 'Wiesel, 'Transact, of the West Virginia State Med. Soc.,' 1871, 63. 
 10 ' Report of the State Board of Health of the State of Michigan, 1876.' 
 ^1 Tiingel (in ' Virchow's Archiv,' 1863, xxvii, 421) mentions a case of trichi- 
 nosis on board a Hamburg vessel, which had been caused by eating of the Hesk 
 of a pig shipped at ValiKiraiso. 
 '« 'Lancet,' 1881, March, 454, and 'Virchow's Arch.,' 1881, Bd. 83, 553.
 
 TiilOHlNA SPIKALIS. 311 
 
 eating- the flesli of a wild boar ; in tliis case the diagnosis 
 was confirmed by Virchow^ from specimens of the muscles 
 sent to him. As regards the occurrence of trichinosis in 
 India, I find only a brief statement that cases of it had been 
 seen in Calcutta. In Ghina, according to an unauthenticated 
 account, those of the inhabitants who do not live in cleanliness 
 suffer from trichinosis ; ^ but there is no corroboration of this 
 fact on the part of medical observers. In Algiers^ encap- 
 suled trichinae were found in a dead body in 1867,^ but there 
 is no further information about the malady there ; and all 
 reference to it is likewise completely wanting for every other 
 part of the continent of Africa. 
 
 § 107. Life-Ujstoey of the Tkichina Parasite. Anoma- 
 lous DiSTElBUTION OF TlilCHlNOSIS. 
 
 Our acquaintance with trichinosis extends, as we have 
 seen, no farther back than the year 1830. It is only within 
 the last twenty or thirty years that we have obtained a more 
 intimate knowledge of it ; although that applies to only a com- 
 paratively small part of the globe. It is all the more necessary 
 to be cautious in drawing conclusions about the oi"igin and 
 geographical distribution of the disease, or about the native 
 habitat of the parasite and its mode of diffusion over the 
 globe, inasmuch as even at the present day, despite the 
 utmost precision of research, the question as to the proper 
 and original host of the 'parasite has not been solved with 
 absolute certainty. There are two animals which enter into 
 competition for this privilege, the pig and the rat ; these are 
 by far the most frequent carriers of the parasite, and it is 
 around them that 'speculation as to the origin of the disease 
 circles. 
 
 If we bear in mind that the first authentic cases of trichi- 
 nosis in man were observed about the year 1830, and that 
 
 1 lb., 554- 
 
 2 'Lancet,' 1864, Dec, 24. 
 
 3 Borkliiin, in ' Vircliow's Arch.,' 1866, Bd. 35, 9. 
 
 ^ Gaillaril, ' Bull, ilc hi sou. de lucd. d'Algcr., 1867, vi; also ' Gaz. hebd. de 
 med.,' 1867, 654.
 
 312 GEOGKAI'HICAL AND HISTORICAL PATHOLOGY. 
 
 this incident coincided witli, or followed close upon, the 
 importation of the small Chinese breed of swine into England 
 and shortly after into North Grermany — if we hear this in mind, 
 admittino- at the same time that the trichina-disease of man is 
 caused solely by eating of the flesh of ti-ichinous pigs, we 
 shall see much that is probable in the opinion held by 
 Gerlach,^ Eupprccht^ and others, that the parasite was 
 imported with these animals into Europe, and perhaps into 
 the United States also. In support of this theoiy, Berkhan 
 calls special attention to the fact that some twenty years 
 ago, or about the time when trichinaB became known in 
 North Germany, Chinese swine were introduced for breeding 
 purposes into an estate called Schlaustedt, and into Hornburg 
 on the Brunswick frontier. This theory sets out by assuming 
 what we have no proof of, that the parasite occurs in China 
 at all. 
 
 From another side, on the assumption, namely, that the 
 rat is the proper carrier of the trichina, the pig being subse- 
 quently infected from it, it has been conjectured that the 
 appearance of the disease in Europe has to be connected with 
 the invasion of the hroion rat (Mus decumauus) from Asia. 
 But, not to mention that the " rat theory," as pointed out 
 by Zenker,^ rests upon error in any case, it has to be 
 admitted that the brown rat was met with as early as the 
 middle of the last century, whereas cases of trichinosis 
 did not occur until lone- after. It is a remarkable fact in 
 the history of the trichina-disease, and one that has not 
 been explained hitherto, that no part of the world, excepting 
 perhaps Russia and the United States, has been so severely 
 visited as North Germany. No doubt the accounts from 
 other countries are too defective to enable us to conclude 
 with certainty ; but this much holds good, that North 
 Germany has suffered from trichinosis much more than South 
 Germany, and that the Scandinavian countries, which can 
 be shown to have no lack of trichinous swine, have been 
 but slightly affected by the trichina-disease. It is obvious 
 that the reason of these variations in the amount of the 
 disease is not to be sought for in any differences in the ways 
 
 ' 'Die Tricliinen,' Hannov, 1866, p. 74. ^ L. c, p. 88. 
 
 ^ 'Arch, fiir kliu. Med.,' 1871, viii, p. 395.
 
 ANCHYLOSTOMA DUODENALE. 313 
 
 o£ living amoBg tlie nationalities in question. Whether this 
 and other puzzling problems in the history of trichinosis will 
 ever find a complete solution is doubtful, inasmuch as it is 
 hardly possible to answer the cardinal question whether the 
 first occurrence of the disease in Europe and North America 
 does in fact belong to quite recent times. Meanwhile it would 
 be a valued service to scientific i*esearch to make out the 
 extent to which trichinosis, both, of men and animals, is met 
 with in other countries besides Europe and the United 
 States of America. 
 
 Anchylostoma duodenale and the Ansemia associated with it. 
 
 § 1 08. Symptoms op the Cachexie aqueuse of West Indian 
 
 Negroes. 
 
 At the beginning of the eighteenth century the attention 
 of French, and Eug'lish observers was drawn to a very 
 destructive form of disease prevalent among- the negroes of 
 the West Indies and Guiana. One set of symptoms pointed 
 to disorder of the intestinal canal, — oppression or pain in the 
 region of the stomach, want of appetite alternating with 
 ravenous hunger, pica (or depraved taste for things inedible 
 and particularly for earthy substances), obstinate consti- 
 pation, and at a subsequent stage diarrhoea. Another series of 
 symptoms arose out of the extreme ana3mia, namely, palpita- 
 tion, dyspna?a after slight bodily exertion, small, soft, and 
 irregular pulse quickening upon active movement, coldness of 
 the skin and pallor (appeai-ing in the negro as brownisli or 
 greenish discoloration), paleness of the mucous membranes, 
 progressive weakness culminating in complete exhaustion, 
 diminution of the secretions, wasting and dropsy. Either 
 set of symptoms was characteristic, death in many of the 
 cases having been ushered in by colliquative phenomena, 
 liasmorrhages, and dropsical effusions into the meninges or 
 into the lungs. The same malady was afterwards met with, 
 as we shall see in the sequel, at other parts of the globe — in 
 Brazil, Egypt, the West Coast of Africa, and elsewhere —
 
 314 GEOGEAPHIGAL AND HISTOlilUAL PATHOLOGY. 
 
 and not only among negroes, but among people of every race 
 and nationality. According to the prominence of the 
 several symptoms, it has been variously named as follows : 
 mal d^estomac, mal de coeur, dirt-eating, hypohremia or 
 anaemia iutertropicalis, oppila9rio or con9a9o (Brazilian), 
 cachexia Africana, cachexie aqueuse (French). 
 
 § 109. Geographical Distribution of Cachexie aqueuse. 
 
 The earliest accounts of this disease are to be found in 
 the narrative of travels by Pere Labat^ of Guadeloupe, and in 
 the history of the British colonies in the West Indies by Bryon 
 Edwards ; " the latter was many years a planter in Jamaica, 
 and attributed most of the deaths among the negroes to two 
 diseases, — trismus nascentium and *' mal d'estomac." Then 
 follow numerous scientific reports^ by English, French and 
 Danish practitioners of the last and present centuries who 
 had had opportunities of observing the malady on several of 
 the JVed Indian Islands,'^ as well as by practitioners in 
 French, English and Dutch Guiana} Of somewhat later 
 date are the notices relating to this form of malignant 
 anaemia from Brazil,^ where it is prevalent over the whole of 
 the country excepting the most southern or sub-tropical 
 provinces — equally on the coast and in the valleys and 
 elevated regions of the interior. Further, we have accounts 
 of the occurrence of the disease in other parts of the 
 Western Hemisphere — in the valleys of the upper basin of 
 the Maraiion in Northern Feru^ among the natives of 
 
 ^ 'Nouv. voyage aux Isles dc rAmeriquc,' Par., 1742, ii, 11. 
 
 ^ ' Hist, of the Brit. Colon, in the West Indies,' Lond., 1793 (quoted by Imray). 
 
 3 An alphabetical list of the authorities is given at the end of the section. 
 
 ■• Hunter, Mason, Telford, Gregory and Ferguson for Jamaica ; Desportes and 
 Clievalier for Domingo; do Cordoba for Porto Kico ; Dons f or St. Thoxnas ; Grail 
 for St. Martin; Moreau de Jounes and Duchassaing for Guadeloupe; Savaresy, 
 Noverre, Carpeutin and Rufz for Martinique; Imray for Dominica; Levacher 
 for Sta. Lucia; Chisholm for Grenada; McCabe for Trinidad. 
 
 ^ Bajon and Scgond i'or Cayenne ; Kodschied and Hancock for Brit. Guiana ; 
 Cragiu, Hille, Landre, v. Leent (1. c, 1880) for Surinam. 
 
 <> Jobim, Sigaud, Ilendu and St. Hilaire, Wucherer, de Rocha, Vauvray, de 
 Moui'a, Souza-Vaz. 
 
 ' Castelnau.
 
 ANCHYLOSTOMA DUODENALE. 31 
 
 K 
 
 Sarayacu on tlio pampas of the Sacramento in Eastern 
 Bolivia,^ and, if only to a sliglit extent, among the negroes 
 in some parts of tlie Suuthern 8tates of tlie American 
 Union." In the Old World we meet with one of the more 
 considerable centres of " cachexie aqueuse " on the West 
 Coast of Africa, where it is confined to Senegambia^ and the 
 Guinea Coast/ so far as our present information enables ns 
 to judge. It is altogether doubtful whether the malady 
 occurs in Algiers^ On the other hand it is very Avidely 
 spread in iJgyjjt,^ whence we obtain those invaluable accounts 
 of cachexia Africana by Griesinger, which first threw light 
 on the nature of the disease. From the East Coast of Africa, 
 also, there are notices of it relating to the Island of Mayotte^ 
 (Comoro Group) and to the Zanzibar Coast.^ In Asiatic 
 territory, this specific form of aneemia would appear to be 
 very rare ; at all events I have found in the whole of the 
 extensive medico-topographical literature of India and the 
 East Indies only a single notice which possibly relates to it, 
 namely, one by Day for Cochin/^ 
 
 ^ Gait. 
 
 - Cliaberfc and Dunciui for Louisiana; Lyell for Alabama and Georgia. The 
 accounts cited by Heusiuger ('Die sogcmuiutc Geophiigie, &c.,' Cussel, 1852) of 
 Goddings for South Carolina, as well as the statements of Little (' Amur. Journ. 
 of Med. Sc./ 1845, July, p. 70) and Lethermau (in Coolidge's 'Report on the 
 U. S. Anuy, &c.,' Washington, 1856, p. t^t^-^), both from Florida, relate undoubtedly 
 to the malarial cachexia. 
 
 '■' Moulin, Thaly, Borius. 
 
 ■* Clarke ; also Stormont, who elsewhere confuses the disease \\'ith malarial 
 cachexia. 
 
 ^ The account by Catteloup ('Mem. de med. milit.,' 1852, viii, i), to whicli 
 Heusinger makes reference, relates to malarial cachexia. Langg, who speaks 
 also of the prevalence of cachexia Africana among the French troops in Algiers 
 ('Bibl. for Laeger,' 1847, ^^'^^■' P- 290), says:— " Sumpfebrene ere derfor endnu 
 stadigt Armeens Svobe, isaer da det Mandskab, sora overstaaer dem, efter flere 
 Recidiver naesten aden Undtagelse angribes af deu afrikanske Kachexie." 
 
 * Sonnini, Savaresy, Hamont et Fischer, llOser, Pruner, Clot- Bey, Griesiuger, 
 Isambert. 
 
 ^ Monesticr, Grcnet. 
 
 ^ Lostalot-Bachoue. 
 
 ^ The notices which Heusinger quotes from Bontius (' Medicina Indorum,* 
 cap. xi) for Java, and from Twining (' Clin, lllustr. of the Diseases of Bengal,' 
 2nd cd., Calcutta, 1835, i> .SQO)) refer undoubtedly to malarial cachexia. When 
 this sheet was in the press, 1 found a notice rjy McConnell (' Lancet,' 1882, July, 
 p. 96), according to which he had seen since 1879 twenty cases of anchylostoma 
 in persons who had died of severe malarial disease, dysentery, pneumonia and
 
 316 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 The authorities for the countries of Nearer and Central 
 Asia (Syria, Arabia, Persia, &c.), as well as for China and 
 Japan are quite silent about it. In the East Indies, how- 
 ever, it is met with ; beiug somewhat frequent, as Van Leent 
 states, among the convicts working in the mines in Borneo. 
 
 In Europe, the disease on a considerable scale has been 
 observed hitherto in only one country, namely, Italy. The 
 first information about it from that country is in the account 
 by Volpato, -who met with it in several rural communes of 
 the district of Treviso {Venetia), especially in children; 
 he described it under the name of " allotriofagia " = " man- 
 giare sostanze non alimentari,'^ knowing nothing at the time, 
 of the writings of previous observers.^ Thereafter came 
 accounts of isolated cases at Ponte Buggianese^ and Florence' 
 (Tuscany), at Tui'iu*' {Piedmont), and at Cesena'^ (Province of 
 Forli in the JEmilia). But it is in Lomhardy that the 
 disease is most widely spread, and indeed truly endemic, 
 particularly in the provinces of Milan and Pavia ;® and to 
 that focus of the sickness there belongs the very severe 
 and often described^ outbreak of the disease among the 
 labourers employed in making the St. Gothard tunnel, 
 an outbreak which did not spare the workmen even on the 
 northern or Swiss side of the mountain. ^° 
 
 It is probable that the area of the malady extends farther 
 than we at present know, as Perroncito, Grassi and Parona, 
 
 the like. In only eiglit of these was there anajmia; and the author would assign 
 the cause of that condition, not to the parasitic trouhle, but to the diseases above 
 ineutioned. He had never seen blood in the stools in these cases. 
 
 1 L. c, 1867. 
 
 - Bugnion (' Eevue nied. de \x Suisse rouiande,' 1881, Mai, p. 274) mentions a 
 case of the disease observed in 1879 by Roth of Easel in a man who served a 
 long time as a soldier in Java and Borneo, and had returned to Europe invalided 
 in 1878. 
 
 ^ Ileschl gives an account of a case of the same kind, observed at Vienna, in a 
 miner who had been born and had lived in Lower Austria; the disease had been 
 contracted, as Heschl thinks, during a somewhat prolonged stay at Udiue, 
 which is also in Venetian territory. 
 
 •* Morelli. * Sonsino, 
 
 ^ Bozzolo, ' Giorn. internut.,' 1. c. '' Cantu. 
 
 ^ Grassi c Parona, Ciniselli. Perroncito (' Ilevue med.,' 1. c.) also gives an 
 iiccount of a case which he saw at Mantua. 
 
 3 Concato, Perroncito, Bozzolo e Pagliaui, Parona, Pistoni. 
 
 1" Souderegger, Bilumler, Schonbiichler, Immermann (in Bugnion, 1. c, 274).
 
 ANCHYLOSTOMA DUODENALE. 317 
 
 Bozzolo and others ai^e inclined to think. Perroncito^ has 
 learned from Messieurs Shillinger and Thot that the same 
 disease has been seen among the miners in Kremnitz and 
 Schemnitz (Himr/arij) ; and the evidence that ho adduces of 
 its occurrence among the miners at St. Etienne in France 
 (Dept. Loire), has recently been confirmed in a paper by 
 Trossat and Eraud.^ It would thus appear that there is 
 good foundation for Perroncito's opinion, based on the 
 observations made hitherto, that many cases of the so-called 
 '^miners' disease'^ fall to be included under this form of 
 anaemia, and that the further experiments and post-mortevi 
 observations which have been instituted specially with a view 
 to the etiological questions referred to below, may be 
 expected to result in a considerable extension of the area of 
 distribution, and in the annexation of a good many of the 
 cases now classed as '^idiopathic anaemia.'^ 
 
 § no. The Cachexia proved to be associated with Anchy- 
 
 LOSTOMA DUODENALE. 
 
 As to the cause of tJie ■yualadij, the views obtaining down 
 to the latest date have been very obscure ; and the obscurity 
 has been all the greater that the disease has been confused 
 with other forms of sickness characterised by the phenomena 
 of general cachexia, more particularly with the malarial 
 cachexia. 
 
 This error occurs, as we have seen, in many of tlie older autLors,. 
 particularly in Heusinger, who has actually named the disease 
 " malarial chlorosis." More recent observers also, such as Duchassaing,. 
 and even some among them, such as Marchand, who are not un- 
 acquainted with the true cause of the malady, confound it with malarial 
 cachexia. The most decisive fact is that the morbid conditions 
 of the abdominal viscera (liver and spleen) which are peculiar to 
 the malarial cachexia, have never been found, the accounts given 
 even by the earlier observers (Dons, Rendu, Segond, Mason, Pruner 
 and others) bearing witness to this. Another pertinent fact is that the 
 disease has been met with especially often in the negro, who, it is well 
 known, enjoys a decided immiinity from malaria. 
 
 ' ' Ceutralbl. fiir die med, Wissensch.,' 1. c. 
 * 'Lyon med.,' 1882, Nr. 25, 217 ff.
 
 818 rxEOGRArillCAL AND HISTOPJCAL PATHOLOGY. 
 
 At first it was believed that the occurrence o£ the disease 
 among uegroes could be explained by their practice (aris- 
 ing either out of bad habit or of a suicidal purpose) of 
 eating dirt or other indigestible substances.^ Others laid 
 the stress upon malarial influences^ and still others upon in- 
 sufficient or bad food, chills, bad sanitation, depressed states 
 of feeling (home- sickness), and the like. Griesinger was 
 the first to throw light upon the nature of the " cachexia 
 Africana,'^ when he showed from his observations in Egypt 
 in the case of fellahs and soldiers, that we had here to do 
 with a parasitic tnalady, — with the presence of AncJiylostoma 
 duodenale in the intestinal canal of the patient, and with the 
 effects resulting therefrom. 
 
 Tlie i^avasite, as is known, was first described by Dubini- of Milan in 
 1843, having been found by him post-mortem in a considerable number 
 of bodies. Pruner^ afterwards mentioned that he had found it in 
 patients in Egypt; and although he adds that "among adults, it is 
 particularly the cachectic, dropsical, and scrofulous who suffer from 
 Anchylostoma duodenale," he did not arrive at a correct view of the 
 relation between the parasites and the " cachexie aqueuse " which he 
 had himself described (1. c, p. 324). Bilharz* discovered the parasite 
 in Egypt anew; and it was in conjunction with Bilharz that Griesinger 
 developed his doctrine of the pai-asitic nature of cachexia Africana. 
 
 This discovery of Griesinger's was afterwards corroborated 
 by Wuclierei', Vauvray, Sonza-Vaz, and other's with respect 
 to the Brazilian disease previously known under the name of 
 '^'^ hypohsemia intertropicalis," or " oppilacao." Vauvray 
 remarks that, since attention had been called to the 
 circumstance by Wucherer, the worm had been found in 
 every case of cachexie aqueuse in Brazil which ended fatally. 
 Further confirmation of the fact was supplied by the 
 inquiries of Camuset and Kerangal-Riou in Cayeune, the 
 latter remai'king that although he leaves it undecided 
 whether the negro disease known as "^ mal de coeur " is 
 
 ' Tliis is a transposition of effoefc and cause. Pica is known to occur often in 
 chlorotic women; and, moreover, it is not an invariulile sign of the disease which 
 we are considering. It has been noted also by Marehand as a symptom of dis- 
 ease among the French convicts in Cayenne; and Volpato, as we have seen, has 
 observed it in Treviso. 
 
 * ' Anuali univ. di med.,' 1843, April 5. 
 
 ^ ' L. c, 244. 
 
 4 'Zeitschr. fur wissenschaftl. Zoologie,' 1852, iv, 55.
 
 ANCIIYLOSTOMA DUODENALE. 319 
 
 exactly covered by the paT^asitic malady, yet lie could give 
 his assurance tliat he had not missed finding the parasite in 
 the intestine in a single case which had ended fatally with 
 the symptoms of that kind of ana3mia, whether the patient 
 were a negro or of another race. The same opinion has 
 been expressed by Monestier and Grenet for Mayotte, by 
 Borius for Senegambia, by Cautu for Cesena, by the whole 
 of the Italian and Swiss physicians who have observed the 
 disease among the workmen at the St. Gothard tunnel, as 
 well as by Perroncito^ and by Trossat and Eraud for the 
 miners of St. Etienne. Indeed the most recent observations 
 go to show that the diagnosis does not rest merely upon 
 finding the woi'm 'post -mortem, but may be also based upon 
 the detection of its eggs in the patient's evacuations. 
 
 The parasite liangs on to the intestinal mucous membrane of its host 
 and sucks its nourishment from the blood. Enormous numbers of 
 them, increasing up to several hundreds, take up their abode in the 
 intestine; hence the explanation of the symptoms of irritation in the 
 digestive organs as well as the symptoms of ever-increasing anaemia. 
 
 §111. Circumstances favorable to the Introduction op the 
 
 Parasite. 
 
 The diffusion of the disease, therefoi'e, is dependent solely 
 on the existence of the parasite and on its introduction 
 into the human organism. According to Leuckart's^ 
 showing for Dochmius trigonocephalus of the dog, and 
 Perroncito's for the Anchylostoma duodenale of man, the 
 mature eggs of the worm, on their discharge from the 
 patient's intestine, undergo their first development in wet 
 soil, being especially favoured by high temperature ; and 
 thus the parasite comes in its larval stage, and doubtless by 
 the medium of the drinking-water, into the human intestine, 
 where it completes its development. We thus explain 
 without difficulty how important for the occurrence of 
 cachexie aqueuse are certain states of soil, and certain 
 
 ^ In the snhjocts which lie oxamiiied, Perroneito found, besides Anchylostoma 
 duodenale, also Anguillula stcrcoralis :ind A. iutcsliiialls. See the next section. 
 2 L. c, ii, 433.
 
 320 aEOGRAPITTOAL AND HISTORICAL PATEOLOGY. 
 
 modes of life, which have often in former times had an 
 erroneous part in the causation assigned to them. Inas- 
 much as the development of the lai'va from the egg- depends 
 essentially upon dampness of the soil, the prevalence of the 
 disease on marshy ground becomes intelligible ; although 
 the malady has not on that account anything to do with 
 the malaria which exists or may develop in or upon the 
 ground. 
 
 Another fact explained by the natural history of the para- 
 site is that the anchylostoma disease is much commoner in 
 the country than in tovms where the drinking-water would 
 be drawn chiefly from deep wells or large conduits. This 
 applies especially to those dwellers in the country wbo are 
 occupied in gardening or farming, as well as to navvies, 
 miners, and the like, who are oftenest exposed to infection 
 on account of taking their drinking-water from shallow 
 pools and water-coiirses. Many examples of this are 
 furnished by Wncherer for Brazil, by Bozzolo for Turin, by 
 the Italian and Swiss practitioners from cases occurring 
 among the workmen employed at the St. Gothard tunnel, 
 and by Perroncito and Trossat for St. Etienne. 
 
 Bozzolo points out, with reference to tlie endemic prevalence of tbe 
 parasite among tbe workmen at the bi'ickworks in tbe neigbbourbood 
 of Turin, tbat these men live with tbeir families close to the brickworks; 
 that tbey get tbeir water supply from springs tbat collect and form 
 puddles in tbe loose soil ; and further, tbat tbey go straight to tbeir 
 meals from digging out tbe clay or from kneading tbe bricks, and are 
 accordingly exposed to tbe risk of introducing tbe larvae of tbe parasite 
 into tbeir mouths by tbeir unwashed bands.^ 
 
 The less careful a person is in the matter of cleanliness 
 in general, the more is he exposed to the risk of introducing 
 the parasite ; and it is this that explains the fact of the 
 anchylostoma disease being rare among the classes in better 
 circumstances, and confined mostly to the proletariat and the 
 worlilng class ; accordingly, where the population is a 
 
 ' I mny direct attention licre to a notice by Riilile (' Deutsclie med. Wochen- 
 schr.,' 187S, No. 46, p. 571) of ii i'orni of " pernicious anaemia" which he observed 
 in the neighbourhood of Bonn among persons occupied in brick-making, and to 
 which he accordingly gave the name of " bricker's anajmia." In one of the 
 cases with a fatal issue, the anatomical examination showed nothing remarkable. 
 The question arises whether the intestine had been searched carefully enough.
 
 ANCHYLOSTOMA DUODENALE. 321 
 
 mixture of nationalities^ it prevails especially among those 
 races and nationalities which consist mainly o£ the latter 
 class. Ou the other hand we may gather from the facts 
 stated in the foregoing sketch of the disease that circum- 
 stances of race and nationality do not of themselves occasion 
 either a predisposition to the disease or immunity against it. 
 A question leading to an interesting train of speculation 
 has been raised by Sonderegger, whether, namely, the 
 occurrence of anchylostoma among the workmen on the 
 Swiss side of the St. Gothard tunnel may not be attributed 
 possibly to transmission of the i^arasite by Italian workmen 
 who had acquired the malady at home. He supposes that 
 the eggs of anchylostoma which are present in the dejecta 
 of Italians suffering from the disease would reach the mud 
 of the water-channels in the tunnel, and that the Swiss 
 workmen and engineers would acquire the infection through 
 their hands and faces getting bespattered with the contents 
 of these channels, and perhaps also through the food getting 
 polluted. The possibility of such a sequence of events 
 cannot well be contested ; and we may be permitted to 
 conjecture that the disease can show itself, and attain to 
 general diffusion, in localities where the parasite is not indi- 
 genous, but in which it finds the conditions required for its 
 development. All that has been learned hitherto of the 
 history of the anchylostoma disease, does not enable us, 
 unfortunately, to decide whether a diffusion of the disease 
 has already taken place anywhere after that fashion. 
 
 List of Wiuters on Anchylostoma duodenale. 
 
 I3aumlci', Correspdzbl. fiir Scliwelzer Aerzte, iSSi, S. lo. Bajon, Nachr. 
 zur Gesch. von Cayenne, from the French. Erfurt, 1780, iii, 11. Borius, 
 Arch, de meJ. nav., 1SS2, Mai, 372. Bozzolo, Giorn. dellasoc. Ital. d'igiene, 
 i88o, ii, Nr. 3, 4 (in conjunction with Pagliani) ; and Giorn. internaz. delle 
 sc. med., 1880, Nr. 10—12. 
 
 Camuset, De I'ancmie trop. observ. a la Gujane fran9. Montp., 1868. 
 Oantu, lil vista clin. di Bologna, 1882, 70. Carpentin, Etud. hygien. et mcd. 
 du camp Jacob, etc. Par., 1873, 44. Casteluau, Expedition, etc., iv, 396. 
 Ohabert, Reflex, sur la malad. spasmod.-lipyrienue, etc. New Orleans, 1820, 
 
 21
 
 322 GEOGRAPHICAL AND HISTOETOAL PATHOLOGY. 
 
 1 88. Chevalier, Lettres sur les malacl. de St. Domingue. Par., 1752, 7. 
 Chisholm, New York med. Eeposlt. Eeprint in Lond. Med. and Phys. 
 Journ., 1799, ii, Nr. 6. Ciniselli, Annal. uiiiv. di med., 1878, Oot., 389. 
 Clarke, Transact, of the Epidemiol. Soc, i860, i, 114. Clot-Bey, Compt. 
 rend, de I'etat de I'enseignement med en Egypte. Par., 1849, So. Concato, 
 Compt. rend., 1880, Nr. 11, 619 (in conjunction with Perroncito) ; and Giorn. 
 della soc. Ital. d'igiene, 1880, ii, 3, 4. Cordoba, Memor. geogr. de la isla de 
 Puerto-Rico. Sanmiltan, 1831. Cragin, Amer. Journ. of Med. Sc, 1836, 
 Pebr., 356. 
 
 Day, Madras Quart. Journ. of Med. Sc, 1862, Jan., 38. Desportes, Hist. 
 des malad. de St. Domingue. Paris, 1770, ii, 15. Dons, Jorn. for med. og 
 chir., 1833, iii, 297. Duchassaing, Gaz. mod. de Paris, 1850, 684. Duncan 
 in Fenner's South. Med. Reports, 1849, i, 194. 
 
 Ferguson, Jamaica Phys. Journ., 1836, Jan. 
 
 Gait, American Journ. of Med. Sc, 1872, Oct., 403. Grail, Essai de 
 topogr. med. de I'ile de St. Martin. Par., 18315, 29. Grassi, Annotaz. 
 cliniche sull' anchilostoma duod. Pav., 1878 (in conjunction with Parona) ; 
 and Annal. univ. di med., 1879. Guigno, 407. Gregory, Midland Med. and 
 Surg. Reporter, 1831, Aug. Grenet, Arch, de med. nav., 1867, Juill, 70. 
 Griesinger, Arch, fiir physiol. Hlkde, 1854, xiii, 555. 
 
 Hamont and Fischer, Mem. de I'Acad. de med., 1835, iv, Nr. i. Hancock, 
 Edinb. Med. and Surg. Journ., 1831, Jan., 67. Heschl, Wien. med. Presse, 
 1876, 925. Hille, in Casper's Wochenschr. fiir Hlkde., 1845, 106. Himter, 
 Obs. on the Diseases of the Army in Jamaica. 2nd Ed., Lond., 1796. 
 
 Imray, Edinb. Med. and Surg. Journ., 1843, April, 304. Isambert, Gaz. 
 med. de Paris, 1857, 234. 
 
 Jobim, Discurso sobre as molestias . . de Rio de Janeiro. Rio, 1835, 27. 
 
 Landre, Tijdschr. voor de Geneesk., 1852, 451. v. Leent, Arch, de ra6i. 
 nav., 1867, Oct., 245, 1880; Nov., 402. Levacher, Guide med. des Antilles. 
 2nd Ed. Par., 1840, 251. Lostalot-Bachoiie, Etude sur la constit. phys. ct 
 med. de I'ile de Zanzibar. Par., 1876, 52. Lyell, Second Visit to the U.S. 
 Lond., 1849, ii, 7. 
 
 Marchand, Des causes et du traitement de I'anemie chez les transportcs ;\ 
 la Guyane frauQ. Montp., 1869. Mason, Edinb. Med. and Surg. Journ., 
 1833, July, 289. McCabe, ib., 1818, Nov., 596. Monestier, Arch, de med. 
 nav., 1867, Mars, 209. Moreau de Jonnes, Journ. de med. par Leroux, 1816, 
 Mai, 15. Morelli, Lo Sperimentale, 1878. Gennaio, 27. Moulin, Pathol, 
 de la race negre, etc. Par., 1866, 20. de Moura, Gaz. med. deBahia, 1872, 
 quoted by Gaz. med. de Paris, 1872, 477. 
 
 Noverre, Journ. hebd. de med., 1833, Oct., 160. 
 
 Pagliani, see Bozzolo. Parona, see Grassi ; and Annali univ. di med., 1880, 
 Sept., 177; Nov., 464. Perroncito, see Concato; and Gaz. dello clin. di 
 Torino, 1880, Nr. 6; Compt. rend., 1880, vol. 90, Nr. 23; II Morgagni, 
 1880, April, 297; Guigno, 452; Revue med. de la Suisse romande, 1881, 
 163; Centralbl. fiir die med. Wissensch., 1881, Nr. 24, 435. Pistoni, 
 Rivista clin. di Bologna, 1880,335. Pruner, Krankh. des Orients. Erlang., 
 1846, 324. 
 
 Rendu, fitud. topogr. et mod. sur le Brcsil. Par., 1848, 109. Riou-
 
 ANGUILLULA STERCORALIS. 323 
 
 Kerangal, Arch, tie med. nav., 1868, Oct., 311. de Rocha, Arch. derHlkde., 
 1868, ix, 178. liodschied, Bemerk. iiber das Ivlima und die Krankh. von 
 Rio Essequebo. Fkft. a. M., 1796, 260. Roser, Ueber einige Ivrankb. des 
 Orients. Augsb., 1837, 48. Rufz, Arch, de med. nav., 1869, Nov., 344. 
 
 Savaresj, De hi fievre jaune. Naples, 1809, 13. Schonbachler, Cor- 
 respondzbl. fiir Schweizcr Aerzte, 1881, Nr. 3, 13. Segond, Transact, med., 
 1833, xiii, 156, and Journ. hebd. des sc. med., 1835, Mars, Nr. 13. Sigaud, 
 Du climat et des mahad. du Bresil. Par., 1844, 129, 315. St. Hilaire, 
 Institut. Sc. physic., 1849, Nr. 45, 86. Sondoregger, Correspondzbl. fiir 
 Schweizer Aerzte, 1880, 393, 431, 646. Sonnini, Reisen in Egypteu, from 
 the French, ii, 385. Sonsino, L'Imparziale, 1878. Maggio. Souza-Vaz, 
 Journ. de therap., 1878, Nr. 22 — 24. Stormont, Topogi'. med. de la cote 
 oecid. de I'Afriqne. Par., 1822,57. 
 
 Telford, Lond. Med. and Phys. Journ., 1822, June, 450. Thaly, Arch.de 
 med. nav., 1867, Septbr., 179. 
 
 Vauvraj', ib., 1869, Mai, 339. Volpato, Gaz. med. Lombarda, 1848,49. 
 
 Wuchercr, Gaz. med. de Bahia, 1866, Nr. 3 — 6; 1867, Nr. 27, 28; and 
 Arch, fiir kiln. Med., 1872, x, 379. 
 
 Anguillala stercoralis and the Endemic Diarrhoea of Cochin 
 
 China. 
 
 § 112. Question op the Relation between the Diaeehcea • 
 
 AND THE PaEASITE. 
 
 Various opinions^ it is well known, are lield by observers 
 as to the etiology of the pernicious chronic intestinal catarrh 
 that occurs in many parts of the tropics. In so far as the 
 question concerns the diarrhoea of Cochin China, of specially 
 evil repute, Normand^ thinks that he has solved it by the 
 detection in the patient's intestine of a parasite belonging to 
 the class of the Angnillul^, to which he has given the name 
 of Anguilltda stercoralis. As physician to the naval hos- 
 pital St. Mandrier at Toulon, he has had many opportunities 
 of observing patients who had acquired that form of diar- 
 rhoea in Cochin China and had been invalided home ; and he 
 is convinced that this parasite is present in almost every case, 
 and often in enormous numbers. 
 
 ^ 'Compt. reud.,' 1876, vol. 83, 316, and ' Avcli. de med. nav.,' 1877, Janv., 35, 
 Fcvr., 102.
 
 324 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Bavay,' who has given an account of tlie natural liistoiy of 
 Anguilhda stercoralis, found along with it in the patient's intestine, but 
 in smaller quantity, a large and a small variety of another worm which 
 he designates Anguillula iritestiuaUs to distinguish them from the 
 other. 
 
 According to Normand, the parasite discovered hy him 
 occurs only in the Cochin China diarrhcca^ being invariably 
 absent in other cases of acute or chronic intestinal catarrh ; 
 and this statement Laveran" has been able to confirm in 
 every respect through his investigation of patients returned 
 from Cochin China. Dounon^ also has found the parasite 
 under the same circumstances, associated with still other 
 intestinal worms (Strongylus, Oxyuris, &c.) ; and, in his 
 view, there are no fewer than six parasites concerned in pro- 
 ducing the Cochin China diarrhoea. 
 
 There can be no doubt, after what has been said and 
 remains to bo said, of the existence of the entozoon 
 under consideration and of its peculiar characters ; but it 
 remains an open question whether the worm is indeed to be 
 considered the true cause of the disease, and not rather a 
 more or less accidental epiphenomenon. The latter view is 
 the one adopted by Liberman,* who declares the anguillula 
 to be not the cause, but the consequence of the intestinal 
 malady, inasmuch as the parasite would find a good feeding 
 ground in. the catarrhal secretions of- the intestine. Chas- 
 tang,^ who gives a full account of some twenty-two cases of 
 chronic diarrhoea observed by him in Saigon (Cochin China), 
 concludes from his observations that the parasite is found 
 only in exceptional cases even in the native habitat of the 
 disease. His words are : 
 
 " Pour ma part (et beaucoup des medecins de Cochin- 
 chine avaient la memo opinion que moi) je ne crois pas 
 encore a I'origine parasitaire de la diarrhee parce qu'on ne 
 trouve presque jamais (pour ne pas dire jamais) I'Anguillule 
 dans la periode d'invasion de la maladie en Cochinchine ; et 
 
 ^ lb., 1877, Janv., 36, Juill., 64. 
 " 'Gaz. hcbd. de uied.,' 1877, Nr. 42, 116. 
 
 3 'Traitemeut de la diaiThee de Cocbiucluue ct de scs affectious parasitaires,' 
 Toulon, 1877. 
 
 * 'Gaz. des liopit.,' 1S77, p. 237. 
 
 * 'Arch, do nied. iiav./ 1878, Juill., p. 29.
 
 ANGUILLULA STERCORALIS. 325 
 
 je croix, ou je serais peut-etre mieux porto ;i penser, quo ce 
 parasite n'est qu'une comcidence ou uu resultat des desordres 
 organiques des tuniques iutestinales, parce que c'est h la 
 periode d^etat ou d'aggravatiou que nous I'avons trouvee 
 quelquefois h Saigon^ et qu'on I'a observee si freqnemment 
 a Phopital Saint-Maudrier/^ 
 
 Beaufils^ also is unable to decide from his experience at 
 
 Vinli-Long (Cocliiu China) whether the parasite is the cause 
 
 or an accidental concomitant of the disease. . Mahe" found the 
 
 anguillula in only a few of the patients admitted into the 
 
 hospital at Brest with Cochin China diarrhoea ; and Chauvin/ 
 
 who succeeded Normand in the naval hospital at Toulon, 
 
 found it only twice in eight cases, while he met with it also 
 
 in two patients with chronic diarrhoea who had been 
 
 invalided home from Martinique, A particular interest 
 
 attaches to the case g'iven by Eyssantier/ of a navy surgeon 
 
 who was admitted into hospital at Toiilon suffering from the 
 
 diarrhoea of Cochin China ; neither Normand nor Bavay had 
 
 been able to find the parasite in the stools, and it was not 
 
 until the patient had been three years in France and was 
 
 convalescent, that the anguillula began to appear in the stools 
 
 in considerable numbers. Lastly, it is worthy of note that 
 
 Perroncito^ has lately found the Anguillula stercoralis and 
 
 intestinalis in several Italian workmen suffering from anchy- 
 
 lostoma, who had been employed in making the St. Gothard 
 
 tunnel. 
 
 The importance of Normand's discovery would, therefore, 
 appear to be a good deal open to question. A safe con- 
 clusion upon it is not to be looked for until further observa- 
 tions have been made, not only in Cochin China, but also in 
 other tropical countries subject to chronic intestinal catarrh. 
 
 ^ lb., 1882, Avri], p. 264. 
 
 2 lb., 1879, Mai, p. 347. 
 
 3 lb., 1878, Fevr., p. 154. 
 
 * ' L'hopital maritime de Saint-ManJrier (pres de Toulon) pendant I'annee 
 1878,' Paris, 1880, p. 29. The author gives a second case of Anguillula stercoralis 
 in a patient who had returned from Martinique with chronic diarrhoea. 
 
 ^ 'Compt. rend.,' 18S0, and 'II Moi-gagui,' 1880, 11. cc.
 
 326 GEOGRArnrcAL and histouical tathology. 
 
 Filaria sanguinis hominis. 
 
 § 113. Importance of Lewis's Discovery. 
 
 One of the most interesting discoveries of recent parasit- 
 ology, wliicli may be set beside the pioneering work of 
 Griesinger on the distoma disease (or the endemic haematuria 
 of Egypt and the Cape due to that parasite) , is the detection 
 of a species of filaria in the vascular system of man. This 
 filaria was first discovered in Brazil by Wucherer, in the urine 
 of haematuria ; it was afterwards detected by Timothy Lewis, 
 in India, in the blood of patients suffering from hasmaturia, 
 and was named by him Filaria sanguinis liominis. A long 
 series of investigations have yielded facts of a remarkable kind 
 as to the nature or life-history of tbc parasite, and as to its rela- 
 tions to other forms of disease, all of them pointing to aifec- 
 tion of the lymphatic system. In view of these discoveries 
 one cannot forbear conjecturing that many other diseases of 
 the tropics, which have hitherto remained obscure in their 
 origin, may find their explanation in the detection of this same 
 filaria. The interest attaching to this discovery, therefore, 
 would warrant us in going more minutely into the history of 
 it than the scope of the work demands. 
 
 § 114. History op the Researches on Endemic Hjjmaturja 
 
 AND Chyluria. 
 
 The first accounts of endemic livematiiria and chyluria date 
 from 18 12, in which year Chapotin published a paper on the 
 occurrence of the disease in the Mauritius.^ His information 
 was afterwards confirmed by Salesse and Rayer, and amp- 
 lified by accounts of the same endemic malady in Reunion 
 by Quevenne and Mazae-Azema. About the same time the 
 
 ^ A list of the authors quoted is given in alphiibctical order at the end of the 
 section.
 
 riLAEIA SANGUINIS HOMINIS, 327 
 
 attention of practitioners was drawn to the disease in Brazil, 
 where it had long been known to exist ; and an ani- 
 mated discussion took place at the Medical Society of Rio 
 on August 15th, 1835, which was, however, pervaded by- 
 obscure views as to the nature of the malady.^ Even in the 
 subsequent notices of haematuria and chyluria in Brazil by 
 Sigaud, Juvenot, and Plagge, we find no progress towards 
 an understanding of the disease ; and it was not until 1 866 
 that Wucherer furnished an explanation of the nature of this 
 peculiar affection by proving that a parasite occurred in the 
 bloody urine of the patients. Stimulated by Griesinger's 
 discovery of the Distoma haematobium in the hsematuria 
 of Egypt, he searched for the ova of that parasite in the 
 urine of patients suffering from haematuria at Bahia. 
 He failed to find them ; but in their place he found an 
 extremely delicate thread-like worm, belonging to the group 
 of Nematodes. At first he attached no material importance 
 to this discovery ; but subsequent observations taught him 
 that the parasite was an invariable factor in the disease, and 
 two years later (1868) he made his discovery public. It 
 found support at once in the clinical history published by 
 Crevaux of a creole patient in Guadeloupe, who was subject 
 to chyluria. 
 
 Meanwhile Lewis, before he could possibly know anything 
 of the discovery of Wucherer, had found, at Calcutta in 1868, 
 in the urine of a patient suffering from chyluria " the embryo 
 of a nematoid worm, which may give a clue to one cause of 
 this curious malady. ^'^ Two years later he detected the same 
 larval worm in the blood of a patient with chronic diarrhoea,^ 
 and after another interval of two years he found it both in 
 the blood and in the lymphatic fluids of persons suffering 
 from elephantiasis of the legs or scrotum, as well as in the 
 blood of hasmaturic patients.^ From these various observa- 
 tions Lewis concluded that it was no mere accidental coinci- 
 dence which he had come upon, but that an intimate connexion 
 subsisted between the chyluria and the elephantiasis — such as 
 
 1 See the report of it in the 'Kevista med. flum.,' 1, c. 
 
 ^ 'Annual Report of the Sanitary Commissioner for India,' 1869. 
 
 3 'Report,' 1872. 
 
 ■• • Report,' 1874, and in ' Indian Annals.'
 
 328 aE0C4KAriIICAL AND HISTORICAL PATHOLOGY. 
 
 had already, indeed, been indicated by Simoni, Jobim, and 
 other practitioners in Brazil/ by Mazae-Azema in Reunion,, 
 and particularly by Vandyke Carter in India. ^ Lewis's 
 conclusion was that to'O^ncal hcemnturia (not including tlie dis- 
 toma disease) and lymphatic elephantiasis were parasitic mala- 
 dies which depended on the presence of the toorm named hy 
 him Filaria sanguinis liominis ; and lie added b}^ way of conjec- 
 ture, tliat tliey were brought about through the blocking of 
 the smallest blood-vessels and lymphatics by the parasites. 
 These observations were followed by the paper of Sonsino, 
 who found the filaria in Egypt, in the first instance in the 
 urine of a hfematuric patient (1874) and afterwards in the 
 blood of a person affected with elephantiasis of the scrotum. 
 Next came the discovery of the parasite in the negro skin, 
 disease called " craw-craw " (of which more in the sequel) by 
 O'Neill, on the West Coast of Africa, and by Aranjo^ at Bahia; 
 and lastly Winckel's detection of it in the chylous ascitic 
 fluid drawn from a woman who had lived for ten years in 
 Surinam. 
 
 Manson, who was occupied with an inquiry on the occur- 
 rence of filaria in Amoy (China), was led by what Lewis 
 taught of the filaria-disease to amplify the view of it somewhat; 
 he showed* that the parasite was found not only in hasma- 
 turia (or chyluria) and elephantiasis but also in other forms 
 of disease dependent on affections of the lymphatic system — 
 in the condition named by him lymph-scrotum, in chylous 
 hydrocele, varicocele, &c. ; that it was not so much a matter 
 
 1 See ' Revista med. fliiui.' It is not improbable that tlic form of disease 
 described by Bonrel-Ronciere ('Arch, de nied. nav.,' 1873, Mai, p. 33s) under 
 the name of "Lymphangitis primitive de Rio de Janeiro," or of "erysipele de 
 Rio de Janeiro," is to be included herewith. 
 
 ^ Carter gives a case of chyluria (or hanuaturia) accompanied with varix 
 lymphaticus and elephantiasis, and he explains the connexion between those three 
 affections in this wise, that, if we suppose a certain feebleness in the walls of the 
 lymphatics and blood-vessels, these would become varicose under the pres- 
 sure of the contained fluid, would rupture in the end, and so give rise to an 
 escape of lymph or blood into the kidneys, ureters, or bladder. We meet with 
 the same view in the writings of later observers, who were acquainted with the 
 filaria and were in a position to associate the lesions of the vessel- walls with that 
 parasite. 
 
 3 'Memoria,' 1875. 
 
 '' 'China Customs' Gazette,' and 'Med. Times,' 1S75, J- f^-
 
 riLAEIA SANGUINIS HOMINIS. 329 
 
 of blocking the blood-vessels but ratliei' of stopping up the 
 larger lymphatic vessels^ perhaps even the thoracic duct 
 itself in certain circumstances ; that this blockings however^ 
 could not be caused by the larva) of the parasite (which were 
 the only form of it hitherto seen by any observer) inasmuch 
 as these were so very minute that they could pass through 
 the smallest vessels with ease ; but that it was here a question 
 of the parent animal or the mature parasite, which had 
 hitherto eluded all attempts to find it. Shortly after the pub- 
 lication of Hanson's paper, this defect was supplied through 
 the observations made almost simultaneously by Bancroft^ in 
 Brisbane (Queensland), by Lewis" in Calcutta, by Silva 
 Aranjo^ in Bahia, and by Dos Santos in Rio. Bancroft 
 found the matui-e parasite first in a lymphatic abscess on 
 the arm, and in a case of hydrocele ; afterwards^ in tumour- 
 like enlargements of the lymphatic glands, in orchitis,, 
 lymphangitis, &c. Lewis detected it first in a case of vari- 
 cose elephantiasis of the scrotum, within a blood-clot that 
 had formed after the swelling had been incised ; along with 
 it he found numerous embryos in the varicose lymphatic 
 vessels and in the fluid of a co-existing hydrocele. Dos 
 Santos found it in a lymph-abscess on the arm ; and Silva 
 Aranjo met with it in a patient who had suffered from 
 haBmaturia for several years, had afterwards become affected 
 with elephantiasis of the scrotum, and had finally developed 
 the skin disease above referred to under the name of " craw- 
 craw." Quite recently Hillis has found the pai-ent animal 
 in the urine of a hajraato-chyluric patient belonging to 
 Demerara. 
 
 § 115. LiFE-HlSTOKY OF FjLAlilA : THE MoSQUITO ITS INTER- 
 MEDIATE IIOST ; PElilODICITY OP THE PHENOMENA. 
 
 These facts having been ascertained (and in part confirmed 
 and amplified by Cobbold, Fayrer, and other authorities in 
 Europe^ in examining the preparations sent to them from the 
 
 1 L, c, 1877. -' li. c, 1877, p. 78. 
 
 3 'Gaz. da I5ahia,' 1877, 1. c. ^ 'Pathol. Trans.,' 1879, p. 407.
 
 330 GEOGRAPHICAL AND niSTORICAL PATHOLOGY. 
 
 tropics) tlie question next arose^ Jioiv does tJic parasite finds its 
 way into ilie human hodij ? Bancroft, in a letter to Cobbold,^ 
 liadj witli mucli acuteness, propounded the question wlietlier 
 the mosquito did not play an important part in these events : 
 " I have wondered/' he says, " if mosquitoes could suck up 
 the hcematozoa and convey them to water. They appear to 
 die in water. I will examine some mosquitoes that have 
 bitten the patient to see if they suck up the filaria3." The 
 question was answered in the affirmative a few months later 
 by Manson/ and placed on a basis of exact investigation. 
 He got a patient affected with filaria to sleep in a room 
 which was lighted up in the evening, the windows being left 
 open ; after the mosquitoes had entered in swarms the room 
 was shut up as completely as possible. In the morning he 
 found the walls covered with hundreds of female mosquitoes 
 filled with blood to the bursting (the male mosquito does not 
 live upon blood and has no sting) ; and the microscopic 
 examination showed that their stomachs contained large 
 numbers of living filaria-embryos, very many more indeed 
 than would be present proportionately in the circulating 
 blood. The following are the conclusions of Hanson's 
 inquiry into the subsequent development of the parasite : 
 Many of the larvae sucked in by the mosquito are digested 
 in its stomach ; others undergo a development in the course of 
 a few days to the perfect worm ; the mosquito when it is full 
 of eggs resorts to water to deposit them and there perishes, 
 so that the parasites, set free by the death of their host, find 
 their way into the water, and thence into the human body. 
 According to Manson's conjecture they enter through the 
 skins of those who come to the infected water to bathe; having 
 thus found their way into the body they continue their 
 progress until such time as they have reached the blood- 
 vessels or lymphatics. Within the human organism they 
 propagate by way of sexual reproduction ; but the develop- 
 ment of the larva to the full-sized worm depends upon that 
 sequence of events in which the mosquito co-operates, as 
 above described. 
 
 Aranjo,^ and more recently Myers, who repeated in 
 
 ' 'Lancet,' 1878, 1. e. '^ 'China Customs' Gazette,' 1877, 1. c. 
 
 ^ 'Gazctta da Bahia,' 1879, 1. c.
 
 riLARIA SANGUINIS HOMINIS. 331 
 
 Formosa tlie experiment with a filaria-patient as devised hy 
 Manson, have confirmed the latter's account of the absorp- 
 tion of the larval filarioe by the blood-sucking mosquitoes ; 
 and Cobbold, who has drawn up a detailed description^ of 
 the metamorphosis of the parasite after Hanson's observa- 
 tions, points out^ that this developmental process in Filaria 
 sanguinis hominis has an analogy in the life-history of Filaria 
 medinensis, which has been shown by Fedschenko to go 
 through the stages of its development in the fresh- water 
 Cyclops. Magelhaes believes that he has found the parasites 
 in the water of a small brook named Carioca, near Rio de 
 Janeiro ; but the statement lacks confirmation. Again, 
 there is no evidence, so far as we have gone, to show whether 
 the parasite enters through the human skin, as Manson 
 assumes and Aranjo and Silva Lima agree, or whether it 
 may not more probably reach the human organism through 
 the drinking of infected water, according to the analogy of 
 Filaria medinensis. 
 
 There is one very remarkable phenomenon in the life of 
 the parasite, likewise pointed out first by Manson, which 
 enables us to understand how it was that the earlier observers, 
 examining the same patient on different occasions, sometimes 
 found the larvae in the blood in large numbers and at other 
 times not a single specimen of them. The fact is that in the 
 night-time, or when the patient is asleep, they swarm in the 
 blood, whereas during the day they disappear almost entirely. 
 This observation also has been confirmed in eveiy respect 
 by Myers, who has satisfied himself by repeated investigation 
 that the parasites show themselves first in the blood shortly 
 after six o'clock in the evening-, their numbers steadily 
 imcreasing and reaching a maximum about midnight, after 
 which a decrease sets in, and the swarm of filaria? disappears 
 altogether between six and eight o'clock in the morning. 
 These observations of Manson and Myers have been corrobo- 
 rated by Stephen Mackenzie'^ in an ingenious experiment 
 which he devised at the London Hospital in the case of a 
 patient invalided home from India with hasmato-chyluria. 
 
 1 'Proc. Linn. Soc.,' 1878. 
 
 2 'Lancet,' 1878, f. c. 
 
 'Path. Trans.,' xxxiii, 1882, p. 394.
 
 332 GEOGRAPniCAL AND HISTORICAL PATHOLOGY. 
 
 During a period of some tbree months, wlien lie was under obsei'va- 
 tion, tlie urine passed by the patient contained sometimes a considerable 
 amount of pure blood or of blood-clot, and sometimes it assumed a milky 
 or chylous character; in the matters that were passed, and particularly 
 in the blood-clot, filarial wore detected, some of them being alive. It 
 Avas a remarkable circumstance that, if thei'e were any diiference in 
 quality between the day and night urine, it depended on the day urine 
 having usually more of blood and fibrinousclot and a larger number of 
 filarJa), while the night urine had a more chylous appearance. The 
 examination of the blood, which was made every three hours for a space 
 of two months, showed that it followed the converse rule as regards the 
 pi'esence or absence of filaria;. During the day they could hardly be 
 found at all in the blood ; it was not until nine o'clock in the evening 
 that they began to show ; they were most numerous about midnight, 
 decreased remai-kably about three in the morning, at six were to be 
 seen only now and then, and from nine in the morning to nine at night 
 were absent altogether.' Changing the patient's meal-times had no effect 
 whatsoever upon this behaviour of the parasite ; but complete reversal 
 of habit, to the extent of lying in bed during the day and being up and 
 about through the night, was followed by a corresponding reversal in 
 the periodical appearance and disappearance of the filaria?, which showed 
 themselves in the daytime and were to be seen only occasionally at 
 night. A return to the patient's ordinary habits brought the parasite 
 back to its original behaviour. 
 
 No explanation at all satisfying lias hitherto been given by 
 observers of this strange phenomenon, which reminds one of 
 the life-history of Oxyuris. In regard to many other ques- 
 tions of filaria-disease the views of authorities are still widely 
 divergent ; for example, as regards the true seat of the para- 
 site, whether it is both the blood-vessels and the lymph- 
 vessels, as Lewis, Pereira, and others assume (with good 
 reason, it seems to me), or whether, as Mauson believes, it 
 is exclusively the lymphatic system ;" or, again, as to the 
 ways in which it affects the human body, and as to the type 
 of disease which ensues. Without attaching any special 
 importance to the scepticism of Fox and Gouet, who would 
 strike out altogether the term " filaria-disease " as the 
 designation of definite forms of illness, inasmuch as they take 
 the parasite to be a harmless guest presenting itself as a 
 casual concomitant of diseases that have been brought about 
 
 ^ Havelburg has recently arrived at almost the same facts in a ease of chyluria 
 which he observed in Brazil. 
 
 - Hiivelbnrg also thinks that tlie lymphatic system is tlie part whicli is really 
 implicated, the filarire passing from thence into the venous system.
 
 FILARIA SANGUINIS HOMINIS. 333 
 
 by other etiological factors ; we may still hesitate before we go 
 very far in the way of extending tlie application of the term. 
 Numerous observations teach us that persons may be invaded 
 by filaria9 without suffering* any appreciable injury to their 
 health ; in many of the cases that have been published there 
 is really no evidence that the sickness stood in any causal 
 relation to the filai'ias co-existins;- with it. It is bevond 
 question^ also^ that cases of chyluria occur in extra-tropical 
 regions, which are quite unconnected with Filaria sanguinis ;^ 
 and I take it, furthei-, to be well-established that " elephan- 
 tiasis " is a pathological term under which are included 
 various kinds of morbid conditions differing' from one another 
 in their anatomy and in their etiology, the filaria- disease 
 being only one of the number. However curious may be 
 the evidence adduced by O'Neill and Aranjo that Filaria san- 
 guinis hominis occurs in diseases of the skin, these observers 
 are still under an obligation to prove to us that the skin 
 disease which they saw does as a matter of fact correspond 
 to the disease known on the West Coast of Africa as '^ craw 
 craw " — a disease which all authorities in that part of the 
 world admit to be nothing else than scabies. I am very 
 doubtful whether it was really the filaria in question that 
 Neilly found in a case at Brest, of a vesicular pruriginous 
 exanthem, closely related^ as Neilly thought, to " craw-craw." 
 
 § ii6. Geographical Distribution of Filaria sanguinis. 
 
 These brief references will suflfice to indicate how much is 
 still wanting to a perfect knowledge of all the circumstances 
 concerned in the filaria disease ; and assuredly the same in- 
 completeness characterises our information about its geo- 
 graphical distribution. The filaria-disease prevails most 
 extensively in the tropical parts of Brazil, equally in the 
 interior and on the coast.^ In the provinces lying most to 
 
 ' Havelburg (1. c, p. 375) thinks that in such cases the filariaB had perhaps been 
 overlooked. His other supposition seems to mo to be much more likely, namely, 
 that there are other morbid processes which may lead to obstruction in the 
 thoracic duct as the filaria) do, and which likewise produce chyluria. 
 k * See the account in ' I'evista med. flumin. ; ' also Sigaud, Juvenot, Plagge, 
 Wucherer, da Silva Lima, 1878, 1. c, and Havelburg.
 
 334 GEOGRAPHICAL AND HISTOEIOAL PATHOLOGY. 
 
 the soutli or in the higher latitudes^ beginning- with the 
 province of Sta. Catarina, the disease in its hfemato-chyluric 
 form is seldom met with. Neither is hjBmaturia endemic 
 in the Argentine Republic, according to Crevaux's^ state- 
 ment as against Juvenot's. How far the latter authority's 
 account of endemic hajmaturia in Chili, Peru, Venezuela 
 (Guaira), and Mexico is deserving of credit, can hardly bo 
 decided, as all other observers in these countries say nothing 
 of the malady in question. For Guiana we have merely the 
 above-mentioned notice by Winckel, who found the parasites 
 in a woman long resident in Surinam, and Hillis's observations 
 on a patient belonging to Demerara. As regards tlie West 
 Indies, mention is made of the disease (hasmato-cliyluria) in 
 Cuba,^ St. Domingo,^ St. Thomas,* Barbadoes,^ Martinique/ 
 and Guadeloupe,^ where it occurs for the most part in merely 
 occasional cases; it would appear, therefore, not to be 
 widely diffused in these colonies. I am at a loss to decide 
 whether the cases mentioned by O'Neill warrant us in con- 
 cluding for the common occurrence of the disease on the 
 West Coast of Africa ; there is not a word about h^ematuria 
 or chyluria in the accounts from that region, and it must 
 remain doubtful for the present whether the elephantiasis 
 that is endemic there depends upon Filaria sanguinis. The 
 occurrence of the parasite in Egypt has been placed beyond 
 doubt by Sonsino and Fayrer. Crevaux^ quotes a paper by 
 MacAuliffe, which I am not acquainted with, to the effect 
 that the people inhabiting the shores of the Zambesi and 
 Lake Nyassa {South Africa) suffer from hgematuria chylosa ; 
 it is certainly a question whether there has not been here 
 some confusion witb the distoma-h^maturia wliich is endemic 
 there (see p. 296). Reliable information on the filaria- 
 disease comes from the Zcmzibar coast,^ Mauritius}^ and 
 Beunion ;^^ and it is probable that the references by Grenet 
 from Mayottc and by Vinson from Madagascar relate to the 
 same disease. Of Filaria sanguinis hominis in Queensland 
 
 ' 'Arch, de mod. iiiiv.,' 1. c. ■ » Beale, 
 
 3 Juvenot. 4 PontoppidiUi. 
 
 * Ralfe, Fayrer. c Rufz, St. Vel, Venturiui. 
 
 7 Crevaux. 8 . A^ch. dc nicd. nav.,' l. c, i;3. 
 
 3 Ferrand. lo Cliapotin, Salessc, Kayer. 
 
 " Quevenne, Mazae-Azema, Casslen, Pellissicr.
 
 riLARIA SANGUINIS HOMINIS. 335 
 
 we liave Bancroft's account ; but it is impossible to decide 
 for the present whether the parasite is indigenous in 
 other parts of the Australian continent. From Oceania 
 there is intelligence of only one case hitherto^ which 
 Cbassaniol and Guyot saw in an individual long resident in 
 Tahiti. 
 
 Next to Brazil, China would appear to be the country 
 most infested by filaria -^ and it is remarkable that an 
 island so near the mainland as Formosa is, according to 
 Myers, quite free from it.^ In India also, according to 
 Lewis, McLeod, McCormack, Ewart, Carter, Barbour and 
 others, the filaria-disease is very common. On tlie other 
 hand, during a residence of many years in the Dutch East 
 Indies, v. Leent and Swaving did not have the opportunity 
 of seeing a single case of ha3maturia chylosa.* 
 
 Such is the extent of our information — it is not all equally 
 trustworthy, and it is certainly very incomplete — as to the 
 occurrence of Filaria sanguinis hominis in various parts of 
 the world. According to our present knowledge, the para- 
 site appears to be indigenous only in tropical regions ; but 
 within these it has been found in persons of all races and 
 nationalities. 
 
 I 
 
 I 
 
 » 
 
 List of Acthokities on Filaria sanguinis hominis. 
 
 Aranjo, Memoria sobre a Filarlose, etc. Bahia, 1875; Gac. med. daBaliia, 
 1877, Oct., Nov. (Arcli. de med. nav., 1878, Mars, 200) ; Gac. med. da 
 Bahia, 1878, Marte, 106. 
 
 Bancroft, Lancet, 1877, July, 70 ; 1878, Jan., 69 ; Transact of the Pathol. 
 Soc, 1879, xxix, 407. Barbour, Glasgow Med. Journ., 1879, Jan., 24. Bourel- 
 Eonciere, Arch, de med. nav., 1878, Aont, 113; Septbr., 192. 
 
 Casslen, Etude sur rhematurie chyleuse, etc. Montp., 1870. Chapotin, 
 Topogi-. med. de I'lsle de France. Par., 1812, 94. Chassaniol et Guyot, 
 Arch, de med. nav., 1878, Janv., 61. Cobbold, Brit. Med. Journ., 1872, 
 July, 92; 1876, June, 780; Lancet, 1877, July, 70; Octbr., 495; 1878, 
 Jan., 69 ; Brit. Med. Journ., 1882, Jan., 51. Corre, Revue des Sc. nat., 
 
 ' Manson, Siegfried. 
 
 ^ His own investigations were made on patients who had come there from the 
 mainland. 
 
 3 According to a statement in Crcvaux, '1' Hematuric,' p. 28.
 
 336 GEOGRAriirCAL AND HISTORICAL PATHOLOGY. 
 
 1872, Scptbr. Crevaux, De I'hematuno chyleuse, etc. Par., 1872 ; Arch, 
 ■de mod. nav., 1874, Septbr., 165; Jourii. de I'Anat. ct de phj^sioL, 1875, 
 172. 
 
 Fayror, Lancet, 1S76, Aug., 2S4 ; 1879, Febr., 18S, 221. Ferrand, L'Union 
 med., 1882, Nr. 140, 625. 
 
 Grenet, Souvenirs uied. do quatre anndes a Mayotte, etc. Montp., 1866. 
 Guct, Arch, de med. nav., 1879, Septbr., 161. Guyot, vide Chassaniol. 
 
 Havelburg, in Virchow's Arch., 1S82, Ixxxix, 365. Hillis, Lancet, 1882, 
 Oct., 659. 
 
 Juvenot, Ilecherches sur Fhematurie endeuiique dans les climats chauds, 
 •etc. Par., 1853. 
 
 Lewis, Report on the Microscopical Characters of Choleraic Deposits. 
 Calcutt., 1870 (from the Annual Report of the Sanitary Commissioner for 
 India, 1869) ; On a Hseraatozoon inhabiting Human Blood. Calcutta, 1872 
 (Append, to the Eiglith Annual Report of the Sanitary Commiss. for 
 India, etc., 1872) ; Tenth Annual Report, 1874, 42 ; Ind. Annals of Med., 
 1874, Jan. ; ib., 1875, July ; Monthl. Microsc. Journal, 1875, May ; Med. 
 Times and Gaz., 1875, Febr., 173; Lancet, 1877, Septbr., 453; Centralbl. 
 fiir die med. Wiss., 1876, Nr. 43; Bengal Asiatic Soc. Journal, 1878, 
 March, 89 ; Brit. Med. Journ., 1878, June, 904 ; Quart. Journ. of Microsc. 
 ,Sc., 1879, April, 245. 
 
 Mackenzie, Lancet, 1881, Oct., 707 ; Path. Trans., xxxiii (18S2), p. 394. 
 Magolhaes, O Progresso med., 1877, Decbr. Manson, Chinese Customs' 
 Gazette, 1875; and Med. Times and Gaz., 1875, Novbr; Customs' Gaz., 
 1877, Nr. 33, and Med. Times and Gaz., 1878, March, 220, 249 ; Chinese 
 Med. Reports, 1880; Lancet, 1881, Jan., 10 ; Med. Times and Gaz., 1881, 
 June, 615; Lancet, 1882, Feb., 289. Mazae-Azema, Gaz. med. de Paris, 
 1858, Nr. 2, p. 35. Myers, Chinese Customs' Med. Reports, 1881 (Lancet, 
 1 881, Decbr., 1015 ; Brit. Med. Journ., 18S2, Jan., 51). 
 
 Nielly, Bull, de I'Acad., de med. de Paris, 1882, 395, 581. 
 
 O'Neill, Lancet, 1875, Febr., 265. 
 
 Pellissier, Consider, sur I'etiologie dcs malad. les plus communes a la 
 Reunion. Par., 1881, 24. Plagge, Monatsbl. fiir Statist. (Suppl. of Deutsche 
 Klin.), 1S57, 71. Pontoppidan, Hospitals Tidende, 1879, '^'^> ^^'- 3- 
 
 Quevenne, Journ. des connaiss. med., 1839, Juill. 
 
 Ralfe, Transact, of the Pathol. Soc, 1879, xxix, 388. Rayer, L'Expcrience, 
 1838,1,577,593; Krankheiten der Nicren. From the French. Erlang., 
 1S44, 500 fP. Ref. in Revista med. fluminense, 1836, April. 
 
 Salesse, Diss, sur I'hematurie, etc. Par., 1832. Dos Santos, Gac. med. da 
 Bahia, 1877, Marte, 137, Novbr. Siegfried, Philad. Med. Times, 1878, Oct., 
 ix, 4. Sigaud, Du climat et des malad. du Bresil. Par., 1844, 398. Silva 
 Lima, Memoria sobre a hematuria chylosa. Bahia, 1876; Gac. mod. da 
 Bahia, 1877, Septbr., Nov. (Arch, do med. nav., 1877, Decbr., 439 ; 1878, 
 March, 200) ; Lancet, 1878, March, 441. Sonsino, Ricerche, etc. (cf. Dis- 
 toma haemat.) ; Rendiconto della reale Acad, di Napoll, 1S74, Fasc. 6; 
 -Sugli ematozoi come contributi alia fauna cntozoica egiziana. Cairo, 1877, 
 10 ; Lancet, 1882, May, 825. 
 
 Vandyke Carter, Transact, of the Bombay Med. Soc, 1862, New Scr., vli.
 
 GUINEA -WORM. 337 
 
 171. Venturini, Aivli. de raed. nav., 1S80, Janv., 50. Vinson, Gaz. hebcl. 
 de mod., 1866, Nr. 49, Feuill, 773. 
 
 Winckel, Arch, fiir klin. Med., 1876, xvii, 303. Wuclierer. Gac. med. da. 
 Baliia, 1S6S, Decbr., Nr. 57; 1SC9, Septbr., Nr. 77 to 79 (Zeitsebr. fiir 
 Parasitonkunde, 1869, i, 376). Arch, de med. nav., 1870, Fcvr., 141. 
 
 Guinea-Worm {FiJaria medinensis, Bracunculus medinensis). 
 
 § 117. History op the Pathology op Dracontiasis. 
 
 Although the Jnsforij of dracontiasis can be followed far 
 back into antiquity, it is to modei'u times that we owe the 
 trne knowledge of the nature of the disease ; while the 
 perfect comprehension of the life-history of the parasite 
 which occasions it belongs to the recent period. Not to 
 mention the indications of the dracnnculus which Bai^tholin, 
 and after him Kiichenmeister, would find in the " fiery 
 serpents " that afflicted the Hebrews in tlieir wanderings in 
 the Desert, the first definite facts about the disease that we 
 meet with are in Plutarch/ who narrates, on the authority of 
 a statement by the geographer Agatharchides, the teacher of 
 Ptolemey Alexander (about 150 B.C.), that the dwellers by 
 the Eed Sea suffer from a serious malady, due to '' n, small 
 serpent '^ {^pannvria f^uK^a) which issues from the skin to 
 gnaw the arms and legs and retires underneath the skin if 
 disturbed, causing the patient intolerable pain. A sub- 
 sequent notice of this worm occurs in Leonides^ (second 
 century of the Christian era), who compares it to the round- 
 worm, and speaks of it as occurring in Ethiopia and India. 
 Galen,^ who confesses that he had never had an opportunity 
 of seeing a case of dracontiasis, expresses doubt whether it 
 is really an affair of a living animal, and not rather an 
 affection of the veins rescmbliug varix ; also Soranus (the 
 methodist no doubt) had said •} " Neque animal prorsus sed 
 
 ^ ' Syini)Osion,' lib. viii, qna^st. 9. 
 ^ In Actius, lib. xiv, cap. 86, od. Hasll, 1 .s.^.;, iii, 69. 
 
 3 'De locis aflectis,' lib. vi, cap. 3, cd. Kiihn, viii, 392, and * Introduetio,' 
 ciip. 19, c. c, xvi, 790. 
 
 •• Accordinj^ to I'aulus, lib. iv, cap. 59, ed. Lugd., 1551, 332. 
 
 vol,. II. 22
 
 338 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 nervosi cujusdam substautiam esse, quod opinionem motus 
 solum praebeat/' These doubts and sui-mises were tbe 
 beginning of an erroneous doctrine which dominated pro- 
 fessional opinion in all subsequent times down even to the 
 commencement of the present century. Even among the 
 Arabian physicians/ who were well acquainted with the 
 malady as it occurs in Arabia and Persia — Khorassan is 
 specially mentioned by Avicenua — and had certainly had it 
 under observation/ there was much vagueness as to its 
 nature ; still more so among the practitioners of the middle 
 ages and first part of the modern period, who had no oppor- 
 tunities of seeing cases of dracontiasis, and relied for their 
 belief solely upon their authorities, Galen and Avicenna, 
 Although it was clearly proved by the unbiassed inquiries of 
 a few investigators of the seventeenth and eighteenth cen- 
 turies — such as Welsch,^ who overthrew Avicenna^s notion 
 of the " vena medinensis " by a rigorous criticism of it, 
 he himself trusting to observations made on persons who 
 had come back to Europe from India affected with dracun- 
 culus, — and still more clearly through the experience 
 brought from countries infested with the parasite by many 
 scientifically trained practitioners and naturalists, such as 
 Lind^and Gallandat from the West Coast of Africa, Kampfer 
 from the shores of the Persian Gulf, Rouppe from Curacao, 
 Pouppe-Desportes and Pere from San Domingo — although 
 it was thus proved that the disease was due to a living 
 
 ' Abulcasem, 'Method, med.,' lib. ii, cap. 91, Basil, 1541, 162; Avicenna, 
 Canon lib. iv. Fen iii, tract, ii, cap. 21, Venet., 1564, ii, 128,- Haly Abbas, Lib. 
 theor., viii, cap. 18, Lib. pract., ix, cap. 64, Lngd., 1523, 98 b., 283 b.; Avenzoar, 
 Theisir, lib. ii, tract, vii, cap. 19, Venet., 1490, fol. 32 b. 
 
 ^ Abulcasem speaks of the parasitic nature of the malady in the following very 
 definite terms : — " Vena haec generatur in cruribus, in terris calidis, sicut in terra 
 arabum et orientalibus, meridionalibusque regionibus, terris aridis. Et quandoque 
 generatur in locis aliis corporis praeter crura. Et gcneratio quideni ejus est a 
 putrefactiouc quae accidit sub cute, sicut accidunt intra corpora serpcntes, 
 vermes, ascarides at vermes inter cutem et carnem." He further mentions a case 
 operated on by himself, in which he removed a " vena " twenty haudbrcaths long, 
 or about sixty inches. As regards the term " vena," I may remark that it is a 
 purely arbitrary rendering of the Arabic term "irk" or "ark," which was used 
 in several senses. 
 
 ^ 'Exercitatio de vena medinensi, &c.,' Aug. Vindel, 1674. 
 
 * The writings of these and other authors quoted are given in alphabetical 
 order at the end of the section.
 
 GUINEA-WORM. 339 
 
 animal witliin tlie human body ; and althougli the foremost 
 men of science in Europe in the first quarter of the present 
 century regarded the question as being so completely settled 
 that Rudolphi^ could say : " Nostris temporibus filariam 
 istam in dubium vocari possit^ fere omnem fidem superat ;" 
 yet it continued to be a subject of controversy whether the 
 alleged worm was not altered connective tissue, or obliterated 
 vessels, or a morbid condition of nerve," until at length 
 the more recent investigations in parasitology dispelled all 
 doubts as to the parasitic nature of the disease. 
 
 § ii8. Geographical Distribution of the Guinea Worm. 
 
 The indigenous habitat of dracunculus is a comparatively 
 small area embracing a few regions of the Eastern Hemi- 
 sphere, mostly intertropical ; and even there the parasite is 
 found only within certain narrow limits. From these, its 
 original seats, the worm has been imported to other lands ; 
 but only in a few such foreign centres has it become 
 domesticated. 
 
 One of the chief seats of dracunculus is the West Coast of 
 Africa from the Senegal down to Cape Lopez. In the basin 
 of the kSenegal the parasite is common both on the level 
 coast country and in the more elevated parts of Senegamhia 
 beyond Bakel to the region of Galam,^ although the banks of 
 the Casamance enjoy immunity.* In less extensive diffusion 
 it occurs on the Sierra Leone Coast;^ but most extensively of 
 all^ on the Grain Coast, Ivory Coast, Gold Coast, and 8lavc 
 Coast, '^ as well as on the shores of the Niger^ and the Gaboon,^ 
 
 1 'Entozoorum synopsis,' Berl., 1819, p. 207. 
 
 2 In the'Edin. Med. and Surg. Journ./ 1831, Jan., p. 112, Graufc publishes 
 an article written in 1830 by Surgeon-General Milne, of Eombay, whose conclusion 
 from a study of a case of dracunculus is—" The substance in question cannot be 
 a worm, because its situation, functions and properties are those of a lymphatic 
 vessel; and hence the idea of its being an animal is an absurdity." 
 
 ■"* See Pare, Berville, Gauthier, Thaly, Berenger-Feraud, Defaut, Hebert, Borius. 
 
 •' Leonard. 
 
 ' Boyle, Clarke (Sierra Leone). 
 
 ^ See Gallandat, Lind, Keynhout, Boyle, Birkmeycr, Ref. in 'Bost. Med. and 
 Surg. Journ.,' 1843, June, p. 293, Ilobinson, Bryson, Daniell, Heymann, Gordoi), 
 Clarke, in ' Transact. Epid. Soc' 
 
 " Feris. 8 oidfield. 9 Pero.
 
 340 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 the more elevated countries inland sucli as the kingdom of 
 Dahomey and the Tellatah territory being apparently quite 
 exempt.^ The points most infested are on the Gold Coast 
 from Apollonia to the Eio Volta^ including Cape Coast 
 Castle/ Elmina/ Cormantia, and Accra ; but there are other 
 places not many miles from these in which there is hardly a 
 trace of the worm to be found.'^ On the Bight of Biafra 
 dracoutiasis begins to be more rarely met with/ and on the 
 coast of Lower Guinea (Congo coast) the disease occurs very 
 seldom if at all.^ 
 
 In the medico-topographical accounts from the countries 
 of the North African seaboard^ the dracunculus is either not 
 mentioned, or, as in the case of Tunis'' and Egypt, ^ its 
 endemic occurrence is expressly denied. In Egypt, as the 
 authorities unanimously state, the parasite had been fre- 
 quently observed after the conquest of the negro countries. 
 (Sennaar and Kordofan), both among the black soldiers 
 brought thence, and among the Arabs, Egyptians and Euro- 
 peans, who had been in the habit of mixing with the former. 
 But, since the negroes ai'e no longer employed in military 
 service, dracoutiasis is now met with only in such persons 
 as had brought the parasite with them from its indigenous 
 regions. 
 
 To the reg'ions of Northern Africa in which dracoutiasis 
 is endemic, belong Nuhia, Kordofan and Darfur^ probably 
 also some localities on the northern borders of the SaJiara;^^ 
 while the Greater Boudan, so far as we know, is, like the 
 Fellatah counti-ies already mentioned, free from the disease. ^^ 
 In Ahyssinia, dracunculus would appear to be found only on 
 the coast.^" For the East Coast of Africa, and adjacent 
 
 ' Duncan. 
 
 ^ Clarke, in 'Transact. Epld. Soc.,' Moriarty. 
 3 Clyiner. "* Busk. 
 
 " Daniell, Bryson. ^ Pere, Falkenstein. 
 
 ' Ferrini. 
 
 ^ Clot-Bey, Fischer, Pruucr, Bilharz, Vauvray. 
 
 5 Bruce, Marduclii, Fischer, Pruner, Mahomed-el-Tounsy, Hartmann. 
 1" According; to the accounts by Fen-ini for Tunis, and Bertherand for Turgurt 
 (Algiers) ; see also Richardson, 1. c. 
 " Tutschek, Quintin. 
 1- Harris, Hartmann, Curric.
 
 GUINEA-WORM. 341 
 
 islands/ as well as for tlio Cape, Australia" aud Oceania, 
 there is no mention of the parasite. 
 
 The endemic seats of dracontiasis on Asiatic soil, are first 
 of all Arabia Petraea (wrongly called 'Hlie stony '^), a few 
 points on the coast of Hejaz and Yemen/ and the south 
 coast of Persia.'^ In other parts of Persia, such as Teheran, 
 the disease is seen only in persons who have come from a 
 distance.^ From Syria there is a statement by Nathan, to 
 the effect that a number of sailors of the English navy, who 
 had never been in tropical or other countries infested by 
 dracunculus, conti'acted the parasite after working in the 
 water for a considei^able time in the Bay of Skanderoom. 
 Even in the northern regions of Nearer Asia, there are 
 isolated centres of the disease to be met with, particularly 
 in some parts of Turhestan, in Khiva, Bokhara'' (limited to 
 the city of that name) and Kokaun / also along the shores 
 of the Sir-Daria [Kirgldz Step-pe),^ and even on the northern 
 shore of the Caspian in latitude 47° N., " prope flumeu 
 Paccum," as Kiimpfer says, meaning probably the banks of 
 the Jack or Ural. 
 
 Next to the West Coast of Africa and the upper basin of 
 the Nile, it is in India that the guinea-worm attains its 
 widest diffusion, and mostly in the northern division of the 
 West Coast, the Rajpootana States and the western parts 
 of the Deccan. Among the least infested parts of the 
 country, according to Balfour, are the North-West Provinces, 
 whence there are accounts of dracontiasis (known to me) only 
 from Dehra Dhun^ (30° N., 95° E.), Sirsa^"^ (29° 31' K, 
 92° 45' E., in the district of Bhatti), aud Hansi^^ (29° 6' N., 
 93° 43' -"^v i^i tli6 district of Hissar) ; also those parts of 
 
 ' According to Collier aud Paton, dracontiasis does not occur iu Mauritius 
 :uid St. Helena. 
 
 - Thomson says the same of New Zealaud. 
 
 ^ Clot-licy, Fischer, Pruner, Harris, Bilharz. Tliore appears to be little reason 
 for calling the worm " Pilaria medinensis," for it is of rare occurrence in Medina, 
 as also at Jeddah. 
 
 * Kampfer, Pruner, Husk, Moore, Polack, Lebluuc. 
 
 * Polack. — Avicenna, whose opinion in this matter must be judged correct, 
 speaks of the endemic prevalence of the malady iu Khorassan. 
 
 6 Mir-Izzet-UUah, Burncs. ' Fedschenko. 
 
 8 Maydell. » Brett. 
 
 1" Minas. " Balfour.
 
 342 GEOGRAPHICAL AND HISTOEIOAL PATHOLOGY. 
 
 Bengal situated in the lower basin of the Ganges, whose 
 immunity is indicated not only by the unanimous statements 
 of Balfour, Greenhow, Twining, Yoigt, and others, but also 
 by the absolute silence as to this disease among the extremely 
 copious medical writings relating to Bengal and Orissa. 
 In the coast belts of the Madras Presidency also (Northern 
 Circars, Carnatic and Cochin) , dracunculus is of comparatively 
 rare occurrence,^ being found only at isolated places, such as 
 the vicinity of Madras" and Pondicherry.'" 
 
 According to all observers,^ the name of the disease is 
 scarcely known on the eastern and western Ghats of this 
 Presidency, and as little on the high ground of Mysore. The 
 single more considerable focus of the malady in this part of 
 India is the plam of the Carnaiic stretching southwards from 
 Mysore between the eastern and the western Ghats towards 
 Cape Comorin, in which Dindigul,^ the Salem district,^ 
 Madura, and many other places^ at a distance of one or two 
 days' journey from the coast, are given as the seats of 
 dracontiasis. But the greatest prevalence of the disease 
 is on the western seaboard at the following places : in the 
 Bombay Presidency, from the latitude of i8° N. up to 
 Gujerat,** — at Kutnagherry, Matunga, Bombay (but not at 
 Kolaba only a few miles from the capital)^ and Daman ; 
 in Gujerat,^^ at Baroda, Caira and .Tambosir ; and at Bhooj, 
 in Cutch.^^ Other great centres of the disease are met with 
 in the Rajpootana States (Mewar and Marwar),^" in the 
 district of Ghanda,^^ at Dhoolia iu Kandeish,^^ at Nagpore 
 in Berar, in the States of the Nizam^^ as at Aurungabad, 
 Jalnah, Hyderabad and Secunderabad, on the east side of the 
 western Ghats, and in the adjoining districts of the Deccan, 
 from which last we have accounts of the prevalence of 
 dracunculus at Ahmednuggar, Jedjhuri, Baramati, Poena, 
 
 ^ Scot, Day. 2 MacKay. 
 
 3 Huillet. ■* Dubois, Lorinser, Gibsou, &c. 
 
 * Annesley. •> Cornish. 
 
 " Dubois. 
 
 3 Morehead, Duncan, Ewart, McGregor, Scott, Bird, Carter, Crespigny. 
 
 9 McGregor, "> Gibson. 
 
 ^' Moore. 1* Ewart, Greenbow, Moore. 
 
 ^3 Dutt. » Mackenzie. 
 
 ^'' Lorinser, Morehead, Cooper.
 
 GUINEA-WORM. 343 
 
 Satara_, Aculcota, Tasgoou^ Miraj and Beejapore/ the district 
 of Savaut-Warri/ Balgam/ Darwar'^ and Bellary.^ 
 
 A means of estimating the relative frequency of the disease in tlie 
 Presidencies of Bombay and Madras respectively, is aflforded by E wart's 
 figures. In Madras from 1829 to 1839, there was one case of 
 dracunculus to 562 native trooj)s, and among the European troops 
 one in 1800; in Bombay during the same period one in 32. At some 
 of the military stations in the Bombay Presidency, according to 
 Morehead, the rate of sickness from dracunculus was 1 2 to 1 7 per cent. 
 of the total strength. 
 
 I£ we may judge from the silence of the authorities^ dracun- 
 culus does not occur at all in Ceylon, Further India, China and 
 Japan. Fi'om tho East Indies wo have information by Heymann, 
 van Leent and v. d. Berg^ that dracontiasis was quite un- 
 known in Java before the arrival of African troops, that the 
 parasite was imported by them from Elmina, that it has dis- 
 appeared again since these military transfers ceased, but that 
 even at present the disease may be seen now and then in 
 Africans^ or in such of the Europeans as had lived for a 
 considerable time on the West Coast of Africa, but no cases 
 of it in the Javanese or other Asiatics who had not left the 
 East Indies. 
 
 According to the unanimous opinion of the medical 
 authorities for Guiana,^ BraziV and the West Indies,^ the 
 dracunculus was imported into these countries of the New 
 World by negroes from tho West Coast of Africa ; and it 
 has almost disappeared again from them, excepting at one 
 or two small centres, since the importation of negroes has 
 ceased. One of these centres is the island of Cura9ao, into 
 which, as Rouppe tells us, the disease was brought as usual 
 by negroes, and in which it is said that there are still cases 
 of dracontiasis occurring somewhat frequently among the 
 native population.^ Tho other centre is the small village 
 
 1 Morehead, Collier, Gibsou. 
 
 2 Kearney. ^ Waller. ^ Forbes. * Eyre. 
 
 ^ Ilodscbied for British Guiaua, Bajou for Cayenne, SchciUer and Hille for 
 Surinam. 
 
 ' Sigaud, Schwarz. 
 
 8 Pere and Pouppe-Desportes for St. Domingo, Sloane for Jamaica, Savaresy 
 for Martinique, Hillary for Barbadoes. 
 
 !> Busk. Pop in writing fromCuraQao ('Nederl. Tijdschr. voor Geneesk/ 1859, 
 iii, 214) makes no mention of the disease.
 
 344 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 of Feiva da Santa Anna in tlie Province of Bahia, between 
 the town of Baliia and Jazeiro^ where there is an endemic 
 focns^ according to statements (which we shall recur to, p. 
 354) by Pereiraand da Silva Lima. Whether the parasite is 
 indigenous there, as the latter authority thinks, or whether it 
 has been imported, as Pereira believes, we are unable to 
 decide. For the remaining countries of South America (the 
 River Plate States, Chili, Peru, Bolivia, Ecuador and Granada) 
 as well as for Central and North America, there is not a single 
 reference to the endemic occurrence of dracontiasis. 
 
 § 119. Relation op Dracontiasis to Heat and Moisture. 
 
 The limitation of the area of dracontiasis almost exclu- 
 sively to regions situated within the tropics raises the sugges- 
 tion that the existence of the parasite which causes the 
 malady is dependent upon circumstances of climate, or, in 
 other words, upon higJi tcm'peratare. No doubt the endemic 
 occurrence of the disease in Turkestan, and on the Kirghiz 
 Steppe, where the mean temperature of the year is scarcely 
 higher than that of the South of Europe, appears to contradict 
 this assumption. But in the problem before us we are con- 
 cerned not with the isotherm but with the isother ; and, in 
 that respect, the regions in question have a truly tropical 
 climate, inasmuch as their mean temperature in summer is 
 26° R. or more (88° Fahr.) ; and, what is especially note- 
 worthy, it is precisely the hot season, notorious for its 
 extreme drought, that forms the proper filaria-seasou, during 
 which, as Burnes states in regard to the city of Bokhara, 
 one eighth of the population suffer from dracontiasis. 
 Moreover, the influence of the hot season on the prevalence 
 of the disease makes itself unmistakeably felt in tropical 
 countries themselves. In almost all the territories infested 
 with dracontiasis, for example, Senegambia,^ the West Coast 
 of Africa,^ Nubia,^ and the various Indian centres (Rajpoo- 
 tana,* Bombay,^ and Madras^), the largest number of cases 
 
 ^ Gautliicr, Borius, Hebert. - Re^'uhout, Robinson, Gordon, Clarke. 
 
 3 Clot-Bey, Fischer, Pruner, Pctherlk. ' Moore (III), Greeuhow. 
 * Bird. ^ Loriuser.
 
 GUINEA-WOEM. 345 
 
 fulls in the rainy season or in tlie liot season following it, 
 that is to say, in April and May, or from June to August — 
 September, according to tlie locality. 
 
 On tliis point we have two considerable series of observations, one by 
 Ewart for Mewar, and the other by Morehead for Bombay. Among the 
 troops composing the Mewar Bheel contingent there occui-red, according 
 to Ewart, 26S2 cases of medina worm during a period of 17 years; and 
 these were distributed over the months of the year as follows : 
 
 September 103 March 239 
 
 October 96 April 420 
 
 November 57 May 525 
 
 December 29 June 493 
 
 January 23 July 376 
 
 February 65 August 256 
 
 373 2309 
 
 According to these figures the ratio of cases in the second column 
 (March to August) was to those in the first (September to February) as 
 6 to I. In Morehead's statistics of 2927 cases of dracunculus admitted 
 into the Bombay hospitals, the distribution throughout the year was as 
 follows : 
 
 October 224 April 273 
 
 November 123 May 448 
 
 December 93 June 480 
 
 January 46 July 428 
 
 February 64 August 337 
 
 March 165 September 246 
 
 715 2212 
 
 This gives a proportion of 3*2 to i. In both places the maximum falls 
 in May and June, amounting in the one series to 1018, or nearly 38 per 
 cent, of the whole, and in the other to 928, or 32 per cent. 
 
 It is impossible to decide absolutely to what extent the 
 Ligli temperature of tlie hot season by itself determines the 
 prevalence of the disease (or infection by the worm) or how far 
 the antecedent or accompanying limvij rains may be associ- 
 ated with it, as some observers are inclined to think. There 
 lire no certain data of the amount of rainfall in each preceding 
 year (during which the infection must have taken place, since 
 the period of development of the parasite lasts from nine to 
 twelve mouths) to place beside the corresponding numerical 
 return of the number of cases ; and the absence of exact
 
 346 GEOGRAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 meteorological facts of tliat kind is most of all to be re- 
 gretted on account of those instances wliero tlie dracontiasis 
 has hrohen out as an epidemic- These epidemics have been 
 observed on several occasions — by Ewart in Mewar^ by Eyre 
 in Bellary, by Leblauc in Persia, by Ferg in Surinam, by 
 Forbes in Darwar, and by Morehead in Kirkee. Some of 
 these authorities would explain them by the fact that there 
 was an unusually heavy rainfall in the previous year, although 
 they do not support that statement by figures, nor adduce 
 evidence that there is ordinarily a tolerably constant relation 
 between the rainfall and the amount of the disease at the 
 particular place. The only statement of a more precise 
 kind that I have met with is one by Ewart, and it does not 
 tell in favour of this theory. The largest number of cases 
 in the period from 1841 to 1858 among the Mewar Bheel 
 contingent, he says, happened in the year 1858, although the 
 amount of the rainfall the year before was within the mean 
 annual range ; the smallest number of cases was in 1855, 
 although the rainfall of 1854 exceeded the annual mean by 
 a good deal (29 inches), and, conversely, when in 1853 ^^® 
 rainfall was as much as i8'4 inches below the annual mean, 
 the cases of dracontiasis that came to be treated in the year 
 1854 were comparatively few. Moreover, it is the opinion of 
 several authorities, among others Robinson for the Gold Coast, 
 Annesley for the Carnatic, and Lorinser for Secunderabad, 
 that hot and dry weather is particularly favorable to the 
 infection ; and it is a not uncommon belief in India, as Ewart 
 tells us, that the frequency of the disease in any year stands 
 in an inverse ratio to the amount of the rainfall the year 
 before. 
 
 § 120. Alleged Pbepeeence op Deacunculus for 
 
 Certain Soils. 
 
 Still more questionable than the rainfall, as an influence 
 upon the amount of the disease (in other words, on the 
 abundance of the parasites and the opportunities for infec- 
 tion by them), are certain conditions of soil, to which some 
 observers would attach significance in this respect. Chisholm
 
 GUINEA-WORM. 347 
 
 was the firsts so far as I know, to attacli special importance 
 to a volcanic soil for the occurrence of dracontiasis, according 
 to his own observations in Grenada. In the same sense 
 Morehead afterwards asserted that the malady was endemic 
 on the western littoral of Hindostan and in the Deccan, 
 nowhere but at those places where basalt (basaltic tufa-trap 
 or the so-called " mohrum ") was the prevailing formation ; 
 and that it did not occur on primary rock, laterite, diluvium, 
 or other formations. In particular he pointed out that as 
 far as the conglomerate rock, consisting mostly of ferruginous 
 clay (laterite) extended along the coast, that is to say, from 
 Cajje Comorin to the mouth of the Bankota, the country was 
 either absolutely free from the malady or was affected by it 
 very slightly ; whereas the proper region of dracunculus 
 is reached when the trap rock crops out to extend along 
 the coast northwards. These statements have been confirmed 
 by Day and Gibson. Waring also has expressed the opinion 
 that the disease is much more common on volcanic trap than 
 on a lateritious soil ; and in a like sense Stewart has pointed to 
 the notable exemption from dracontiasis enjoyed by Jubbul- 
 pore, situated on laterite, in the Nerbudda district, while 
 the disease is endemic on sandy soil in the vicinity of the 
 town. Horton also has brought forward the prevalence of 
 dracunculus on the volcanic trap or on the metamorphic rock 
 of the Gold Coast. 
 
 I shall not attempt to decide whether volcanic rock is in any 
 degree favorable to the prevalence (or the existence) of the 
 guinea-worm ; but it is quite eri'oneous to suppose that 
 laterite prevents it. And if we look at the kinds of soil 
 upon which the disease is endemic in other parts of the world 
 it becomes extremely questionable whether the geological 
 character of the ground has any influence whatsoever upon 
 the occurrence of dracontiasis, that is to say, of the dracun- 
 culus parasite. 
 
 In Mewar and other parts of the Rajpoot States wliicli arc affected 
 witli dracontiasis, the soil is of the oldest formations (granite, gneiss, red 
 sandstone and the hke). In the plain of the Carnatic, where we have 
 seen that there is a very extensive focus of Llie disease, we find primitive 
 rocks and clay slate. Those parts of Nahia where the malady is most 
 endemic rest iipon sandstone covered by a layer of calcareous tufa
 
 348 GEOGEAPHICAL AND HISTORICAL PATHOLOGY. 
 
 (belonging to more recent formations), or by a considerable stratum of 
 clayey or calcareous diluvium, or in parts covered by laterite. In 
 Bakel (Senegambia) we meet witb di'acunculus on calcareous clay slate. 
 At many points on the Guinea Coast where dracontiasis is most 
 frequent, the soil is of laterite and is covered at the estuaries of the 
 Niger and other large rivers with more or less of feiTuginous diluvial 
 clay washed down from the higher regions; whereas at other points 
 where volcanic and particularly basaltic formations are most promi- 
 nent, such as the Sierra Leone coast, the disease is of the rarest occur- 
 rence, and on the Congo coast is quite unknown. Bokhara, which is 
 severely infested by the parasite, rests on a soil of loam impregnated 
 with salt. 
 
 § 121. No Racial^ Social, or other Immunity prom Dracon- 
 tiasis. 
 
 Dracontiasis lias been found among all racds and 
 nationalities, in all classes of societi/, at all periods of life, 
 and in both sexes. No doubt the Europeans suffer less tlian 
 the negroes or other indigenous inhabitants of the affected 
 regions ; and cases are rarer among persons in good circum- 
 stances than among the woi-king class, the common soldiers 
 and such like ; rarer also in the female sex than in the male. 
 But the sole reason is that the one are exposed less to the 
 infection, or take more care to avoid it than the other. The 
 more frequent, however, are the opportunities of infection, 
 the more do these differences appear to be equalised. Thus 
 in the Presidency of Madras from 1829 to 1839, there was one 
 case to 562 men for the whole of the native troops, but only 
 one to 1880 for the European troops; on the other hand, in 
 the severely affected Presidency of Bombay, the rate of 
 sickness in the years 1832 and 1833 was almost the same in 
 the two classes of soldiers, being about 3 per cent, of the 
 total strength. 
 
 § 122. Larval Worms in Water corresponding to Guinea- 
 worm. 
 
 The mode of infection of the human body, or the manner 
 of invasion of the pai-asite, has been the subject of erroneous
 
 GUINEA-WORM. 349' 
 
 or at all events vague notions until quite recently, wlien it 
 was thoroughly cleared up by the researches of Fedschenko 
 in Turkestan. It had been loug* recognised and clearly 
 stated by many scientific travellers and practitioners wha 
 had had opportunities of observing the medina-worm in its 
 habitats, that it did not arise in the human body dc novo, as 
 was still believed at the beginning of the century by those 
 who applied the doctrine of spontaneous generation to the 
 case of the intestinal parasites ; but that it invaded the body 
 from without, not indeed in the mature form, but as a larva. 
 Another opinion, firmly held by most of the natives of the- 
 infected countries, that the infection is caused by drinking 
 the water of certain wells, pools, tanks, or sluggish water- 
 courses,^ has not only been countenanced by scientific 
 observers,^ but has been apparently corroborated by some of 
 them when they showed from the examination of the sus- 
 pected water, or of the damp or marshy ground near it, that 
 these contained filaria-like worms often in enormous numbers, 
 which resembled dracunculus or its larva, and might there- 
 fore be regarded as the offspring of that parasite. 
 
 The first published observations of that kind, so far as I 
 know, were those of Chisholm. In his account^ of the water 
 of certain wells in Grenada, which were notorious as the 
 source of the filaria disease, he says : " In the water, which 
 contains the embryos of the dracunculi, the naked eye dis- 
 tinguishes innumerable animalcules, darting in every direc- 
 tion with astonishing force and rapidity ; these, on being- 
 subjected to examination in a small microscope, exhibit a 
 very extraordinary figure, differing from any animalcules 
 hitherto described." 
 
 1 "In all countries," says Chisholm (' Edinb. Journ.,' 1. c, 150), "in which the 
 Dracnnculus is endemic, tlic prevailing belief of the people is, tliat it proceeds 
 from drinking water which contains the ova or tlic embryo of the ariimal." 
 
 ^ Thus, in Bruce's 'Travels' it is stated that tlie worm usually attacks thosfr 
 persons whose practice it is to drink stagnant water. Chevalier also, in his 
 letters on the diseases of San Domingo, says: "Ccs vers sont engendros dans le 
 corps par les mauvaises-eaux ;" Kiimpfer and other travellers expressing them- 
 selves to the same effect. Among practitioners, again, there has been only one 
 opinion, — that the parasite, or its eggs or hirvre, come to the human body out of 
 water, their views diverging only as to the mode of entrance. 
 
 3 First publislied in the 2nd ed. of his "Essay on the Boullam Pestilential 
 Fever in the West Indian Islands, 1793-96," 2 vols., i, 571, note, i8oi,and after- 
 wards in ' Kdin. Journ.,' 1. c, p. 150.
 
 350 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Duncan, who found on microscopic examination o£ tlie 
 mature female that the uterus was packed full of embryos 
 {" the white matter filling the inner tube like thick cream is 
 a mass of living young ones "), goes on to say that ^' the soil 
 and pools abound in the rains with a worm smaller and 
 more slender, but otherwise exceedingly like Nharroo " — the 
 colloquial name for dracunculus in India. Forbes, writing 
 of Darwar says : ''I examined several of the tanks in the 
 neighbourhood and found the mud on their banks, and in 
 their half dry beds, abundantly supplied with animalcules, 
 some of them very much resembling those produced by the 
 guinea- worm when infestiug the human limb .... 
 Two kinds of these animalcules may be detected in the soft 
 mud : one kind seven or eight times the size of the guinea- 
 worm animalcule, the other exactly resembling it." 
 
 Brett says that he has found dracunculus in flood-pools on 
 the banks of the river Dhun, notably at Dehra-Dhun ; and 
 a writer from the Gold Coast^ alleges that he saw in rain- 
 water taken from a cistern two filarias which proved on 
 microscopic examination to be the real Filaria medinensis. 
 Carter, also, expressed a very definite opinion on the 
 identity with di-acunculus of a certain species of filaria which 
 he found in tanks (and named accordingly " tank-worms ") ; 
 and this view was afterwards accepted by Schwarz, who had 
 opportunities during a residence in Bombay of comparing 
 the embryos of dracunculus with the tank-worms in question. 
 Ewart also adopted that opinion, pointing out, as Carter had 
 already done, that these parasites were never found in pure 
 water, and that those persons who used nothing but pure 
 water, were never affected with dracunculus. 
 
 § 123. Evidence eor and against the Entrance oi' Dracun- 
 culus WITH THE Drinking-water and through the Skin 
 respectively. 
 
 I do not attempt to decide how much or how little credit 
 we should give to these observations, or to some of them, 
 
 ' See 'Boston Med. and Surg. Journ.,' 184.3, June, p. 293.
 
 GUINEA-WORM. 351 
 
 Carter's iu particular/ They served^ at all events, to 
 confirm the opinion that the invasion of the human body by 
 the parasite took place in the larval form out of water ; and 
 the attention was then mostly directed towards answering 
 the question, hy toliat door the 'parasite entered, whether by 
 the digestive organs (in drinking-water), as had been almost 
 universally assumed according to the notices above given, or 
 through the skin. 
 
 The objections taken to the drinking-water theory by 
 many observers are supported partly on negative and partly 
 on positive grounds. Not to mention the purely hypo- 
 thetical exception that has been taken to it from a physio- 
 logical point of view (by Clymer), the fact has been dwelt 
 upon that there are places infested by the parasite where 
 natives and European take their drinking-water from the 
 same source, and yet the former suffer from dracunculus to 
 a much greater extent than the latter, who not unfrcquently 
 indeed escape it altogether. 
 
 But the consideration that has special weight with the 
 opponents of the drinking-water theory is that the worm, in 
 the great majority of cases, has its seat in the subcutaneous 
 connective tissues, particularly of the feet ; and accordingly 
 in those parts of the body that are farthest from the supposed 
 channels of invasion. 
 
 Of 133 cases observed by Lorinser, 80 bad tbe parasite located in the 
 skin of tbe foot or ankle, 39 in tbe leg, 6 in tbe tbigb, 2 in tbe scrotum, 
 and 5 in tbe forearm. Of 210 cases given by Ewart, 120 bad tbe filaria 
 in tbe foot and ankle, 67 in tbe leg, 5 in tbe tbigb, 2 in tbe scrotum 
 and tbigb, 2 in tbe abdominal wall and tbigb, 2 in tbe forearm, 2 in tbe 
 back and tbigb, 7 in tbe knee and forearm, and i eacb in tbe tbigb, 
 abdominal wall and back, in tbe tbigb and penis, and in tbe scrotum, 
 perineum and groin. Of 369 cases treated by Grierson, i,^^ bad the 
 parasite located in tbe lower extremities, 29 in tbe i;pper, and 5 on tbe 
 trunk. 
 
 This is certainly a very remarkable fact ; and it may easily 
 
 lead us to think that the guinea-Avorm comes to the body 
 
 from the soil or water, not by imbibition, but through the 
 
 skin (pores or sweat-glands). Rouppe had formerly inclined 
 
 towards that opinion "quia [dracunculi] eos qui midis 
 
 ^ Compare Leuckart's uot very favorable verdict on Carter's doctrine (' Para- 
 siten des Menschen,' ii, 703).
 
 352 GEOGEArmCziL AND UrSTOrvrOAL TATHOLOGY. 
 
 pedibus iiiceduut jirae aliis plus invadaiit j'^ and the same 
 fact lias served to determiuc the views of many observers in 
 Nnbia,^ on the Guinea Coast," and in India/ who pointed out 
 that the malady occurred chiefly among those who went 
 about on the damp marshy ground, just as the natives do in 
 the tropics, or waded in swamps, or had to work in standing 
 water, or who bathed in the same • and thus Brysou says of 
 the filaria), by Avay of summing up, that " they are generally 
 found in those parts that are most exposed to the influence 
 of external objects." 
 
 There has been, moi'eover, no lack of individual observa- 
 tions which seemed to give support to this theory. Heath 
 observes, in his account of an outbreak of dracontiasis among 
 the crew of a ship which had lain a long time in the port of 
 Bombay, that the oflficers were engaged on shore just as 
 much as the crew and drank the same water; but the crew 
 when employed on shore wore nothing but shirt and trowsers, 
 whereas the officers, who escaped the disease, were completely 
 clad and were protected by boots or shoes against the invasion 
 of the filaria. Clarke relates that the troops in the barracks 
 at Cape Coast Castle, in 1858, slept on mats on the ground, 
 and suffered much from dracontiasis ; but the cases became 
 considerably less common after beds were erected. Busk 
 says that cases of guinea-worm have occurred on the West 
 Coast of Africa in Europeans who had never been ashore, 
 but had merely exposed some uncovered part of the body to 
 the water in the boats of the natives. Interest Avas specially 
 excited by the statement of Bruce'* that the " bheesties " or 
 water-carriers in India, who carry the water in a leathern 
 bag depending from the shoulders over the back and flanks, 
 suffered from dracunculus chiefly in those parts of the body 
 which came into direct contact with the bag ; and that state- 
 ment was afterwards confirmed by Scott. 
 
 Plausible as this theory has always seemed, and ener- 
 getically as Carter has lately entered the lists for it ; still the 
 great majority of observers, relying on unambiguous experi- 
 
 ^ Clot-Bey, Fischer, Pruuer, Pethei'ik. 
 
 - Brvson, Busli, Clarke in ' Epidemiol. Transact.,' 1. c. 
 
 •* Bruce,' Ediub. Journ.,' 1. c, Bird, Eyre, Gibson, lleatli, Mackenzie, Carter, &c. 
 
 ■' ' Edin. Med. and Surg. Journ.,' I.e., p. 147 (note i).
 
 GUINEA-WOEM. 353 
 
 «iices, have remained true to tlie original idea of the parasite 
 heing introduced with the drinking-water. The argument 
 for entrance through the skin, which is derived from the 
 localisation of the parasite in the subcutaneous connective 
 tissue of the lower extremity, has been decisively met by 
 Ewart when he points to the distant wanderings of many 
 other parasites within the human body, and to their vai'ious 
 favourite seats in some particular organ or tissue far 
 removed from the point of invasion (echinococcus of the 
 liver, cysticercus of the connective tissue, trichina of muscle, 
 &c.), although in these cases there could not be the smallest 
 doubt that they entered by the digestive canal. Again, it 
 has been shown that dracuuculus has occurred in a very 
 large number of cases where there had been no exposure to 
 infection through the skin, but on the other hand, particular 
 care taken to avoid it — cases of persons belonging to the 
 better-off classes, such as officers, civilian officials, and the 
 like. 
 
 The statements of Bruce and Scott as to the occurrence 
 of the worm in Indian water-carriers at those parts of the 
 body which come into direct contact with the water-bags, 
 have been rejected by Smyttan, Morehead, and Ewart as 
 -absolutely without foundation : 
 
 '' I have never observed," says Smyttan, '' that Beesties 
 most frequently have the guinea-worm in those parts which 
 come in contact with the leathern water-bag, nor does it 
 appear to me, that they are in any degree more subject to 
 them than other descriptions of people ;'' and Morehead 
 confirms this as follows : " I can affirm, after ample oppor- 
 tunity, and no little attention bestowed on the study of 
 dracunculus, that I am unable to bring to my recollection a 
 single instance of a water-carrier affected with it at that 
 part on which the water-bag rests, nor have I any reason 
 for supposing that they suffer more than other classes." 
 
 But the leading argument in favour of the access of the 
 parasite by the drinking-water is furnished by the instances 
 where dracontiasis has broken out endemically or epidemic- 
 ally under circumstances which leave no doubt as to the mode 
 of infection. Chisholm had long ago satisfied himself that 
 <the malady occurred on the Grenada plantations only among 
 
 TOL. TT. 2o
 
 354. GEOGEAPHIOAL AND HISTORICAL PATHOLOGY. 
 
 those negroes who used to drink from the poo]s of water 
 that had been partly filled by the tide and were therefore 
 brackish ; whereas the negroes who used rain-water remained 
 exempt^ and the disease vanished from the plantations alto- 
 gether when springs beyond the influence of the tide came 
 into use^ or when bricked cisterns were erected. Dubois's 
 experience was the same as regards the distribution of 
 dracunculus among the natives on the banks of the Cauvery 
 (Southern India). Ferg observed in 1801 on a coffee 
 plantation (Beninenburg) in Surinam, an epidemic of filariaa 
 in which nearly 200 negroes became affected within a space 
 of four or five months, and not only the field hands, but also 
 the slaves employed in the house of the manager, who had 
 nothing in common with the others except the water supply ; 
 and the inquiry that was set on foot showed that it was the 
 use of drinking-water from the spring which had been the 
 true cause of the outbreak. In Secunderabad, according to 
 Cooper, an epidemic of filariee occurred among the native 
 troops, which was almost exclusively coufincd to two com- 
 panies that had got their water supply from a particular 
 well. Dutt had under treatment iSo cases of dracontiasis 
 from a village near Warora (Central Provinces), all of whom 
 had got their drinking-water from a filthy well, while other 
 inhabitants of the village, who had used a different water, 
 continued free from the disease. A fact of great interest in 
 this connexion is the outbreak of dracontiasis in 1849 among 
 the members of two trading caravans who encamped on the 
 road from Bahia to Jazeiro beside a stream a few leagues 
 distant from Feira de Santa Anna ; disregarding the 
 warnings of the natives, they made use of the water for 
 drinking, although it is expressly stated that they did not 
 bathe in it ; and a few months later all the members of the 
 party fell ill with the excepti<)n of a negro, who Avas the only 
 one of their number that had not drank the water. More- 
 over, the same consequences had followed, according to a 
 practitioner living at Feii^a de Santa Anna, in the case of 
 fifty of the inhabitants of a commune some six miles from 
 that place, and among these there were several who had not 
 bathed in the stream but inerely drank the water. 
 
 The question as to the mode of entrance of the guinea-
 
 GUINEA-WORM. 355 
 
 worm into tlie liumau body lias recently been brought near 
 a solution, if not finally solved, by the researclies of 
 Fedsclienko. That observer has shown^ that the embryos of 
 dracunculus enter the body of the small Cyclops, which, 
 abounds everywhere, and develop in the interior of the 
 latter into a larval form which had not been recognised 
 before ; that this invasion by the embiyos takes place on the 
 ventral surface of the cyclops ; and that the development to 
 the larval state within the intermediate host takes place 
 usually above the intestine in the dorsal half of the body- 
 cavity." For the present we have no positive facts as to the 
 later stages of the process ; but it is a probable conjecture 
 that the infection of the human body takes place thi^ough the 
 cyclopeans whicli contain the larval parasite being taken in 
 along witli the drinking-water, the larva) attaining their 
 freedom in the stomach of man, starting on their travels, 
 and undergoing development into the mature animal in a 
 tissue of the human body adapted thereto. The infection of 
 the cyclopeans by filarial embryos presupposes, -naturally, 
 that the latter find their way into water where their liosts 
 live ; but as Leuckart justly remarks, sucb opportunities can 
 hardly ever be wanting where the worm is at all common. 
 Moreover, this process enables us to understand the fact 
 already mentioned, that dracunculus occurs mostly at places 
 where there are the conditions most suited to the existence 
 of the cyclopeans, namely sluggish, shallow or stagnant 
 waters, pools abounding in vegetation, tanks, swamps, and 
 the like ; and in that respect also it will appear that there is 
 justification for Ewart^s conjecture that the decline in the 
 cases of dracontiasis during the last ten years of his obser- 
 vations in the Mewar Bheel contingent is to be attributed to 
 improvement of the water supply. 
 
 In the period from i84[ to 1849, tlie number of cases amon£? these 
 troops amounted to i8'24 per cent, of tlie total strength, while from 
 1849 to 1858 it fell to i3'93 per cent. This is to be explained, says 
 Ewart, through the growing conviction that the malady was of most 
 frequent occurrence among those persons in the cantonments who 
 
 ' I follow the account of LeuckarL (1. c, p. 704), as tlie Iniiguage of the 
 ori:.jin!il paper is not familiar to lue. 
 
 - For f Hither particulars of the larval development see Leuckart, 1. c.
 
 356 CIEOGIiAPHICAL AND HISTORICAL PATHOLOGY. 
 
 were " tlie filtlaiest drinkers." Being convinced of this, the more in- 
 telligent of the men had used greater care of recent years in choosing 
 what wells they would drink from. The European families resident 
 there enjoy perfect immunity from dracunculus, the reason being, as 
 Ewart is convinced, that they take the greatest care about their water- 
 supply ; and even among such of the native civilian population as take 
 their drinking-water exclusively from wells that are kept clean, not a 
 single case has occurred. 
 
 § 124. Guinea- WORM has followed the African Negro to 
 America and elsewhere. 
 
 All the authorities for Brazil^, Guiaua, the West Indies, 
 Egypt, aud the East Indies agree in stating that dracontiasis 
 was quite unknown in these countries before the importation 
 of the negro ; and in the subsequent period it has been 
 always the African part of the population that has supplied 
 the largest contingent of the sick. With the suppression of 
 the slave trade, or, in other words, the cessation of frequent 
 and extensive intercourse between the countries of the negro 
 (especially the Guinea Coast) and the countries above named, 
 the disease in most of the latter fell to a minimum or dis- 
 appeared altogether. There can be hardly any doubt, there- 
 fore, about the transmissihility of dracontiasis or of the 
 parasite which underlies it ; and the interesting researches 
 of Fedschenko supply the information as to the manner of 
 that transmission. At the same time it follows from the 
 experience of these countries, that the parasite is able to 
 survive and to become domesticated outside its native habitat 
 only under certain conditions ; but the nature of these con- 
 ditions cannot be in any way inferred either from the older 
 observations or from the results of Fedschenko's inquiries. 
 In like manner, for all those places in the Eastern Hemisphere 
 where dracontiasis is now endemic, the question remains 
 undecided, whether they were the original habitats of the 
 parasite, or whether some of them, affording the conditions 
 necessary to the existence of the guinea- worm, may not have 
 been secondarily infected. For India in particular, this 
 question may be urged. According to Gramberg,^ the 
 
 '■ Quoted by Leuckart from tlie * Geneesk. Tijdschr. voor NederL Indie,' 1861, 
 ix, p. 632.
 
 GUINEA- WORM. 357 
 
 disease was imported by negro troops into Bombay, wliich 
 is now the bead- quarters of it in India. From Madras,^ 
 Waring gives tbe following example of the formation of new 
 endemic centres : Previous to 1834 tbe city, and in pai'ticular 
 certain of its subm-bs, enjoyed almost complete immunity 
 from dracontiasis. In 1834 and 1835 cases occurred here 
 and there, and since that time the disease has gained so 
 much in extent that it must now be reckoned among tbe 
 maladies of most freqent occurrence. While the number 
 of cases from 1834 to 1838 amounted to 222 in all, they rose 
 in 1839-43 to 387, and in 1844-48 to 920. "I do not 
 think," says Waring, "that we can come to any other con- 
 clusions than that, whatever may be the cause of the disease, 
 it may be transplanted from place to place, and that localities 
 previously exempt may become the seat of the affection." 
 
 List op Writers on Guinea-worm. 
 
 Annesley, Eeserclies into tlie . . more Prevalent Diseases of India. Lond., 
 1S41, 67. 
 
 Bajon, Nachrichtcn von Cayenne, etc., iii, 95. Balfour, Edinb. Med. 
 Journ., 185S, Novbr., 442. Berenger-Feraud, Malad. des Europeens an 
 Senegal. Par., 1875, 336. Bertherand, Med. et hjg. des Arabes. Par., 
 1855, 426. Berville, Gaz. des hopit., 1858, Nr. 37, 147. Bilharz, Zeitschr. 
 der Wien. Acrzte, 1858, 448. Bird, Calcutta Med. Transact., 1825, i, 153. 
 Birkmeycr, De filaria med. comment. Onoldi, 1838. Borius, Arch, de 
 med. nav., 1882, Mai, 373. Boudin, Geogr. et stat. med., i, 345. Boyle, 
 Med. Account of the Western Coast of Africa. Lond., 1831, 394. Brett, 
 Essay on some of the Surg. Diseases of India. Calcutta, 1840, 470. Bruce 
 (I), Travels in Nubia, etc. (Pr. Transl. Par., 1791, iii, 43). Bruce (II), 
 Edinb. Mod. and Surg. Journ., 1806, Apr., 145. Bryson, Report on the 
 Climate and Diseases of the African Station. Lond., 1847, 259. van der 
 Berg, De Gencesheer in Nederlandsch-Indie. Batavia, 1882, i, 103. Burnes, 
 Calcutta Med. Transact,, 1836, viii, 459. Busk, Med. Times, 1846, May. 
 
 Carter, Bombay Med. Trans., 1855, New Ser., ii, 4,5, 252, 1859 ; New Ser., 
 iv, 215. Chisholm, On the Malignant Pestil. Fever, etc. Lond., 1801, i, 
 57 ; Edinb. Med. and Surg. Journ., 1815, April, 145. Clarice, Sierra Leone, 
 etc. Lond., 1844; Transact, of the Epidemiol. Soc, i860, i, 118. Clot- 
 Bey, Lancette fran?., 1830, Novbr.; Eper^u gen. sur I'Egypte, ii, 319; 
 Compt. rend, do I'enscignement med. en Egypte. Par., 1849. Clymer, 
 Amer. Journ. of Med. Sc, 1S59, Oct., 375. Collier, Med. Gaz., 1S36, Nov., 
 
 * L. c, p. 500.
 
 358 C.EOGEArHIOAL AND niSTOBICAL PATHOLOGY. 
 
 217. Cooper, Med. Times and Gaz., 1871, May, 617. Cornish, Madras 
 Quart. Journ. of Med. Sc., 1861, Oct., 314. Courbon, Observ. topogr. ot 
 med. rec. . . a Tisthme de Suez, etc. Par., 1861, 69. Crespigny, Bombay 
 Med. Transact., 1859, ^^^^ >^er., iv, 94. Currie, Brit. Army Reports for 
 1867, ix, 296. 
 
 Daniel], Med. Topogr. of the Gulf of Guinea. Lond., 1S49, 44. Day, 
 Madras Quart. Journ. of Med. Sc, 1862, Jan., 36. Defaut, Hist, clinique 
 de I'hopital marit. de Goree, etc. Par., 1877, 134. Dubois, Edinb. Med. 
 and Surg. Journ., 1806, July, 360. Duncan (I), Travels in the Sahara, etc. 
 Duncan (II), Calcutta Med. Transact., 1835, vii, 273. Dutt, Brit. Med. 
 Journ., 1880, March, 488. 
 
 Ewart, Indian Annals of Med. So., 18/^9, July, 470. Eyre, Madras 
 Quart. Journ. of Med. Sc, i86r, Apr., 30S. 
 
 Ealkenstein, in Virchow's Arch., 1877, Ixxi, 421. Fedschenlco (Proto- 
 l\olle der Freundo der Naturwiss. in Moskau [Russian], 1869, 71, and 1874, 
 51), in Leuckart, Pavasiten, ii, 644 If. Ferg, -Tahrb. der deutsch. Med., i, 
 151. Feris, Arch, de med. nav., 1879, Mai, 329. Ferrini, Saggio sul clima 
 e sulle precipue malatt. . . di Tunisi, etc. Milano, i860, 134. Fischer, 
 Miinch. med. Jahrb., 1838, iv. Heft 4. Forbes, Bombay Med. Transact., 
 1838, i, 215. 
 
 Gallandat, Journ. de med., 1760, xli, 24. Gardiner, Brit. Army Reports 
 for 1863, V, 329. Gauthier, Des endemics an Senegal. Par., 1865, 43. 
 Gibson, Bombay Med. Transact., 1838, i, 69, 1839, ii, 209. Gordon, Edinb. 
 Med. Journ., 1856, Decbr. Greenhow, Ind. Annals of Med. Sc, 1856, 
 April, 556; i860, Novbr., 31. Grierson, Bombay Med. Transact., 1841, iv, 
 
 90- 
 
 Harris, The Highlands of J^lthiopia. Loud., 1844, iii, 389. Hartmann, 
 
 Naturg.-med. Skizze der NillJinder. Berl., i86r^. Heath, Edinb. Med. and 
 Surg. Journ., 1816, Jan., 120. Hebert, Uneannee med. a Dagana (Senegal). 
 Par., 1880, 41. Heymann, Darstellung der Krnnkh. der Tropenlandei*. 
 Wiirzb., 18515, 220. Hillary, Observations on . . . Epid. Diseases in Barba- 
 does, 2nd ed. Loud., 1766. Hille, in Casper's Wochenschr. fiir die ges. 
 Heilkde., 1845, 556. Horton, Brit. Army Reports for 1868, x, 335. 
 Huillet, Arch, de med. uav., 1868, Fevr., 87. 
 
 Kaempfer, Amoenit. exot. med., Fasc iii. Lemgo, 17 12, 524. Kearney, 
 Bombay Med. Transact., 1859, -^^^ *^*^i'-' i^' ^1-- Kennedy, Calcutta Med. 
 Transact., 1825, i, 165. 
 
 Leblanc, Journ, de thcirap., 1879, 98. v. Leent, Arch, de med. nav., 
 1867, Oct., 250. Leonard, Observ. med. rec. an poste de Sed'hiou (Senegal), 
 etc. Par., 1869. Lind, Essay on Diseases Incidental to Europeans in Hot 
 Climates. Lend., 1768, 57. Lorinser, Madras Quart. Med. Journ., 1839, 
 i,!46. 
 
 M'Gregor, Edinb. Med. and Surg. Journ., 1805, July, 284. Mackenzie, 
 Bombay Med. Transact., 1859, New Ser., iv, 138. MacKay, Madras 
 Montlil. Journ. of Med. Sc, 1870, April, 292. Mahomed-el-Toun.sy, Voyage 
 au Dai-four. Pur., 1845, 286. Marduchi, in Clot-Bey's Aper^u. Maydell, 
 NonnuUa topogr. med. Orenburgensem spect. Dorpat, 1849. Minas, Ind. 
 Annals of Med. Sc, 1856, April, 56S. Mir-Izzet-Ullah, Journ. of the Roy.
 
 GUINEA-WORM. 859 
 
 Asiat. Soc, viii, 335. Moore (I), P., Assoc. Med. Jourii., 1856, Nov., 996. 
 Moore (II), Bombay Med. Trcansact., 1861, New Ser., vi, 313. Moore (III), 
 R., Lancet, 1874, Novbr., 750. Moreliead, Calcutta Med. Transact., 1834, 
 vi, 418, 1836, viii, 49, and Clinical Researches on Disease in India. Lond., 
 1S56, ii, 709. Moriarty, Med. Times and Gaz., 1866, Decbr., 663. 
 
 Nathan, ib., 1868, Nov., 542. 
 
 Oldfield, Lond. Med. and Surg. Journ., 1835, Nov., 403. 
 
 Paton, Edinb. Med. and Surg. Journ., 1806, April, 151. Perc, Joum. de 
 med., 1774, xlii, 121. Pereira, Arch, de med. nav., 1877, Oct., 295. 
 Petherik, Egypt, tlie Soudan, etc. Edinb., 1861, 332. Polak, Wochenbl. 
 ziir Zeitschr. der Wien. Aerzte, 1857, 760. Pouppe-Desportes, Histoire des 
 maladies de St. Domingue. Pai*., 1770, ii, 271. Pruner, Krankh. des 
 Orients, 250. 
 
 Quintin, Extr. d'un voyage dans le Soudan. Par., 1869. 
 
 Ref., in Bost. Med. and Surg. Journ., 1843, June, 293. Reynhout, 
 Hippocrates. Magazijn, 1820, vi, Nr. i. Richardson, Travels in the Great 
 Desert o£ Sahara, etc. Lond., 1848, i, 196. Robinson, Med. Gaz., 1846, i, 
 70. Rodschied, Med. und chir. Bemerk. iiber . . Rio Essequebo. Frkft., 
 1796, 301. Ross, Sketch of the Med. History of the Native Army of 
 Bengal for the Year 1868. Calcutta, t868. Rouppe, De morbis navigan- 
 tium. Lugd. Batav., 1764, 282. 
 
 Savarcsy, De la fievre jaune. NapL, 1809, 8. Scholler, Diss. sist. observ. 
 super morbos Surinamensium. Gott., 1781, 40. Schwarz, Zeitschr. der 
 Wien. Aerzte, 1858, 581. Scot, Edinb. Med. and Surg. Journ., 182 1, Jan., 
 g6. Scott, Med.-Chir. Review, 1823, June. Sigaud, Du climat et des 
 malad. du Brcsil. Par., 1844, 133. da Silva Lima, Arch, de med. nav., 
 1881, Mai, 395 (see Veterinarian, 1879, Pebr., seq.). Sloane, Diseases of 
 Jamaica. Germ. Transl., Augsb., 1784, 91. Smyttan, Calcutta Med. 
 Transact., 1825, i, 179. Stewart, Indian Annals of Med. Sc, 1858, Jan., 88. 
 Thaly, Arch, de med. nav., 1867, Mars, 173. Thomson, Brit, and Foreign 
 Med.-Chir. Rev., 1855, Oct. Tutschek, Oest. med. Wochenschr., 1846, 208. 
 Twining, Calcutta Med. Transact., 1835, vii, 4^9. 
 
 Vauvray, Arch, de med, nav., 1873, Septbr., 161. Voigt, Bibl. forLaeger, 
 
 1833- ii' 5- 
 Waller, Bombay Med. Transact., 1859, New Ser., iv, 64. Waring, Ind. 
 
 Annals of Med. Sc, 1856, April, 496.
 
 360 GEOGKAFHIOAL AND HISTOEIOAL PATHOLOGY. 
 
 Insects} 
 
 § 125. Geographical Distribution op Sarcoptes Scabiei — 
 
 THE Itch Insect. 
 
 Historically and geographically considered, this parasite is 
 coextensive with the human race itself." Among the para- 
 sitic diseases that have been known in every age and in all 
 parts of the woi'ld, the itch takes the foremost place. It 
 has not rarely assumed the character of an epidemic under 
 such unhygienic influences as specially favour the spreading 
 and lodging of the parasite f not rarely also it has gained 
 and maintained an endemic sway over the inhabitants of 
 those countries or districts where ignorance, rough manners 
 and the indolence springing from them have had the effect 
 of keeping the social habits down at a primitive level. 
 
 We have no definite figures whereby to estimate the extent 
 to which the itch is endemic in various parts of the woi'ld, 
 the prevalence of the malady being denoted merely by such 
 general terms as " rare/' " common/' " very common/' or 
 " geuerally diffused." But according to that kind of infor- 
 mation, and so far as it goes, the portions of European soil 
 most infested by the itch are Iceland,^ the Faroe Islands,^ 
 Norway, Poland, Btissia, some parts of Eastern Germany and 
 of France, Turkey and the Ionian Islands. 
 
 1 As I mentioned at the beginning of this chapter, I intend to consider here 
 only those insects which have the character of true parasitic feeders upon man, 
 and are at the same time among the more common or endemic of their class. 
 
 ^ Hehra has published a very exhaustive inquiry into the history of the 
 disease from remote antiquity down to the present time (" Acute Exantheme 
 und Hautkrankheiten," in 'Virchow's Handb. der spec. Pathol, und Therap.,' 
 Erlangen, i860, i, 410). 
 
 ^ In the Napoleonic wars the sufferers from the itch in the French armies 
 were counted by the hundred thousand. In tlie hospitals of Prague in 1S66, 
 according to Peters ('Prager Vicrteljahrschr. fiir Heilkde.,' 1868, iv, 179; 1874, 
 ii, i), the number of patients admitted with the itch was ii2g, while in 1867 it 
 was 2256; in the years following there was again a decrease proportionate to the 
 rise. No doubt the state of war in 1866 made the difference there also. 
 
 * Schleisner, 'Island undersogt, &c.,' 26; Pinsen, ' Jagttagelser, &c.,' Kjob., 
 1874, 137. 
 
 * Manicus, 'Bibl. for Laeger,' 1824, 15.
 
 ITCH. 361 
 
 In Iceland, according to Finsen, the disease would appear to be rarer 
 now than formerly. As regards France, Lanquetini says : " II y a 
 encore dans le Jura plusieurs villages, dont les habitants sont a peu pres 
 tous galeux." And Hardy,= referring to Lower Brittany, says: "La 
 gale s empare du sujet quelques jours apres sa naissance, le suit dans 
 toute sa carriere et ne I'abandonne qu' a la mort." In the island of 
 Cephalonia, according to Robertson,^ one third of the whole 60 000 
 inhabitants had the itch. 
 
 On Asiatic soil, the parasite is universally diffused in 
 Siberia and Kamschatha,' as well as in China' and in 
 Ja:pan , where, as Vidal (following- Siebold) tells us, three- 
 fourtlis of the whole population have the itch; and, as 
 Friedel declares, not only the natives but also foreigners are 
 affected. It is common also in the East Indies,^ where van 
 Leent says of it : " La gale est tellement repandue parmi 
 les indigenes, que beaucoup d'individus n'y portent m6me 
 plus attontion,^^ adding that this holds good not only for the 
 lower classes but also for people in better circumstances. 
 Almost all the authorities for India'' mention the enormous 
 frequency of this parasite among the native population: 
 "On pent dire,^' says Huillet, -que presque tous ceux 
 [galeux] de la basse classe vivent avec elle [la gale] sans 
 chercher a s^en guerir." The same is true of Arabia^'' and of 
 Persia, where, according to Polak,!^ one half of the soldiers 
 m a regiment arrived at Teheran from Tabriz, had the itch. 
 A remarkable exemption is enjoyed by some of the island- 
 
 i ' Notice SUV la gale,' Par., 1859, 63. 
 
 " ■ herons sm- les maladies de la peau,' Par., 1859, i'' Mi- 
 ■ Lond. Med. Repository,' 18 18, June, 461. 
 Ilaupt, 'Med. Ztg. Uussl.,' 1845, .^75- 
 Bogorodsky, ib., 1854, lO- 
 
 « Wilson, ' Med. Notes on China,' Lond., 1846, 22. 
 
 7 Friedel, ' Bcitr. zur Kenutniss des Kli.nas und der Kraukl,. Ost-Asiens,' 
 Berl., 186.^, ,,, 2r; Albrecht, « Petersb. u>ed. Zeitschr.,' 1862, iii, 5,; Vidal 
 1. ascande lonibrieoide en Chine et an Japou,' Montp., 1865 
 
 « Hey„,ann 'Krankh. in den Tropenlanden,' Wurzb., is.^S, 222; v. Leent, 
 Arch, de med. nav.,' ,867, Oct., 250; 1872, Jan., 22; ,87^, Pevr., 102. 
 
 « loung,' Calcutta Med. Transact.,' ,826, ii, 334; Leslie, ib., 183^, vi,6r, 
 
 Crespagny,' Bombay Med. Transact.,' 18,9, N.S., iv, 94; Day, ' Madnls Quart. 
 
 Journ. of Med So ' 1862, Jan.. 23; Cleveland, ib., .863, Jan., 26; Milroy. 
 
 Iransact. of the Epidemiol. Soc.,' ,866, ii, ,50; Huillet. 'Arch, de med. nav ^ 
 
 1068, Jan., 26. ■' 
 
 1" Palgrave, in ' I'Union med.,' 1866, Nr. 20, 308. 
 
 »' 'Wochenbl. zur Zeitsehr. der Gesellsch. der Wiener Aerzte,' 1857, 756. 
 
 2 i 
 
 3 i 
 4 
 
 5
 
 3G2 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 groups of Oceania ; wliilc the itcli is quite g'cncral among tlie 
 Kanakas of the JIaioaiian Ittlaiids,^ it is the unanimous opinion 
 of several French practitioners^ that it rarely occurs on the 
 Society Islands (Tahiti), and according to Turner^ it is rare 
 also in the Samoa group. From Africa there are accounts 
 of its endemic prevalence on the Mozambique^ Coast, in 
 Ahyssiriia,^ Egypt, ^ Tunis ^ among the native population of 
 Algiers,^ especially the Kabyles, wlio arc eaten up by the 
 itch (" devores "), as Challan puts it; also on the West 
 Coast^ where the malady, known under the name of " craw- 
 craw/'^° or by the Portuguese term " sarna/^ has attacked 
 the greater part of the negro population ; and in the Canary 
 Islands^^ especially Gomera and Palma, where nearly the 
 whole inhabitants are likewise permanently subject to it. 
 In the Western Hemisphere the two chief regions of itch, so 
 far as I can learn, are Brazil^" and Perii}^ In Guiana it is 
 known under the name of " maracane," in Brazil as "^ sarna '^ 
 (the Portuguese term, but various chronic skin diseases are 
 included under it), and in Peru as " carracha," a distinction 
 being drawn in that country between a milder vesicular 
 
 ^ Gulick, 'New York Joiiin. of Mod.,' 1855, Miircli; Duplouy, 'Arch, de med. 
 nav.,' 1S64, Dec, 486. 
 
 - Kef. ib., 1865, Oct., 291. 
 
 3 'Glasgow Med. Jourii.,' 1S70, Aug., 502. 
 
 '' Lichtenstein, in ' Hufelaiul's Jourii. der Ilcilkde.,' 1804, xix, H. i, 180. 
 
 " Ccurboii, ' Observ. topogr. et med., &e.,' Par., i86), ^;^. 
 
 " Pruiier, ' Kr.'inkb. des Orients,' Krlang., 1S46, 142; Pox, ' Med. Times and 
 ■Gaz.,' 1867, Feb., 165. 
 
 ' Ferriui, ' Saggio snl clinia . . di Tunisi, &c.,' Milaiio, i860, 1S2. 
 
 ■^ Gandineau, ' Mem. de med.'milit.,' 1842, lii, 20S ; Deleau, ib., 230; Armand, 
 •'Med. ct hyg. des pays ebauds, &c.,' Par. (1853), 419; Bazille, ' Gaz. med. de 
 PAlgeric,' 1868, 39; Cballau, ib., 117. I may remark here that the so-called 
 " Gale bcdouine" is not the itch, bnt Lichen simplex (see Ariuand, 1. c). 
 
 3 Boyle, 'Account of the VVestcrn Coast of Africa,' Lond., 1831, 391 ; Oldfield, 
 ' Lond. Med. and Surg. Journ.,' 1835, Nov., 403 ; Bryson, ' Report on the Climate 
 and Diseases of the African Station,' Loud., 1847, 258; Duncan, 'Travels in 
 Western Africa,' Lond., 1847, i, 32 ; Daniell, ' Sketch of the Med. Topogr. of the 
 Gulf of Guinea,' Lond., 1849, 114; Clarke, ' Transact, of the Epidemiol. Soc.,' 
 i860, i, 104 ; Abeliii, ' Etude sur le Gabon,' Par., 1872, 31 ; Feris, 'Arch, de med. 
 nav.,' 1879, Mai, 330. 
 
 ^^ See O'Neill's remarks on Filaria sanguinis given at p. ^^^. 
 
 1' Bef. in ' Arch, de med. nav.,' 1867, April, 253. 
 
 1^ Sigaud, ' Du cliiiiat et des malad. du Brosil,' Par., 1844, 397. 
 
 13 Smith, in ' Ediub. Med. and Surg. Journ,,' 1840, April, 339.
 
 ITCH. 3G3 
 
 form ('^ carraclia fiua ") on the coast, and a more severe 
 pustular form (" cari-aclia sierrana ") among the monutains. 
 
 § 126. Want op Cleanliness the Single Favouring 
 Condition for the Itch. 
 
 The great prevalence of itch in high and loiu latitudes 
 contrasting with its comparatively rare occurrence in the 
 temperate zone, is not explained by the circumstances of climate 
 any more than its common occurrence among the natives 
 of these regions, and its small number of victims among 
 foreigners (Europeans), is explicable on the ground of racial 
 or national 2)6culiaritics. The single determining factor is 
 the development of the sense for cleanliness corresponding 
 to the degree of cultivation in general, the appreciation of 
 the care of the sldn^ and of its careful treatment when out 
 of order ; in short, the degree of consideration given by the 
 individual or the community to the withstanding of injurious 
 influences (among the rest the itch insect) and to the com- 
 batting of the same. Not only is the number of cases 
 dependent thereon, but also the intensity which the disease 
 attains to ; for where the itch is most widely diffused, there also 
 it induces the severest forms of skin disease, — the pustular, 
 impetiginous, and ecthymatous eruptions, and the ulcerations 
 that have been found among the natives of India (the most 
 notorious being the ^'Malabar itch "), of Egypt, the West 
 Coast of Africa,^Mozambique, Pern, and other countries.
 
 36 1 GEOGRAPHICAL AND IITSTOEICAL PATHOLOGY. 
 
 Sandjiea} {Pulex, BJiynchojJrion penetrans). 
 
 § 127. Geographical Distribution op Sandi'Lea. 
 
 This parasite is iudigenous only to tlie tropical regions of 
 the Western Hemispliere, from 23" N. (Mexico) to 28° S.^ 
 Quite recently (1872) it was imported^ by a vessel from 
 Brazil into the Gaboon Coast and the Congo Coast, where it 
 soon became a widely diffused and frightful scourge to the 
 natives.* In the Western Hemisphere, where the first 
 European immigrants soon made the acquaintance of this 
 extremely troublesome insect, its range includes Mexico 
 (both the easteim and western provinces), all the States of 
 Central America both on the Pacific and Atlantic side, 
 
 ^ The colloquial names for this parasite are chigue, cliogo, or tchike iu the 
 West Indies, sikka in Guiana, bicho, tunga, jatccuha, and migor in Brazil, nigua 
 ill Mexico, and picque in Paraguay. 
 
 2 It is only the female that can be considered a true parasite, and she only for 
 the reproductive period, or up to the maturation and extrusion of the eggs. 
 The animal bores through the human skin with its head (particularly under the 
 toe-nails), while its body remains free above the skin. After the eggs liave been 
 extruded, the animal dies, shrivels up, and drops oil' from the skin of its host. 
 The unimpregnated females and the males feed on blood from time to time, like 
 Fulex irriians. See Karsten, ' Beitr. zur Kenntniss des Rhynchopriou penetrans,' 
 Mosk., 1864, p. 59; Guyou, 'Gaz. med. de Paris,' 1863, p. 163; ' Compt. rend.,' 
 1870, Ixx, 785. 
 
 3 Falkenstein, in ' Virchow's Arch.,' 1877, vok Ixxi, p. 436 ; Bnllay, ' L'Ogooue,' 
 Paris, 1880, p. 41 ; Bey, ' Anual. d'hyg.,' 1880, Juin, p. 496. 
 
 * According to Skripitziu, a Russian physician (quoted in the ' Zeitschr. fiir 
 die ges. Med.,' 1840, xiii, 76, from the ' Gesuudheitsfreund' (1838), a Russian 
 journal of popular medicine), Pulex penetrans would have been domesticated in 
 Africa before the date iu the text, inasmuch as it was found upon negroes during 
 their shipment from the Congo coast or Mozambique to America. This state- 
 ment stands quite by itself, and I believe it to be a mistake, as the medical 
 accounts from the Mozambique coast make no reference whatever to the parasite. 
 
 '•' The earliest information of it in that country was given by Chappc d'Anto- 
 roche ('Voyage en Californie,' Paris, 1772, p. 20). Later accounts will be found 
 in Uslar, ' Preuss. med. Vereins-Ztg., 1843, Nr. 36 (for Oajaca); Vizy, 'Mem. dc 
 med. milit.,' 1863, Octbr., 316 (for the east coast and the highlands); Lucas, 
 'La fregatte "la Victoire" a Guaymas et a Mazatlan,' Par., 18C8, 41 (for 
 Mazatlan, on the west coast).
 
 HANDELEA. 365 
 
 (Honduras,^ Guatemala/ Costa Rica,^ San Salvador/ and 
 Panama)/ New Granada,^ G-iiiana^ the West Indies^ 
 Brazil^ and the tropical parts of Paragiiay^^ Chill^^ and 
 FeruP 
 
 § 128. Instances of the Sandflea in Europe. 
 
 It thus appears that Tulex 'penetrans, as a pertinacious 
 form of parasitic life, is strictly confined to the tropics, 
 Avithin which it is capable of transference from one place to 
 
 ^ Hamilton, 'Annals of Milit. Surgery,' Loud., 1864, 142. 
 
 ^ Bernoulli, ' Schweiz. raed. Zeitschr.,' 1864, iii, 100. 
 
 ^ Scliwalbc, 'Arch, fiir kliu. Med.,' 1875, xv, 347. 
 
 ■• Guzman, ' Essai de topogr. phys. et med. do la republique du Salvador,' Par., 
 1869, 125. 
 
 ^ Eoulin ('Compt. rend.,' 1870, Ixx, 792) publishes a letter by a Bishop of 
 Panama, dated 1688, in which it is stated that as early as 1538 a division of 
 Spanish troops was disabled from marching by swarms of the jjarasite settling iu 
 their feet. In recent times the French troops under Bazaiue, in the Mexican 
 expedition, had the same unfortun;ite experience. 
 
 * Humboldt, 'Voyage,' vii, 250 ; Goudot, quoted by Bonnet, 'Arch, de med. 
 nav.,' 1867, Aout, 95. 
 
 ^ Bajou, ' Nachrichten zur Geschichte . . von Cayenne,' from the French. 
 Erf., 1780, i, 91; Rodschied, ' Bemerk, iibcr das Klima . . von liio Esequebo,' 
 Frankf., 1796, 306; Campet, ' Traite prat, des malad. graves des pays chauds,' 
 Par., 1802, 454; Ferg, ' Jahrb. der deutsch. Med.,' 1813, i, 149; Nieger, ' De 
 la puce pcnetrante des pays chauds,' Strasb., 1859; ^^V' ' Nederl. Tijdschr. 
 voor Gcneesk,' 1859, ii'> 213; v. Hasselt, ib., i860, iv, 727; Bonnet, 1. c, 
 1867, Juill, 19, Aout, 81, Octbr., 258. 
 
 ^ The earliest account of the parasite in the West Indies is given by Ovicdo 
 ('Cronica de las Indias,' 1547, fol. xxi). Subsequent notices of it occur in 
 Sloane, ' Diseases of Jamaica,' Germ, ed., Augsb., 1784, p. 87 ; Moselcy, ' Treatise 
 on Tropical Diseases, &c.,' Lond., 1787; Savaresy, ' De la fievrc jaune,' Napl., 
 1809, 93; Labat, 'Annal. de la med. physiol.,' 1833, Avril ; Levacher, 'Guide 
 med. des Antilles,' Paris, 1840, p. 325 ; Brassac, 'Arch, de med. nav.,' 1865, Dec, 
 J). 510; Moulin, 'Pathol, de la race negre,' Paris, 1866, p. 26. 
 
 ' The first mention of it in Brazil is by Piso ('Hist, rerum natural. Brasilicns.' 
 1648, p. 249). Later authorities are Lallcmant, in 'Schmidt's Jahrb. der Med.,' 
 1842, XXXV, J 71; Burmeister, ' Reise in Brasilien,' J 853; Canovillc, ' Des lesions 
 produites par la chique, &c.,' Par., 1880. 
 
 '" Munck and llosenskjold, ' Vetcnsk. Akad. Forlull.,' 1849, Nr. 2; Mante- 
 gazza, ' Lettere med. sulla America meridion.,' Milano, i860, i, 284. 
 
 ^' Molina (' Saggio sulla storia naturale de Chili,' 1/82, p. 214) expressly 
 mentions that the parasite is confined to certain parts of the country, notably 
 Coquimbo, in 29° N. 
 
 '■■' Tschudi, ' Oest. med. Wochenschr., 1846, p. 472.
 
 366 aEOGBAPIIIGAL AND HISTORICAL PATIiOLOGY. 
 
 anotlier, as shown by its introduction into tlie West Coast of 
 Africa. That it can subsist fOr a brief period in temperate 
 Latitudes also^ is proved beyond doubt by several observed 
 facts. 
 
 An interesting case of tlie kind is given by Bonnet :' On board u 
 hospital ship which had sailed from Cayenne (Isles du Salut) in July, 
 1866, one of the engineers was laid up, about the latitude of the Azores, 
 with an abscess over the great toe, which was found on examination to 
 be due to a sandflea that had bored its way into the tissues. On 
 September ist, the vessel arrived at Toulon, where she underwent 
 repairs, and in January following she Avas again commissioned. A 
 sailor who had been occupied about the bunkers while the coals were 
 being taken in, was attacked with an inllammation of the foot between 
 the toes, and the ship's surgeon detected at the spot a living female 
 sandflea full of eggs. It I'ollows'that the insect had survived more than 
 six months, under very various conditions of weather and climate. A 
 similar case came under Laboulbeue's- observation in a man Avho had 
 arrived in Paris from Pernaiubuco, two living specimens of sandflea full 
 of eggs having been found in the skin of the little toe. 
 
 § 129. Sandflea acquired in Filthy Huts and PiGGERiEs in 
 
 THE Teopics. 
 
 Generally speakini2^, Fulex penetrans occurs more fre- 
 quently on low plains, especially the sea coast or the hanks of 
 rivers, than on high ground in the interior -^ although the 
 observations of Uslar and Vizy in Mexico show that it has 
 been met with also at considerable elevations. The head- 
 quarters of the parasite are everywhere filthy and dilapidated 
 human dwellings such as the huts of negroes and Indians, 
 or cattle sheds, and most of all piggeries. It occurs also in 
 houses that are kept with cleanliuess, but very rarely,"^ anel 
 under the circumstances stated in § 130. Not a single case 
 of pulex-invasion was found by Vizy among the French 
 troops quartered in the town of Orizaba or in the monas- 
 teries which had been converted into barracks ; whereas 
 many cases occurred among those sections of the troops Avho 
 
 ' L. c, p. 99. 
 
 ' 'Annal do la soc. eutomol. dc France,' 1SC7, ser. iv, tome vii, BulL, p. 6. 
 
 3 Brassac, Bonnet. 
 
 * Karsten, Vizy, Bonnet, Carnoville.
 
 SANDFI-EA. 367 
 
 lived in tlie half- dilapidated Indian Imts^ as well as among- 
 the Mexican troops located in the suburbs where herds of 
 swine were roaming al)out the adjoining gardens, and among- 
 a division of Zouaves who lived in sheds that had formerly 
 been used for keepiug pigs in. 
 
 § 130. Sandplba enters Houses in the E-ainy Season. 
 
 A very high temperature and very copious rainfall are 
 destructive of the insect as well as of its eggs and larvse. 
 Accordingly when that kind of weather sets in, the larvse may 
 be seen to bur}^ themselves in sand or rubbish-heaps. Mean- 
 while the mature insects take refuge in the dai'kest corners; 
 they resort at such times even to dwelling houses, where they 
 take up their quarters among the ashes or wood-shavings, or 
 in the dustbin or rubbish-heap, or in the unbearded floors 
 of rooms. In this way we explain the fact of the inhabitants 
 suffering most from the parasite at the end of the dry season 
 and the beginning of the rains. 
 
 § 131. Peesons most liable to Sandflea. 
 
 Race or nationality have no influence as regards immunity 
 from or invasion by the parasite. Indeed, newly-arrived 
 strangers suffer on the whole more frequently and more 
 severely than the natives or the acclimatised, the explanation 
 being, as Harsten^ points out, that " strangers pay no heed to 
 the faint itching which the animal causes in boring through 
 the skin, not knowing the significance of that slight pain ; 
 and the animal once in its nest gives no further trouble, if 
 the slightly inflamed bit of skin where it is located be not 
 pressed upon or scratched.'^ Bonnet's^ view is the same; and 
 he points out that the Indian tribes in Cayenne protect them- 
 selves against the sandflea by anointing the skin with 
 " Orleans " (roucou), and that the women always carry one 
 or two needles with which to remove the insect the moment 
 it has got into the skin. Speaking of the coolies from India 
 ' L. c, p. 58. 2 L. c, p. loi.
 
 o68 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 "wlio come to Cayenne to work on tlie Freucli plantations. 
 Bonnet says, " Us sont, a leur arrivee, litteralement devores 
 par les puces penetrautes. Un de ces liommes provenant 
 des mines auriferes de I'Approuage, avait plus de 300 sacs 
 de cliiques disseminees dans divei^ses regions du corps. '^ 
 
 As regards tlie individual his chance of protection against 
 this parasite, as against others, will depend on the degree 
 of cleanliness which he practises, and on his carefulness not 
 to expose the naked feet in those places where the insect 
 lurks, inasmuch as the feet are the parts that it mostly 
 attacks. It is generally found on the toes, particularly 
 under the nails, being rarer in other parts of the foot, and 
 only now and then met with in the skin of the scrotum, 
 knee, upper extremity, neck and back. 
 
 § 132. Larv^ op Flies in the Nasal Passages. 
 
 An extremely painful and not unfrequently dangerous 
 affection of the 7iasal passages is that which is caused by the 
 entrance into them of the larvss of flies. The danger, when 
 it occurs, is dependent on the fact that the inflammatory pro- 
 cess produced by the lai'v^e undergoing their development, 
 does not remain confined to the mucous membrane of the 
 nasal cavity, but extends to that of the frontal sinuses and 
 the antrum, where it causes an ulcerative process and ulti- 
 mately caries, and sometimes even perforation into the cranial 
 cavity and fatal meningitis. In other cases the larvas have 
 found their way into the throat and even into the larynx, 
 where they have been no less destructive in their operations. 
 
 This disease has been observed at many parts of the world 
 in all latitudes ; but it has been especially frequent in several 
 regions of the tropics, and in these it has to some extent the 
 character of an endemic. This applies particularly to India 
 (where the disease is known under the colloquial name of
 
 LARVJ5 IN THE NASAL PASSAGES. 369 
 
 '' peenasli ")/ Mexico^ Central America^ Cayenne,^ Neio 
 Granada,^ Brazil,^ and the Argentine Rejyuhlic,'^ where the 
 malady bears the name of '^ myiasis ^^ or popularly ^^bicheiro ; '' 
 also to Senegamhia, where, according to Berenger Feraud/ 
 all the cases observed hitherto have come from one locality, 
 the district of Thies lying to the south-east of Cayor, 
 although it is probable that the disease is indigenous to all 
 the lower part of the Colony. 
 
 § 133. LARViE POUND IN THE NaSAL PASSAGES BELONG MOSTLY 
 
 TO Tropical Species. 
 
 This preponderance of the disease in the tropics is doubt- 
 less to be explained by the circumstance that it is only larvae 
 of certain species of flies proper to tropical regions which 
 make the nasal cavities of man their favourite resort. Even 
 if we admit the fact put forward by Frantzius, Moore, 
 Brandjlo and others, that it is those persons suffering from 
 ozoena who are mostly affected by the disease, the insect 
 finding itself attracted to the nose by the smell coming 
 from it — even if this should pass unchallenged, it is still 
 obviously insufficient to explain the comparative frequency 
 of the malady in the tropics, inasmuch as there is no evidence 
 
 ' McGregor, ' Calcutta Med. Transact.,' 1829, iv, 28; Lahory, ' Ind. Annals of 
 Med. Sc.,' 1855, Oct.; Rustoiujee, ' Eombay Med. Transact.,' 1861, N.S., vi, 
 App. xxviii, 1862, N.S., vii, App. xxi; Day, 'Madras Quart. Journ. of Med. Sc.,' 
 1862, Jan., 37; 'Lyons, 'Indian Annals of Med. Sc.,' 1862, May, 55; Moore, 
 'Med. Times and Gaz.,' 1869, Aug., 269. 
 
 ' Weber. 'Mem. dc med. niilit.,' 1867, Fevr., 158; Luca«, 'La fregatte "la 
 Victoire" h Guaymas et a Mazatlan,' Par., 1868, 47. 
 
 ^ Frantzius, in ' Virchow's Arch.,' 1868, xliii, 98; Bernoulli, ' Schweiz. med. 
 Zeitschr.,' 1862, iii, 100. 
 
 ■• Coquerel, ' Arch. gen. de med.,' 1858, Mai, and " Compt. rend, de la soc. de 
 biologic," in ' Gaz. med. de Paris,' 1858, 430 ; Daunt, ' Dublin Med. Press,' i860, 
 Sept. ; Audouit, ' Des desordres produits chez Thorame par les larves de la Lucilia 
 liominivorax,' Par., 1864; Gourrier, 'Arch, de med. nav.,' 1879, Juin, 471 ; 
 Prima, 'Considerations sur la Lucilia hominivorax,' Par., i88i. 
 
 * Safl'rey, ' Tour du monde,' 1873, Sem. ii, 100. 
 
 ^ Daunt, 1. e. ; Brandao, ' Revist. med. da Bahia, 1876, Dec, in 'Arch, de 
 med. nav.,' 1877, Avril, 314. 
 
 ^ Conil, ' Act. de la Acad, nacional de ciencias,' 1879, iii, 69, and ' Nouv. cas. 
 de myiasis observes dans la province de Cordova,' Cord., 1880. 
 
 * 'Maladies des Europeens au Senegal,' Par., 1875, i, 233. 
 
 VOL. II. 24
 
 }} 
 
 §70 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 that an amount of ozoena proportionate to tlie parasitic affec- 
 tion occurs tliere any more than it does in other latitudes. 
 
 It is probable that the insects which mostly give rise to the 
 malady are various s]:)edes of Calliphorm ; but the chief part 
 would appear to be played by a species described by 
 Coquerel under the name of Lucilia hominivorax, being per 
 haps identical with CalHjihora vomitoria, or the " varejeira 
 (Brandao), and with Galliphora anthropophaga (Conil). 
 
 According to several observers the principal occasions of 
 the insect entering the nose are when the individual is in a 
 state of drunken unconsciousness or sound asleep in the 
 open air. 
 
 § 134. BoTS IN THE Human Subject. 
 
 Another diptera-disease of man, observed, like the former, 
 unusually often in particular parts of the world, is the so-called 
 " hots/^ or the larvse of various species of Oestrus developing 
 in the stihcutaneous connective tissue. The first information 
 of a quasi-endemic pi'evalence of this affection came from 
 Cayenne, where the parasite is known under the name of 
 " ver macaque "^ ; there are accounts of it also from New 
 Granada" and Brazil,^ and, according to Frantzius, it is 
 somewhat common in all the warmer and moister parts of 
 Central and South America. 
 
 Belonging to tlie same group, possibly, is a disease known in Peru under 
 tbe name of "iita," which is endemic, according to Smith''and Tschudi,'^ 
 in various parts of that country, particularly in the Quebrada of Santa 
 Rosa de Quibe, on the road from Lima to the mines of Cerro Pasco ; it 
 consists of an inflammation caused by the boring of a parasite through 
 the skin, generally of the scrotum, the sequel being an ulcer which takes 
 on a cancerous (?) or lupous (?) character, and ends fatally in unbear- 
 able pain and severe haemorrhages. 
 
 1 Thion de la Chaume in bis translation of Lind, ' Essai, &c.,' Par., 1 785, 75 ; 
 Bonnet, ' Du parasitisme,' Montp., 1870. 
 - Goudot, 'Annal. des sc. nat.,' iii, 221. 
 
 ^ Account in * Gaz. med. da Bahia,' quoted by Key, 'Annal. d'liyg.,' 1880, 
 Juiu, 501, 
 
 Ediub. Med. and Surg. Journ.,' 1840, April, 339. 
 Oeeter. med. Wochenschr.,' 1846, 509.
 
 BOTS IN THE HUMAN SUBJECT. 371 
 
 From high latitudes also, there are accounts of similar 
 endemics of bots, such as the one given by Spence^ for the 
 Shetland Islands, and those by Hoegk/ Thesen/ and Boeck^ 
 for various parts of Nonvaij. For obvious reasons the 
 malady is found oftener among country people who are 
 occupied with cattle-tending and who sleep out of doors. It 
 is a noteworthy fact that the parasite in man is nearly always 
 on the head or trunk, and only exceptionally on the extrem- 
 ities. 
 
 ' 'Edinb. Med. Journ.,' 1858, Nov., p. 417. 
 
 - 'Norsk Magaz. for Laegevidensk,' 1869, xxiii, 489. 
 
 3 lb., 1872; 'Noid. med. Selsk. Fordhl.,' 89. 
 
 * Ih., 1871; 'Selsk. Fordhl.,' 227.
 
 CHAPTER X. 
 PARASITIC rUNGI. 
 
 § 135. PlTYKIASlS VeRSICOLOE AND FaVDS. 
 
 Of the parasitic fungi we liave to consider here ouly those 
 which produce diseases of the skin, the so-called dermato- 
 mycoses. Two of these, pityriasis versicolor and favus, 
 have little of interest for geographical inquiry. Both dis- 
 eases, or their respective fungi^ — the Microsporon furfur and 
 AcJiorion Schoenleinii — wouldappear to be distributed univers- 
 ally over the globe, without attaining a properly endemic 
 character at any one place. 
 
 The comparatively large amount of favus among the 
 Jewish population, particularly the male part of it, in Russia, 
 Poland, Hungary, Galizia, and the Levant,^ as well as among 
 the Mohammedan population in Turlcey^ Asia Minor, Syria^ 
 Persia,^ Egypt,^ Algiers,^ and Morocco^ is perhaps to be 
 explained by their religious practice of always going with 
 the head covered. It is not so easy to account for the 
 frequent occurrence of the malady in France (particularly 
 the southern provinces),^ and in some parts of Italy (again 
 
 ' Eder, ' Zeitsclir. der Wien. Aerzte,' 1853, i, 244; Zeissl, ' Oest. Zeitschr. fiir 
 pract. Heilkde.,' 1864, Nr. 31. 
 
 2 Rigler, ' Die Tiirkei uiul deren Bewolmer,' ii, 80. 
 
 ' Pruner, ' Krankheiten des Orients,' 149. 
 
 ■• Polak, ' Woehenbl. zur Zeitschr. der Wiener Aerzte,' 1857, 743- 
 
 * In the military hospitals there is a special department for favus patients. 
 See Fox, ' Med. Times and Gaz.,' 1867, Feh., p. 165, 
 
 '■ Armand, *Med. et hyg. des pays chauds, &c.,' 419; Cliallau, ' Gaz. med. de 
 I'Algerie,' 1868, 119 ; "la teigne se rencontre a chaque pas," he says. 
 
 ' Account in ' Med. Times and Gaz.,' 1877, July, 97. 
 
 ^ Bergeron, 'Bull, de I'Acad. de med.,' xxx, 1864, 20, 27, Dec. He estimate* 
 the number of favus patients in the Herault district at 30 per 1000 of the 
 population.
 
 FAVUS. 3V3 
 
 mostly in the soutliern provinces/ sucli as Apulia, Capitanata, 
 the Abruzzi, Basilicata and Calabria) ; nor the fact, often 
 adverted to, that favus is much commoner in Scotland^ than 
 in England, beiug met with, as in France, to a much greater 
 extent among the country people than among the residents 
 in towns, although the case is exactly the opposite with 
 herpes tonsurans ; nor, finally, to explain why favus is quite 
 unknown in the Island of Martinique, as Rufz^ and Bergeron* 
 agree in saying that it is. 
 
 There can be no question here of influences of climate^ 
 and other general causes, or of a physiological predis- 
 position in the individual towards or against, depending on 
 circumstances of race and nationality. We are in fact 
 driven to believe that the occurrence of Achorion Schoen- 
 leinii is associated with certain conditions of locality, its 
 transmission taking place more readily under some circum- 
 stances than under others ; and the detei'mining factor is 
 possibly the greater or less amount of favus among the 
 domestic animals, from which it is well known to be often 
 transmitted to man. As we know nothing of the existence 
 of the fungus away from the body of man or other animals, it 
 is impossible for the present to form any definite opinion 
 as to what those circumstances are. What we may conclude 
 is that ivant of cleanliness is one of the chief factors in the 
 diffusion of favus and pityriasis versicolor, as of all other 
 communicable dermatomycoses. 
 
 ^ Lombroso, 'Eivista clin. di Bologna,' 1872, 225; Sormani, ' Geogr. nosol. 
 critalla,' Roma, 1881, 32r. From the conscription lists for the years 1864-77, 
 the number of favus ii:itients in Italy is estimated at g'l per 1000 inhabitants; 
 but while the proportion in the southern provinces named in the text is 20 per 
 1000 and upwards, it is only 2 per 1000 in the northern districts of Casale, Alba, 
 Cuneo, Eelluno, Padua, Ilovigo, Florence, &c. The number of cases has decreased 
 considerably of late. 
 
 - Anderson, 'Lancet,' 1871, Nov., 743; Bennett, ' Ediub. Monthl. Journ. of 
 Med. Sc.,' 1850, July, 40. 
 
 •* ' Gaz, med. de Paris,' 1859, 4'9' 
 
 •• ' Annal. d'hyg.,' 1865, xxiii. 
 The fact that favus is often seen in high latitudes, as in Kamschatka 
 (Bogonodsky, 'Med. Ztg. Russlauds,' 1854, No. i), shows that it is not the warm 
 climate of Southern Europe and the East which determines its occurrence.
 
 374 GEOGEAPHICAL AND HISTOEIOAL PATHOLOGY, 
 
 § 136. Heepes Tonsurans ok Eingworm. 
 
 Ringworm plays a considerably greater part than favus or 
 pityriasis in the statistics of sickness,, especially from tropical 
 countries, in many of which this parasitic skin disease has a 
 truly endemic character. We have more particular accounts 
 of it from India,^ the Malmj Archipelago," Cochin China,^' 
 China, Japan, several of the island-groups of Oceania (of 
 which more in the sequel), Nossi-Be'^ near Madagascar, 
 Abyssinia,^ Egypt,^ the West Coast of Africa,'^ the West 
 Indies,^ Guiana,^ and Feru}^ Even in the higher latitudes 
 of the Eastern Hemisphere, herpes tonsurans is much more 
 common than favus ; and the same is true of the North 
 American continent. ^^ 
 
 The preponderance of the disease in the tropics warrants 
 the conjecture that the climate, or a high temperature and a 
 large amount of moisture, are a material furtherance to the 
 Trichophyton tonsurans ; and this idea finds support in the 
 fact that the amount and. severity of the malady increase in 
 the rainy and hot seasons, while they diminish in the cold 
 season. Leclerc states that patients with ringworm coming 
 
 1 Voigt, 'Bibl. for Laeger/ J833, July, 2; Young, 'Calcutta Med. Transact./ 
 1826, ii, 334. 
 
 » Lesson, ' Voyage med. autour du moudc,' Par., 1829, 98 ; Ileyuiann, ' Darstell. 
 der Krankh. in den Tropenliindern,' Wlirzb., 1855, 202 ; v. Leent, 'Arch, de med. 
 nav.,' 1867, Octbr., 250; 1873, Fevr., 102. 
 
 3 Leclerc, 'L'herpes circine en Cochlnchine,' Montp., 1871J Beaufils, 'Arch, 
 de med. nav.,' 1882, Avril, 276. 
 
 4 Corre, ib., 1878, Novbr., 408. 
 
 5 Blanc, 'Gaz. hebd. de med.,' 1874, Nr. 21, 330. 
 
 ^ Pruner, 'Krankh. des Orients,' 149; Hartmann, 1. c. 
 
 7 Thaly, 'Arch, de med. nav.,' 1867, Sptbr., 187; Abclin, ' Etude sur le Gabon,' 
 Par., 1872, 31. 
 
 s Hillary, 'Diseases of Barbadoes,' Germ, ed., Leipz., 1776, 420; St. Vel, 
 'Malad. des regions iutertropicales,' Par., 1868, 484. 
 
 ^ Nissaeus, ' De uouuullis in Colonia Surinameusl observat. morb.,' Harderovici,. 
 1 79 1 ; Rodschied, ' Bemerk. iiber das Klima , . von Rio Essequebo,' Frankf . a. 
 M., 1796, 256. 
 
 "* Smith, 'Edinb. Med. and Surg. Journ.,' 1840, April, 339. 
 
 11 Bulkley, 'Chicago Med. Journ.,' 1877, Nov.; 'Transact, of the American 
 Dermatol. Soc.,' 1878, 28. 
 
 12 Fox and Farquhar, ' On certain Endemic Skin and other Diseases of India, 
 «&c.,' Lond., 1876; Leclerc, 1. c.
 
 RINGWORM. 375 
 
 from Cochin China to Europe improve considerably as they 
 enter the higher latitudes, but a fresh access of the disease 
 occurs when they approach the tropical heat of the Arabian 
 coast. The fact of ringworm occurring chiefly among the 
 coloured population of the tropics, which has been dwelt upon 
 by a number of observers such as Pruner for the negroes in 
 Egypt, Leeson for the Malays of the East Indies, van Leent^ 
 for the Chinese in Banka, and Corre for the Malagasys in 
 Nossi-Be, is to be explained not so much by racial differ- 
 ences as by the circumstances of living, that is to say, by want 
 of cleanliness and by carelessness, which give considerable 
 facilities for the spread of the parasite and may even raise 
 the malady to an epidemic' It is an established fact that 
 the parasite is often transmitted to man by domesticated 
 animals such as the cat and dog. 
 
 Various forms of Herpes tonsurans. — Herpes tonsurans, as 
 is well known, occurs in a variety of forms, which have 
 given rise to various synonyms of the malady, such as 
 porrigo scutulata, herpes circinatus s. annularis (ringworm), 
 sycosis parasitaria, and onychomycosis. The following para- 
 graphs relate to skin diseases concerning which it is impos- 
 sible to decide with certainty whether they are merely 
 varieties of herpes tonsurans, depending on climatic or other 
 circumstances, or whether they are peculiar species of 
 dermatomycoses. 
 
 § 137. Ctunb,^ Tokelau Kingworm (Lafa Tokelau), and 
 
 Cascadoe. 
 
 Under the name of " gune," Fox* gave the following 
 description of a skin disease which was prevalent in endemic 
 form in the Kingsjnill or Gilbert Grouy (under the line in 
 
 ^ 'Arch, de med, nav.,' 1873, 1. c. 
 
 ^ Gorley ('Lyon med.,' 1880, No. 27, p. 28) gives an account of an epidemic 
 of Trichophyton tonsurans at Fernay, It began in a barber's shop, to which 
 the parasite had been brought by country people, and it spread through a large 
 circle of the inhabitants. 
 
 3 The term " gune " means, not skin disease, but " skin" (Koniger, in ' Virchow's 
 Archiv,' 1878, vol. Ixxii, p. 414). 
 
 ^ In Wilkes's ' Narrative of the U.S. Exploring Expedition, 1844,' vol. v, p. 104.
 
 376 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 172 E.), and in a few of the neighbouring island-groups of 
 
 Oceanda : 
 
 This disease, which closely resembles ringworm in the stages of its 
 development, begins as a small ring covered with scales, about an 
 inch in diameter; this circle increases gradually, another ring forms 
 inside it, and a new ring inside that, which has meanwhile enlarged 
 considerably. It often happens that a number of rings arise in one 
 part of the body side by side, which coalesce and give rise to various 
 forms of serpiginous and concentric figures. In the end the whole 
 body appears to be covered with a scaly deposit which always produces 
 very intense itching. When the scales fall off, there remain behind 
 innumerable rings and sinuous lines of a livid colour, which disfigure 
 the individual very much, and not unfrequently for the whole of his life, 
 although his general health does not appear to be affected. 
 
 Tokelau or Union Island Ringworm. — ■According to Turner,^ 
 who gave the disease the name of herpes desquamans to 
 distinguish it from the ordinary herpes tonsurans, this malady 
 was introduced from the Gilbert Islands into the Union or 
 ToJcehm Group (particularly into Bowditch Island) and sub- 
 sequently into the Samoa Islands. From the former of 
 these it got the name of Tokelau ringworm (Lafa Tokelau). 
 Koniger," who has had opportunities of studying the disease 
 in the Samoa Islands, says that the importation from Tamana 
 (Gilbert Islands) had probably not taken place before i860, 
 that it had attained only a limited diffusion in Samoa at the 
 time of his residence there (1872), and that it had shown 
 itself in the Caroline and Pelew Islands as well. His account 
 is as follows : 
 
 The malady begins with an eruption of small papules mostly grouped 
 in circles, which cause intense itching and desquamation of the epi- 
 dermis around their growing periphery. Afterwards these circular 
 efflorescences coalesce, the skin becoming at the same time hard, dry 
 and brittle, and, in the end, when the disease has become diffused over 
 the whole body, the skin looks as if covered with a clayey substance. An 
 examination shows that this substance consists of epidermic scales of 
 various sizes up to half an inch, which are in part detached and in part 
 still adhering to the skin. The hair of the body is almost gone at the 
 places where the eruption occurs, but not the hair of the head, where 
 the eruption is very scanty, as it is also on the face. The only incon- 
 venience to the patient is the itching, which is often unbeai'able. 
 
 ^ 'Glasgow Med. Journ.,' 1870, Aug., 502. 
 2 ' Virchow's Arch.," 1878, Bd. 72, 413.
 
 RINGWORM. 377 
 
 Microscopic examination sliows that the seat of the malady is limited 
 to the epidermic layers. Among the epidermic cells there are more 
 or less dense strata of mycelial threads with transparent colourless 
 contents, as well as spherical cells filled with homogeneous substance 
 occurring either in groups or singly. Koniger has found the mycelium 
 only in recent cases. 
 
 Macg'regor^ has lately met witli the same disease in tlie 
 Fiji Islands, but only in persons wlio had. come from the 
 Solomon Islands, the New Hebrides or the Lime Islands, 
 never in natives of Fiji or in Europeans. His account of the 
 skin affection agrees almost exactly with that of Koniger, 
 including- the statement that the hairy scalp and the face 
 and forehead are almost never attacked. 
 
 Further accounts of the same peculiar dermatomycosis 
 (i. e. a skin disease identical with Tokelau ringworm) have 
 been given by Corre" for the Island of Nossi-Be, and by 
 Manson^ for Malacca and the Malay Archipelago. Corre 
 found it among" the Malagasys and Anjouanais; Manson 
 (who speaks of it under the name of '^tinea imbricata") met 
 with a few cases of it also in China and other parts of 
 Eastern Asia, but only in individuals who had come from 
 Malacca or elsewhere in the East Indies. 
 
 Gascadoe. — We may perhaps include in this group of 
 parasitic skin diseases the malady described by Pompe von 
 Meerdervoort/ under the name of " cascadoe/^ which he 
 found in 1859 to be endemic to the extent of 5 per cent, of 
 the population in several of the Moluccas (Gisser, Calietaroe, 
 Ceram, Coram Laut, Goram, and the Aroe Islands). 
 
 This malady, which always begins to develop at the earliest periods 
 of childhood (second to fourth year), is characterised in the first instance 
 by an outbreak of round or oval spots of a grey colour, either in per- 
 fectly symmetrical rings or scattered about irregularly; they occur 
 first on the back and chest, afterwai'ds on the extremities, and are soon 
 followed by more or less troublesome itching accompanied by peeling 
 of the skin. At a later stage, the skin is found to be dry, hard and 
 parchment-like, the dark-coloured spots become covered with fine scales, 
 and the condition extends gradually and uniformly over all the skin, 
 
 ' 'Glasgow Med. Jouni.,' 1876, July, 343. 
 ^ 'Arch, de med. nav.,' 1878, Novbr., 408. 
 
 ^ 'Med. Reports of the Imperial Maritime Customs for China, 1879,' abstract 
 iu 'Med. Times and Gaz.,' 1879, Sept., 342. 
 
 ^ 'Nederl. Tijdschr. voor Geneesk/ 1859, "'» 629.
 
 378 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 excepting that of the face which always remains free. At a still later 
 period the scales ai-e larger, thicker, and of horny consistence, and the 
 skin now looks as if it were coated with a layer of clay (whence the 
 name of " huitklei " or clay-skin) which had cracked in many places, 
 forming fissures of various depths. Apart from the itching of the skin 
 the patient is in no way inconvenienced. 
 
 ^ 138. Eelation of these Local Varieties op Ringwoem 
 
 TO Herpes Tonsurans. 
 
 Observers are not at all agreed, as we liave already 
 remarked, in tlieir view of tlie relation of tlie above group 
 of skin diseases to herpes tonsurans. Tilbury Fox^ and 
 Farqukar are in favour of an identity of origin for the various 
 forms of disease described as "^ Burmese/^ " Indian/' 
 " Chinese " and other ringworms named after countries, 
 assuming that the condition is in all cases due to Tricho- 
 phyton tonsurans, and that the variety of form depends 
 merely on the external influences. Manson and Macgregor, 
 again, are satisfied that the parasite in Tokelau ringworm 
 is a different one from Trichophyton ; while Corre and 
 Konigor have not come to a decided conclusion. The 
 arguments which have been adduced (and, it seems to me, 
 with good reason) against the genetic identity of herpes 
 circinatus and Tokelau ringworm are based upon the differ- 
 ence between the two forms as regards type of disease and 
 natural history of the parasite. 
 
 Regarding the type of the disease, it is a noteworthy fact 
 that Tokelau ringworm, like '^ cascadoe,'' never occurs on 
 the hairy parts of the head — a fact which Corre would 
 attach all the more importance to from having met with 
 numerous cases of ordinary herpes tonsurans on the hairy 
 scalp among children in Nossi-Be; that it spi-eads, on the 
 other hand, often over the whole body, in contrast to the 
 habit of herpes circinatus ; and finally, as Koniger points 
 out, that the spots in herpes circinatus break out with more 
 intense inflammatory accompaniments than in Tokelau ring- 
 worm, the redness of the skin and formation of vesicles 
 being more considerable, while, in the later stages of herpes 
 ^ 'On certain Endemic Skin and other Diseases of India, &c.,' Lond., 1876, 59.
 
 MAL DE LOS PINTOS. 379 
 
 circinatus but never iu Tokelau ringworm^ tlie spots heal at 
 tlie centre and extend at the periphery, so as ultimately to 
 form rings o£ several inches diameter. 
 
 Regarding the life-history of the parasite itself, Macgregor 
 observes that the mycelial threads are much more numerous 
 while the spores are fewer and smaller, in Tokelau ringworm 
 than in circinate herpes ; and Manson states that the spores 
 in the former are of an oval form, and that the mycelial 
 threads do not show those swellings and constrictions which 
 have been observed in Trichophyton. Moreover, we learn 
 from Manson that the inoculation experiments which he has 
 frequently practised with the fungus of Tokelau ringworm, 
 have in all cases produced that particular type of disease, 
 and never herpes circinatus. 
 
 Mai de los pintos. 
 
 § 139. Clinical Chaeacters of the Pinta Disease. 
 
 Under the name of " mal de los pintos " or other colloquial 
 synonym,^ a highly remarkable skin disease has been de- 
 scribed, which would appear to be eudemic exclusively in a 
 few tropical regions of the Western Hemisphere, particularly 
 on the slopes of the Cordillera. The mycotic nature of this 
 disease has been placed beyond doubt by the recent paper 
 of Gastambide." 
 
 * Pinta, mal pintado, tinna (iu Mexico); cute or carate (in Venezuela and 
 Granada); quirica (in Panama). 
 
 ^ I give here in alphabetical order the names of writers on the disease so far 
 as known to me : — Alibert, in ' Revue med.,' 1829, Aug., p. 228 (based on a case 
 under his own observation, and on reports from Granada by Zea, Bonpland, 
 Daste, and Roulin) ; Burkhurt, ' Aufenthalt und Reise in Mexico,' Stuttg., 1837 
 i, 213; Chassin (based on a memoir by Gomez communicated to the Institut de 
 France, but not published); Gastambide, ' Prcsse med. beige,' 1881, Nr. ,^3, 35, 
 39, 41 ; Girard, 'Relation med. de la campague de la f'regate "le d'Assas" dans 
 les mers du Sud, &c.,' Montp., 1868, 13; Gomez, ' Du carathes ou tache cnde- 
 mique des Cordilleres,' Par., 1879; Heller, ' Wiener Sitzungsber.,' 1848, Nr. 3, 
 122; Iryz, ' Independencia Medica,' 1882, Jan., abstract in ' Brit. Med. Journ./ 
 1882, Novbr., 903; M'Clellan, 'Lend. Med. Repository,' 1826, .\xvi, 167; 
 Miihlenpfordt, 'Versuch einer Schilderung der Republik Mexico,' Stuttg., 1844 
 i> 355 J Miiller, ' Monatsbl. fiir med. vStatistik,' 1847, 43-
 
 380 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 The disease comes out in the form of spots of various 
 discoloration, with scaling of the epidermis over the affected 
 parts of the skin and more or less intense itching, the general 
 well-being of the patient remaining otherwise unaffected. 
 According to these characters it corresponds most closely, 
 among diseases classed as dermatomycoses, to pityriasis 
 versicolor. 
 
 In exceptional cases the outbreak of the malady is preceded by a 
 series of symptoms^ of a general kind, such as chills and heats, head- 
 ache, thirst, loss of appetite, sickness and it may be vomiting, diarrhoea 
 and profuse sweating. These continue from four to seven days, after 
 which there is a pause of some forty days, and then the first signs of the 
 skin affection appear.^ Usually, however, the disease develops quite 
 gradually as a purely local affection, and without producing any sign 
 whatsoever of constitutional disturbance. 
 
 As regards colour, form, size and number, the spots show great 
 differences in different cases. According to the colour, they may be 
 divided into black or greyish, blue, red and dull white. It often happens 
 that all the discolorations in one person have the same chai'acter ; in 
 other cases they show various colours at different parts of the body, 
 so that those affected present a very striking piebald appearance. 
 In the latter cases, the spots at the beginning of the disease are usually 
 all of one coloui-, and it is not until a later stage that spots of other 
 colours begin to appear on parts of the skin hitherto vinaffected. 
 
 A change from one kind of discoloration to another has never been 
 observed, the shade of colour assumed from the outset in each spot 
 remaining the same throughout the whole course of the disease. Some- 
 times the skin affection is confined to one small area of the sui'face of 
 the body, at other times the spots occur in great numbers. From small 
 beginnings they increase in size on all sides us the disease advances, 
 and they may even become confluent ; in this way they extend by 
 degrees over a large part of the body or over the whole of it, including 
 the hairy parts of the head ; the palms of the hands and soles of the feet 
 are the only parts Avhere they are never seen. Usually they show 
 themselves first on the extremities and the face, that is to say, on the 
 uncovered parts of the body. In form they are either somewhat 
 rounded or quite irregular, and either sharply defined or with margins 
 obliterated, passing by gradual transition into the normal colour of the 
 skin. Pressure on the spots makes no difference to their colour, and 
 it may be seen at the same time that they are on a level with the skin 
 
 1 The sketch of the disease that follows is mostly based upon the latest and 
 most complete accounts of it by Gomez, Iryz, and Gastambide. 
 
 - Gastambide and Iryz make no reference to tliis prodromal stage. It appears 
 -to me to be doubtful whether there is in reality any intimate connexion between 
 the skin disease and these symptoms, which point clearly to gastric disorder.
 
 MAL DE LOS PINTOS. 381 
 
 and not raised. Wlien the malady lias been in progress for some time, 
 the skin at the affected places looks for the most part rough and dry ;. 
 more rarely it is moist and greasy to the feel. Meanwhile, desquamation 
 of the epidermis had begun with the first development of the afi'ectiou 
 and continues during the whole course of it, having a furfuraceous 
 character at the outset, but with the scales several millimetres in 
 diameter later on. When the lesion attacks the hairy parts of the 
 body, the hairs turn white and thin, and at length fall out. Along 
 with the desquamation, and in proportion to its copiousness, there is 
 always a more or less troublesome amount of itching, which is for the 
 most part acutest in the first hours of the night, so that it interferes 
 with the patient's sleep. 
 
 Another noteworthy thing is an obnoxious smell which the patient 
 difi'uses around him, compared by some observers to the smell of foul 
 linen that has been left in a damp place, and by others, to the odour 
 of cat's urine. No one has ever noted symptoms of constitutional 
 illness in this skin disease ; excepting for the disagreeable itching, the 
 general health of the patients is nowise disturbed, and they ai*e able to 
 go about their usual business. 
 
 The course of the disease is always chronic, months and sometimes, 
 years elapsing during which the skin affection may remain stationary 
 with only a slight extension over the body. This applies particularly 
 to the red and white variety, whereas in the black and blue form the 
 difi"usion over the surface is usually more rapid and moi-e general. 
 If the patient takes proper care of himself (above all observing strict 
 cleanliness), and if he is properly treated, the malady will disappear,, 
 although it is easily brought back; where these conditions are not 
 observed, it may last through the patient's whole life-time. 
 
 § 140. History of the Pinta Defective, 
 
 In the Jdstory of tlie " mal iniitado,^' nothing is known 
 with certainty of the time and place of its origin. Gastam- 
 bide states that it was prevalent in southern parts of America 
 before the Spanish conquest of Mexico^ and was imported 
 into Mexico subsequently. M'Clellan assigns the earliest 
 appearance of it in Mexico to the year 1775; it is said to- 
 have shown itself first in the northern part of the Province 
 of Yalladolid in the neighbourhood of Jurillo, and shortly 
 after the first eruption of that volcano, and to have spread 
 from that point southw^ards as far as Mascala.
 
 382 GEOGRAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 § 141. Pbesent Geogkaphical Distkibution of the Pinta. 
 
 The present distrilmtion-area of the pinta, so far as it can 
 be made out witli certainty, includes Mexico, Central America, 
 Venezuela, New Granada, Peru and Chili. 
 
 In Mexico^ it is endemic only in the " tierra caliente ^' of 
 the west coast, particularly in the Provinces of Guerrero 
 (at Acapulco), Valladolid and Michoacan ; it occurs more 
 rarely (never according to M^Clellan) in the "tierra tem- 
 plada ; '^ and its farthest range eastwards is into the western 
 districts of the Province of Tabasco, where Heller saw it on 
 the banks of the Grijalva. The East Coast of Mexico 
 appears to have had no visitation of the malady. Heine- 
 mann^ expressly says that he had seen no case of it at Vera 
 Cruz, and he seems to indicate that the discolorations of skin 
 which he saw among mestizzos at Oaxaca had nothing in 
 common with the mal pintado. Eegarding the frequency 
 of the disease, Gastambide says that in some villages of the 
 above-mentioned districts of Mexico, 9 per cent, of the 
 inhabitants are affected with it; and M'Clellan in 1826 saw 
 at the capital a whole regiment composed exclusively of 
 pintados. 
 
 In Panama it would appear from the statement of Gomez^ 
 to be rare.* In Venezuela the endemic seats of the malady 
 are the Provinces of Barquisimeto and Merida.^ But its 
 widest distribution is in Neiv Granada; throughout almost 
 the whole of that country it is endemic, more particularly 
 in San Jose de Cucuta, in the basin of the Meta, in Cun- 
 dinamarca, in the valleys of Guaduas, Tocamina and La 
 Mesa, in the lower valleys of the Provinces of Tolima and 
 Antioquia, in Cauca, in the districts of Valencia, Fonseka, 
 La Paz, Soldado, and other districts on the Magdalena, and 
 in most other parts of the Magdalena Province. There is a 
 
 ' Miiller, M'Clellan, Miihlenpfordt, Burkbart, Girard, Heller, Gastambide. 
 
 ' * Vircbow's Arcbiv,' 1873, Iviii, 189. 
 
 ^ L. c, 22. 
 
 ■^ It is a question wbetbei- tbe " leprous spots " mentioned by Young (' Narra- 
 tive of a Residence on tbe Mosquito Shoie,' Loud., 1847, P- 26) as occurring 
 among tbe natives of the Mosquito Coast were not of this nature. (See p. 28.) 
 
 * Gomez, p. 21.
 
 MAL DE LOS PINTOS. 383 
 
 want of definite information about the distribution of the 
 disease in Peru and CJiill ; Gastambide mentions the mal 
 pintado as occurring in tlie former^ and there is a brief 
 notice of its existence in Chili in one of Poppig's papers. 
 
 So far as we may conckide from what we know at present 
 of its area of distribution, the pinta belongs to the class of 
 highly troijical diseases. In Mexico it is endemic only in the 
 " tierra caliente " of the west coast at altitudes up to 400 
 or 500 metres (1500 feet)/ and in Granada only at places 
 with a mean temperature of 20° to 30° C. (68° to 85° Fahr.) .^ 
 The influence of a high temperature is further shown in the 
 fact adduced by Gastambide that the recrudescence of the 
 malady always coincides with the beginning of the warm 
 season (spring) ; *or, in other words, it is then that the itching 
 of the skin becomes particularly troublesome. A damp soil, 
 also, appears to help the number of cases ; at least, the 
 authorities^ are unanimous in saying that the damj) or swampy 
 banks of rivers are its chief seats. 
 
 § 142. Predisposing Causes. 
 
 As with all parasitic skin diseases, so with this particular 
 form a principal factor in its existence is hygienic neglect, 
 and, above all, ivant of cleanliness. It had been pointed out 
 by M'Clellan that cases of the pinta were much rarer among 
 the better-to-do classes in Mexico, than among the lower 
 orders living in squalor and misery; that well-to-do people, 
 who had among their servants persons affected with the 
 pinta, escaped the malady, as did also the rest of the servants 
 in the house, provided they practised the greatest cleanliness 
 of body by means of ablutions, baths, and the like ; whereas, 
 in other cases where these precautions were neglected, the 
 household would become infected. To the same effect, 
 Gastambide says -^ 
 
 " On peut observer le pinto aussi biep cliez les personnes puissant 
 d'une ; certaine aisance, que cliez les classes pauvres, Toutefois la 
 maladie sevit en proportion incomparablement plus forte dans les 
 
 1 M'Clellan, Muller, Gastambide. * Gomez. 
 
 3 Alibert, Gomez, 17, 22; Gastambide, 260. * L. e., p. 260.
 
 384 GEOGRAPHICAL AND HTSTOEICAL PATHOLOGY. 
 
 classes necessiteuses, la ou les habitudes de eonfort et de proprete 
 font defaut. . . . La misere avec tons ses inconvenients, le manque 
 de proprete sont des antecedents tres appropries a I'apparition de cette 
 aiFection, a son developpement ulterieur, a sa duree indefinie." 
 
 Almost in tlie same words, Gomez sums up liis observa- 
 tions as to tlie influence of hygiene on the amount of the 
 disease : '' En resume nous pouvous reduire toute cette 
 serie des causes a une seule — la misere." It is this then, 
 and not any racial peculiarity that explains with a high 
 degree of probability the fact of the pinta being infinitely 
 more common among the native Indians, the negroes and 
 the mestizzos, than among the whites ; and although these 
 latter have by no means an absolute immunity from the 
 disease,^ yet they never take it until they have resided a con- 
 siderable time at one of the disease-centres (Gastambide). 
 
 § 143. Due to a Fungus in the Rete Mucosum. 
 
 It is only by the most recent inquiries that the true cause 
 of the disease has been settled. Some authorities^ have 
 adopted the notion, which used to be in general currency, 
 that mal de los pintos is purely an affair of absorption of the 
 normal pigment of the skin, or of a deposit of new pigment (in 
 the red, blue and black varieties) . Others thought that they 
 could discover in the skin affection an indication of syphilis 
 or leprosy ; or they identified it with the dermatoses that 
 occur in pellagra as a consequence of using damaged maize. 
 But these opinions are contradicted by the absence of all 
 symptoms in the pinta pointing to constitutional disturbance. 
 Chassin laid most stress on the use of drinking-water rich 
 in salts, especially common salt. Another belief, deeply 
 rooted in the popular fancy, is that the skin disease follows 
 the sting of an insect bearing the name of '' jegen " or 
 "comegen," which no one has been able to give any further 
 account of. 
 
 Writing on the mal de los pintos, in the first edition of 
 this work I expressed the opinion, that " this skin disease, 
 like pityriasis versicolor, is an affair of an epiphyte ; '' and 
 » Alibert, M'Clellan, Heller. » Miiller, Girard.
 
 MAL DE LOS PINTOS. 385 
 
 my conjecture has lately been confirmed fully by the published 
 observations of Gastambide : 
 
 " Microscopic examination," he says,' " reveals between the more 
 deeply situated polygonal epidermic cells a deposit of small bodies, 
 either perfectly spberical with a diameter of 8 micromill., or more oval 
 and measuring 6 to 8 micromill, one way, and lo to 12 the other. At the 
 first glance they appear to be of a uniformly black colour, but when 
 the light is made to fall obliquely they are found to be cells with their 
 exterior formed of a transparent membrane, and filled within by a 
 yellowish fluid having a large number of dark-coloured granular 
 particles suspended in it, which become more obvious on adding acetic 
 acid. Besides these cells, there are nearly always to be found fragments 
 of tubes or tube-like filaments, which are attached to the former, accord- 
 ing to one observer (Sandoval), like the stalk to a cherry; they are iS to 
 20 micromill. broad and 2 thick, of a white colour, with a definite con- 
 tour and highly refractive, showing no trace of dichotomous branching, 
 hut tapering from a somewhat broad base to a blunted point." 
 
 " La veritable cause de la maladie/' says Gastambide in 
 •concluding bis paper^ " est done trouvee. II me semble 
 incontestable que nous nous trouvons la en presence d^un 
 parasite vegetal, d'un champignon microscopique^ qui par 
 son implantation et son developpement sur la peau, produit 
 les lesions anatomiques qu^on constate dans cette affection. 
 De ce que nous venous de dire s'en suit tout naturellement 
 que le mal du pinto doit etre range dans les cadres noso- 
 grapbiques, dans la classe des dermatomycoses." 
 
 Whether the various colours of the spots in the pinta 
 xiisease are pi'oduced by various species of the fungus, or 
 whether the differences in colour depend on the epiphyte 
 being located in the superficial or deep layers of the epi- 
 dermis, Gastambide docs not attempt to decide ; but the 
 microscopic examination of the affected pieces of skin is 
 rather in favour of the second suggestion. The black and 
 blue spots extending in continuity over the surface depend, 
 .he tells us, upon an affection of the upper epidermic layers ; 
 .they never go so deep as the rete mucosum, and when they 
 are cured, there is no trace left of any change in the skin — 
 which can seldom be said of the red, and still less of the 
 white variety. These red and white spots, in fact, have 
 their seat in the deeper layers of the epidermis. Osorio" 
 
 ' L. c, p. 261. 
 
 - Quoted by Gomez, p. 74, 
 
 vol.. II. 25
 
 386 GEOGEAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 has come to tlie same conclusion, al though, he was unaware 
 of the parasitic nature of the disease, hokling it to be a 
 simple deposition of pigment : 
 
 " La coloration du caratlics," he says, " depend de I'arrangement et 
 de la distribution de la matiere pigmentaire, et de la des differences de 
 nuances, qui passent du noir au bleu et du bleu au rouge, laissant des 
 intervalles de peau sans couleur et communiquant a, la pcau I'aspect 
 du marbre ou du jaspe. Quand ces intervalles sont tres grands, le 
 carathes est nomme blanc." 
 
 § 144. A Communicable Disease. 
 
 The fact that the mal de los pintos is decidedly communi- 
 cable, gives further probabilitj to the parasitic Hature of the 
 malady. " The disease is said to be infectious," says 
 M'Clellan, "and facts seem to corroborate the account. 
 I have seen persons, who were born and bred up in the 
 higher districts, where it is not known except by report, 
 after having lived for a few years in the low country in 
 habits of intimacy with the people, return with the disease. 
 Nurses who are infected with it, and have been employed 
 in the higher districts, have communicated it to children.'' 
 
 Gastambide^ gives several typical cases of the disease 
 being carried from place to place, and of its farther dispersion 
 by continuous infections ; and he conjectures, as Gomez^ had 
 done, that the alleged origin of the disease from the sting 
 of an insect, does not consist so much in the injury done, as 
 in an infection by means of that which the insect carried. 
 
 § 145. Other Tkopical Discolgeatuons of the Skin. 
 
 Besides these accounts of the pinta disease coming from 
 various regions of America, and relating undoubtedly to one 
 and the same malady, we find many other notices in the 
 medico-topographical literature of tropical and subtropical 
 countries referring to decolorations or discolorations of the 
 skin, under such names as albinism, vitiligo and chloasma. 
 
 * L. c, p. 276, 2 L c., p. 17.
 
 MAL DE LOS PINTOS. 387 
 
 It is mostly among tlie coloured races that tliese occur ; but 
 tte accounts of them are so extremely slight, so obscure, 
 and so lacking in microscopic details of the affected parts, 
 that it is impossible to form a trustworthy opinion as to the 
 nature of the affections. There would be very little interest 
 in a complete enumeration of these discolorations, mostly 
 known to us by their vernacular names, inasmuch as nothing 
 is known of them but the name and the colour. It is possible 
 that many of them may be dem atomy coses, some of them 
 perhaps identical with the pinta disease itself. 
 
 For example, Sigaud^ and Martins^ give an account of 
 cases of spotted discoloration among certain tribes of Indians 
 in Brazil, the latter author writing as follows : 
 
 " The whole body seemed as if irregularly sprinkled over with blackish 
 spots of various sizes, mostly round, and either discrete or confluent, 
 which gave the impression of slight indurations of the skin yielding a 
 small amount of scabby secretion, while their surface was uneven and 
 drier than the skin elsewhere. The skin round the spots was often 
 paler than the healthy skin, in fact, nearly white. . . . This skin 
 disease is regarded by the neighbouring tribes as a national distinction 
 of the Puru-Puriis, Amamatis and Catavixis, who are on that account 
 called 'the spotted' (pinix^inima-tapuiijo) . . . The malady is said 
 also to be hereditary, and even infectious." 
 
 There are other accounts from Guiana of a skin disease 
 similar to the " carate ; ^' among them a recent reference to 
 it from Surinam by Pop,^ who speaks of it under the name of 
 "lota;" and the same affection appears from the writmgs of 
 Savaresy,^ Levacher^ and others to be somewhat common in 
 the West Indies. Levacher^s reference is to a skin disease 
 prevalent among the negroes and mulattoes, which is charac- 
 terised by numerous irregular spots of a yellowish and milky, 
 or coffee-chocolate colour, occurring on the face, neck, chest, 
 and other parts of the body ; even in its name it would 
 appear to have some analogy to the " lota " of Surinam, for 
 the persons affected with it in the West Indies are known 
 as " lotards " or '' leotards." 
 
 1 'Du climat et des maladies du Bresil,' Par., 1844, 117. 
 
 ^ 'Das Naturell, die Kranklieiteu . . der Urbewolmer Brasiliens,' Miincheu p, 
 66. (Reprinted from ' Bucbner's Repertorium fiir die Pharmacia,' x.xxiii, 289,) 
 ^ 'Nederl. Tijdschr. voor Geueesk,' 1859, iii, 213. 
 ■• 'De la fievre jaune,' NapL, 1809, 8i. 
 5 ' Guide med. des Antilles,' Par., 1840, 320.
 
 388 GEOGKAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 § 146. Dubious Instances of Spotted Skin. 
 
 The relation to the mal do los piutos, and to the dermato- 
 mycoses in general, of certain discolorations o£ the skin in 
 various tropical and subtropical regions of the Old World, 
 is more questionable. Girard stands alone in thinking that 
 he has seen the pinta disease among the negi-oes in Sene- 
 gamMa and the Gaboon, and I am unable to say how much 
 weight is to be attached to his statement. We are equally 
 at a loss to decide upon the nature of the peculiar discolora- 
 tions of the skin mentioned by Pruner^ as occurring among 
 the coloured races in Syria, Egypt, Arabia, and other eastern 
 countries ; or upon the nature of a similar disease among the 
 negroes in Tunis (which Ferrini^ describes, moreover, as 
 communicable), or of the variety found in Reunion? The 
 same difficulty meets us in dealing with a skin disease found 
 among the natives in the eastern districts of Lower Bengal, 
 which consists, according to Leslie,''^ in a peculiar spotted 
 discoloration or decoloration of the skin, and is thought to 
 be caused by drinking certain kinds of water. 
 
 1 ' Die Krankh. des Orients/ Erlaug., 1 846, 151. 
 
 * L. c, 261. " Questo morbo e tenuto diigli indigcni in concetto di contagioso, 
 e pare vcramente die lo sia, poiche il Coinin. Protomodico Lunibroso I'ha veduto 
 diffondersi con facility nei soldati da uno all' ultro, ed anche il Cav. dott. Tagiuri 
 vide, che se il soldato affetto da vitiliggine non veniva suLito riformato, egli la 
 communicava al vicino di letto." 
 
 3 Chapotin, ' Topogr. mod. de Pile de France,' Par., 1812, 70. 
 
 * 'Calcutta Med. Transact.,' 1834, vi, 62.
 
 CHAPTER XI. 
 ERYSIPELAS. 
 
 Under the title of " Infective Traumatic Diseases," we 
 may place together three nosological forms, Erysipelas, 
 Puerperal Fever and Hospital Gangrene, which have this 
 much in common, that they bear the characteristics of an 
 infective process, and are in their origin dependent on the 
 existence of some breach of continuity in the external or 
 internal surfaces of the body. In the three following chapters 
 I shall inquire into the relation of those three diseases to one 
 another and to other infective diseases, from the point of 
 view of their history and geogi'aphical circumstances, or in 
 their etiological aspects. 
 
 § 147. History of the Teem " Erysipelas." Definition 
 
 OP THE Disease. 
 
 The word "erysipelas," as the designation of an inflam- 
 matory redness of the skin, running the course of a fever 
 and quickly extending from one point to a larger or smaller 
 area of the surface around (hence the term " Rothlauf " in 
 use in Germany as early as the sixteenth century), is as old 
 as Medicine itself. In the very earliest medical writings of 
 antiquity, the word is used in that sense ; and although the 
 opinions of the profession on the process underlying the 
 disease, and most of all on the extent to which the term 
 might be stretched in denoting a single morbid process, 
 have undergone many changes, yet the name itself has con- 
 tinued down to the present day.
 
 390 GEOGRAPHICAL AND HISTOKICAL PATHOLOGY. 
 
 There ai-e a few interesting references to erysipelas in tlie Hippocratic 
 Collection, and more especially in certain of the books which are pi'obably 
 the work of Hippocrates himself.^ He distinguishes already between 
 idiopathic and traumatic erysipelas, or erysipelas with and without 
 wounding ; and that distinction has been maintained by the later Greek 
 and Roman physicians," by the Arabian^ and other practitioners of the 
 middle ages/ as well as by the whole profession in the modern period, 
 and, to some extent, even down to the present day. Moreover, the 
 term " erysipelas " is a very comprehensive one even in Hippocrates ; 
 for it is clear that he includes in it various purulent and gangrenous 
 processes occurring on the surface of the body. It appears to have 
 been stretched still farther by the later writers of the school of Cos, who 
 were led by their dogma of the humours to use the term erysipelas as 
 an equivalent of " bilious dyscrasia," and so to speak of an erysipelas 
 of the lungs, erysipelas of the uterus, and so on.^ This doctrine, subse- 
 quently extended by Galen, was the dominant one throughout all the 
 period following, down to the overthrow of the Galenic system ; and 
 in its place there came other theories worked out either from the 
 humoral point of view or from that of solidism. Any account of these 
 developments of the doctrine of erysipelas lies outside the limits of my 
 task, and is of no importance for the historical account of the disease 
 itself. 
 
 ' 'Epidcmiorum,' lib. iii, sect, iii, § 3, 4, ed. Littre, iii, 70 — 76; ' De capitis 
 vulneribus, § 20, ed. c, iii, 254 ; ' De vuhieribus,' § 9, ed. c, vi, 407. 
 
 * Celsus says (lib. v, cap. 26, § ^^, ed. Almeloveeu, Basil, 1 748, 302), " Id autem 
 quod f.pvffi'TrtXag vocari dixi, non solum vulneri supervenire sed sine hoc quoque 
 oriri consuevit." So also Galen, 'Method, med.,' lib. xiv, cap. ii, ed. Kiibn, x, 
 949; Oribasius, 'Synopsis,' lib. vii, cap. 32; Paulus, lib. iv, cap. 21, Basil, 1551, 
 341. The remark of Aiitius (lib. xiv, cap. 60, ed. Montauo, Basil, 1535, iii, 58) 
 is noteworthy : " Saepe enim in cuti tantum dift'unditur (scil. inflammatio), carnem 
 ipsam nihil injuria afficiens, idque est quod exquisite erysipelas nuncupatur." 
 
 ' Avicenna, ' Canon,' lib. iv, fen. iii, fract. i, cap. 4, 5, ed. Venet., 1564, ii, 109 ; 
 Ali Abbas, 'Pract.,' lib. iii, cap. xxviii, ed. Lugd., 1523, 194 b. 
 
 * Such as the writers of the school of Salerno: Ruggiero, 'Chirurgia,' lib. iii, 
 cap. viii, de erysipelate superveniente vulneri (in de Renzi, ' Collect. Salernit.,' ii, 
 472); Rolando, ' Morb. mcd. ratio,' lib. iii, cap. ix ; ' Glossulae quatuor magis- 
 troruni,' lib. i, p. vi, cap. 23 (in de Renzi, 1. c, ii, 559), and Guido (of Chauliac), 
 ' Chir. Tr.,' ii, cap. 3, Lugd., 1572, 64 (following Avicenna, Ali Abbas, &c.). 
 
 ^ No doubt many of the physicians and surgeons of ancient and mediaeval 
 times rightly saw that erysipelas occurred mostly in association with wounds. 
 Thus de Vigo says (' Chirurgia,' lib. ii, tract, i, cap. 4, 5, ed. Lugd., 152 1, fol. xv) : 
 " Accidit etiam ut plurimum in vulneribus a medico male tractatis." The opinion 
 of Tagault (' lust, chirurg.,' lib. i, cap. 8, in Gessner, ' De Chirurg. script. Tiguri,' 
 "SSSj 25), which is adopted almost exactly by Guido, is also noteworthy : " Verum 
 ac legitimum erysipelas raro terminatur suppuratione, sed magna ex parte insen- 
 sibili transpiratione seu resolutione." From a general survey of the professional 
 writings of that period, it would appear that it was the surgeons who held the 
 most correct views of erysipelas.
 
 EEYSIPELAS. 391 
 
 In tlieso changing aspects of the term " erysipelas/' are 
 reflected the various systems and theories which have domi- 
 nated the schools of medicine from century to century. The 
 history of the doctrine of the rose (Rothlauf) affords a sort 
 of picture of the development of scientific medicine. And 
 although the most recent inquiries into thie disease have 
 departed from the doctrinal point of view and have invested 
 themselves with a character for precision, still we have only 
 to glance at the latest and most important writings on 
 erysipelas, — by Velpeau, Pirogoff, Volkmann, Billroth, Orth, 
 Lukomsky, Tillmanns, Fehleisen and others, — in order to see 
 how far we still are from a common understanding as to 
 what we should include under " Rothlauf,'^ how widely this 
 term may be stretched to embrace inflammatory processes in 
 the skin and subcutaneous tissues, how some would have us 
 think of " erysipelatous affections of the mucous and serous 
 membranes, as well as of other tissues " — in a word, in order 
 to see how the term " erysipelas " has come to characterise 
 a morbid process that is one in its origin but various in its 
 forms. 
 
 In seeking for the means of satisfactorily answering the 
 question which we propose to ourselves, we shall have to go 
 to the essential cause of the disease. However widely men's 
 views still diverge as to what we name '' erysipelas," or ought 
 so to name, there is no longer any doubt that the disease 
 itself, be the word used in as narrow or as comprehensive a 
 sense as any one pleases, consists in an infective process. 
 If, then, the specifically infective matters be recognised for 
 one of the various nosological forms included under erysipelas, 
 best of all for the so-called "erysipele legitime," the detection 
 of that specific matter in other forms would justify us in 
 deciding that they belonged to the morbid states compre- 
 hended in the notion " erysipelas," just as we might conclude 
 from its absence in still other forms that these latter were 
 outside the meaning of the term. 
 
 But although the latest researches on this very " erysi- 
 pele legitime " have disclosed facts, as will appear, that are 
 deserving of all attention, yet these are not adequate to the 
 solution of the problem before us ; and thus we are left for 
 the present to develop our notion of the disease merely from
 
 392 GEOGEAPHIOAL AND HISTOEIOAL PATHOLOGY. 
 
 the clinical and epidemiological point of view, or out of 
 observations upon and reasonings about tlie type of tlie malady 
 in the individual and in the epidemic. From that point of 
 view, which I shall adhere to throughout this chapter, I may 
 define erysipelas to be an infective inflammation-disease of the 
 skin or of one of the mucous membranes near to the external 
 surface of the body (mouth, throat, vagina, &c.), which in all 
 probability proceeds invariably from a solution of continuity 
 or wound, and is characterised by its rapid extension over 
 the surface, and by the infective fever that accompanies the 
 local process ; the latter in many cases is confined to the skin, 
 and in such cases mostly heals rapidly, leaving no permanent 
 effects ; but in other cases it extends to the subcutaneous (or 
 submucous) tissue, sometimes even to still more deeply 
 situated parts (phlegmonous erysipelas), and leads to more 
 or less considerable suppurations spreading along the surface, 
 or to gangrenous destruction of parts (malignant or gan- 
 grenous erysipelas), under certain circumstances even to 
 secondary affections of other (internal) tissues or organs. 
 
 § 148. Mostly a Disease op the Temperate Zone. 
 
 Just as it has been met with at all periods in the history 
 of mankind, erysipelas occurs in all parts of the world — in 
 some, however, more commonly than in others. 
 
 The available statistics, which are extremely cumbrous 
 and, for many reasons, not very trustworthy, do not enable 
 us to state in figures the amount of the disease in the various 
 countries or regions of the globe. This much we may con- 
 clude from them of a general nature, that the malady has 
 been found to be tolerably uniform in distribvition and in the 
 number of cases throughout the temperate zone of both hemi- 
 spheres. 
 
 Of the comparatively frequent occuri-ence of the rose in 
 the polar regions, we have accounts from Iceland, the Faroe 
 Islands, where it is not unfrequently epidemic,^ Greenland, 
 where it has also broken out repeatedly in great epidemics, 
 
 1 Martius, ' Revue med.,' 1844, Fevr.j accounts in ' Sundbedskoll. Forliandl. for 
 Aaret; 1846, 13; 1851, 35; 1855, St.
 
 ERYSIPELAS. 353 
 
 and where it would appear to be more common in the 
 northern districts than in the soutliern_,^ and from Alaslca 
 (New Archangel).^ 
 
 From warm and subtropical latitudes, we have similar 
 accounts of the prevalence of the disease — from such countries 
 as Turkey,^ Asia Minor^ (the Troad), Syria,^ Fersia,^ Eg]ji:>t^ 
 Tunis^ and Algiers? In Japan erysipelas would appear to 
 be very uncommon, for Wernich did not see a single malig- 
 nant case of it during a residence of several years.^*^ Whether 
 the really tropical regions enjoy that remarkable freedom 
 from erysipelas which has often been claimed for them is 
 doubtful ; at all events, the information from these countries 
 is to be received with caution. Cello^^ says that he did not 
 see ten cases of simple erysipelas during a seven years' 
 residence in Mexico (mostly at Mazatlan) ; Christie^" knew 
 of only one case in Zanzihar in the space of five years ; 
 Yoigt,^' Mackinnon,-^* Huillet^'' and others emphasise the rarity 
 of its occurrence in India; Tschudi^*' mentions that it is much 
 commoner in Peru in the '^puna'^ region than in the Eastern 
 Sierra. On the other side, Pellissier^' says that he has seen 
 erysipelas very often in Reunion; and it follows from the 
 statements of Annesley^^ and Morehead,^^ that traumatic 
 
 ^ Lange, ' Bemaertn. om Groulands Sygdomsforliokl,' Kjobenh., 1864, 37. 
 
 ' Elaschke, 'Topogr. rued, portus Novi-Archangelcensis,' Petropoli, 1842, 65. 
 
 ^ Iligler, 'Die Tiirkei und deren Bewoliner, &f.,' Wien, 1852, ii, 50. 
 
 ■* Vircllow, ill his ' Arcliiv,' 1879/ ^'-^- 77' ^74- 
 
 ^ Tobler, ' Beitr. zur med. Topogr. von Jerusalem,' Berl., 1852, 39. 
 
 '' Polak, ' Woclienbl. der Gesellsch. der Wiener Aerztc,' 1857, Nr. 46, 737. 
 
 ' Pruner, 'Krankbeiten des Orients,' 1 19. 
 
 ^ Ferrini, ' Saggio sul clima . . di Tunisi, &c.,' Milano, i860, 1S5. 
 
 9 Guyon, ' Gaz. med. de Paris,' 1839, ^i"- 4^5 Villctte, 'Mem. de med. milit.,'^ 
 1842, liii, 1 25 ; Burdiat, ' Observ. et reflex, sur des cas nombreux d'erysipeles, &c./' 
 Montp., 1847 (relating to the camp at Teniet-el-Had). 
 '" ' Geograpbisch-med. Studien, &c.,' Berl., 1878, 196. 
 1' 'Hygiene des pays chauds,' Par., 1848. 
 ^- ' Brit. Med. Journ.,' 1872, June, 577. 
 13 'Bibl. for Laeger,' 1833, Heft 3, 2. 
 '■^ ' Indian Annals of Med. Sc.,' 1854, Oct., 177. 
 
 15 'Arch, de med. uav.,' 1868, 25. During a residence of several years at 
 Pondieherry, be saw only one severe case of traumatic erysipelas, 
 ^fi 'Oest. med. Wochenschr.,' 1846, 661. 
 
 ^' 'Consider, sur I'etat des malad. les plus communes a la Reunion,' Par., 1881, 46.. 
 1* 'Researches into the more prevalent Diseases of India,' Lond., 1841, 544. 
 1^ 'Clin. Researches on Disease iu India,' Lond., 1856, i, 361.
 
 394 GEOGRAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 erysipelas is far from rare in India, and that it becomes 
 epidemic from time to time under the same circumstances as 
 in other parts of the world. 
 
 No weight attaches, however, to the data of Jobim, Rendu, ^ 
 Sisraud^ and other authorities for Brazil as to the endemic 
 prevalence there of wildfire of the legs ; for the disease in 
 those cases is clearly not erysipelas but elephantine dermatitis 
 (pachydermia) . 
 
 § 149. Endemics and Epidemics, mostly in Hospitals. 
 
 Erysipelas occurs either sporadically or in epidemics. 
 The head-quarters of the disease have always been found 
 in self-contained places occupied by a considerable number 
 of persons, most of all in hospitals, where erysipelas is not 
 unfrequently endemic for long periods, and, next to them, in 
 lying-in and foundling hospitals, lunatic asylums, educational 
 institutions, ships, and the like. On the other hand, among 
 the people at large, sporadic cases of erysipelas occur com- 
 paratively seldom ; no doubt from time to time there are 
 cases occurring in groups, forming a kind of epidemic, but 
 it is the exception for these outbreaks to reach any consider- 
 able extent, and they sometimes coincide with the epidemics 
 of erysipelas in hospitals. 
 
 The literature of medicine is full of references to the endemics of 
 erysipelas in hosjntcds. I may mention, by way of examples, Boinet's* 
 account for the Hotel Dieu of Paris, relating to certain notorious wards 
 in particular, that of Wells'* for various hospitals in London at the 
 end of last century and beginning of the present, of Fenger^ for the 
 Frederiks Hospital at Copenhagen, of Kern*' for the University Clinique 
 at Marburg, of Reese^ for the Bellvue Hospital of New York, and of a 
 
 ^ ' Etudes topogr. et med. sur le Bresil,' Par., 1848, 74. 
 
 ' 'Du climat ct des malad. du Bresil,' Par., 1844, 157, 369. Compare the 
 account by da Silva('Arcl). de nied. nav.,' 1880, Mai, 331) of a form of ery- 
 sipelas and lymphangitis prevalent in Brazil. 
 
 2 ' Journ. des connaiss. med.-chir.,' 1839, ^i'- 7- 
 
 * ' Transact, of the Soc. for tlie Improvement of Med. and Chir. Knowledge, 
 i8oo, ii, 213. 
 
 * 'De erysipelate ambulanti disqu.,' Havn., 1842. 
 
 ^ 'De erysipelate, imprimis epidemico,' Marb., 1845. 
 7 ' Amer. Journ. of Med. Sc.,' 1850, Jan., 98.
 
 ERYSIPELAS. 395 
 
 writer^ whose account relates to tlie hospital at Melbourne. Still more 
 numerous are tbe accounts of eindemics of the disease in Jwspitals and 
 lying-in institutions.^ Among the more recent records of hospital erysi- 
 pelas, I may mention those of Serrc for the Hotel Dieu of Montpellier 
 in 1840, Marjolin and Langier^ for the Hopital Beaujon in 1843, Billroth'* 
 and Waeckerling"^ for the Zurich Hospital in 1859-60, Bourgeois'' for 
 the hospital at Estempes in 1S60, Desgranges'' and Oilier^ for the Hotel 
 Dieu of Lyons the same year, Fenestre" for the Hopital Beaujon of 
 Paris also the same year, Pujos'° for the Hopital St. Andre at Bordeaux 
 in 1863, Ponfick" for the Heidelberg Surgical Clinique in 1866, Oilier'^ 
 for the Hotel Dieu of Lyons in 1S67, Yolkmann^^ for the Halle Surgical 
 Clinique in 1868, Savory'^ for St. Bartholomew's Hospital (London) in 
 1872-73, and Miller'^ for the Edinburgh Infirmary in 1879-80. 
 
 As regards epidemics of enjsipelas in lunatic asylums, we have an 
 account by Rayor of one in Paris in 1 828 ; in educational institutions, 
 the paper of v. Ny mann"^ relating to Smolna ; on hoard ship, an account 
 by Busk'7 of an endemic on the hospital ship "Dreadnought" in 1837- 
 38, as well as notices of its prevalence in the British Mediterranean 
 fleet'* in 1S52, and one by Smart" on the epidemic of 1824 in Devonport 
 dockyard and on that of 1873-74 in Portsmouth dockyard. Instances 
 of extensive epidemics of erysipelas occurring elsewhere than in such 
 j)laces are given by the following writers : — Black^" for the epidemic at 
 Bolton in 1832, Wutzer"' for the disease at Bonn in 1849, Alison'-^ for 
 the erysipelas of 1850 in Edinburgh, Deutsch-^ for that of 1856 in the 
 
 I 'Med. Times and Gaz.,' 1871, March, 287. 
 
 - For the epidemics of erysipelas in lying-in hospitals, see the chapter on 
 " Puerperal Fever." 
 
 ' 'Arch. gen. de med.,' 1846, Dcbr., 414. 
 
 • ' Arch, fiir klin. Chir.,' ii, 460. 
 
 '^ 'Deutsche Klin.,' 1861, Nr. 19. 
 
 ^ ' Journ. des connalss. med. -chir.,' 1861. 
 
 7 ' Gaz. med. de Lyon,' 1861, Juiu. 
 
 8 lb., AOut. 
 
 9 ' Sur une epideraie d'erysipele, &c.,' Par., 1861. 
 ^0 'De I'erysipele epidemique,' Par., 1865. 
 
 11 'Deutsche Klin.,' 1867, Nr. 20 ff. 
 
 >'^ ' Lyon medical,' 1868, Nr. 37. 
 
 '3 'Handb. der Chii-.,' by Pitha-Billrotb, i, 2 Abth., 153. 
 
 1^ 'Brit. Med. Journ.,' 1873, Jan., 5. 
 
 15 'Edinb. Med. Journ.,' 1880, June, 1095. 
 
 i" 'Arch, fiir Kinderheilkde.,' 1880, i, 466, 
 
 17 In Nunneley, 'Treatise on the Nature . . of Erysipelas,' Loud., 1841, 146. 
 
 ^^ 'Statist. Reports,' 1853, 122. 
 
 I'J ' Brit. Med. Journ.,' 1880, Feb., 200. 
 
 ^ 'Transact, of the Prov. Med. Assoc.,' 1837, ^j ^o.v 
 
 "^^ ' Rbein. Mouatsschr. fiir pract. Aerzte,' 1849, Splbr., Octbr. 
 
 -2 'Edinb. Monthl. Journ. of Med.,' 1851, Jan., 72. 
 
 23 ' Preuss. med. Vereins-Ztg.,' 1857, Nr. 49.
 
 396 GEOGEAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Circle of Pless, Uppei* Silesia, tlie reporbers^ on an epidemic in several 
 communes of the Lower Rhine in 1858, Lange- for the disease in North 
 Greenland, 1861, Pujos^ for the epidemic of 1863 in Bordeaux and several 
 other places in the Gironde, Dechambre'' for the disease in Paris at the 
 same time, the reporters* for several counties in Pennsylvania in 1866 
 and 1872-73, Tibbits"' for the epidemic of 1873 at Bristol, Radcliffe'' 
 for Oxford in 1874, and Baader^ for the village of Buus (Canton Neu- 
 chatel) in 1875-76. 
 
 § 150. Epidemics complicated with Throat- Affection. 
 
 Besides tlie affecfciou of the skin, there occur iu the course 
 of the erysipelatous process certain lesions of organs ; and 
 of these the one that has most interest for our inquiry is the 
 inflammatory affection of the mucous membrane of the throaty 
 which appears either primarily or secondarily during the 
 attack. It consists either in simple catarrh or in phlegmon, 
 or it assumes the so-called diphtheritic character, that is to 
 say, a tendency to necrosis; and it may spread from the 
 throat to the larynx, giving rise to symptoms of oedema of 
 the glottis or of laryngeal croup. In correspondence with, 
 the severity of the local lesions under those circumstances, 
 there is an aggravation of the constitutional symptoms due 
 to general infection ; secondary foci of disease may even 
 arise in the internal organs (meninges, lungs, intestine, &c.), 
 and the malady may acquire a " typhoid " character which 
 will warrant us in speaking of it as erysipelas ty^hoides or 
 erysipelas maUgnum. 
 
 This malignant form of erysipelas occurs either sporadically 
 (not rarely during epidemics of ordinary erysipelas of the skin) 
 or it may occur in groups of cases or even in considerable 
 epidemics. One of the earliest references of the latter kind 
 will be found in Darluc^s® account of an epidemic of erysipelas 
 
 1 'Tiav. du conscil departement d'hyg. publ. du Bas-Rhin,' 1865, ii, 2. 
 ' L. c. 3 L. c. 
 
 4 'Gaz. hebd. de med.,' 1863, Nr. 30. 
 
 ' 'Transact, of the Pennsylvania State Med. Soc.,' 1867; 1873, 129, 169, 174; 
 1874, 226. 
 
 " 'Lancet,' 1864, June, 832. 
 
 ' 'Brit. Med. Journ.,' 1875, May. 651. 
 
 ^ ' Correspondenbzl. fiir Schweiz. Aerzte,' 1877, Nr. 3 ft". 
 
 9 'Journ. de med.,' 1757, Juill, vol. vii, 55.
 
 ERYSIPELAS. 397 
 
 observed by him at Caillan in the summer of 1750, in which 
 the rose in the face was followed in many cases by a severe 
 affection of the throat or larynx, the patients dying with 
 symptoms of an '^ esquinancie funeste/^ The same type 
 presented itself in the epidemic at Montrose in 1822, of 
 which Gibson^ says: ''The disease was not so much confined 
 to the head or face, as common erysipelas, but it frequently 
 attacked other parts of the surface of the body. Sometimes 
 the internal fauces were attacked, and if it spread to the 
 trachea it generally proved fatal.'' 
 
 Other instances are the epidemic of 1833—34 in Dublin, 
 described by McDowell," and that of 1847 i^ London, 
 reported on by Gull and Lever f also the hospital erysipelas 
 which was prevalent in 1870—71 in the military ambulance 
 at Berlin, where cases of erysipelas of the face complicated 
 with catarrhal, phlegmonous or diphtheritic angina, were 
 observed by Hesse and Hiller.* Sporadic cases of the same 
 kind have been reported by Stevenson,^ Arnott,^ Simon,^ 
 zum Sande,^ Heubner,^ Jacobs^^ and others. In a report 
 of the sui;gical clinique at Greifswald for the year 1876, 
 Schiiller says :'^ , 
 
 *' The coincidence with erysipelas of diphtheritis of wounds and 
 mucous membranes, which had formerly been noticed from time to 
 time, appears to have been regarded as something more than an acci- 
 dent, even although no particular importance was attached to it. Now- 
 a-days that phenomenon is justly regarded with greater attention. 
 In such cases we are very often able to make out a diphtheritic process, 
 either proceeding directly from the erysipelas or arising during the 
 existence of the latter, and attacking not only the wound but also the 
 mucous membrane of the mouth and throat. Hardly less interesting 
 [than the coincidence of the diphtheritis of wounds with erysipelas] is 
 the observed correspondence between erysipelas and diphtheria of the 
 
 1 'Transact, of the Edinb. Med.-Chir. Soc.,' 1828, iii, 94. 
 
 - 'Dublin Quart. Journ. of Med. So.,' 18.34, ^ov., 161. 
 
 ^ 'Med. Gaz.,' 1849, June. 
 
 "* ' Deutsche med. Wocheuschr.,' 1876, .309, 32.3. 
 
 5 'Transact, of the Edinb. Med.-Chir. Soc.,' 1826, ii, 128. 
 
 ° ' Lond. Med. and Phys. Journ.,' 1827, March, 194. 
 
 ' ' Arch. gen. de med.,' 1865, Oct. 
 
 ** 'Journ. fiir Kindei-kr.,' 1871, Ivii, 57. 
 
 " ' Jahrb. fur Kinderheilkde.,' 1872, vi, 105. 
 
 '" ' Prcsse med. beige,' 1875, Nr. 16. 
 
 '^ ' Deutsche Zeitschr. fiir Clururgie,' 1877, viii, 540 ff.
 
 398 GEOGKAPEIOAL AND HISTORICAL PATHOLOGY. 
 
 inucons membrane of tlie montli and throat. The latter, no doubt, has 
 its prototype in the pharyngeal catarrhs which very often accompany 
 erysipelas. But the same complication has been observed in more 
 considerable epidemics, one of which in North America is described by 
 Hirsch." 
 
 The concluding reference here is to those epidemics of 
 erysipelas in the Western Hemisphere^ particularly in the 
 United States^ with complications of severe throat affection 
 and distinguished by so-called typhoid phenomena^ to which 
 I directed the attention of the profession in Germany in the 
 first edition of this work, and which constitute one of the 
 most interesting episodes in the history of erysipelas.^ 
 
 § 151. Remakkable Series op Epidemics in North 
 
 America. 
 
 The first accounts of these epidemics of malignant or 
 typhoid erysipelas in the Western Hemisphere date from 
 the years 1822— 1836 (see the tabular survey at p. 401). 
 From 1 84 1 onwards the disease grew into a pandemic which 
 did not cease until the beginning of the sixties. The sub- 
 sequent accounts from that part of the world relate to more 
 isolated epidemic outbreaks. 
 
 The type of the disease may be gathered from the follow- 
 ing account, which has been compiled from the best sources.^ 
 
 Clinical characters. — The disease broke out either suddenly with 
 febrile manifestations, or it developed gradually. In either case the 
 patient complained, before there was any affection of the skin or 
 throat, of extreme weakness, of pains in the head, back and limbs, and 
 of sickness. Shortly after, pain in swallowing began to be noticed,. 
 
 ' Volkmann is incliued to think that in these epidemics we have to do with 
 "an affection very closely related to diphtheritis, perhaps even with pure diph- 
 theritis of tlie throat." From the point of view of morhid anatomy, tliis opinion 
 is perfectly justified; but from the clinical and etiological points of view I am 
 nnable to agree with it, the less so that the profession in North America, at 
 the time when the observations on these epidemics were made and recorded, were 
 very well acquainted with angina maligna or diphtheritic angina. I reserve the 
 more particular defence of m^ views on the significance of " diphtheria" until the 
 chapter on Angina maligna {or the so-called diphtheria of the throat). 
 
 ^ The references to authorities are given in one of the columns of the chrono- 
 logical table.
 
 ERYSIPELAS. 399 
 
 being the earliest characteristic symptom; an examination showed 
 swelling of the tonsils and mucous membrane of the throat, which, in 
 the milder cases, were red and (edematous, and afterwards looked to be 
 covered by a layer of purulent mucus ; while, in the more severe 
 developments of the malady, the mucous membrane of the pharynx was 
 seen to be reddened or of a dark j)urple colour, which extended 
 gradually to the gums, the tongue, and the side of the cheeks, the 
 tongue itself swelling greatly and assuming a dark brown colour — 
 whence the popular name of "black tongue." In such cases the 
 mucous membrane, especially where it is reflected over the gums and 
 alveolar process, was often found covered with ash-coloured sloughs; 
 when these were thrown off, deep ulcers remained behind, which made 
 the act of swallowing extremely painful. Sometimes the pharyngeal 
 inflammation extended to the larynx and trachea, when the symptoms 
 of croup would supervene ; at other times it extended to the nasal 
 passages, and thence to the frontal sinuses and even to the antrum. 
 These manifestations, which were almost always accompanied by 
 swelling of the lymphatic glands of the neck, sometimes by lymphan- 
 gitis or severe neuralgias of the temporal and occipital regions, lasted 
 usually until such time as the exanthem appeared on the skin, which 
 was generally within the first two days, but sometimes not until later. 
 In many cases there was only a slight development of erysipelas, and 
 in some it appears to have been absent altogether, the patients suffering 
 from the throat affection only. The outbreak of erysipelas was usually 
 indicated by tension, heat, and stinging pains in the affected part; in 
 a short time the skin looked to be more or less swollen, and of a dark 
 or bright red according as the lesion was deeply seated or on the 
 surface. If the upper layers of the skin only were involved, the course 
 of the disease was usually that of simple erysipelas ; but if the sub- 
 cutaneous tissue were also implicated, the result was often deep and wide- 
 spread ichorous and gangrenous destruction of tissue. In many cases 
 it was the connective tissue that was first attacked, particularly in the 
 axilla, where the destructive process would not unfrequently extend to 
 the muscles and lymphatic glands ; so that shreds of exfoliated connec- 
 tive tissue, fragments of lymph-glands, and the like were discharged with 
 the ichor when the abscess was opened, and muscles or even bones were 
 laid bare. The ichor that was let out was so strongly corrosive that it 
 attacked the hardest steel as if it had been nitric acid, and instruments 
 which had been used to open the abscess and left lying for some hours 
 without being cleaned, were completely eaten into and rendered useless 
 Another and more fi-equent issue of the deep process was gangrene 
 which sometimes set in on the shortest notice, and would destroy the 
 whole substance of a limb, and in some cases the soft parts of the whole 
 of one side of the face. Although the erysipelas occurred in all parts of 
 the body, its chief seat was the fa,ce, where it usually began about the 
 wing of the nose or the canthus of the eye, extending upwards to the 
 scalp and downwards to the neck and shoulders, and sometimes even 
 over the whole body. The deeper collections of matter, also, were found
 
 400 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 in all parts of the body ; in one case Bennet saw them begin to form in 
 the axilla and gradually spread over most of the trunk. 
 
 Besides those two strictly pathognomonic conditions, many other 
 local affections occurred in the course of the malady, but not so uni- 
 formly : siich as bronchitis and pneumonia, pleurisy, meningitis, peri- 
 tonitis (an almost constant symptom of the disease in Greenland, and 
 of the epidemic in Montgomery County in the spring of 1852), and 
 affections of the intestinal mucous membi-ane (revealed in life by 
 Tomiting and purging), or of the genito-urinary system, in which case 
 suppression of urine and bleeding from the urethra were not unfre- 
 quently observed. 
 
 The fever, in well-developed cases, had always a typhoid character. 
 It must appear remarkable that the rigors observed at the beginning 
 of the disease should have recurred more than once during its course 
 without any obvious connexion with exacerbations of the fever. Various 
 -degrees of the malady could be distinguished according to the more or 
 less intense development of the complications above sketched. Not 
 unfrequently it was of so mild a type that the patient hardly required 
 medical treatment ; another time it would be so malignant that death 
 occurred on the third or fourth day. In cases of a favorable type, 
 the attacks of angina ceased with the appearance of the erysipelas; a 
 few days later the exanthem faded, desquamation set in, and with it 
 there was not unfrequently a formation of numerous small abscesses 
 under the skin, which healed quickly, however, under simple treat- 
 ment. When the type of the attack was unfavorable, the exanthem 
 assumed a bluish colour, the skin and connective tissue sloughed, large 
 burrowing abscesses formed having the surviving tracts of connective 
 tissue for their basis, the pulse was small and quick, the tongue looked 
 as if coated with a dark brown dry crust, the urine was scanty, diarrhoea 
 and delirium supervened, and death took place usually within ten days 
 of the firbt appearance of the exanthem. Just as rapid, and almost as 
 fatal, was the course of those cases in which signs of inflammation 
 appeared in the respiratory organs, the meninges, &c., death taking 
 place nearly always within the first eight days, and in most cases 
 within the first six. Finally, in the class of cases where considerable 
 centres of suppuration had developed in the connective tissue, the 
 disease was often protracted many months ; and, even when convales- 
 cence went on well, thei'e would often be most important functional 
 irregularities, atrophy of muscles, and the like remaining over. 
 
 Morbid anatomy. — As to the state of parts found in those who died of 
 this disease we have only a few meagre notices.' The most complete 
 are those by Nathusius, who had opportunities of examining the bodies 
 of three negroes after death from typhoid erysipelas. The bodies always 
 
 ' Ou the very first appearance of the disease several physicians, who had 
 examined the bodies of persons dead of typhoid erysipelas, were seized with it 
 and died; and it wiis their solicitude to escape the same fate tliat restrained the 
 United States' practitioners, who were not generally indifferent to the morbid 
 anatomy, from making post-mortem examinations in this disease.
 
 ERYSIPELAS. 
 
 401 
 
 looked emaciated, witli no blood in them, the skin and connective tissue 
 at the places where the exanthem had been observed during life infil- 
 trated with a gelatinous exudation, which extended into the connective 
 tissue of the nearest muscles and glands, the membranes of the brain 
 and spinal cord full of blood, some bloody serum in the ventricles of the 
 brain and in the pericardium, the heart relaxed and containing a soft 
 black clot in the ventricle, the bronchi injected and full of mucus, the 
 lungs full of blood (hypostatic pneumonia), serous fluid in the pleura 
 and peritoneum, the mucous membrane of the stomach and intestine 
 ecchymosed, the vicinity of the Peyer's patches in the lower end of the 
 ileum congested, but never any ulceration, the mesenteric glands 
 swollen, the liver full of blood, and the spleen soft and friable. The 
 state of the kidneys is not mentioned. Dexter and Hall in one case 
 found the liver softened, the peritoneum injected and containing a dark 
 coloured ichorous fluid with shreds in it, and the coils of inflamed 
 intestine slightly glued together. Bennet ' observed, in another case, 
 the costal pleura on the right side injected and sticking to the visceral 
 layer by means of recent adhesions, the pulmonary pleura of the left side 
 everywhere deep red with eight ounces of sero-sanguineous fluid in the 
 cavity, the substance of both lungs normal. In a second case, which pre- 
 sented no signs of intestinal affection during life, he found the follicles 
 in the lower end of the ileum very prominent, especially near the ileo- 
 ca3cal valve, but none of them were ulcerated; mesenteric glands and 
 spleen perfectly normal. 
 
 Chronological Tabic of all the known Eindemics of Malignant Erysijyelas 
 in Atnerica from 1S22 to 1881. 
 
 Epidemic. 
 
 Time. 
 
 1822 
 
 Spring 
 
 1826 
 
 
 3J 
 
 Winter 
 
 1832 
 
 1833 
 1836 
 
 1841 
 
 Spring 
 Winter 
 
 » 
 
 Summer 
 
 Place. 
 
 Authority. 
 
 Nova Scotia, New Bruns- 
 wick 
 Jamaica (Kingston) 
 
 Vermont (Burlington).. 
 
 New York (Ogdeusburg) 
 Ohio (St. Clairsville) ... 
 Ohio (Preble County)... 
 Ohio 
 
 East Canada 
 
 Bayard, New York Med. 
 Journ., 1 83 1, May, 54. 
 
 Leon, New York Med. and 
 Phys. Journ., 1827, April. 
 
 Drake, Treat, on the Prin- 
 cipal Diseas. of the Inte- 
 rior Valley of N. America, 
 Philad., 1854, ii, 623. 
 
 Drake, 1. c. 
 
 Drake, 1. c. 
 
 Drake, 1. c. 
 
 Holston, Transact, of the 
 Ohio State Med. Soc.,1857. 
 
 Drake, 1. c. 
 
 ' Xew Yurk Jouiu. of ^'^ed.,' i^-t,, July 20, p. 23. 
 
 VOL. II. 
 
 26
 
 402 
 
 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Epidemic. 
 
 Time. 
 
 I84I-2 
 
 Winter 
 
 1842 
 
 55 
 
 Spring 
 
 » 
 
 Autumn 
 
 J5 
 
 November 
 
 1843 
 
 Winter 
 
 Si 
 
 Spring 
 
 55 
 
 55 
 
 55 
 
 November 
 
 5> 
 
 December 
 
 1843-4 
 
 Winter 
 
 55 
 
 55 
 
 55 
 
 55 
 
 55 
 
 55 
 
 55 
 
 55 
 
 55 
 
 55 
 
 1844 
 
 55 
 Spring 
 
 ?5 
 
 55 
 
 55 
 
 5> 
 
 55 
 55 
 
 55 
 
 Winter 
 
 55 
 
 55 
 
 55 
 
 55 
 
 55 
 
 55 
 
 1845 
 5) 
 
 February 
 Spring 
 
 Place. 
 
 Vermont (Middleburg) ... 
 
 New York (Moriab) 
 
 Vermont (St. Albans) 
 
 Diffusion along Lake 
 Champlain and the Con- 
 necticut River 
 
 New York (Cortlandville 
 and other centres) 
 
 Indiana (Ripley County), 
 in considerable diffusion 
 
 Missoui'i (various places) . 
 
 Ohio (Miamy Valley) 
 North Greenland 
 
 New York (Erie County).. 
 
 Indiana and Michigan. 
 
 Canada (Montreal) 
 
 New York (vai-ious places 
 
 Illinois (Blumington) 
 
 Ohio (Montgomery County) 
 
 Wisconsin (Milwaukie) . 
 Kentucky (Louisville) .... 
 
 Only in the Hospital 
 Missis sippi(various places) 
 North Greenland 
 
 Drake, 1. c. 
 Drake, 1. c. 
 Hall and Dexter, Amer. 
 
 .Tourn. of Med. Sc, 1844, 
 
 Jan. 
 
 Shijiman, New York Journ. 
 
 of Med., 1846, Jan., 25. 
 Sutton, Western Lancet, 
 
 1843, Nov., 308. 
 Bennet, Western Journ. of 
 
 Med., viii, no. 
 Drake, 1. c. 
 Accnt. in Sundhedscolleg. 
 
 Forhandl. Aaret, 1844, 57. 
 Jewett, Buffalo Med. 
 
 •Journ., iii, 262. 
 Shipman, 1. c. ; Meeker, 
 
 Illinois Med. and Surg. 
 
 Journ,, 1844, June. 
 
 Pennsylvania (Delaware 
 
 County) 
 Tennessee (Memphis, Co 
 
 lumbia) 
 
 Mississippi (Grand Gulf) . 
 New York (Livingston Co.' 
 
 Indiana (Laporte) 
 
 Missouri (St. Louis and 
 
 vicinity) 
 Virginia (Petersburg) . . . , 
 
 Alabama (Courtland) 
 North Greenland 
 
 Authority. 
 
 1 
 
 Drake, 1. c. 
 
 Carey, Transact, of the 
 Amer. Med. Assoc, 1854, 
 vi, 310. 
 
 Drake, 1. c. 
 
 Sundhedscoll. Forhdl. for 
 Aaret, 1845, 37; Kayser, 
 Ugeskrift for Laeger,. 
 1846, Nr. 15, 229. 
 
 Young, Amer. Med. Ex- 
 aminer, 1844, Sept. 
 
 Shanks, Western Journ. of 
 Med., iii, 12 ; Robard, ib., 
 iv, 285. 
 
 Drake, 1. c, 628. 
 
 Drake, 1. c. 
 
 Shipman, 1. c. 
 
 Moore, Missouri Med. and 
 Surg. Journ., ii, 97. 
 
 Peebles Amer.Med. Journ., 
 1846, Jan., 23. 
 
 Drake, 1. c. 
 
 Sundhedscoll. Forhdl. for 
 Aaret, 1846, 15.
 
 EKYSIPELAS. 
 
 403 
 
 Epidemic. 
 
 Time. 
 
 1845 
 
 1845-6 
 
 1847 
 
 1847-8 
 
 1848 
 
 1848-9 
 
 1850 
 
 1851 
 
 1851-2 
 
 1852 
 
 Spring 
 Autumn 
 
 Winter 
 Spring 
 
 Autumn 
 Winter 
 
 February 
 Winter 
 
 Spring 
 
 Summer 
 Winter 
 
 Place. 
 
 Indiana (Logansport) 
 
 New York (Ontario and 
 
 Erie County) 
 North Carolina (Elizabeth, 
 
 Raleigh) 
 
 Pennsy 1 vania( Uniontown ) 
 
 Ohio (Meigs County) 
 
 Michigan (various places) 
 
 Connecticut (Bridgeport) 
 
 Pennsylvania (various 
 places) 
 
 New Jersey 
 
 Connecticut .« 
 
 Ohio 
 
 Mississippi (Jackson) .... 
 
 Connecticut (Hartford 
 County) 
 
 Ohio (Brown County) 
 
 Mississippi (Vicksburg).. 
 Louisiana (New Orleans) 
 
 Only in the Hospital 
 Massachusetts (Boston, a 
 
 few cases) 
 Pennsylvania (Armstrong 
 
 County) 
 
 Michigan (Detroit) 
 
 Pennsylvania (Blair Co.) 
 
 California (Sacramento).. 
 
 Pennsylvania (various 
 places) 
 
 Ohio (Shelby County).... 
 Ohio(MontgomeryCounty) 
 Kentucky (Bordstown) . 
 
 Authority. 
 
 Fitch, Illinois and Indiana 
 Med. and Surg. Journ., i, i . 
 
 Drake, 1. c. ; Pelt, Buffalo 
 Med. Journ., i, 193. 
 
 Nathusius, Do erysij)elate 
 typh. Diss. BeroL, 1856; 
 McKee, South. Med, Re- 
 port, ii, 410. 
 
 [ Drake, 1. c. 
 
 Drake, I.e.; Pitcher, Trans- 
 act, of the Amer. Med. 
 Assoc, 1853, V. 
 
 Bennett, New York Journ. 
 of Med., 1848, May, and 
 Amer. Journ. of Med. Sc, 
 1S50, April, 377. 
 
 Corson and Geiger, Trans- 
 act, of the Pennsylvania 
 State Med. Soc, 1848. 
 
 ! Accounts in Ti-ansact. of 
 the Amer. Med. Assoc, 
 1850, ii. 
 Farrar, Southern Med. Re- 
 ports, i, 355. 
 
 Russel, Proc of the Con- 
 nect. State Med. Soc, 1855. 
 
 Drake, 1. c. 
 
 Morland, Amer. Journ. of 
 Med. Sc, 1850, Oct., 318. 
 
 Gillespie, Amer. Med. Ex- 
 aminer, 1 85 1, March. 
 
 Pitcher, 1. c (ad ann. 1847). 
 
 Rodrigue, in Transact, of 
 the Pennsylvania State 
 Med. Soc, 1S52. 
 
 Blake, Amer. Journ. of 
 Med. Sc, 1852, July, 59. 
 
 Accounts in Transact., 1. c 
 (ad ann. 1851); Leasure, 
 Amer. Journ. of Med. Sc, 
 1856, Jan., 45. 
 
 Carey, 1. c. 
 
 lb. 
 
 Mattingly, St. Louis Med. 
 and Surg. Journ., 1853, 
 May, 217.
 
 404 GEOGKAPHLCAL AND HISTOEICAL PATHOLOGY. 
 
 Epidemic. 
 
 Authority. 
 
 Time. 
 
 Place. 
 
 1852 
 
 1853-4 
 1854 
 
 35 
 1864 
 
 » 
 
 1866 
 1870 
 1880 
 
 January 
 "Winter 
 
 February 
 
 Winter 
 and 
 
 Spring 
 
 • • • 
 
 Autumn 
 
 Missouri (Platte County, 
 sporadic cases) 
 
 Ohio (Highland County) . . . 
 
 Pennsylvania (Montgo- 
 mery County) 
 
 New Tork (Venango Co.) 
 
 Pennsylvania (very widely 
 
 spread) 
 Illinois (Birmingham, Chi- 
 
 cago,Waverly,and various 
 
 other places) 
 
 Pennsylvania (Lehigh Co. 
 and others) 
 
 • 
 
 Minnesota (Ramsey Co. 
 and other places) 
 
 Wisconsin and other 
 States in the North-west 
 
 Ridley, New Tork Journ. 
 of Med., 1853, Jan., 41. 
 Carey, 1. c. 
 Corson, 1. c. 
 
 Avery ,Transact.of the New 
 Tork State Med.Soc ., 1 855 . 
 
 Transact, of the Pennsyl. 
 State Med. Soc, 1864. 
 
 King,Amer. Journ. of Med. 
 Sc, 1865, Jan., 274; ac- 
 counts by Davis in Trans- 
 act, of the Illinois State 
 Med. Soc, 1864; McVey, 
 ib., 1865. 
 
 Accounts in Transact, of 
 the Pennsylv. State Med. 
 Soc, 1867. 
 
 Hand, in Transact, of the 
 Minnesota State Med. 
 Soc, 1871. 
 
 Meachem, Transact, of the 
 State Med. Soc. of Wis- 
 consin, 1 88 1. 
 
 This tabular survey presents a picture of the distribution and the 
 epidemic outbreaks of the disease in North America, which is unques- 
 tionably a very incomplete one ; and its incompleteness is borne out by 
 the language of Holmes^ in 1 854 : " Yiewed as an epidemic, the disease 
 demands attention from physicians in the West. We suppose small- 
 pox or cholera would not cause greater consternation in many neigh- 
 bourhoods, than the appearance of that violent type of erysipelas known, 
 from a prominent sign, as the " black tongue ;" but, even when unac- 
 companied by this feature, the disease is much dreaded in the Western 
 States. We believe that it is a disease more common in the West than 
 in the East ; and from what we have seen and read and heai-d of it, we 
 are disposed to think that no part of the earth has suflFered more from 
 epidemic erysipelas than Illinois, Indiana, Missouri, and parts of 
 Tennessee and Iowa. There is scarcely a year, or season, in which 
 you may not hear of several centres of the disease in these States ; 
 Michigan, Wisconsin and Minnesota Territory, have also suffered 
 much from it. It has raged with great violence on the plains on the 
 route to California ; has been very common and of grave type in 
 
 1 'Transact, of the Amer. Med. Assoc./ 1854, xv, 155.
 
 ERYSIPELAS. 405 
 
 Santa Fe ; and in California it is a frequent and mncli dreaded 
 disease. In wet and cold spring months, it is common in Louisiana 
 and Texas ; it extends as an epidemic from Maine to Mexico, from 
 Minnesota Territory to Florida." 
 
 This statement accords with all the information that I have 
 been able to gather, so far at least as relates to the period 
 during which the disease had been most severe in North 
 America. At the same time it bears out the result that we 
 arrive at from the foregoing detailed table of the epidemics 
 in regard to the predominance of malignant erysii?elas in the 
 Western States. Of the 70 epidemics above mentioned, 3 
 were prevalent in Greenland (all 3 in North Greenland)/ i in 
 Nova Scotia and New Brunswick, 2 in Canada, 7 in the New 
 England States (Vermont, Massachusetts and- Connecticut), 
 18 in the eastern central States (New York, New Jersey 
 and Pennsylvania), 5 in the middle central States (Virginia, 
 Kentucky, Tennessee, North Carolina), 26 in the Western 
 States (Ohio, Indiana, Illinois, Michigan, Wisconsin, Mis- 
 souri, Minnesota), 6 in the Southern States (Alabama, 
 Mississippi, Louisiana), and i in California. The epidemic 
 observed at Kingston, Jamaica, in 1826 stands by itself. 
 The extent to which the disease spread in the several locali- 
 ties has been very various ; here and there the cases occurred 
 in more or less considerable groups, sometimes in hospitals 
 only ; at other places the diffusion was general. Equally 
 various was the duration of the several epidemics, which in 
 some instances amounted to a few months, and in others 
 exceeded a year. Regarded as a whole, the incidence of 
 malignant erysipelas gives us the impression of a series of 
 small and circumscribed epidemics rather than of pandemic 
 prevalence, such as is proper to cholera, the acute exanthe- 
 mata, and other spreading diseases. 
 
 § 152. Influence of Climate. 
 
 The fact that erysipelas is distributed over the whole globe 
 proves that injlnrncc of climate has at least no essential 
 significance for the occurrence of the disease. At the same 
 
 1 See § 148.
 
 406 GEOGRAPHICAL AND HISTORICAL TATHOLOGT. 
 
 time wo may conclude with a good deal of certainty that it 
 is more rarely met with in lower latitudes, at least that form 
 of it which is independent of hospitals. The same relation 
 comes out in the epidemic incidence of malignant erysipelas 
 in the Western Hemisphere, where the disease has been 
 much more frequent and much more extensive in the north- 
 western and northern States of the American Union than in 
 the central and southern. 
 
 § 153. Influence op Season and Weather. 
 
 Further support of this idea will be found in the fact that 
 the amount of the sickness shows a dependence on the season 
 of the year corresponding in a measure to the relation to 
 climate. The larger number of observers are of opinion 
 that erysipelas occurs more frequently in the colder than in 
 the warmer months of the year ; this is the conclusion of 
 Haller from ten years' observations in the General Hospital 
 of Vienna, of Eschbaum ^ from the experience of fifteen 
 years (1865 — 1879) in the clinique and policlinique of Bonn, 
 of Boinet and other Parisian hospital physicians and sur- 
 geons for the Hotel Dieu, of Gosselin from seven years' 
 observation in the Hopital Beaujon, the Charite and the 
 Pitie in Paris, of Pujos from the practice of the Hopital St. 
 Andre in Bordeaux, of Borbone " from the statistics of the 
 Turin hospital, of Copland^ and Doig* on the basis of obser- 
 vations made in London, of v. Nymanu from the experience 
 of the Educational Institute at Smolna, of Ucke for Samara, 
 Polak for Persia, Annesley for India, and of Reese^ and an 
 anonymous authority® from eleven years' (1861 — 1871) ob- 
 servations in the Bellvue Hospital of New York. Also in 
 the North American epidemics of malignant erysipelas, the 
 greatest incidence of the disease has been very distinctly in 
 
 1 'Beitr. zur Statistik einiger acut entziiudl. und Infections-krankheiten/ 
 Bonn, 1880, p. 20. 
 
 2 ' Giorn. della Acad, di med. di Torino/ 1878. 
 ^ ' Dictionary of Pract. Med.,' iii. 
 
 •* 'Med. Times and Gaz.,' 1862, Sept., 72, 
 * 'Amer. Journ. of Med. Sc.,' 1850, Jan., 98. 
 ^ 'New York Med. Record,' 1872, Sept.,' 373.
 
 ERYSIPELAS. 407 
 
 the cold months, as may be seen in the foregoing table of 
 them. 
 
 The connexion, then, of erysipelas with the colder seasons 
 of the year, which, if not an absolute one, is at least re- 
 markably uniform, may be explained by the direct influ- 
 ence of the kind of weather, the weather, namely, which is 
 proper to autumn and early spring. At all events many 
 observers are agreed that considerable fluctuations in tem- 
 perature, and more particularly the change to cold and damp 
 weather, help materially to produce the disease ; and in like 
 manner several of the authorities are of opinion that the 
 epidemics in North America were most prevalent in times of 
 cold and damp. We must regard it for the present an open 
 question how this pathogenetic influence of the weather is to 
 be interpreted — whether it increases the predisposition of 
 individuals to become ill, or whether it stands in some rela- 
 tion to the morbific cause, favouring the origin and diffusion 
 of the disease itself. Doubtless we have here to consider 
 also the influence which the season exerts on the people's 
 mode of life, a subject which I shall have occasion to 
 inquire more fully into in the sequel. Meanwhile, in 
 framing an opinion on the question before us, it should be 
 kept in mind that erysipelas has occurred not unfrequently 
 in summer, and that it has spread to a considerable extent 
 during dry and warm weather, and even during heat, as at 
 Devonport^ in 1824, Paris^ in 1863, in Algiers'^ in 1844, and 
 in New Brunswick in 1822. 
 
 § 154. Alleged Influence of Damp Soil. 
 
 I hold it to be very doubtful whether states of the ground, 
 such as elevation, geological characters, moisture and the 
 like, have any real significance for the occurrence of ery- 
 sipelas. As in almost all the infective diseases of late, so 
 in erysipelas special importance for the pathogenesis has 
 been assigned to the copious saturation of the ground, or, in 
 other words, to its swampy character. Thus Boinet points 
 
 ^ Smart, 1. c. ' Ducliambre, 1. c. ^ Burdiat, 1. c.
 
 408 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 out that the Hotel Dieu is built close to the Seiue, whose 
 sluggish stream at that point produces -excessive saturation 
 of the ground and contributes to the development of putrid 
 effluvia : '^ J'ai remarque encore," he says, after giving a 
 detailed statement of the facts^ " qu'il y avait une certaine 
 coincidence entre les grands ernes de la vSeine et Fapparition 
 des erysipeles. Toutes les fois quo la Seine s'accroit, elle se 
 repand dans les caves de l'H6tel-Dieu_, et I'eau y sejourno 
 pendant six semaines, deux mois, plus on moins ; alors et 
 pendant tout le temps qu' elle met a s'ecouler, on voit regner 
 ces erysipeles et tons les malades qui ont subi de grandes 
 operations succombent." But when the water falls and the 
 ground is left dry, on the season of warmth and drought 
 setting in, an abatement of the disease sets in also. Annesley 
 remarks of the incidence of erysipelas in the hospitals of 
 India that " this occurrence is most fi^equently observed to 
 take place in the more marshy and unwholesome situations 
 near the mouths and banks of rivers ;^' and other hospital 
 physicians and surgeons have published similar observations 
 to prove the great frequency of erysipelas in buildings 
 erected on damp sites. Further, some of the North 
 American practitioners have believed themselves warranted 
 in assuming that a marshy soil favoured the production and 
 diffusion of the malignant erysipelas on that continent ; 
 thus Nathusius pointed out that the disease was prevalent 
 in the swampy districts of North Carolina and adjoining 
 parts of Virginia, and the chroniclers of the epidemic at 
 Burlington, Yt., call attention to the situation of the town 
 on the shore of Lake Champlain. 
 
 The influence of this factor upon the origin and propaga- 
 tion of the disease in hospitals cannot be made out with any 
 kind of trustworthiness, inasmuch as a good many other 
 etiological factors have to be taken into account along with 
 it ; and it remains accordingly a question what importance, 
 if any, the wetness of the soil assumes among them. It is 
 at least certain that small and clean -kept hospitals have 
 seldom or never been visited by erysipelas, a damp situation 
 notwithstanding ; whereas there are many large hospitals, on 
 a dry site but under the converse conditions of hygiene, that 
 have never been altogether free from the disease, and have
 
 ERYSIPELAS. 409 
 
 often liad it in the form of an ej)idemic lasting foi' months, 
 although there had been no corresponding change in the 
 state of the ground. 
 
 This alleged influence of a swampy soil on the outbreak 
 and spread of malignant erysipelas in North America has 
 been absolutely rejected for good reasons by the great 
 majority of observers. " This supposition/' say Hall and 
 Dexter/ " is disproved by the fact of remote situations ; the 
 hilly regions of the interior, secluded from any emanations 
 of moisture, being alike obnoxious to the influence of this 
 fatal scourge." In Pennsylvania it has been just the hilly 
 districts that have been affected oftcnest and most severely. 
 From the facts that he had collected relating to the distri- 
 bution of the disease, Drake" concludes : " Its victims dwelt 
 upon rocks of every kind, on granite, limestone, sandstone, 
 slate and clay, and of every geological age, from the primi- 
 tive to the alluvial ; it occurred on mountain slopes, low hills, 
 and flat bottom-lands /' and the same conclusion has been 
 come to by Bennet, Sutton and others. 
 
 § 155. No Eacial Immunities. 
 
 According to the experience of Rigler in Tui'key, Polak 
 in Persia, Pruner in Egypt, and Tschudi among the Indian 
 population of Peru, the various races and nationalities would 
 appear to be about equally predisposed towards erysipelas. 
 Thevenot's assertion that the negro race enjoys immunity 
 from erysipelas has been absolutely contradicted by Clias- 
 saniol ;^ Parrar and Nathusius, also, have seen malignant 
 erysipelas in the negroes, although less commonly, as the 
 latter remarks, than in mulattoes and whites, the proportions 
 being as 10 to 15 and 20. 
 
 Witli reference to tlie type of tlie skin-aflFection in the coloured^'races, 
 Rigler says that the skin assumes a copper colour in the brown races, 
 whereas in negroes the presence of an erysipelas is shown merely by 
 rise of temperature, by swelling which pits on pressure, and by subse- 
 quent desqviamution of the cuticle. The new-formed epidermis appears 
 
 ' L. c, p. 21. ' L. c, p. 625, 
 
 ^ 'Arch, de ined. nav./ 1855, Mai, p. 514.
 
 410 GEOGRAPHICAL AND HISTOKrOAL PATHOLOGY. 
 
 for a time less dusky than at otlier parts of the skin, but it shortly 
 acquires the original look in consequence of abundant deposition of 
 pigment. 
 
 § 156. Breaks out both in Insanitary and Clean 
 
 Hospitals. 
 
 An importance not to be underi'atecl in tlie production and 
 diffusion of erysipelas attaches to unhygienic conditions, to 
 the accumulation of products of decomposition and putre- 
 faction in dwelliug'-houses, to the overcrowding of the same 
 with no regard to their cleanliness and ventilation, and to the 
 entrance of sewer gases or of solid particles in the form of 
 dust from cesspits and the like. It is obvious that these 
 nuisances have a quite special influence in hospital wards, 
 particularly in those set apart for the reception of surgical 
 cases ; and this is the reason or part of the reason why the 
 disease is particularly often endemic or epidemic, as the so- 
 called " erysipelas nosocomiale," on the surgical side of 
 large and much frequented hospitals. The greater preva- 
 lence of erysipelas in the cold season, which we have already 
 referred to, may not improbably be connected with the same 
 factor in the causation, inasmuch as it is often difficult at 
 that time of the year to secure a continuous and sufficient 
 ventilation of the wards. The literature of medicine is rich 
 in observations which establish the importance of this etiolo- 
 gical factor beyond doubt, proviug in fact, that the disease 
 has been obviated either permanently or for considerable 
 periods when those nuisances which had called forth the 
 endemics or epidemics of it had been removed. 
 
 Summing up the experience of hospital physicians and surgeons in 
 England, Gregory^ enumerates the following as material causes of 
 hospital erysipelas: overcrowding of the wards, particularly with 
 patients suffering from extensive suppurating wounds or discharging 
 other morbid secretions to a large amount ; insufficient cleansing of 
 beds, mattresses, walls, &c. ; inadequate ventilation of the wards. This 
 is the conclusion to be drawn also from the observations of Doig, 
 Erichsen,^ Campbell de Morgan,^ and other English sui-geons, and from 
 
 ^ 'Lectures on the Eruptive Fevers,' Lontl., 1843. 
 
 * 'Brit. Med. Journ.,' 1874, Jan., 134. 
 
 ^ In Holmes' 'System of Surgery,' 2ud ed., Lond., 1869, i, 206.
 
 ERYSIPELAS. 411 
 
 those of Fenger' at the Frederiks-Hospital of Copenliagen. Ericlisen, 
 wlio gives bis own experience at University College Hospital in the 
 autumn of 1872 in support of his opinion, says: "that erysipelas is 
 often of epidemic origin, there can be no question, but the influence of 
 any epidemic is immensely increased by an unhealthy condition of a 
 ward from overcrowding." Campbell de Morgan observes that, at the 
 Middlesex Hospital, erysipelas, which used to be veiy common, became 
 much rarer when the sanitary condition of the hospital was improved, 
 particularly through the adequate ventilation of the wards ; if patients 
 were admitted with erysipelas, it no longer spread from them to 
 other patients, as it used to do. For the same hospital, Thomson- 
 gives the following interesting fact : In one of the largest wards on the 
 ground floor, cases of erysipelas occurred time after time for a number 
 of years in two beds placed one on each side of a window. On inquiry 
 it was found that the common dust-hole of the hospital was situated in 
 a vault in the western front area exactly under this window and that it 
 had been left open, the efiluvia from it entering through the window and 
 particularly affecting the two beds in question. Great care was taken to 
 have the dust-hole thoroughly covered in, whereupon the endemic came 
 to an end for a time. After a considerable period, cases of erysipelas 
 again began to occur in those two beds, when it was found on inquiry 
 that the dust-hole had been again left open. The nuisance was taken 
 away altogether, and no more cases of erysipelas were seen in that ward 
 for a number of years. In the Radcliffe Infirmary at Oxford a severe 
 epidemic of erysipelas occurred in the summer and autumn of 1874, 
 which owed its origin, as Netten Radcliffe^ showed, to conditions of the 
 same kind but worse in degree, namely, the entrance of sewer gas from 
 drains blocked with faical matters. In the surgical division of the 
 hospital at Rostock, Konig^ had occasion to follow a small epidemic of 
 erysipelas, whose origin could be traced to the pillows used on the 
 operating-table being covered with dried blood-stains ; during a certain 
 period every operation done on that tal>le had been followed by ei-y- 
 sipelas ; but on the changing the pillows the endemic ceased all at once. 
 
 However highly we may rate the importance of the noxious 
 influence in question^ for producing erysipelas and causing 
 it to spread^ it is in something else that we have to seek for 
 the true and essential morbific factor. " Even in hospitals 
 that are admirably constructed," says Volkmann, " that have 
 been made salubrious to the point of luxury, and are per- 
 fectly ventilated — even in these there have occurred epi- 
 demics of erysipelas of the severest kind; and the most 
 
 1 'De erysipelate ambulanti disqii,' Havn., 1842. 
 ' 'Med. Times and Gaz.,' 1856, Dec. 
 3 'Brit. Med. Journ.,' 1875, i, 651. 
 * 'Arch, der Heilkuade,' 1870, p. 23.
 
 412 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 scrupulous cleanliness and care bave not succeeded in put- 
 ting a stop to them/^ Ample confirmation of tliis is afforded 
 by the Loudon hospitals, which, as Fergussou says, are 
 never free from erysipelas, notwithstanding the extreme 
 cleanliness practised in them, and despite the most abundant 
 ventilation. In the Hopital St. Andre at Bordeaux, which 
 is highly prized as a " model institution,^' it appears from 
 the statements of Pujos that even the cleanest and best 
 constructed wards do not escape erysipelas. Oilier records 
 that, for a long period previous to the year 1867, the severest 
 operations had been performed at the Lyons hospital without 
 erysipelas occurring ; but from that date onwards the larger 
 number of the cases operated upon were attacked with 
 erysipelas, although no cause could be found for it in the 
 condition of the place. 
 
 But the non-dependence of erysipelas upon the above- 
 mentioned factors is proved best of all by its epidemic 
 occurrence outside hospitals, among village populations at 
 large, and not unfrequently in coincidence with the develop- 
 ment or intensification of the disease in the hospitals. This 
 fact confronts us on a large scale in the North American 
 epidemics, in which the most remarkable circumstance was 
 that the disease was prevalent in country districts much 
 more frequently and much more extensively than in large 
 and populous towns. We should not, therefore, judge of 
 the importance of these unsanitary conditions in producing 
 erysipelas, otherwise than we judge of their influence in 
 other infective diseases; they afford a soil which is favorable 
 to the development of such diseases, whether because they 
 so affect the human organisation as to make it receptive 
 of the proper morbific thing, or because they are concerned 
 in some definite manner in the development of this moi-bific 
 thing itself. 
 
 § 157. The Morbid Poison — a Micrococcus. 
 
 In consideration of these facts, and in ^^ew of the circum- 
 stance that the erysipelatous process has markedly the 
 character of an infective disease, the conviction has long
 
 ERYSIPELAS. 413 
 
 been held that the malady was caused by a specific noxious 
 something — by a morbid poison. This opinion has found 
 support in the results of inquiries made by Hiiter,^ Orth/ Nep- 
 veau/ Lukomsky,* and Klebs/ and especially in the evidence 
 recently adduced by Koch/ and still better by Fehleisen/ as 
 to the constant occurrence of a species of bacterium (micro- 
 coccus),, with definite characters, in the diseased tissues and 
 in the lymphatic vessels.^ 
 
 There need be less hesitation than ever in accepting the 
 jjarasitic nature of the disease, now that its coimnunicahility 
 — which had been asserted originally by English surgeons^ 
 on the ground of clinical observation, and afterwards by 
 
 1 'Bed. klin. Wochenschr.,' 1869, 357. 
 
 * 'Arch, fiir experim. Pathologie,' 1873, i, 81. 
 ' 'Gaz. ined. do Paris/ 1873, 32. 
 
 ^ In ' Virchow's Archiv/ 1874, Ix, 418. 
 
 * 'Arch, fiir experim. Pathol.,' 1854, iii, iv. 
 
 ® 'Untersuchuiigen iiber die Aetiologie der WuudinfectionskrankheiteD,* 
 Leipz., 1878. 
 
 ' 'Deutsche Zeitschr. fiir Chirurgie,' 1882, xvi, 391, and ' Sitzungsber. der 
 Wiirzb. phys.-mcd. Gesellsch.,' 1882, N.r. 8. 
 
 8 Indirect evidence of the parasitic nature of erysipelas is afforded by recent 
 experience of the antiseptic treatment of wounds. Since the introduction of that 
 practice erysipelas of wounds has been almost banished from surgical wards, 
 which used to be permanent seats of the malady, and often required to be closed 
 on account of its disastrous outbreaks. On this point, see Volkmann, ' Ver- 
 handl der dcutschen Gesellsch. fiir Chirurgie,' 1877, 64; Tillmanns, in the 
 ' Deutsche Chirurgie ' of Billrotli and Liicke, v, 75 (for the surgical clinique of 
 Halle); Nussbaum, 'Die chirurgische Kliuik zu Miinchen im Jahre 1875,' 
 Stuttg., 1875; and ' Leitfaden zur antiseptischen Wundbehandlung,' 3 Aufl. 
 Stuttg. 1879. ■• 
 
 " The earliest statements occur in the reports of English hospital surgeons, 
 such as Wells (1. c), Dickson ('Med.-Chir. Rev.,' 1819, April, p. 615), "Weather- 
 head ('Diagnosis between Erysipelas, Phlegmon, &c.,' Lond., 1819), Stevenson, 
 Arnott, and others. A number of later observations on this point are collected by 
 Volkmann (1. c, p. 155). Of still more recent date are the papers by Oilier 
 (1. c.) for the epidemic of 1867 in the Lyons Hospital; by Borboue (1. c.) from . 
 observations in the hospital of Turin; by Erichsen for University College Hos- 
 pital; by Beghle (' Ediu. Monthly Journ.,' 1852, Sept., p. 243) from experiences 
 of private practice iu Edinburgh; by Tibbits ('Lancet,' 1874, June, p. 832) from 
 hospital and private practice in Bristol ; by Nettcu Kadcliffe (1. c.) for the Oxford 
 Infirmary; by Maclagan ('Brit. Med. Journ.,' 1876, Sept., p. 395) from private 
 practice; by Miller (' Edin. Med. Jour.,' 1880, June, p. 1095) for the Edinburgh 
 Infirmary ; by Liicke (' Berl, klin. Wochenschr.,' 1868, p. 457) for the hospital at 
 Bern; by Baader (' Correspoudenzbl. fiir Schwcizer Aerztc,' 1877, No, 3) for the 
 epidemic at the village of Buus, in Xeuchatel ; and by Schiiller ('Deutsche 
 Zeitschr. fiir Chirurgie,' 1877, viii, p. 501) for the surgical cliniqueat Greifswald.
 
 414 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Frencli and German — has been proved with exactitude by 
 means of the experiments on animals conducted by Orth, 
 Koch, Tillmanns^ and others, and most decisively of all by 
 Fehleisen's inoculation experiments on man with micrococci 
 of pure cultivation.^ We may consider it to be an open 
 question for the present, whence the joarasite comes ; also 
 whether it reproduces itself only within the human body, or 
 whether it grows outside as well, finding in the above- 
 described defects of hygiene a soil specially suited for its 
 reproduction. Again, concerning the factors which deter- 
 mine the type of the disease and the modifications of the 
 same, we are unable by means of the facts known to us to 
 come to any conclusion. In many cases it is unquestionably 
 the individuality of the patient that makes the difference ; 
 but in many other cases, and particularly in epidemic out- 
 breaks of the disease in its malignant form, that explanation 
 does not apply. In these matters we are groping in the 
 same obscurity which enshrouds the causes of mild or severe 
 type in other infective diseases, as I have remarked more 
 particularly when writing of scarlet fever (I, pp. 187 — 192). 
 
 § 158. Point of Oeigin. — Mode op Teansmission. 
 
 The opinions of observers are still divided as to the mode 
 of trans7nission of the disease ; whether an attack of erysipelas 
 presupposes under all circumstances a breach of continuity 
 in the surface of the body, that is to say, whether the only 
 kind of erysipelas is an erysipelas of wounds ; or whether the 
 morbid poison may not be taken up also by the intact skin or 
 mucous membrane. The former of these views is the one 
 that is preferred by the larger number of experienced sur- 
 geons. The infinite difficulty, nay even the impossibility of 
 detecting slight injuries in each particular case, especially in 
 
 1 L. c, p. 9. 
 
 2 ' Wurzb. Verbandl.,' 1. c. Hen- Fehleisen has now (Dec, 1882) made a large 
 number of experiments of that kind, all of tbem with the therapeutical inten- 
 tion of dispelling tumours. The whole of the experiments succeeded, and the 
 erysipelas always ran a perfectly typical course, Tbrough the kindness of Ilerr 
 Fehleisen I have had the opportunity of seeing a successful inoculation experi- 
 ment of his in Herr v. Bergmann's surgical clinique here.
 
 ERYSIPELAS. 415 
 
 the mucous membranes near where they pass into the skin, 
 makes this question one of the most intricate in the natural 
 history of erysipelas, and one that can never be altogether 
 finally settled. For my own part I am constrained by force 
 of recorded observations to give up the distinction which I 
 drew in the first edition of this work, between simple (exan- 
 thematic) erysipelas and malignant (typhoid) erysipelas. 
 There are many clinical observations in favour of the trans- 
 mission of the morbid poison by surgical instruments, 
 bandages or other things used by patients, that is to say, 
 in favour of contagion in the narrower sense of the term. 
 But in the majority of cases, no such means of transmission 
 can be made out ; and one is rather driven to think that 
 the reproduction of the morbid poison really takes place out- 
 side the human body, and that the virus is for the most part 
 carried by currents of air.
 
 CHAPTER XII. 
 
 PUERPERAL FEVER. 
 
 § 159. The Modern Doctrine started by Semmelweiss and 
 
 continued by hiesch. 
 
 The first and most acceptable duty of modern medicine is 
 the prevention of disease; and in practically applying that 
 principle, medicine bas achieved its most brilliant success in 
 regard to the diseased processes incidental to wounds. 
 Evidence of this is afforded, as we have seen, by the good 
 effects of the antiseptic method of dressing wounds in pre- 
 venting traumatic erysipelas. The prophylactic rules directed 
 against the occurrence of hospital gangrene and the so-called 
 septic wound-diseases have proved to be not less beneficial ; 
 and for the puerperal infective diseases, whose admission 
 into the group of traumatic diseases hardly anyone nowadays 
 will object to, the same holds good. 
 
 Rational prophylaxis against a disease must be based upon 
 an acquaintance with and consideration of the causes which 
 underlie it directly or remotely. Setting out from this prin- 
 ciple, and working on the basis of experiences at the lying- 
 in hospital of Vienna in 1847, Semmelweiss developed his 
 doctrine of the prophylaxis of puerperal fever. And although 
 his view of the causative conditions was one-sided, he was 
 still a true pioneer in elaborating the doctrine of the origin 
 and prevention of that disease, and his work was of great 
 service not only to the Vienna lying-in house but to man- 
 kind at large. I take credit to myself for having, in the 
 first edition of this work, stood forward as his exponent and 
 for having directed the attention of the profession in Germany 
 to his writings, which had been little noticed up to that time. 
 My endeavour was to enlarge the doctrine of Semmelweiss
 
 PUERPEEAL EEVEE. 417 
 
 on the genesis of child-bed fever, by means of experiences 
 of the disease collected down to a later date, or to arrive at 
 a more comprehensive view of its etiology ; and I have had 
 the satisfaction of seeing the results of my inquiries received 
 with approval by the first gynaecologists in Germany. I shall 
 thus share with Semmelweiss the credit of being named 
 a founder of the rational doctrine of the origin of puerperal 
 fever. So much the more is it my present duty in this new 
 edition to subject the opinions that I then expressed to a 
 rigorous criticism in the light of knowledge gained in the 
 interval, to turn to account for this particular infective 
 disease the advances which science has made in the depart- 
 ment of infective disease in general, and thus, in adherence 
 to the facts and with as complete a presentation of them as 
 possible, to mark the point which our knowledge of the 
 ways of origin of puerperal fever has now reached, the point 
 from which our practice has to start in framing the phrophyl- 
 actic measures to bo adopted against this disastrous malady. 
 
 § 1 60. PUEEPEEAL FeVEE IN FORMEE TiMES. 
 
 There is no doubt that puerperal infective disease, or — 
 to adopt an equivalent and familiar term for the sake of 
 brevity — puerperal fever has been prevalent in all ages, 
 just as its geographical distribution extends over the whole 
 habitable globe. And as the amount of this sickness varies 
 in different parts of the world, according to the social life 
 and hygienic circumstances of the population, there have 
 probably been corresponding differences in the frequency 
 of the disease in the various epochs through which the human 
 race has passed. The extent of those differences we are 
 certainly unable to estimate, by reason of the scanty notices 
 of the disease which have come down to us from ancient and 
 mediaeval times, and the absence of accurate iuformatiou 
 from the sixteenth and seventeenth centuries. 
 
 In the epidemiological writings of Hippocrates,' there occm' a number 
 of excellently drawn vip clinical histories of puerperal fever, and in the 
 
 ' 'Lib. Epidcraiorum,' i, sect, iii, Aegra Nr. 4, 5, 11, ed. Littre ii, 690, 694, 
 708; 'Epid.,' lib. iii, sect, ii, Aegra 10, 11, 12, c. c. iii, 60—62 ; lib. iii,' sect, iii, 
 Aegra 2, 14, e. c. iii, 108, 140. 
 
 VOL. II. 27
 
 418 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 pseudo-Hippocratic treatise 'De movbis mulierum'' the subject is con- 
 sidered at lengtli. Moreover it follows from the account^ given by Hippo- 
 crates of the diseases among the inhabitants of Thasos that the malady 
 had been common in those days and had occurred in a sort of epidemic. 
 (" yvvaiKtQ C£ tvocrriaav /ttj' TroXXai . . iSvaroKeov ^k TrXtTcrrai, Kal fitra Toilc 
 TOKovQ t7rtv6crtov,ical iOvrjaKov avrai /idXia-ra.") Celsus,^ however, confines 
 himself to one remark, which probably points to puerperal fever 
 (" mulier ex partu si cum febre, vehementibus etiam et assiduis capitis 
 doloribus premitur, in periculo mortis est ") ; and Galen'' contributes 
 nothing of his own, but merely repeats the statements of Hippocrates. 
 Soranus and Moschion, the gynajcologists of the Greek medicine, make 
 no mention whatsoever of the disease ; and Arabian physicians such as 
 Avicenna,^ as well as the physicians of the middle ages, have nothing 
 more to say than that women in childbed sometimes took fever, which 
 led to their death. 
 
 In the medical writers of the sixteenth and seventeenth centuries, such 
 as Trincavella,'' Mercado,' Riviere,^ de la Boe,'' Sennert^" and Sydenham," 
 we find statements about puerperal fever which go rather more into 
 particulars, although they hardly do justice to the properly clinical 
 side of the question. Willis was the first to appreciate correctly the 
 peculiar character of the disease as compared with other febrile pro- 
 cesses ; he introduced the name " febris puerperarum," and undertook 
 a searching inquiry into the beginnings and course of child-bed fever; 
 he even went so far as to connect the origin of the disease with laceration 
 of the uterus during labour and to refer it to a " miasma venenatum."'- 
 After Willis came Strother," Hoffmann," and others. 
 
 Although, as we have said, it is impossible to estimate 
 from tlie professional writings at our service, the extent to 
 which child-bed fever had been prevalent in past times ; yet 
 we are justified by the fact, observed during the present 
 
 ^ Lib. i, § 49 — 54, e. c. viii, io8, seq. 
 * Lib. i, sect, ii, § 8, e. c. ii, 646. 
 ^ ' De met!.,' lil). ii, cnp. 8. 
 
 ■* In the commentaries to tlie above-quoted passages in Hippocrates. 
 ^ ' Canon,' lib. iii, Fen. xxi, tract, ii, cap. 33, Venet., 1564, i, 929. 
 ^ ' De ratione curandi, &c.,' lib. xi, cap. ii, ff. in '0pp.,' Lugd., 1586, 1, 
 291, seq. 
 
 ' ' De mulierum affect.,' lib. iv, cap. x, xi. 
 ^ ' Praxis med.,' lib. ix, Norimb., 16S8, 287. 
 ^ ' Prax. med.,' lib. iii, cap. viii, § 13, seq., Amstel., 1679, 554. 
 ^" ' Pract. med.,' lib. iv, sect, vii, cap. xi, Wittenbg., 1660, 467. 
 " ' Diss, epistol. ad Cole de affect, liyster..' in ' Opp./ Genev., 1736, i, 279. 
 ^* 'De febribus,' cap. xvi, in 'Opp.,' Amstel., 1682, 124. 
 ^^ 'Critical Essay on Fevers,' cap. ix, Lond,, 1718, 212. 
 
 " 'Med. rationalis system,' torn, iv, Pars i, sect, ii, cap. x, in 'Opp,' Genev., 
 1748, ii, 156.
 
 PUERPERAL FEVER. 
 
 419- 
 
 century and tlie preceding, that it clings mostly to lying-in 
 hospitals, in believing that the important place which puer- 
 peral fever now takes in the statistics of sickness and mortality 
 of civilised countries dates no farther back than the end of 
 the seventeenth or beginning of the eighteenth century, or 
 from the period when the first maternity hospitals or other 
 institutions for the reception of the lying-in were established. 
 
 i6i. Present Distribution. 
 
 Regarding the geogra'pliical distrilndion of puerperal fever , 
 the want of information from many parts of the world, 
 particularly those within tropical and subtropical latitudes, 
 does not permit us to do more than conclude generally that 
 the disease extends over the whole habitable globe. For the 
 same reason I am unable to say whether any considerable 
 differences exist in the number of cases at various parts of 
 the world, not including the cases of child-bed fever in lying- 
 in hospitals. As a general rule, child-bed fever would appear 
 to occur most frequently in highly- civilised countries with a 
 crowded population and situated in higher latitudes. With- 
 out attaching too mucb importance to the following statistics 
 of the disease collected from some of the civilised States of 
 Europte, I think they may be used to form an approximate 
 estimate. 
 
 Table of Deaths from Puerperal Fever per 1000 Deliveries} 
 
 Place. 
 
 St. Petersburg 
 
 Sweden 
 
 Norway'' 
 
 Denmark 
 
 England 
 
 England 
 
 Prussia 
 
 Baden 
 
 Belgium 
 
 Geneva 
 
 Genoa , 
 
 Period. 
 
 Deaths per 
 1000. 
 
 Authority. 
 
 1845-59 
 
 7-0 
 
 Hugenberger.'- 
 
 1861-75 
 
 57 
 
 Netzel.2 
 
 1859-68 
 
 57 
 
 Vogt.s 
 
 1866-74 
 
 60 
 
 Weis." 
 
 1818-41 
 1847-50 
 
 8-0 ■) 
 60 i 
 
 d'Espine." 
 
 1816-75 
 
 80 
 
 Boebr.s 
 
 1851-63 
 
 7-6 
 
 Hegar.'^ 
 
 1851-55 
 
 6-0 
 
 d'Espine.^ 
 
 13 years 
 
 80 d'Espine.' 
 
 1857-66 
 
 4'2 Sormani.'" 
 
 ^ For footnotes see bottom of next page.
 
 420 GEOGEAPHICAL AND HISTORICAL TATHOLOGY. 
 
 For Turhey, and foi* Constantinople in particular, Eiglei'^ 
 says tliat, although tlie absence of lying-in hospitals makes 
 child-bed fever rarer than in most other cities of Europe, 
 yet the disease does occur from time to time. Also the 
 most northern countries of Europe are by no means exempt 
 from it. In Iceland it is not so very rarely met with/ cases 
 occurring from time to time even in large numbers, as in 
 1842 and 1845, The same holds good for Greenland, where 
 groups of puerperal fever cases occur, at all events now and 
 then, as in 1844 and 1847.^ In the cultivated parts of 
 North America it is just as extensive as on European soil. 
 It is of interest to notice the remark of a United States 
 authority,* on the occurrence of puerperal fever in that country, 
 in a criticism of the gynaecological work of Lee (1835) : 
 " In this country we have fortunately had but little experience 
 of the alarmingly fatal epidemics that have spread their 
 devastating influence over different sections of Great Britain;" 
 and Hildreth,^ writing from Washington, Ohio, in 1830, says, 
 " Puerperal fevers are much less common than in more 
 populous places." From Central America and the West 
 Indies our information about child-bed fever is meagre, but 
 it serves to prove that the disease is no stranger to these 
 countries. For the Continent of Africa, I have found only 
 one notice, by Pruner,^ according to which puerperal fever 
 in Egypt is neither so common nor so general as in Europe, 
 
 ' ' Die Tiirkei nnd deren Bewohncr, &c.,' Wien, 1850, ii, 338. 
 ^ Sehleisnor, 'Island iindersop;t, &c.,' Kjobenli., 1849, 5°- 
 
 * Account in ' Sundhedskoll. Forhdl. for Aaret 1844,' 57 ; Lange, ' Bemaerkn. 
 cm Qronlands Sygdomsforliold.,' Kjobenli., 1864, 40. 
 
 •* • Amer. Journ. of Med. Sc.,' 1835, ^6^-> 4.^9* 
 
 * lb., 1830, Feb., 300. 
 
 ^ ' Krankheiten dcs Orients,' Erlang., 1847, 278. 
 
 ^ The death-rate among women delivered in private houses. 
 
 ^ See the list of authors at the end of the chapter. 
 
 ■' 'Hygiea,' 1879, xli, i77- 
 
 "* Including those who died in Maternity hospitals. 
 
 *• 'Norsk. Mag. for Laegevidensk,' 1872, iii, Raekke ii, 414. 
 
 * ' Hygien. Meddelelser,' 1875, Nye 11., i, 124. 
 ' 'Gaz. des hopit.,' 1858, Nr. 54, 213. 
 
 * ' Zeitschr. fiir Geburtsh. nnd Gyniikol.,' iii, 81. 
 
 ^ 'Die Sterblichkeit wiihrcud der Schwangerschaft, &c.,' Freiburg, 1868, 25, 
 '" ' Geogr. nosol. dell' Italia,' Roma, 1881, 176.
 
 PUERPEEAL FEVER, 421 
 
 althougli it has sometimes been met with to a more consider- 
 able extent, as, for example, in 1844, when a ''puerperal 
 influence " is said to have reached from Alexandria to the 
 Thebaid. In Port Said, as Vauvray^ tells us, it is almost 
 unknown. In India, according to Webb^ and Twining,^ 
 child- bed fever is by no means rare among the Hindu women, 
 -and it is sometimes prevalent to a considerable extent. The 
 observations of Baelz* leave no doubt of the occurrence of 
 the disease in Japau, even if it be only in isolated cases. 
 On the Australian Continent^ and in New Zealand^ puerperal 
 fever would appear to have been very rare down to about 
 the middle of the present century ; but I have no more 
 recent information of the disease in those colonies. In 
 Tasmania it Avas first seen, so far as Dempster^ knew, in the 
 autumn of 1833 in the district of Norfolk, several women 
 having taken it together. According to later accounts by 
 Hall and Miller,^ child-bed fever is far from uncommon 
 there, whether in the lying-in hospital (where it was epidemic 
 in 1851—52) or among* women confined in their own homes. 
 The only notice for 8011th America that I know of is one by 
 Feris,^° according to which the disease was disastrously 
 prevalent at Monte Video in 1875. 
 
 § 162. EriDEMic Outbreaks. 
 
 Although our information on the geographical distribution 
 of puerperal fever is very incomplete, and the statistical 
 returns of the disease among the populations of the 
 various parts of the world are below the real total ; yet 
 
 ^ ' Arch, de med. nuv.,' 1873, Sept., 188. 
 ■•^ ' Patbologia Iiidica/ Lond., 1848,336. 
 
 ^ ' Clinical Illustrations of the more important Diseases of Bengal,' Calcutta, 
 1835, i>» 433- 
 * ' Intectionskrankheiten in Japan,' Yokohama, 1882, 5. 
 ^ Account iu ' Lancet,' 1845, Sept., 321. 
 6 Thomson, ' Brit, and Foreign Med.-Chir. Rev.,' 1854, Oct. 
 ' ' Transact, of the Calcutta Med. 80c.,' 1836, vii, 358. 
 ^ 'Transact, of the Epidemiol. Soc.,' 1866, ii, 69. 
 3 • Glasgow Med. Journ.,' 1878, Aug., 345. 
 '" 'Arch, de mcd. nav.,' 1879, Oct., 253.
 
 422 
 
 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 it is an undoubted fact that the disease has been infinitely 
 more common, whether in sporadic cases, or in epidemics 
 and endemics, within maternity hospitals or in the lying-in 
 departments of general hospitals than outside them, that is 
 to say, than among women confined at their own dwellings. 
 At the same time it is not altogether rare for child-bed fever 
 to be prevalent to a very considerable extent among the 
 latter ; and sometimes it even takes the character of an 
 epidemic. 
 
 In the following table I have put together, in chronological 
 order, a list of the epidemics of puerperal fever that have 
 come to my knowledge. Although I am far from claiming 
 it to be a complete list of all the observations on record, yet 
 it will suffice to bring out several points of interest for the 
 history of the disease and for the study of its etiology. 
 
 Table of Epidemics of Fuerpcral Fever. 
 
 Time. 
 
 1664 
 
 • • • 
 
 1672 
 
 • • • 
 
 I7I3 
 
 • ■ • 
 
 1723 
 
 1736-37 
 1746 
 
 winter 
 Jan. — Marcli 
 
 1750 
 
 1760 
 I76I 
 
 Spring 
 July — Dec. 
 
 May — July 
 
 1765-66 
 
 ... 
 
 >J 
 
 
 >> 
 
 
 1767 
 
 99 
 
 
 9i 
 
 Dec. — May 
 
 Paris 
 
 Copenhagen . 
 Rouen, Caen. 
 FrankftonM. 
 
 Paris 
 
 Paris 
 
 Lyons 
 
 London .. 
 Aberdeen 
 London .. 
 
 Copenhagen 
 Rotterdam... 
 Derbyshire.. 
 
 Groningen . . . 
 
 Heugon 
 
 (Normandy) 
 Dublin 
 
 Authority. 
 
 Obstetric wards of the 
 Hotel Dieu Peu.i 
 
 In the town ^ Bartholin. 
 
 Ditto de la Motte. 
 
 Ditto Hoffmann. 
 
 Ditto Fodere. 
 
 Hotel Dieu and in the 
 town ,.. Malouin. 
 
 Hotel Dieu Pouteau. 
 
 British Lying-in Hosp. Leake. 
 ^ Mackintosh. 
 
 In a small private 
 
 Lying-in Hosp White, 
 
 Lying-m Hosp Saxtorph. 
 
 In the town Bikker. 
 
 In various parts of the 
 county in this andi 
 following years Butter. 
 
 Vicinity of the town... v. Doveren. 
 
 In the parish Lepecq de la 
 
 I Cloture. 
 
 Rotunda 'Jos. Clarke. 
 
 ^ The authorities named in this column are given in alphabetical order at the 
 end of the chapter. 
 
 " In the town " means that the disease occurred outside the lying-in hospitaL
 
 PUERPEEAL PEVEK. 
 
 423 
 
 Time. 
 
 Place. 
 
 Area of diffusion. 
 
 Authority. 
 
 1 769-70 
 
 Nov. — May 
 Autumn 
 
 Feb. and fol. 
 months 
 Winter 
 
 March — May 
 
 Summer 
 
 Summer 
 Jan. — March 
 
 February 
 Sept. — Nov. 
 Nov. — Jan. 
 Jan. and fol. 
 
 months 
 Dec — March 
 
 Sept.— Dec. 
 
 Sept. — July 
 
 Spring and 
 
 Summer 
 
 Mar. — April 
 
 July — Jan. 
 
 Nov. — Jan. 
 Dec— Oct. 
 
 Oct. — April 
 Dec. — May 
 
 London 
 
 Vienna 
 
 Rotterdam . . . 
 London 
 
 Edinburgh... 
 
 Paris 
 
 Dublin 
 
 Stockholm ... 
 Vienna 
 
 Copenhagen . 
 
 Berlin 
 
 Westminster, British, 
 and other Lying- 
 in Hosps.; also in 
 the town 
 
 / Leake, 
 
 C White. 
 
 1770 
 
 St. Marx Lying-in 
 Hosp 
 
 Fauken. 
 
 
 In the town 
 
 Bikker. 
 
 1771 
 
 In several Lying-in 
 Hosps 
 
 White. 
 
 1772 
 
 Obsteti-ic wards of the 
 Infirmary 
 
 7 Young, 
 j Clarke. 
 
 1774-75 
 
 1774 
 1777 
 
 j» 
 
 1778 
 
 Hotel Dieu, and many 
 
 cases in the town . . . 
 
 Rotunda 
 
 Lying-in Hosp.^ 
 
 Obstetric wards of the 
 
 General Hosp 
 
 Lying-in Hosp. ; also a 
 
 few cases in the town 
 
 Cases in the town 
 
 Hotel Dieu ; also a few 
 
 cases in the town . . . 
 
 Cases in the town 
 
 Lving-in Hosp 
 
 Ref. I. 
 Jos. Clarke. 
 Netzel. 
 
 Stoll. 
 
 Saxtorph. 
 Selle. 
 
 
 Paris 
 
 
 1780 
 1781 
 1781-82 
 1782 
 
 1783-84 
 
 Bei'lin 
 
 Geoffroy. 
 Selle. 
 
 Cassel 
 
 Osiander. 
 
 Paris 
 
 Hopital Vaugirard ... 
 Lying-in Hosp. ; also 
 
 cases in the town . . . 
 Many cases in town 
 
 and vicinity 
 
 Doublet. 
 
 Copenhagen . 
 
 Gladenbach . 
 (Giessen) 
 Copenhagen. 
 
 Arzago 
 
 (Lombardy) 
 Poitiers 
 
 Dublin 
 
 London 
 
 Dublin 
 
 Aberdeen . . . 
 
 Copenhagen . 
 
 Vienna 
 
 Stockholm . . . 
 
 Tode. 
 Diel. 
 
 1786 
 1786-87 
 
 Lying-in Hosp 
 
 Bang, 
 
 Widely prevalent in 
 the village ... 
 
 Salomonsen. 
 Cerri. 
 
 1787 
 
 Many cases in the 
 town 
 
 Lamarque. 
 
 
 Rotunda 
 
 Jos. Clarke. 
 
 1787-88 
 
 1788-89 
 1789-92 
 
 In a Lying-in Hosp. ; 
 
 also cases in the town 
 
 Rotunda 
 
 John Clarke. 
 Jos. Clarke. 
 
 Lying-in Hosp. ; ahso 
 many cases in the 
 new town 
 
 Gordon. 
 
 1791-92 
 
 1792-93 
 1793 
 
 Lying-in Hosp. ; a few 
 
 cases in the town . . . 
 
 Lying-in Hosp 
 
 7 Boysen 
 3 Rinck. 
 Ficker. 
 
 
 Netzel. 
 
 Amsterdam . 
 Rouen 
 
 Lying-in Hosp 
 
 Thijssen. 
 Leroy- 
 
 1793 
 
 Hospice de L'humanite 
 
 
 
 1 In using Netzcl's Ecports on Child-bed Fever in the Lying-in Hospital of 
 Stockholm from 1755 to 1877, 1 have taken all those years iu which the mor- 
 talit.y was more than 6 per cent, of the women confined.
 
 424 
 
 GEOrxRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Time. 
 
 Place. 
 
 Area of diffasion. 
 
 Authority. 
 
 1794 
 1795-96 
 
 1798 
 
 Autumn and 
 
 Winter 
 Mar.— April 
 
 Winter 
 Dec— Feb. 
 
 Aug. — Sept. 
 
 Jan. — May 
 Winter 
 
 Summer and 
 
 Autumn 
 June — April 
 
 Jan. and fol. 
 months 
 
 Winter 
 Jan. — Dec. 
 
 July — June 
 
 Spring 
 Winter 
 
 Summer 
 
 Autumn 
 
 Sept. — Dec. 
 Oct. — Aug. 
 
 Oct.— March 
 
 Stockholm ... 
 
 
 Netzel. 
 
 Vienna 
 
 Creteil 
 
 (Dpt. Seine) 
 
 Grenoble . . . 
 
 Trier 
 
 Lying-in Hosp 
 
 Jaesrer. 
 
 Many cases in the 
 villasre 
 
 Nebel. 
 Ref. II. 
 
 1799] 
 18003 
 1801-2 
 
 Many cases in the town 
 
 Many cases in town 
 and vicinity 
 
 Ref . III. 
 
 
 Dublin 
 
 Rostock 
 
 Yorkshire ... 
 Milan 
 
 Burckhardt. 
 
 1S03 
 
 Rotunda 
 
 Douglas. 
 
 1805 
 
 Several cases in town 
 and vicinity 
 
 Nolde. 
 
 I 80S- I 2 
 
 At Barnsley, Leeds. 
 Huddersfield, and 
 other towns 
 
 ]Hey, 
 f Bradley. 
 
 1810 
 
 Santa Catarina Lying- 
 in Hosp 
 
 Several cases in the 
 town and vicinity . . . 
 
 Rotunda 
 
 
 1810-I1 
 
 Landsberg . . . 
 
 Dublin 
 
 Stockholm ... 
 London 
 
 Heidelberg. . . 
 
 London 
 
 Durham 
 
 Dublin 
 
 Northumber- 
 land 
 
 Abingdon ... 
 (Berkshire) 
 
 Prague 
 
 Edinburgh... 
 
 Dublin 
 
 Philadelphia 
 Wiirzbui'g . . . 
 
 Stockholm ... 
 London 
 
 Lyons 
 
 Ozanam. 
 
 Punch. 
 Douglas. 
 
 1811 
 
 5J 
 
 Lying-in Hosp 
 
 Many cases in the 
 vicinity 
 
 Netzel. 
 Ramsbotham 
 
 I8II-I2 
 I8I2 
 >» 
 
 Lying-in Hosp. ; occa- 
 sional cases in town 
 
 Many cases at Hollo- 
 way & other suburbs 
 
 Numerous cases at 
 vaxious localities in 
 the county 
 
 ■) Njigele, 
 3 Bayrhofer. 
 
 Dunn. 
 
 Armstrong. 
 ■) Douglas, 
 3 Brenan. 
 
 Armstrong. 
 
 I8I2-I3 
 I8I3 
 
 Rotunda ; occasional 
 cases in the town . . . 
 
 At Sunderland, Aln- 
 wick, Newcastle, and 
 other places 
 
 I8I3-I4 
 
 In the town and neigh- 
 bourhood 
 
 West. 
 
 I8I4 
 
 Lyinsr-in Hosp 
 
 Quadrat. 
 Cardiff. 
 
 1814-15 
 
 Matei-nity ■ a few cases 
 in the town 
 
 I815 
 
 Rotunda 
 
 
 1816-17 
 I817 
 
 Pennsylvania Hosp. ... 
 Lyiner-in Hosp 
 
 Hodge. 
 d'Outrepont, 
 
 Netzel. 
 
 J» 
 
 Ditto 
 
 I818 
 
 In a Lying-in Hosp., 
 and some cases in 
 the town 
 
 Armstrong. 
 
 •J 
 
 Lyingj-in Hosp 
 
 Cliet. 
 
 I818-I9 
 
 Prague 
 
 Wurzburg . . . 
 
 Ditto, and many cases 
 in the town 
 
 Bischoff. 
 
 J> 
 
 Lyinff-in Hosp 
 
 d'Outrepont, 
 
 i,n. 
 

 
 PUERPERAL PEVilE. 
 
 425 
 
 Time. 
 
 iSiy 
 
 1819-20 
 
 May — July- 
 July — Nov. 
 
 Dec. — March 
 
 Winter 
 
 Dec. — Aug. 
 Oct. — Jan. 
 
 Place. 
 
 Stockholm , 
 
 Lyons 
 
 Vienna . . . , 
 
 Glassrow , 
 
 Wiirzbm-g 
 
 Area of dltfusioc. 
 
 Lying-in Hosp 
 
 Ditto 
 
 Ditto, and a few cases 
 in the town and sub- 
 urbs 
 
 Many cases in certain 
 suburbs 
 
 Lying-in Hosp 
 
 Stockholm . . . Ditto 
 
 Kiel 
 
 Dresden , 
 Bavaria , 
 
 1821 
 1821-22 
 
 1822-23 
 
 >> 
 1823 
 
 1824 
 
 1S24-25 
 1825 
 
 Winter 
 
 Spring and 
 
 Summer 
 March 21 — 
 
 Sept. 22 
 
 Winter 
 January 
 
 Winter 
 Jan. — May 
 Nov. — Jan. 
 Jan. — April 
 
 Dublin 
 
 Lyons 
 
 Scotland . 
 
 Marburg. 
 Vienna . 
 London . 
 
 Dublin . 
 London . 
 Dresden . 
 Munich . 
 Berlin . . . . 
 
 Ditto 
 
 Ditto 
 
 At Bamberg, in the 
 Lying-in Hosp., and 
 subsequently many 
 cases in the town 
 numerous cases at 
 Ansbach, Niiruberg, 
 and Dillingen 
 
 In the Lying-in Hosp. 
 
 Charite 
 
 Authority. 
 
 Net'/el. 
 Cliet. 
 
 Ref. IV. 
 
 Burns. 
 d'Outrepont, 
 
 I-III, 
 Schloss. 
 Caderschjold, 
 
 I. 
 Michaelis. 
 Oarus, I. 
 
 1- 
 
 Pfeufer, 
 Schilling. 
 
 1825-26 Winter 
 
 Nov. and fol 
 months 
 
 1826 
 
 Jan. — June 
 
 London 
 
 Hanover 
 
 Prague 
 
 Edinburgh. . . 
 Stockholm... 
 
 Nastiitten ... 
 
 (Nassau) 
 Stockholm... 
 
 Berlin 
 
 Dublin 
 
 Paris 
 
 Many cases at Edin- 
 burgh, Glasgow, Stir- 
 ling and other places 
 
 Lying-in Hosp 
 
 Ditto 
 
 Queen Charlotte's Ly 
 ing-in Hosp 
 
 Rotuuda 
 
 In a Lying-in Hosp... 
 
 Lying-in Hosp 
 
 Ditto 
 
 Ditto, and many cases 
 in the town 
 
 In a Lyiiig-in Hosp.. 
 
 Lying-in Hosp 
 
 Ditto 
 
 Maternity Hosp 
 
 Lying-in Hosp 
 
 Birmingham 
 
 Widely spread in the 
 locality 
 
 Lying-in Hosjd 
 
 Charite 
 
 Rotunda 
 
 Hotel Dieu 
 
 Lying-in Hosp. ; a few 
 cases in the town ... 
 
 Douglas, 
 
 Collins. 
 
 Baudelocque. 
 
 ! Campbell, 
 Mackintosh 
 
 Busch. 
 Lippich. 
 
 Ferguson. 
 Collins. 
 Gooch. 
 Carus, II. 
 Graf. 
 
 Siebold. 
 Ferguson. 
 Dommes. 
 Quadrat. 
 Sidey. 
 
 Caderschjold, 
 II. 
 
 Ricker. 
 
 Netzel. 
 
 Neumann. 
 
 Collins. 
 
 Baudelocque. 
 
 Ingleby.
 
 426 
 
 GEOGEAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Time. 
 
 Place. 
 
 Area of diffusion. 
 
 Authority. 
 
 1827 
 1827-28 
 
 April — May 
 Nov. — Jan. 
 
 Autumn and 
 Winter 
 
 Feb. — Aug. 
 Whole year 
 
 Winter 
 
 April — June 
 
 Summer of 
 
 1830 to 
 Autm.ofi83i 
 
 Dec. — March 
 
 Winter and 
 Spring 
 
 Autumn 
 
 Aug.' — Dec. 
 
 Winter 
 April — June 
 
 Aug. — Sept. 
 
 Autumn 
 
 Feb. — March 
 
 Oct., 1833- 
 May, 1835 
 
 Jan. — May 
 
 Barmen 
 
 Neuenhaus... 
 (Bentheim) 
 
 Dublin 
 
 London 
 
 Amsterdam . 
 
 Vienna 
 
 Hanover 
 
 Dublin 
 
 Copenhagen . 
 Paris 
 
 Many cases in the town 
 
 Many cases in town 
 
 and vicinity 
 
 Sonderland. 
 
 Miquel. 
 Collins. 
 
 1828 
 
 Rotunda 
 
 1S28-29 
 
 Westminster Lying-in 
 Hosp. ; many cases 
 in the town 
 
 ^ Hingeston, 
 >• Gooch, 
 ) Ferguson. 
 Tilanus. 
 
 
 Lying-in Hosp 
 
 1829 
 
 Ditto 
 
 
 Ditto 
 
 Dommes. 
 
 
 Rotunda 
 
 Collins. 
 
 
 Lying-in Hosp 
 
 Kayser. 
 Tonnelle, 
 
 
 La Maternite 
 
 1830 
 
 Toulouse 
 
 Prague 
 
 Dresden 
 
 Kiel 
 
 Many cases in the town 
 Lvingr-in Hosp 
 
 Duplay. 
 Brun. 
 Quadrat. 
 Haase, I. 
 
 
 Ditto 
 
 
 Ditto 
 
 Michaelis. 
 
 1830-31 
 
 Giessen 
 
 Paris 
 
 Ditto 
 
 Ritgen. 
 Cruveilhier 
 
 La Maternite 
 
 1831 
 
 Manchester . 
 
 Philadelphia 
 
 Usingen 
 
 (Nassau) 
 Stockholm . . . 
 Aylesbury ... 
 Plymouth ... 
 Paris 
 
 Lying-in Hosp. ; many 
 cases in the town . . . 
 
 Pennsylvania Hosp.... 
 
 Many cases in the 
 village 
 
 Nonat. 
 
 Robertson. 
 Hodge, 
 
 Ricker. 
 
 
 Lying-in Hosp 
 
 Netzel. 
 
 J1 
 
 Many cases in the town 
 Ditto 
 
 Oeely. 
 Blackmore. 
 
 
 Hotel Dieu and Mater- 
 nite 
 
 
 
 Munich 
 
 Bonn 
 
 Nonat. 
 
 1832 
 
 Lyinsr-in Hosp 
 
 Martin, I. 
 
 Many cases in Lying- 
 in Hosp. and in the 
 town 
 
 
 
 Usingen 
 
 Vienna 
 
 Birmingham 
 
 Edinburgh... 
 
 Philadelphia 
 
 Prague 
 
 Gratz 
 
 Levin. 
 
 1833 
 
 Many cases in village 
 (2nd time) 
 
 Ricker. 
 
 
 Lying-in Hosp 
 
 
 »> 
 
 Ditto; some cases in 
 the town 
 
 ■) Ingleby, 
 5 Elkington. 
 
 Patterson. 
 
 »i 
 
 Numerous cases in the 
 town 
 
 it 
 
 1833-35 
 1834 
 
 Pennsylvania Hosp.... 
 Lying-in Hosp 
 
 Hodge. 
 
 Quadrat. 
 
 Scholler. 
 
 Ditto 
 
 
 Vienna 
 
 Ditto 
 
 Bartsch, 
 
 
 
 Martin, II.
 
 PUERPERAL FEVER, 
 
 427 
 
 Time. 
 
 1834 
 
 1834- 
 1835 
 
 35 
 
 1835 
 1836 
 
 1837 
 
 1837- 
 1838 
 
 -36 
 
 38 
 
 183S 
 1839 
 
 -39 
 
 1839-40 
 
 1840 
 
 1840- 
 1841 
 
 41 
 
 Autumn 
 
 Jan. — Marcb 
 
 Sept.— Mar. 
 
 Mar.— Ai:)ril 
 Autumn 
 
 Winter 
 Spring 
 
 Winter and 
 
 Spring 
 Jan. — Feb. 
 
 January 
 
 Feb.— May 
 
 March— May 
 
 Dec. — April 
 
 Jan. — May 
 
 Autumn 
 
 Mar. — Aug. 
 
 Nov. — July 
 
 Jan.— March 
 
 May — July 
 
 Oct. — Jan. 
 
 Oct.— Dec. 
 
 Nov. — Dec. 
 
 Spring 
 
 Sept. — Mar. 
 
 Dec— Mar. 
 
 Jan. — March 
 March 
 
 Pliice. 
 
 Dublin 
 
 Paris 
 
 Trarbach . . . 
 
 (Coblenz) 
 Bamberg . . . 
 
 Kiel 
 
 Paimbceuf ... 
 (Loire infer.) 
 
 Hanover 
 
 Wiirzburg ... 
 
 Kiel 
 
 Hadamar . . . 
 (Nassau) 
 Vienna 
 
 Dublin ...") 
 Dublin ...3 
 
 Dresden 
 
 Copenhagen . 
 
 Greifswald... 
 
 London 
 
 Dresden 
 
 Paris 
 
 Prague 
 
 Dresden 
 
 Wangen 
 
 Copenhagen . 
 
 Diilmen 
 
 (Coesfeld) 
 Stockholm ... 
 
 Paris 
 
 Prague 
 
 Berlin J 
 
 Halle 
 
 Stockholm ... 
 Doncaster ... 
 Paris 
 
 Area of diffusion. 
 
 New Rotunda, follow- 
 ing a few cases in 
 other lying-in houses 
 and in the town 
 
 La Maternite 
 
 Many cases in the town 
 
 Authority. 
 
 Lying-in Hosp., and in 
 the town 
 
 Ditto, ditto 
 
 Many cases in the ar- 
 rondissement 
 
 Lying-in Hosp 
 
 Ditto, and in the town 
 
 Lying-in Hosp 
 
 Small epidemic in the 
 
 place 
 
 Lying-in Hosp 
 
 New Rotunda 
 
 Lying-in Hosp 
 
 Ditto ; also some cases 
 
 in the town 
 
 Ditto, ditto 
 
 In a Lying-in Hosp.... 
 
 Lying-in Hosp 
 
 Clinique 
 
 Lying-in Hosp 
 
 Ditto 
 
 All the women confined 
 
 during tliat period . 
 
 Lying-iu Hosp 
 
 'Many cases 
 parish 
 
 in the 
 
 Lying-in Hosp. 
 
 Hotel Dieu 
 
 Lying-in Hosp. 
 
 Charite ; also many 
 cases in the town ... 
 
 Lying-in Hosp , 
 
 Ditto 
 
 Many cases in the town 
 Maternite andClinique 
 
 Beatty, I. 
 
 Tanchou. 
 
 Graff. 
 
 Rapp. 
 
 Michaelis. 
 
 Aubinais. 
 Dommes. 
 d'Outrepont, 
 IV. 
 
 Michaelis. 
 
 Ricker. 
 
 Hauner, 
 
 Helm. 
 
 Beatty, II. 
 
 Haase, II. 
 7 Midler, 
 5 Ref. V. 
 Berndt. 
 Ferguson. 
 Haase, II. 
 Dubois, I, 
 Voillemier. 
 Jungmann,I. 
 Haase, III. 
 
 Zengerle. 
 
 Kayser, 
 
 Miiller. 
 
 Ref. VI. 
 
 Elliot, 
 Netzel. 
 Bourdon. 
 Jungmaun, 
 II. 
 
 r Schonlein, 
 
 \ Jonas, 
 
 1 de Lingen, 
 
 V.Diemer. 
 Litzmann. 
 [Netzel. 
 Storrs. 
 Dubois, II, 
 Ref. VII.
 
 428 
 
 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 
 Time. 
 
 Place. 
 
 Area of diffusion. 
 
 Authority. 
 
 1841-42 
 1842 
 
 Dec — May 
 
 Jan. — March 
 
 Mar. — April 
 Feb. — May 
 Jan. — Dec. 
 Feb. — June 
 
 Spring and 
 Summer 
 
 Jan. — April 
 Aug.— Dec. 
 
 Sept. — Nov. 
 
 Spring 
 July— Oct. 
 
 Sept. — Nov. 
 Feb. — June 
 
 Nov. — Dec. 
 Summer 
 
 Winter 
 March 
 
 Winter 
 
 99 
 
 Spring 
 July 
 
 Nov.— Feb. 
 Dec. and fol. 
 
 months 
 Dec. — March 
 
 Millersburgh 
 (Ohio) 
 
 Peitz 
 
 Lying-in House; after- 
 wards many cases in 
 the town .. 
 
 Numerous cases in the 
 town 
 
 Bowen. 
 
 Philadelphia 
 Paris 
 
 Schlesier. 
 
 
 Lying-in Hosp 
 
 Wilson. 
 
 
 La Maternite 
 
 Ref. VIII. 
 
 
 Gratz 
 
 Lvingr-in Hosp 
 
 Gotz. 
 
 
 Rennes 
 
 Rouen 
 
 Hotel Dieu 
 
 Botrel. 
 
 1843 
 
 ?» 
 3J 
 
 Lving'-in Hosn 
 
 Hervieux. 
 
 Dorpat 
 
 Paris \ 
 
 Paris 1 
 
 Stockholm... 
 Rouen 
 
 Ditto ; also several 
 cases in the town . . . 
 
 In all the Lying-in 
 Hospitals, and many 
 cases in the town as 
 well 
 
 Koch. 
 
 / Bouchut, 
 t Bidault. 
 
 1844 
 
 Lying-in Hosp 
 
 Netzel. 
 
 Ditto 
 
 Hervieux. 
 
 
 Paris 
 
 Ditto 
 
 Bouchut, 
 
 
 Rennes 
 
 Girrcsheini . . 
 
 (near Diis- 
 
 seldorf) 
 Copenhagen . 
 
 Hads-Herred 
 (Aarhuus, 
 Jutland) 
 
 Aalborg 
 
 .lacobshavn . 
 (N. Green- 
 land) 
 
 Lyons 
 
 Hotel Dieu 
 
 Bidault. 
 Botrel. 
 
 
 In the villasre 
 
 Scheider. 
 
 
 Lying-in Hosp 
 
 Kayser, 
 Ref. IX. 
 Schiiifer, 
 Jespersen. 
 
 Spcyer. 
 
 Kayser, II. 
 
 Yernay. 
 
 McClintock,I 
 
 Hervieux. 
 
 39 
 )9 
 
 Throughout the parish 
 
 Many cases in the town 
 
 Small epidemic in the 
 
 settlement 
 
 1844-45 
 1845 
 
 Lying-in Hosp 
 
 Dublin 
 
 Rouen 
 
 Rotunda 
 
 Lying-in Hosp 
 
 1845-46 
 
 Paris 
 
 Chiefly in Hotel Dieu 
 and Charite ; also in 
 Hopital St.Louis and 
 La Pitie, and many 
 cases in the town . . . 
 
 Lying-in Hosp 
 
 
 Lyons 
 
 Ref. XII. 
 
 Yernay. 
 
 Netzel. 
 
 1846 
 
 Stockholm . . . 
 
 Vienna 
 
 Rouen 
 
 Ditto 
 
 
 Ditto 
 
 
 
 Ditto 
 
 
 
 St.Petersbrg. 
 Groningen . . . 
 
 Wlirzburg ... 
 Toulouse 
 
 Berlin 
 
 Obstetric Institute ... 
 Lying-in Hosp 
 
 Hugenberger 
 Baart de la 
 
 1846-47 
 
 Ditto 
 
 Faille. 
 Heymer. 
 
 d'Orbcastle. 
 
 99 
 
 Ditto, and in Hotel 
 Dieu 
 
 99 
 
 Charite 
 
 Yirchow, I. 
 
 
 

 
 
 
 PUEEPEIIAL FEVER. 
 
 429 
 
 Time. 
 
 Place. 
 
 Area of difEusion. 
 
 Authority. 
 
 1847 
 
 April 
 
 Spring and 
 Autumn 
 December 
 
 Sept. — June 
 
 March 
 
 Spring 
 
 Nov.— Feb. 
 
 Oct. and fol. 
 months 
 
 July — Sept. 
 
 Sept. — Jan. 
 
 Dec— May 
 
 Spring 
 Winter 
 Feb, and fol. 
 months 
 Winter 
 
 Autumn 
 
 Feb. — April 
 
 July — Sept. 
 
 June — May 
 
 Dec— Feb. 
 
 Nov.— May 
 Feb.— March 
 
 Stuttgart . . . 
 Ohio 
 
 Lvinsr-in Hosn 
 
 Elsfissei", I. 
 
 Numerous cases in 
 many parts of the 
 State 
 
 
 
 Kiel 
 
 Holston. 
 
 1848 
 1849 
 
 Lying-in Hosp 
 
 Michaelis. 
 
 St.Petersbrg. 
 
 Bornholm ... 
 
 Stockholm . . . 
 Bern 
 
 Obstetric Institute ... 
 
 Many cases through- 
 out the population. . . 
 Lvinfi:-in Hosp 
 
 Hugenberger 
 
 Ref. X. 
 Netzel. 
 
 Ditto 
 
 Herrmann. 
 
 1849-50 
 
 Stuttgart . . . 
 
 Tiibingen .., 
 Copeniaagen . 
 Stockholm ... 
 Reze 
 
 Ditto ; also many cases 
 in the town, and in 
 other parts of Wiir- 
 tembersr 
 
 Elsasser, II.. 
 
 1849-50 
 1850 
 
 Lying-in Hosp 
 
 Reuss. 
 
 Many cases in the town 
 Lvine-in Hosp 
 
 Hassing. 
 Netzel. 
 
 
 In the village 
 
 Galicier. 
 
 1850-51 
 
 (Loire infer.) 
 New York . . . 
 
 Stockholm... 
 
 Christiania . 
 
 Bordeaux ... 
 Pennsylvania 
 
 Brakel 
 
 (Minden) 
 Tasmania ... 
 Leer 
 
 Maternity attached to 
 the Coloured Home 
 Hosp 
 
 Parkins. 
 
 1 85 1 
 
 Gen. Lying-in Hosp... 
 
 Ditto ; also a few cases 
 in the town 
 
 Retzius, L- 
 
 Faye. 
 Burguet. 
 
 / Leasure^ 
 C Ref. XI. 
 
 1851-52 
 
 Many cases in the town 
 
 Numerous cases in 
 
 many parts of the 
 
 State 
 
 J9 
 
 Many cases in the town 
 Lying-in Hosp 
 
 Disse, 
 Hall. 
 
 
 In the village and 
 
 country around 
 
 Clinique 
 
 
 1852 
 
 1852-53 
 1853 
 
 (Hanover) 
 Paris 
 
 Kirchhoff. 
 Dubois, III. 
 
 St.Petersbrg. 
 St.Petersbrg. 
 Groningen . . . 
 
 Berlin 
 
 [ Obstetric Institute . 
 Lying-in Hosp 
 
 Hugenberger 
 Baart de la 
 
 Obstet. division of the 
 Charite 
 
 Faille. 
 
 
 Paris 
 
 Crede. 
 
 1854 
 >> 
 
 1854-55 
 
 185.5-56 
 1856 
 
 La Maternite 
 
 Charrier. 
 
 Munich 
 
 St.Petersbrg 
 
 Dunkirk 
 
 Dublin 
 
 St.Petersbrg 
 Middleburg 
 
 Many cases in the town 
 Obstetric Institute ... 
 Many cases in the town 
 Rotunda ; also some 
 cases in the town ... 
 Obstetric Institute . . . 
 In the town, and at 
 other places in Zee- 
 land 
 
 Berliner. ""^ 
 Hugenberger 
 Zandyk. 
 7 McClin- 
 5 tock, IL 
 Hugenberger 
 
 Doornick.
 
 430 
 
 GEOGRAPHICAL AND HISTOEICAL PATHOLOGV 
 
 Time. 
 
 Place. 
 
 Area of diffusion. 
 
 Authority. 
 
 1856 
 1856-57 
 
 Dec. — June 
 
 Nov. — March 
 
 Mar. — April 
 
 Winter 
 
 Whole year 
 
 March — May 
 
 Autumn and 
 
 Winter 
 
 June — Dec. 
 
 May — June 
 
 Nov. — Mar. 
 
 Feb.— April 
 
 July — Nov. 
 February 
 
 Winter 
 
 Aug. — Jan. 
 Jan. — June 
 
 )j 
 
 Winter 
 
 Jail. — Sept. 
 
 Jan.— Feb. 
 
 Winter 
 
 Oct. — Aug. 
 Winter 
 
 Oct.— Feb. 
 
 Paris 
 
 Clinique 
 
 Dubois, III, 
 
 Munich 
 
 Strasburg ... 
 
 Prague 
 
 Berlin 
 
 New Lying-in Hosp. ; 
 subsequently in other 
 Lying-in Hosp., and 
 many cases in town 
 and vicinity 
 
 Martin, III, 
 
 )) 
 
 Obstetric Clinique ; 
 also cases in town 
 and vicinity 
 
 Levy. 
 Dor. 
 
 18.^,7 
 1857-58 
 
 Lying-in Hosp 
 
 Charite 
 
 Virchow, II. 
 
 New York ... 
 
 Prague 
 
 Berlin 
 
 Bellevue Hosp 
 
 Barker. 
 
 i8p;8 
 
 Lvinar- in Hosp 
 
 Heiss. 
 
 
 Obstetrical Clinique... 
 
 Lying-in Hosp. ; after- 
 wards many cases in 
 the town 
 
 Martin. 
 
 ?> 
 
 Helsingfors . 
 Trient 
 
 1 Pipping- 
 C skjold. 
 
 
 Alle Laste Institution 
 Lvin s-in Hosp 
 
 Esterle. 
 
 
 Bern 
 
 Hermann. 
 
 
 Paris 
 
 Clinique 
 
 Dubois, III. 
 
 1858-59 
 1859 
 
 St.Petersbrg. 
 
 Wiirzburg . . . 
 
 St.Petersbrg. 
 Amsterdam . 
 
 Prague 
 
 Berlin 
 
 Obstetric Institute ... 
 
 Lying-in Hosp. ; also 
 cases in the town 
 and vicinity 
 
 Hugenberger 
 Griinewald. 
 
 ") V. Franque, 
 
 Scanzoni. 
 
 3> 
 
 Obstetric Institute ... 
 
 Maternity wards of the 
 
 Hosp 
 
 Hugenberger 
 Lehmann. 
 
 1859-60 
 
 Lvinff-in Hosp. 
 
 W^eber. 
 
 Charite ; Royal Ma- 
 ternity Institution; 
 also many cases in 
 the town 
 
 ^ 
 
 
 Stockholm ... 
 
 Giessen 
 
 Wiirzburg ... 
 
 Munich 
 
 Strasburg . . . 
 Prague 
 
 Paris 
 
 ( Martin,IV, 
 C Nagel. 
 
 
 Lvinsr-in Hosp 
 
 Retzius, II. 
 
 
 Ditto 
 
 Kehrer. 
 
 i860 
 
 Ditto 
 
 v.Franque,II. 
 Hecker, I. 
 
 
 Ditto 
 
 1860-61 
 
 Ditto 
 
 Sieffermann. 
 
 1861 
 
 Ditto ; and many cases 
 
 in the town also 
 
 Hopital St. Louis 
 
 Rotunda; also a few 
 cases in the town 
 and vicinity 
 
 Loscbner. 
 Pihan- 
 
 1861-62 
 
 Dublin 
 
 Munich 
 
 Vienna 
 
 Jena . 
 
 Dufeillay. 
 Denham. 
 
 
 Lying-in Hosp 
 
 Hecker, II. 
 
 
 Ditto 
 
 SpJith, 
 
 Rupert, 
 
 Netzel. 
 
 1862-63 
 1863 
 
 Ditto 
 
 Stockholm . . . 
 Olmiitz 
 
 Ditto 
 
 1863-64 
 
 Ditto 
 
 Schoefl. 
 
 

 
 PUERPERAL FEVER. 
 
 431 
 
 Time. 
 
 Place. 
 
 Area of diflusion. 
 
 Authority. 
 
 1863-65 
 1864 
 
 ... ] 
 ... i 
 Spring 
 
 June — Aug. 
 
 May 
 
 Winter 
 
 Autumn 
 January 
 
 Oct.— Nov. 
 
 Feb.— April 
 Nov. — Jan. 
 
 Winter 
 
 Winter and 
 Spring 
 
 Jan. — May 
 December 
 
 Mar. — Aug. 
 
 Schwezingen 
 
 Stockholm ... 
 Mannheim... 
 
 Lyons 
 
 Numerous cases in the 
 town and four ad- 
 joining villages 
 
 Lviner-in Hosp 
 
 Naumann. 
 
 Netzel. 
 
 1865 
 
 Slight epidemic in the 
 town 
 
 Stehberger. 
 
 1866 
 
 Maternity department 
 of the Gharite 
 
 
 Diirkheim ... 
 Lvons 
 
 Fonteret. 
 
 >i 
 
 Slight epidemic in the 
 town 
 
 Kaufmann. 
 
 1868 
 
 Hopital de la Croix- 
 Rousse 
 
 
 
 Montpellier . 
 Berlin 
 
 Guyenot. 
 3erre. 
 
 1868-69 
 
 Lying-in Hosp 
 
 
 Obstetrical wai'ds of 
 the Gharite 
 
 
 
 Paris 
 
 Schultze. 
 
 
 Hopital de la Pitie ... 
 Hopital St. Antoine . . . 
 
 Lying-in Hosp 
 
 Ref. XIII. 
 
 1869 
 
 1870 
 
 Paris 
 
 Lorain, 
 
 Breslau 
 
 Philadelphia 
 
 Stockholm . . . 
 Bensheim ... 
 
 (Hesse) 
 Paris 
 
 Martin, Y. 
 Spiegelberg. 
 
 Parjy. 
 
 Netzel. 
 
 1870-74 
 
 1872 
 
 Severe epidemic in the 
 Philadelphia Hosp. . 
 Lying-in Hosp. 
 
 
 In the villasre 
 
 Kraus. 
 
 
 Hopital St. Antoine . . . 
 
 Slight epidemic in the 
 
 town 
 
 Qninquaud. 
 Ahlfeld. 
 
 1872-73 
 
 Leipzig 
 
 Melbourne . . . 
 New York . . . 
 
 Paris 
 
 1873 
 
 Lying-in Hosp.; also 
 in the town 
 
 Ref. XIY. 
 
 1873-74 
 1S78 
 
 Matern. departments 
 of the Bellevue and 
 Charity Hospitals... 
 
 Hopital Beaujon 
 
 Obstetrical Glinique... 
 
 Slight epidemic in the 
 village 
 
 Lusk. 
 Chevance. 
 
 1879 
 
 3J 
 
 Cracow 
 
 Schwen- ") 
 ingen... ) 
 Berlin 
 
 Mars. 
 Haehnle. 
 
 
 Obstetrical Avai'ds of 
 the Gharite 
 
 
 
 
 Runge. 
 
 

 
 432 GEOGEAPHIOAL AND HISTOEICAL PATHOLOGY. 
 
 § 163. Epidemics most frequent in Cold and Wet 
 
 Weather. 
 
 Altliougli we may assume without hesitation that child- 
 bed fever is more common in tropical and subtropical regions 
 than the scanty information from such countries would lead 
 us to suppose, the disease is at any rate rarer in them than 
 in higher latitudes. Without doubt this is explained in 
 great part by the fact that lying-in institutions, which are 
 the chief seats of the malady, have been introduced to a very 
 much smaller extent in the former than in the latter, being 
 in fact non-existent in the more uncivilised countries. But 
 the relative exemption of warm countries is to be explained 
 in part also by the climate. I find evidence of this in the 
 fact that in the temperate and high latitudes the maximum 
 of sickness falls in the cold season and the minimum in the 
 warm. Almost all the observers, both old and new, such as 
 Riviere, Willis, Bartholin, Manning,^ de la Koche,^ Duges,^ 
 Conquest,* Dubreilh,^ Yirchow,^ and Hervieux,'^ are agreed in 
 saying that the epidemic or endemic prevalence of the dis- 
 ease falls in winter or spring ; and these observations of 
 individual authorities are fully borne out by statistics. 
 
 Of 195 epidemics in tlie above table, for whicli the time of prevalence 
 is accurately given, the numbers in tbe several seasons are as follows : 
 Winter . . .66 Autumn and Winter . 1 1 
 
 Spring . . .34 Summer . . .10 
 
 Winter and Spring . 25 Summer and Autumn . 7 
 
 Autumn . . .21 Spring and Summer . 5 
 
 Sixteen epidemics lasted tbrougli more than one season. According to 
 Hugenberger's^ data for the Obstetric Institute of St. Petersburg, the 
 following are the proportions for the several seasons during a period 
 of fifteen years : 
 
 ^ 'Treatise on Female Diseases,' LoncL, 1771, .^60. 
 
 ^ ' Reehercbes sur la nature et le traitement de la fievre puerperale, &c.,' Par., 
 1783- 
 
 ^ ' Journ. geu.de med.,' 1828, tome cv, 98. 
 
 ■* 'Observations on Puerperal Inflammation, &c.,' Lond., 1830. 
 
 * ' De la fievre puerp. epidemique,' Bordeaux, 184S. 
 
 ^ 'Monatsscbr. fiir Geburtskde.,' 1858, xi. 
 
 ' L. c. (see list of autbors), p. 58. 
 
 8 ' Das Puerperalfieber im St. Petersburger Hebammen-InsHtute, &c.,' St. 
 Petersb., 1862, 5.
 
 PUERPERAL FEVER. 
 
 433 
 
 Table of Sichness and Mortality from Puerperal Fever at the St. Peters- 
 burg Lying-in Hospital for the several seasons during 15 years. 
 
 V\rinter . 
 Spring . 
 Autumn 
 Summer 
 
 Confinements. 
 
 2106 
 
 1934 
 2069 
 1927 
 
 Cases of 
 puerperal fever. 
 
 405 or 19-23% 
 292 or 1509 
 310 or I4'9S 
 
 227 or ii'77J 
 
 Deaths from 
 puerperal fever. 
 
 88 or 4-18% 
 66 or 341 
 45 or 2-17 
 39 or 2 '02 
 
 The following are Spiitli's ' figures for the two cliniques of the AUge- 
 meine Gebarhaus of Vienna during a period of twenty-four years 
 (1840— 1863): 
 
 Similar Table for the Vienna Allgemeine Gebarhaus, 1840 — 1863. 
 
 January .... 
 February . . . 
 
 March 
 
 April 
 
 May 
 
 June 
 
 July 
 
 August 
 
 September . 
 
 October 
 
 November... 
 December... 
 
 First clinique. 
 
 Confinements. 
 
 8307 
 7926 
 
 8323 
 7688 
 
 8239 
 
 7149 
 6900 
 
 6699 
 
 6976 
 
 7322 
 
 7222 
 
 7699 
 
 Deaths. 
 
 535 
 420 
 
 457 
 
 413 
 302 
 
 221 
 
 271 
 
 260 
 
 242 
 
 456 
 
 488 
 491 
 
 Per cent. 
 
 6-4 
 5-2 
 5'4 
 53 
 3-6 
 3-0 
 
 3"9 
 3-8 
 3"4 
 6-3 
 
 67 
 6-3 
 
 Second clinique. 
 
 Confinements. 
 
 Deaths. 
 
 6776 
 
 243 
 
 6542 
 
 180 
 
 7068 
 
 289 
 
 6520 
 
 237 
 
 6834 
 
 183 
 
 6230 
 
 142 
 
 6071 
 
 125 
 
 6067 
 
 126 
 
 6218 
 
 188 
 
 6191 
 
 194 
 
 6228 
 
 231 
 
 66t2 
 
 258 
 
 Per cent. 
 
 3-5 
 
 27 
 40 
 
 3-6 
 2-6 
 
 2'2 
 2'0 
 2-0 
 30 
 31 
 
 37 
 3-8 
 
 Fi'om this it follows that in the first clinique the death-rate of the 
 summer months was to that of the winter months as 3'o to 67, and in 
 the second clinique as 2 to 4, or about half as great. 
 
 At Bergen, according to Vogt,^ there were 137 deaths from child-bed 
 fever in the lying-in hospital and throughout the town during a period 
 <if thirteen years, the incidence in the several months being as follows : 
 
 Oct. 
 15 
 
 
 Nov. Dec. 
 21 21 
 
 Jan. 
 20 
 
 
 Feb. 
 15 
 
 March 
 II 
 
 Total, 94. 
 
 April 
 10 
 
 
 May June 
 5 7 
 
 July 
 9 
 
 
 Aug. 
 8 
 
 Sept. 
 2 
 
 Total, 41. 
 
 
 1 
 2 
 
 ' Zeitschr. dcr Wiener Aeizte,' 1. c. 
 'Norsk M.igiiz. for Laege\ideusli,' 1S72, 
 
 iii, li. ii, 
 
 419. 
 
 VOL. 
 
 il 
 
 
 
 
 
 
 23
 
 434 
 
 GEOGEAPHIGAL AND HISTORICAL PATHOLOGY. 
 
 If we take April to be in the cold season, the death-rate of the seven 
 eold months is to that of the five warm months as I4"85 to 6-2. 
 
 I take the following figures from Lusk's ' paper on the mortality from 
 childbed fever in New York from 1867 to 1875. 
 
 Deaths from Puerperal Fever in Neio Yorh during nine years. 
 
 December 
 
 
 
 173) 
 
 
 January 
 
 
 
 197 > Winter 
 
 . 614 
 
 February 
 
 
 
 244) 
 
 
 March . 
 
 
 
 255) 
 
 
 April . 
 
 
 
 236 V Spring 
 
 . 694 
 
 May 
 
 
 
 203) 
 
 
 June . 
 
 
 
 • 136) 
 
 
 July . 
 
 
 
 . 1 1 1 (■ Summer 
 
 • 371 
 
 August 
 
 
 
 . 124) 
 
 
 September 
 
 
 
 . 78) 
 
 
 October 
 
 
 
 72 >■ Autumn 
 
 . 268 
 
 November 
 
 
 
 iiS) 
 
 
 Total 
 
 1947 
 
 In the six cold months the deaths were 1223, and in the six warm 
 months 724, the proportion being nearly the same as at Vienna and 
 Bergen. 
 
 In the Paris Maternite, according to Hervieux," there were, from 
 1830 to 1 84 1, confinements to the number of 18,108 in the six cold 
 months, and a mortality of 868 or 4"8 per cent. ; in the six warm months 
 the confinements numbered 15,956, and the mortality was 465 or 2 -9 per 
 cent. So that here again the proportion was the same as in the other 
 cases. 
 
 § 164. The Influence or Cold Weather an indirect one. 
 
 The prevalence of the disease as an epidemic or endemic 
 during tlie cold months is often traced to the Mnd of weather 
 proper to the season ; or, in other words, the effects of cold 
 ■weather, especially of cold and wet and of sudden changes 
 of temperature, on lying-in women or women recently con- 
 fined have been regarded as a material factor in the produc- 
 tion of the disease. I consider this interpretation of the facts 
 to be erroneous. 
 
 Not to mention that the malady has been as prevalent in 
 mild weather as in extreme cold, in dry weather as in wet, 
 
 ^ L. c. = L. c, p. 58.
 
 PUERPERAL FEVEE. 435 
 
 in steady weatber as in changeable^ tliat doctrine is more espe- 
 cially opposed by two facts : firstly^ the severest epidemics 
 of puerperal fever have often been prevalent in one lying-in 
 hospital of a city (Vienna, Berlin, London, Paris), Avhile the 
 other maternity hospitals of the place, experiencing the same 
 kind of weather, have felt the disease to a very slight extent 
 or not at all (a circumstance to which I shall recur) ; and, 
 secondly, the women confined at the lying-in hospital of a 
 town may be decimated by child-bed fever, while those con- 
 fined at their own homes, and therefore not less exposed to 
 the alleged harmful influence but probably more so (as among 
 the poor) will have escaped the disease altogether. Nay more, 
 the outbreak and prevalence of puerperal fever have been 
 found to be much less dependent on the season of the year 
 in private houses than in lying-in hospitals. Thus, Bradley 
 remarks of the state of the weather during the prevalence of 
 the disease at many places in Yorkshire in 1808-12: '^ It 
 prevailed equally in cold and hot weather, in wet and dry 
 seasons, in winter and summer." At Rostock in 1805 it 
 occurred during the hot weather of summer, and there are 
 several other epidemics in which a similar state of things 
 may be discovered. 
 
 Many observers liave arrived at the same opinion as to the influence 
 of the weather on the production of the disease. Thus Cruveilhier, in 
 his account of the epidemic at the Paris Maternite in 1830-31, says: 
 "J'ai vainement cherche dans les vicissitudes atmosphcriques, soit 
 brusques, soit graduelles, dans le froid sec 0x1 dans le froid humide, les 
 causes de I'epidemie ;" and Yoillemie]* is led to the same conchision by 
 his experience of the 1838 epidemic in the Paris Clinique. In his report 
 on puerperal fever at the Obstetric Institute of St. Petersburg, Grlin- 
 waldt says : " The weather had no influence at all, either in stai-ting the 
 sickness or in continuing it. A careful comparison of the state of the 
 barometer and thermometer, and of the direction of the wind from day 
 to day, showed that the cases occurred equally in all kinds of wind and 
 weather, and showed also that the atmosphei'ic conditions which 
 obtained on the day of the child's birth had no constant relation to the 
 subsequent course of the confinement." 
 
 Therefore, although Ave cannot doubt that epidemics of 
 child-bed fever stand in some definite relation to the season, 
 the cold months bringing a greater mortality than the warm ; 
 yet these differences cannot be explained by the direct effects
 
 436 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 of the weather on lying-in or lately confined women ; and it is 
 reasonable to suppose that it is the change in the hygienic 
 condition of the lying-in hospitals brought about by the cold 
 season which furnishes the real grounds for the rise of the 
 sick-rate and death-rate. The influence of the season would, 
 accordingly, be not a direct one, but an indirect ; and such is 
 the conclusion to which Spath, Hervieux and others have 
 come. 
 
 § 165. Kind op Soil op no Account. 
 
 It would hardly do for even the most enthusiastic advo- 
 cates of the doctrine of the soil and the sub-soil water to 
 make the nature of the ground answerable for the epidemic 
 or endemic occurrence of puerperal fever. The disease has 
 been prevalent at all elevations, — in lofty and dry localities 
 as well as in low and damp, — on sandy or swampy soil as 
 well as upon rocky ; and if there were any further doubt 
 about the matter, it would be at once dispelled by the fact 
 that, in the same institution, one division may be infested by 
 the severest epidemics of child-bed fever for months together, 
 while the women confined in another division, sepai-ated 
 from the first only by the walls, are enjoying the best of 
 health. 
 
 § 166. Specially a Disease op Lying-in Hospitals. 
 
 Nothing in the history of puerperal fever, so far as we can 
 follow it during the last three centuries, comes out so promi- 
 nently and uniformly among the various factors with which 
 the origin of the disease appears to be somehow bound up, 
 than '\t& great ^prevalence in lying-in hospitals, contrasting with 
 its comparatively rare occurrence outside those institutions. 
 Although it must be conceded, as we have already seen, that 
 the cases of sickness and death from puerperal fever among 
 women confined at their own homes, as given in statistics, are 
 below the real number ; yet the difference between that num- 
 ber and the figures of the sick-rate and death-rate in lying-in 
 hospitals is so great that the severest sceptic will not be
 
 PUERPERAL EEVER. 437 
 
 able to argue away tlie preponderance of child-bed fever in 
 the latter. According to tlie statistical table given at 
 p. 419, the deaths from puerperal fever in various civilised 
 European countries, among women confined at their homes, 
 averaged from o'6 to 0*7 per cent, of the confinements ; but 
 in lying-in hospitals the average rises to 2 or 4 per cent., 
 and under unfavorable circumstances it may rise even 
 higher. 
 
 Lefort^ calculates that of 934,781 women who were con- 
 fined at their homes in various towns of Europe, 4405 or 
 o'47 per cent, died in child-bed; whereas among 888,312 
 women confined at lying-in hospitals, the deaths were 30,549 
 or 3*4 per cent. The mortality among puerperte at St. 
 Petersburg over a period of fifteen years was 0.7 per cent. ; 
 but in the Obstetric Institute of that City during the same 
 period it was 3*8 per cent., and in the other lying-in hospitals 
 it was as high as 4*6 per cent. These data are taken from 
 the essay of Hugenberger,^ who adds that, although the 
 disease was six times epidemic in the Obstetric Institute 
 during that period, not a single epidemic was observed in 
 the liberties of the city. In the six great lying-in institutes 
 of Paris (Maternite, Clinique, Hotel Dieu, St. Louis, St. 
 Antoine and Lariboisiere) the mortality among puerperas, 
 according to observations extending over sixty years^ (1802- 
 1862) averaged 4*8 per cent, whereas among women confined 
 at their homes it was reckoned at not quite o"6 per cent. In 
 Genoa from 1857 ^^ 1866 there died in child-bed only 0*42 
 per cent, of the women confined at their own homes, whereas 
 the deaths at the lying-in hospital from 1855 to 1866 reached 
 the enormous average of 8*8 per cent. At the maternity 
 hospital of Pavia the deaths in child-bed averaged 2*3 per 
 cent from 1861 to 1869. The lying-in hospital of Rome had 
 the disease so regularly that it had to be closed almost every 
 year on account of epidemic puerperal fever.* Lastly it is a 
 noteworthy fact that, of the 288 epidemics in the above table, 
 1 78 were exclusively in lying-in hospitals or other institutes for 
 
 ^ ' Gaz. (les Hopit.,' 1866, 152. 
 
 2 ' Das Piierperalfieber,' &c., 48. 
 
 3 Tarnier, 'Gaz. des Hopit.,' 1866, 151. 
 '• Sormani, 1. c.
 
 438 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 women in labour, 46 were in such institutions and more or 
 less also among the women confined at their homes, 52 were 
 in the towns or villages or their immediate vicinity, and 12 
 were widely prevalent over considerable tracts of country. 
 
 § 167. Eelation to ovek-crowding in Lying-in HosriTALS. 
 
 It follows from this that puerperal fever has markedly 
 the character of o, disease of liosintah. Accordingly, when 
 gyngecologists inquire into the cause of the disease, they 
 always turn their attention to finding out the circumstances 
 in lying-in hospitals with which the endemic persistence 
 of the malady or its epidemic outbreaks appear to be asso- 
 ciated. 
 
 Several of the earlier observers who occupied themselves 
 particularly with this disease, such as Mercado, Willis and 
 Sydenham, had recognised the fact that in child-bed fever 
 they had to do with an infective process. According to the 
 notions of the time, it was designated a " putrid " disease 
 and was included in the class of " febres putrida? ;" and that 
 doctrine, of English and Geimian origin, obtained a footing 
 also in France after the overthrow of the system of Broussais. 
 Meanwhile, the decomposition or putrefaction of animal or 
 other organic matters had come to be recognised as an 
 influence in the producing of " putrid " diseases (afterwards 
 called "typhous") ; and thus the conviction steadily gained 
 ground that the source of the mahidy had to be looked for 
 in the overcrowding of wards for lying-in or newly-confined 
 women, and in the want of cleanliness and ventilation 
 associated therewith, all the more so that the puerperal 
 process itself gave rise to putrefying products of decom- 
 position in abundance. The cause of the disease was sup- 
 posed, accordingly, to arise from that mephitic state of things, 
 in the form of a miasma which was suspended in the air and 
 inhaled by the puerperal women ; the toxic process thereby 
 induced in them located itself chiefly in the genitals and 
 the organs adjoining, as being the imrs minoris resistentise. 
 Experience showed that the introduction of one case of 
 child-bed fever into a lying in hospital or ward was quickly
 
 PUERPERAL PEVER. 439 
 
 followed by the appearance of the disease in other women 
 who had been confined ; and from this it was inferred that 
 the disease had the character of communicability, or that a 
 contagium, developed within the body of the patient, which 
 was eliminated therefrom and caused the disease to spread 
 independently of miasmatic influences. 
 
 Underlying this theory is the assumption that defects of 
 hygiene, especially those arising from overcrowding of the 
 lying-in wards, afford a real opportunity for the creation of 
 epidemic or endemic foci of child-bed fever; and that assump- 
 tion has been received with hardly any objection in more 
 recent times on the part of the medical directors of lying-in 
 institutions. In the very earliest epidemiological notice of 
 puerperal fever that we possess, the one relating to the 
 Hotel Dieu of Paris in 1664, it is pointed out that the 
 hospital was crowded with patients at the time, an unusually 
 large number of them being cases with wounds ; that the 
 ventilation of the wards was extremely defective ; and, as 
 expressly stated, that the lying-in department was directly 
 over the wards occupied by the surgical cases. Cruveilhier 
 writes to the same effect in his report on the epidemic of 
 child-bed fever at the Paris Maternite in 1830: '^j'ai con- 
 stamment vu," he says, " les maladies prendre un caractere 
 de gravite indomptable avec Tencombrement, ou s^attenuer 
 par I'effet de la diminution de population." In like manner 
 Dubois and Voillemier speak in their accounts of the epi- 
 demic of 1838 at the Clinique, the former dwelling upon the 
 unfortunate proximity of the institution to the dissecting 
 rooms, and the latter remarking : '^^j'ai dit qu'outre les causes 
 d'infection particulieres a chaquc maison d^accouchements, 
 il en existait une autre, qui leur etait commune a toutes, 
 c'est la reunion d'un grand nombre de femmes accouchees 
 sur un meme point." 
 
 Accounts of the same kind oome from the Maternite of 
 Lyons. Referring to the winter epidemics there in 1844-45 
 and 1845-46, Vernay says that the hospital was greatly 
 overcrowded and that the ventilation was bad on account 
 of the cold ; and as regards the epidemic in the summer of 
 1 866, Fonteret tells us that, according to the very exhaustive 
 inquiries of Dr. Delore, the medical director, the cause of
 
 440 GEOORAPHIOAL AND HISTOEICAL PATHOLOGY. 
 
 the epidemic had to he assigned to nothing but these internal 
 sanitary defects. In the report by Caderschjold on an epi- 
 demic of child-bed fever in the Stockholm Lying-in Hospital 
 in 1825, we find that the disease gained in extent just in 
 proportion as the wards became crowded with patients ; and 
 that in subsequent years puerperal fever had broken out 
 always when the hospital was particularly full. There is a 
 very interesting paper by Eetzius on the outbreak and pro- 
 gress of the disease in the same place in i860 : 
 
 " Beds in the lying-in hospital," lie says, " had been bespoken by an 
 unusual number of women at the beginning of the year, and the number 
 of patients that entered was more than the regulation allowed or than 
 provision was made for. The admissions increased from day to day, to 
 such an extent that neither the wards nor the bedding could be aired 
 as they should have been." The consequences of this insanitary state 
 of matters were soon shoAvn in an epidemic outbreak of puerperal fever, 
 of which we shall have to speak moi*e particularly iu the sequel ; the 
 disease, we are told, occurred " up to the end of March in the lower 
 storey only, in the rooms set apart for the instruction of midwives. 
 No lying-in woman who had a room to herself, with upwards of two 
 thousand cubic feet of air, was attacked. In the common wards, which 
 were adapted properly for three persons, it became necessary, in conse- 
 quence of the pressure, to place four, so that the cubic space was 
 reduced. Such an encroachment, although it may do no harm for a 
 short period, cannot be endured for long, even supposing that perfect 
 ventilation has been kept up all the time." The disease did not abate 
 until vigorous measures to overcome these defects of hygiene were 
 drawn up and carried into effect. 
 
 A state of things like the above has often been observed 
 in the maternity hospitals of Dublin. Thus Clarke observes 
 that the disease broke out in that city in 1787, at a time 
 when the lying-in hospital was so crowded that they were 
 sometimes obliged, '' contrary to custom/' to put two 
 women in one bed. Douglas says that, according to his 
 experience of the epidemics of 18 10 and 1812-1813, we may 
 assume with all certainty that " a ver}'^ full maternity 
 hospital and a quick succession of confinements has a very 
 important influence on the production of child-bed fever.'' 
 In like manner it broke out, in the new maternity hospital 
 in Dublin, according to Beatty first in October, 1834, at a time 
 when it was overcrowded. In Priestley's resume of the 
 recommendations on puerperal fever drawn up by the
 
 PUBEPERAL FEVER. 441 
 
 Obstetrical Society of London, there is the following passage^ 
 relating to the present question : " The influence of vitiated 
 atmosphere in overcrowded hospitals in producing an 
 endemic form of the disease is only too well confirmed. 
 Whenever a number of lying-in women are aggregated 
 together, there is danger that a miasm may be generated, 
 which will develope puerperal fever, and it is by no means 
 easy to define the amount of ventilation and isolation which 
 are necessary to prevent these untoward consequences." 
 
 Litzmann," in his account of the epidemic of child-bed 
 fever from 1840 to 1841 at the lying-in hospital of Halle, 
 dwells upon the fact that the institution, all the time that the 
 outbreak lasted, was unusually crowded with women about 
 to be confined or newly confined, so that the airing and 
 cleaning of the rooms could not be carried out to the extent 
 that was to be wished. The same unfortunate condition of 
 things was remarked in the epidemic of 1849 at the Stuttgart 
 lying-in hospital ; also, in the maternity hospital of Bern in 
 1858, overcrowding preceded the epidemic, the disease being 
 strictly limited at first to the two wards in which most 
 of the newly confined women were (and in which they all 
 spent the first few days after the child was born), while it 
 did not show itself in the third ward until it became neces- 
 sary to crowd the puerperaa into it also. If there were any 
 further doubt about the importance of this etiological factor 
 in the production of child-bed fever, it would disappear when 
 we reflect on what is admitted by all, that nothing is more 
 certain to bring an epidemic of puerperal fever to an end 
 in a lying-in hospital than temporarily vacating the rooms 
 where the disease has been, and thoroughly airing and clean- 
 ing them. Many of the older observers, such as Young, 
 Clark, and Gooch, had often found this confirmed in their 
 experience ; and there are still more numerous observations 
 to the same effect from later times, such as those for Dublin 
 in 1836 and 1837, for Vienna in 1792, for Copenhagen in 
 1839, for Kiel from 1834 to 1836, for St. Petersburg in 185 8,. 
 and for Stockholm in 1825, 1840 and 1858. Writing of the 
 Bellvuc Hospital of New York, Reese^ says : " A sudden 
 
 1 'Brit. Med. Journ.,' 1876, Jan., p. 36. 2 j^ ^^ ^ ^^g 
 
 Amer. Jouvn. of Med. Sc.,' 1850, Jiin., 99. . 
 
 3 (
 
 442 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 eruption of puerperal fever lias appeared in the lying-in- 
 wards several different tiraes^ the epidemic character of 
 which has been in every instance promptly arrested by 
 abruptly changing the apartments to another floor of the 
 house, having a different exposure to the external air, and 
 in which a due ventilation could be secured. The wards in 
 which the fever appeared where meanwhile thoroughly 
 oleansed and purified by white-washing &c. ; and not until 
 thoroughly aired and renewed by a change of furniture and 
 bedding have they been again occupied.^' 
 
 Whenever puerperal fever has appeai'ed in the Bellvne 
 Hospital within the last ten or twenty years, according to 
 Lusk's^ account, the adoption of these measures has been 
 attended with the same successful result. Harris^ speaks in 
 the same sense, from his experience in the lying-in depart- 
 ment of the Pennsylvania Hospital of Philadelphia ; and 
 Hugenberger^ says : 
 
 " How much more the atmospliere of the hospital has to do with the 
 production of an outbreak of puerperal fever than any other epidemical 
 influence, was clearly proved in a negative way after the restriction of 
 admissions and the closing of the lying-in hospital [of St, Petersburg] 
 in 1846, 1848, and 1859 ; and the fact will be made clear to us, not only 
 hy the better condition of things always brought about after the 
 wards, bedding, and furniture had been cleaned and disinfected, but 
 also because the autumn months of those years in which the needed 
 repairs and painting of the lying-in rooms, wards, and corridors had 
 been done during the summer, were always the healthiest." 
 
 Furthermore, the factor of disease which we are now 
 considering has been found to obtain, according to many 
 observations, not onl}^ in lying-in hospitals but also in 
 private houses. In the account of the groups of puerperal 
 fever cases at Paris in 1746, we read that 'Ma maladie n'a 
 attaque que les pauvres femmes.^' Douglas says that, 
 although no station in life is exempt from child-bed fever, 
 the disease is decidedly more frequent among the poorer 
 classes. In the Edinburgh epidemic of 1821, there were, 
 it is true, some cases among puerpcra? in comfortable circum- 
 stances ; but the quarter of the town principally affected was 
 
 1 ' Amer. Journ. of Obstetrics,' 1875, Nov., viii. 
 ^ 'Auier. Journ. of Med. Sc.,' 1847, Jan., 87. 
 * L. c., 51.
 
 PUERPEEAL FEVEE. 443 
 
 where the poor lived. Twining and Webb are agreed in 
 saying that the real reason why child-bed fever in India is 
 more common among the Hindu women than among others, 
 is the filth and the utter want of ventilation of the rooms 
 in which they are confined. 
 
 " The woman after delivery," says Webb, " is placed in a small damp 
 room, very ill ventilated, with one small door only, no window or 
 opening in the nature of a chimney. The door is always closed ; the 
 room is in a corner of the compound . . . and in a temporary hut of mats 
 and bamboo, thatched with straw or grass . . . detached from the house, 
 and generally kept for the purpose of the women of the family being 
 delivered in it." 
 
 This is perhaps the factor in the etiology that should 
 help us most to understand what has been already men- 
 tioned, that lying-in hospitals have their visitations of puer- 
 peral fever oftenest in the cold seasons of the year. In the 
 first place the number of persons resorting to these institutions 
 is usually much greater in the cold months than in the warmer 
 seasons, for reasons that are obvious ; and therefore they are 
 more frequently overcrowded at that time. In the second 
 place, there are much greater difficulties in the way of 
 sufficient ventilation during the winter months than at other 
 times. 
 
 "There can hardly be a doubt any longei*," says Spath, "of the cor- 
 rectness of the principle above stated, that the winter months with 
 their lower temperature have no direct ill effect on the state of health 
 in lying-in hospitals. An injurious influence they do indeed exert, but 
 I am convinced that it is by causing iDvxtrefying animal matters to 
 collect in the building. For, on the one hand, it is impossible to keep 
 the air in the rooms as pure as could be wished, owing to the want of 
 ventilating appliances suited for an inclement season or bad weather. 
 . . . On the other hand, there is usually a greater demand for acommo- 
 dation in winter ; and that is an additional and positive reason why 
 decomposition-products accumulate." Many other observers have ex- 
 pressed the same opinion.' 
 
 If we compare the effect of these insanitaiy conditions 
 upon the production of child-bed fever, with the significance 
 of the same for the oi'igin of erysipelas, we shall discover 
 the most perfect resemblance between the two diseases as 
 
 ' See the report on the epidemic of 1846 in tlie lying-in hospitals of Paris, 
 and the papers by Vernay, of Lyons, and Lusk, of New York.
 
 444 GEOGRAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 regards pathogenesis; and tliat i-esemblance comes out besides 
 in the fact that child-bed fever, like erysipelas, is neither 
 dependent of necessity upon the presence of these noxious 
 things for its existence, nor is the very worst state of 
 sanitation always followed by an outbreak of the disease. 
 Over and over again has puerperal fever occurred in lying-in 
 hospitals and in private life, both sporadically and in epi- 
 demics, without anyone being able to discover even a remote 
 occasion for it in overcrowding, want of cleanliness, deficient 
 ventilation or other noxious influence of the same class. 
 
 The following epidemics (or aggregates of cases) are 
 examples of this: Heidelberg in 1811, the Paris Maternite 
 in 1829, the Hotel Dieu and other lying-in hospitals of Paris 
 in 1 83 1 and 1844, the Pennsylvania Hospital of Philadelphia 
 in 1833, the lying-in hospital of Hanover in 1835, Schwezingen 
 in 1863-65 and, in 1857, i860 and 1861, and the newly-built 
 and elegantly appointed lying-in institution at Munich, ''in 
 which every possible source of infection was not only avoided 
 with the greatest care and watchfulness, nay even with painful 
 anxiety in the building and internal arrangement of the 
 hospital as well as in the service of the attendants, but was 
 day and night looked for, guarded against and fought against 
 in the case of each individual admission.^^^ 
 
 On the other hand, there are many lying-in hospitals 
 Avhich have escaped puerperal fever for years together, 
 despite their having been often overcrowded. In the old 
 Dublin Rotunda the disease broke out for the first time in 
 1767, or more than ten years after it was opened, and in the 
 British Lying-in Hospital (London) not until 1760, or when 
 it had been open eleven years. In his account of the epidemic 
 of puerperal fever at the lying-in hospital of Bern in 1858, 
 Hermann mentions that the institution had often been over- 
 crowded before, without the sickness showing itself. Semmel- 
 weiss gives statistics to prove that the extent of the disease 
 in the Vienna lying-in hospital was by no means in direct 
 proportion to the number of puerperal women taken in and 
 tended. And there have been many other experiences of a 
 like kind published by other observers. In estimating the 
 importance of this etiological factor for the production of 
 
 ' Martin (iii), 1. c.
 
 PUERPERAL FEVER. 445 
 
 child-bed fever, just as for tlie genesis of erysipelas, we shall 
 have to see in those insanitary conditions only a peculiarly 
 favorable soil for the proper cause of the disease to develop 
 in, or for the disease to spread in. 
 
 § 1 68. Evidence against the theory op a miasmatic origin. 
 
 It is this fact of puerperal fever seeming to break out not 
 unfrequently quite apart from such external influences, that 
 has given strong support to the theory of its miasmatic or 
 contagious-miasmatic origin. It has been assumed that there 
 is in child-bed fever a specific morbid poison, whether deve- 
 loped out of the puerperal process or otherwise produced, 
 which is more or less widely diffused like the virus of scarlatina 
 or typhus ; this virus is taken into the blood in one way or 
 another and brings about a general infection, which runs its 
 course under some circumstances without forming local 
 centres of disease (although usually the consequeuces are 
 local lesions chiefly in the genital organs and the parts 
 adjoining), and which gets transmitted (by contagion) from 
 one person to another. The support for this theory was 
 found, as wo have seen, in the fact that in many cases no 
 atmospheric, hygienic, or other noxious influences capable of 
 accounting for an outbreak of the disease, could be detected. 
 Another piece of evidence was that there had coincided with 
 puerperal epidemics in the lying-in hospitals more or less 
 numerous cases of the fever among women confined at their 
 own homes ; nay more, that it had grown into an epidemic 
 in villages or towns quite independently of any occurrence 
 of it in a lying-in hospital, that the epidemic had spread 
 over considerable tracts of country, and had in some in- 
 stances assumed even a pandemic character, breaking out at 
 one and the same time in not a few parts of Europe. It is 
 beyond the limits of my task to state here the endless vari- 
 ations upon this theme which have commended themselve.5 
 to individual observers. I shall restrict myself to a presen- 
 tation of facts, exclusively historical and epidemiological, 
 which make against this doctrine of the origin of the disease
 
 446 GEOGRAPHICAL AND HISTOE[CAL PATHOLOGY. 
 
 — a doctrine that lias been accepted bj prominent gynaeco- 
 logists of the most recent period. 
 
 Firstly, in regard to the coincidence of the disease within 
 lying-in hospitals and among puerperse confined at their own 
 homes, the facts in the above table show that such a coinci- 
 dence has been observed only forty-six times in all out of 
 two hundred and twenty-four epidemics ; of these forty-six, 
 it is expressly stated that in twenty-six the number of cases 
 of puerperal fever outside the hospital was trifling ; for five 
 more there is no definite information as to the number of 
 outside cases, doubtless because they were only here and 
 there ; and there are only fifteen epidemics of which it can be 
 said that many cases were observed in private houses side by 
 side with the epidemic diffusion of the disease in the lying-in 
 hospital. I shall have occasion to show in the sequel that 
 coincidences of the disease within and without the lying-in 
 hospital, which would appear to have been much rarer in the 
 last ten or twenty years than before, may be explained, 
 for those cases where the coincidence was not a mere 
 accident, in a perfectly satisfactory manner without being 
 obliged to resort to the assumption of a morbid jDoison 
 acting over a wide range, or of a " constitutio epide- 
 mica." 
 
 How little justification there is for making that assumption 
 under the particular circumstances, is proved by the history of 
 epidemics which have been confined exclusively to lying-in 
 hospitals. Numerous authorities dwell with special emphasis 
 on the fact that many times during hospital epidemics of child- 
 bed fever, often of a disastrous type and lasting for months, 
 there had not been a single case among the women confined 
 elsewhere than at the hospital — that the latter had in fact 
 enjoyed singularly good health. Further, it has been often 
 remarked that, in cities where malignant puerperal fever is 
 epidemic every few years in one. or more of the lying-in 
 hospitals, the disease occurs compai-atively seldom outside 
 these institutions, and is never, or hardly ever, truly epi- 
 demic. This holds good for Dublin,^ according to the infor- 
 
 ^ Of 19 epidemics recorded from 1760 to 7862, there were only 4 (iu 1812-13, 
 1834, 1854, and 1861) in which it was observed that cases occurred among 
 women confined at their homes, besides the cases in the hospital epidemic
 
 PUERPERAL FEVER. 
 
 447 
 
 mation of Clarke and Douglas, for Birraingliam according 
 to Ingleby, and it could be proved also for Vienna. As 
 regards Coblenz we are told by Wegeler^ that tlie oldest 
 practitioners there could not call to mind a single epidemic 
 of child-bed fever in the town, although every few years the 
 disease attained a great height in the lying-in hospital. 
 Hugenberger remarks that, during the period from 1845 ^^ 
 1849, when puerperal fever was six times epidemic in the 
 Obstetric Institute at St. Petersburg, the city itself had 
 remained quite free from epidemics of it. But the most 
 significant evidence against the ''^ miasmatic " theory of the 
 origin of puerperal fever is afforded by the fact brought out 
 in the following tables, that in cities with more than one 
 lying-in hospital, there has very rarely been any coincidence 
 noticed between the epidemics in each ; but on the other 
 hand it has happened over and over again that one or more 
 of these institutions have enjoyed good health while the 
 disease has been making havoc in another ; and that there 
 have been the same differences between the various sections 
 of a lying-in hospital separated from one another only by 
 thin walls. ^ 
 
 Table of the MortalUij from Ghild-bed Fever from year to 
 year in various Lying-in Hospitals of the same city. 
 
 Paris. 
 
 1844 
 
 1845 
 1846 
 1847 
 1848 
 
 Hotel 
 Dieu. 
 
 5-rj57o 
 
 6-66 „ 
 
 3-57 » 
 2-94 „ 
 
 Pitle. 
 
 Margue- 
 rite. 
 
 12-50"/, 
 8-33 .-, 
 
 8-33 » 
 irii „ 
 
 8-33 „ 
 
 S-SS^/o 
 
 3"22 „ 
 4-80 „ 
 
 Hopit. des Maison cV 
 Cliniq. [ Accoucb. 
 
 I 
 
 3;577« 
 3 33 '» 
 3"7o >. 
 2-38 „ 
 
 2'00 ,, 
 
 4-357o 
 370 „ 
 3"84 „ 
 3'22 „ 
 270 „ 
 
 Beaujon. 
 
 ry88"/o 
 625 „ 
 
 7'I4 » 
 i'72 „ 
 384 „ 
 
 St. 
 Louis. 
 
 &6&% 
 
 3"84 1. 
 2-63 „ 
 
 178,, 
 I '07 ,, 
 
 ^ ' Versuche einei' nied. Topogr. von Koblenz,' Kobl., 1835, }}. 41. 
 * See Arnetb's ' Geburtsliiilfo und Gyiiiikologic' (Wien, 1853, p. 47) witb 
 reference to the great Ijing-iu hospital oi' Vienna.
 
 448 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 St. Petersburg. 
 
 
 Obstetric 
 
 Training 
 
 
 Obstetric 
 
 Training 
 
 
 Institute. 
 
 House. 
 
 
 Institute. 
 
 House. 
 
 1845 
 
 2-3"/o 
 
 6-47o 
 
 1853 
 
 2-47o 
 
 3-6»/o 
 
 1846 
 
 47 >y 
 
 4*o„ 
 
 1854 
 
 2'4 M 
 
 2-8 „ 
 
 1847 
 
 2-2 „ 
 
 2-2 „ 
 
 1855 
 
 2-6 „ 
 
 4' 2 „ 
 
 1848 
 
 6-3 >. 
 
 4"6 „ 
 
 1856 
 
 35 " 
 
 60 „ 
 
 1849 
 
 3*4 >. 
 
 5'8 „ 
 
 1857 
 
 i'4„ 
 
 5-2 „ 
 
 1850 
 
 2-8 „ 
 
 8-4 „ 
 
 1858 
 
 2-4 „ 
 
 5" I » 
 
 I85I 
 
 1-2 „ 
 
 5-3.. 
 
 1859 
 
 4"o„ 
 
 53 » 
 
 1852 
 
 2-5 » 
 
 8-9 „ 
 
 
 
 
 Vienna. 
 
 1833 
 1834 
 
 1835 
 1836 
 
 1837 
 1838 
 
 1839 
 1840 
 
 1 841 
 
 1843 
 
 1843 
 1844 
 
 1845 
 
 1846 
 
 1847 
 
 Lying-in Hosp. Lying-in Hosp 
 Division I. Division II. 
 
 5-297o 
 7"7i » 
 5*55 ., 
 7-47 » 
 909 .. 
 304 .. 
 5'42 „ 
 
 9'24 >. 
 7-80 „ 
 
 15-75 » 
 895 „ 
 8-23 „ 
 6-90 „ 
 
 1 1 "44 ., 
 
 2-26"/„ 
 
 8-6o „ 
 
 4'99 " 
 7'84 .. 
 6-99 „ 
 494 >. 
 4'52 „ 
 2-65 „ 
 3*52 „ 
 7'59 .' 
 5-98 „ 
 
 2"30 .. 
 2*03 „ 
 
 279 " 
 096 „ 
 
 Lying-in Hosp. 
 Division I. 
 
 1848 
 1849 
 1850 
 1851 
 1852 
 
 1853 
 1854 
 1855 
 1856 
 
 1857 
 1858 
 1859 
 i860 
 1861 
 
 i-277o 
 266 „ 
 
 1*97 '. 
 
 178,, 
 
 4"04 ,. 
 
 2-13 " 
 9-10 „ 
 
 541 » 
 
 3'97 » 
 2-96 „ 
 
 2-04 „ 
 
 178 „ 
 1-96 „ 
 
 360 „ 
 
 Lying-in Hosp. 
 Division II. 
 
 x-337o 
 2-58 „ 
 I 65 „ 
 3*56 » 
 
 571 » 
 i'92 „ 
 6-i8 „ 
 
 5'92 ,. 
 407 ,. 
 
 2-i8„ 
 
 i'43 M 
 o-6i „ 
 
 I -60 „ 
 
 4*07 „ 
 
 The instances of a succession of cases of child-bed fever 
 among the residents of a locality at large, which have been 
 designated by the somewhat exaggerated name of '' epi- 
 demics," have received important elucidations from the 
 experience of the last half century or more. These experi- 
 ences serve to prove that the dispersion of the disease depends 
 on anything but a '^puerperal miasma;'' and, as I shall show 
 in the sequel, they have furnished us witli most valuable 
 knowledge for the explanation of its real mode of origin and 
 its dilTusion. lu the meantime we may remark of these
 
 PUERPERAL FEVER. 449 
 
 " epidemics," tliat wlien they have occurred in large towns, 
 as at Aberdeen in 1789 and Leeds in 1807, they have usually 
 been confined within a small range or to one quarter of the 
 town, not a single case of the sickness occurring among the 
 lying-in women in adjoining districts. 
 
 Finally, as regards the simultaneous occurrence of child- 
 bed fever in various parts of Europe (to which the experiences 
 of the years 1781, 18 19, 1825—26 and 1834—35 bear witness), 
 there has been a theory of a quasi-pandemic diffusion of the 
 disease deduced therefrom ; but that deduction is based upon 
 an arbitrary and erroneous association of heterogeneous 
 elements. If the cases of puerperal fever occurring in 
 groups had been more frequently reported than as a matter 
 of fact they are, we should probably find hardly one year in 
 which the disease had not been simultaneously prevalent in 
 various parts of our continent to a notable extent ; and the 
 instances that now seem to be rare would lose much of their 
 exceptional character. But even as the case stands, we are 
 entitled to ask what right anyone has to conclude for the 
 general operation of a common cause from the co-existence 
 of a disease, say at Paris and Vienna, or at Dublin and Gratz. 
 We have only to glance over the chronological table of puer- 
 peral fever epidemics, such as it is, to discover that there 
 has been every few years a coincidence of that sort in the 
 time of prevalence of the malady among a more or less con- 
 siderable number of lying-in institutions. But we cannot 
 seriously suppose that a disease which may have broken out 
 in five or ten of the maternity hospitals of Europe, while 
 there has not been a trace of a puerperal fever epidemic in 
 other places or even in other hospitals of the same town, had 
 owed its origin to a morbific cause generally diffused over 
 wide tracts of country. 
 
 § 169. Evidence op the Transmission of Infection. 
 
 An idea of much greater promise for the discovery of the 
 origin of child-bed fever than all the tracing of it to a 
 miasmatic source, is the one that was long ago indicated by 
 
 VOL. 11. 29
 
 450 GEOGRAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 Willi s^^ was afterwards developed by writers such as Eisen- 
 mann and Helm, and in recent years has grown to be a well- 
 established theory — the idea, namely, that jpuerjperal fever is 
 a septic or infective traumatic malady. The evidence for the 
 correctness of that view, adduced by me in the presentation 
 of facts in the first edition of this work, was accepted almost 
 unanimously by German gynijecologists. I am justified, 
 therefore, in making a somewhat detailed statement of the 
 data on which the proof rests ; and I shall select the weightiest 
 of the observations which I collected originally, adding to 
 them, by way of further confirmation, such of the more recent 
 as are specially worthy of note. 
 
 (i) Denman ('Introduction to the Practice of Midwifery,' Lond., 
 1788, ii chap., 19) was tlie first, so far as I know, to allege that childbed 
 fever was sometimes carried by doctors and mid wives, who had been in 
 attendance on puerperal fever patients, to other lying-in women. 
 
 (2) Gordon (' Treatise on the Epidemic Puerperal Fever of Aberdeen,' 
 Lond., 1795), in his account of the Aberdeen epidemic of 1789-92, gives 
 several cases where midwives or nurses in attendance on patients with 
 puerperal fever, had carried away locial secretion on their hands, and 
 had given the disease to the lying-in women whom they next had to 
 deliver. In the same way the infection was carried from Aberdeen to a 
 woman who lived at Fintray ; and the midwife who delivered her, and 
 attended her through the fever, gave the infection to two other women 
 in childbed in the same parish. 
 
 (3) Armstrong (see List of Writers), in his account of the epidemic 
 of puerperal fever in Northumberland in 181 3- 14, has the following: 
 "It is a singular fact that, in whatever place the fever in question 
 occurred, it was principally limited to the practice of one accoucheur in 
 that place. To adduce an example in point, Mr. Gregson attended, 
 with three solitary exceptions, all the women who were afflicted with 
 the puerperal fever at Sunderland, and that gentleman has, with a 
 liberality which does him the greatest credit, declared that in his 
 practice the fever was excited and kept up by contagion." 
 
 (4) Douglas (1. c.) says : " I know that during one of the epidemics 
 [in the Rotunda] an accoucheur attended several women [in Dublin] in 
 their confinement, who all took puerperal fever and died. . . . The young 
 man was so afraid that he had introduced something contagious that 
 he would attend no other crying woman while the epidemic lasted." 
 
 (5) GoocH (' Account of some of the most important Diseases peculiar 
 
 ^ Enumerating the " causa; evidentes " of " febris puerperalium putrida," 
 Willis says (1. c, 129): "Hue faciunt partus laboriosus, circa uterum unitas 
 soluta, contusio, rerum praeternaturalium retentio. dispositio ulcerosa et pleraque 
 alia accidentia, quae necessitate quadam inducuntur."
 
 PUERPEEAL FEVER. 451 
 
 to Women,' Lond., 1829, p. 4) says : " There is still anotber remarkable 
 circumstance in the prevalent or epidemic form of this disease. It is 
 not uncommon for the greater number of cases to occur in the practice 
 of one man, whilst the other practitioners of tlie neighbourhood, who 
 are not more skilful or more busy, meet with few or none. A practi- 
 tioner opened the body of a woman who had died of puerperal fever, 
 and continued to wear the same clothes. A lady whom he delivered a 
 few days afterwards was attacked with and died of a similar disease ; 
 two more of his lying-in patients, in rapid succession, met with the 
 same fate. Struck by the thought that he might have carried the 
 contagion in his clothes, he instantly changed them, and met -vvitli no 
 more cases of the kind. A woman in the country, who was employed 
 as a washerwoman and nurse, washed the linen of one who had died of 
 puerperal fever ; the next lying-in patient she nursed died of the same 
 disease ; a third nursed by her met witli the same fate, till the neigh- 
 bourhood, getting afraid of her, ceased to employ her." 
 
 (6) RoBERTON ('Med. Gazette,' ix, 1831-32, p. 503), in his account 
 of the Manchester epidemic of 1830, says: "Mrs. A. B., a midwife in 
 great practice among the patients of the [Manchester Lying-in] Charity, 
 had on the 4th of the preceding month (Dec, 1830) delivered a poor 
 woman, who soon died witli symptoms of puerperal fever. From this 
 date to the 4th of Jan. inclusive — exactly one month — this midwife 
 delivered thirty women residing in different parts of an extensive 
 suburb, of which number sixteen caught the disease, and all of them 
 ultimately died. These were the only cases of puerperal fever which, 
 had for a considerable time occurred in Manchester. The midwives, 
 commonly twenty-five in number, deliver on an average ninety women 
 per week, which is about thi-ee hundred and eighty in a month. Now, 
 of this number delivered during the month in question, none had puer- 
 peral fever except the patients of Mrs. A. B. Tet all this time this 
 woman was crossing the other midwives in every direction, scores of 
 the patients of the Charity being delivered by them in the very same 
 •quarters where her cases of fever were happening. 
 
 " The decision of the medical officers of the Charity was to the eff'ect 
 that Mrs. A. B. should abandon her practice for a. short period and go 
 to the country. In a short time after this meeting, cases of puerperal 
 fever among the patients of other midwives, as well as in private prac- 
 tice, began to appear in various parts of the towu. In the course of the 
 spring months a great number of women died of this fever. It never 
 prevailed more generally, nor perhaps even more fatally, in Manchester. 
 By about the beginning of June it had disappeared. . . . That the fever 
 was occasionally conveyed directly from the diseased to the whole, I 
 possess other evidence than I have stated, 
 
 " In one instance, within my knowledge, a practitioner introduced the 
 catheter in the case of a poor woman labouring under puerperal fevei', 
 late in the evening; and in the course of the said night he had to 
 attend a lady in her confinement a little way in the coimtry. On the 
 morning of the second day after delivery, this lady had a violent rigor and
 
 452 GEOGKAPHTCAL AND HISTOIilCAL PATHOLOGY. 
 
 the other early symptoms of the malady. In another instance a surgeon 
 was called, while in the act of inspecting the body of a woman who died 
 of this fever, to attend a labour; within forty-eight hours after being 
 put to bed, the woman was seized with the fever." 
 
 (7) Campbell ('Med. Gaz.,' is, 1831, p. 354), writing of the puer- 
 peral fever in Edinburgh, says: "In October, 1821, I assisted at the 
 dissection of a woman who died of the disease, after an abortion of the 
 early months ; the pelvic viscera, with the external coats were removed, 
 and I carried them in my pocket to the class-room. The same evening, 
 without changing my clothes, I attended the delivery of a poor woman 
 in the Canongate ; she died. Next morning I went in the same clothes 
 to assist some of my pupils who were engaged with a woman in Bride- 
 well, whom I delivered with forceps ; she died. And of many others 
 who were seized with the disease within a few weeks, three others shared 
 the same fate in succession." 
 
 (8) Hutchinson mentions the following fact : Two doctors residing 
 ten miles apart met in consultation over a patient with phlegmonous 
 erysipelas who lived at a place midway. At their visit each of them 
 made a free examination of the affected limb and its discharging sur- 
 face with his hands ; within the next thirty or forty hours each of them 
 delivered a woman in his own district, and both women took puerperal 
 fever and died. 
 
 (9) Ingleby (1. c.) is the authority for the following: In 1833 a 
 friend of his in pi-actice in Birmingham attended a lady for phlegmonous 
 erysipelas, and found it necessary to make free incisions into the 
 inflamed part. On the 28th August, at six in the evening, having just 
 done that operation, he attended a lady in her confinement, who was 
 seized with puerperal fever two days after, and died. Another patient, 
 whom he confined the same evening, shared the same fate (Case II). 
 On the 3rd September, or two or three days after the first fatal case, he 
 attended a third labour, and in that case also the woman died of child- 
 bed fever on the third day of her confinement. On Sept. 4 another 
 labour, and again puerperal fever, which in this case fortunately ended 
 in recovery. On Sept. 5 the doctor, with his assistant, made an ex- 
 amination of the body in Case II, and each of them then went without 
 changing his clothes to attend a case of labour ; both tlie women took 
 puerperal fever, and one of them died. Still wearing the same clothes, 
 the doctor delivered yet another woman on the 7th September, and she 
 too died of puerperal fever five days after. Several slighter cases of the 
 disease followed, and he then laid aside his midwifery practice for a 
 time, wherewith the " epidemic " came to an end. 
 
 Another practitionei', who had also been making free incisions into a 
 patient's arm for phlegmonous erysipelas, was called half an hour after 
 to a woman in labour. He found placenta prsevia and did the operation 
 necessary; next day the woman took puerperal fever and died. Six or 
 seven hours after that confinement, the same practitioner was called to- 
 another case of labour; here again childbed fever appeared the day 
 after, but this time it ran a favorable course. In November, 1836,.
 
 PUERPEEAL EEVER. 453 
 
 Dr. Ingleby was present at tlie necropsy of a woman dead of puerperal 
 fever, when the practitioner whose case it was told him that he had 
 ■opened several abscesses shortly before he went to deliver the woman, 
 and that she became ill on the day after her confinement. Dr. Ingleby 
 cautioned him of the risks he incurred, and enjoined him to keep an eye 
 on the other patients whom he had delivered during the last few days. 
 This was on Thursday morning, and on Saturday he came to Dr. 
 Ingleby to say that three more of the women whom he had attended in 
 labour had taken puerperal fever, two of them having been confined on 
 the Tuesday and the other on Thursday. Cases V and VI, which both 
 ended fatally, occurred on the Monday following, and thei-e was a 
 seventh case, which fortunately recovered. This practitioner then gave 
 up his midwifery practice for a time, and the " epidemic " ceased. 
 
 (10) Clark ('Med. Gazette,' v, 1847, p. 331) attended two women in 
 labour in May, 1847, at eight days' interval; both of them took puer- 
 l^eral fever and died. When the first case occurred, he thought that 
 the noxious influences were purely local, in the dwelling, &c., of the 
 patient. But after the second case, he found out the real cause. On 
 the day that he delivered the first Avoman, he had made free incisions 
 into the arm of a sailor who had been admitted into the Colchester 
 Union Workhouse with phlegmonous erysipelas ; he had then gone to 
 attend the labour, and had probably brought the infection to the 
 patient. He at once gave up his midwifery practice for a time ; and, 
 besides those two cases, no more puerperal fever occurred at that time 
 in Colchester, 
 
 (11) Storks ('Prov. Med. Journ.,' 1842, March, No. 15) gives the 
 following history of the Doncaster epidemic of 1841 : "During the 
 whole of the winter of 1840-41, erysipelas, typhus fever, and scarlatina 
 of a malignant form, prevailed in Doncaster to an unusual extent, 
 especially erysipelas, which I have never before known to be so general 
 or severe. Puerperal fever was never known to have prevailed epidemi- 
 cally up to this time, or if it did so, it was never acknowledged. On the 
 night of January 7th, or early on the morning of the 8th, the most 
 aevere night of the winter, when the thermometer was lower than it had 
 been for many years, I attended Mrs. D. (Case I), a hard-working 
 washerwoman, with her tenth child. Her labour was perfectly natural, 
 though rather more severe than she was accustomed to, and she had 
 some severe rigors previous to delivery, which I asci'ibed to the severity 
 of the night. On the morning of the 9th, thirty hours after delivery, 
 she was seized with another severe rigor, succeeded by severe abdominal 
 pain, excessively rapid pulse, and all the symptoms ascribed to puer- 
 peral fever in its severe foi-m. She died on the morning of the 12th. 
 [Than follow seven other fatal cases from 17th Jan. to 27th Feb.] 
 Being now led to suspect that some cxtra-puei'peral causes pi-oduced 
 the mischief, I mentioned the cases which I was most inclined to blame 
 to Dr. Thompson, of Sheffield, who confirmed me in the belief that the 
 fever had probably sprung from them. One was a case which had been 
 in the commencement gangrenous erysipelas of the leg and foot in a
 
 454 GEOGRAPHICAL AND HISTOEIGAL PATHOLOGY. 
 
 stout, gross woman. On looking back at tliis case I recollected ttat I 
 had been called to her on the very evening prior to my attending 
 Mrs. D. (Case I). ... I left off the practice for a month, and am happy 
 to say that since that time I have had but one case to cause me any 
 uneasiness." 
 
 (12) Storrs ('Prov. Med. Journ.,' 1843, Dec, p. 163) gives also the 
 following facts communicated to him by friends : Dr. Reedal, of Sheffield, 
 undertook the treatment of a young man with a suppurating bubo, 
 which had taken on a phagedasnic character. He had never had a case 
 of puerperal fever in his practice before, and no case of the sort had 
 been seen in the town ; but between the 27th October, the day on which 
 he began to treat the bubo, and the 3rd November, five women delivered 
 by him took puerperal fever and died ; in a sixth case the confinement 
 pi'ogressed favorably, and in a seventh the attack of puei'peral fever 
 was mild. Dr. Reedal pointed out that the fatalities had happened to 
 women whom he had been called to after bandaging his bubo-patient,, 
 that they occurred in the most diverse parts of the town, and that as 
 soon as he ceased attendance on the patient with the bubo, he had no 
 more cases of puerperal fever in his practice to deplore. 
 
 Three practitioners who took part in the examination of a person 
 dead of a strangulated hernia, which was found to be gangrenous, were 
 shortly after in attendance on a number of women in labour, several of 
 whom took puerperal fever and died. Thereupon they gave up their 
 midwifery practice for a time, and had no more misfortunes uf that 
 kind among their lying-in patients to blame themselves for. 
 
 (13) Lee ('Med. Gazette,' 1843, Aug., p. 755) relates the following: 
 A doctor in the vicinity of London made an examination on the i6th 
 of March of the body of a woman dead of puerperal pei-itonitis ;^ 
 between that date and the 6th April, thi-ee women confined by him took 
 puerperal fever. Lee himself went straight from a post-mortem on a 
 case of puerperal fever to a woman in labour, who also took the disease. 
 In December, 1830, a midwife of the British Lying-in Hospital, who 
 had two cases of puerperal fever under her charge, made an examina- 
 tion of a pregnant woman, whose labour shortly began, and who 
 sickened and died the day after she was delivered. 
 
 A practitioner in the west end of London, who had to treat a case of 
 phlegmonous erysipelas of the leg with a great amount of discharo-e, 
 lost three of his midwifery patients at that same time from puerperal 
 fever. Lee assisted him at the examination of one of the bodies, and, in 
 spite of every precaution, the two next cases that he attended in. labour 
 took the fever and died. The same misfortune happened to Lee several 
 times afterwards. 
 
 (14) Elkington ('Prov. Med. Journ.,' 1844, January, p. 2S7) nar- 
 rates the following facts concerning the Birmingham epidemic of 1833 - 
 " My attention was first directed to puerperal fever as an epidemic in 
 1833. On the 28th of Aug., 1833, after visiting a bad case of erysipelas 
 at the edge of the town, and making free incisions through the diseased 
 part, I attended Mrs. J., living in the centre of the town, who, after a
 
 PUERPERAL FEVER. 455 
 
 favorable labour, was confined of her second child. She was doing 
 well until the evening of the third day, Aug. 31, when she was attacked 
 with fever and died Sept. 3. On Aug. 28 also I attended Mrs. C. of her 
 first child, and went directly from attending Mrs. J. Mrs. 0. had a 
 severe labour, followed by flooding, and was feverish and poorly from 
 the first day. She was taken worse on the 30th, and died Sept. 4. On 
 Sept. 3 I attended Mrs. E. of her third child. She had a favorable 
 labour, and went on well till the 5th. She was then attacked with 
 fever and died on the 9th. On Sept. 5 I examined the body of Mrs. C, 
 the second patient, assisted by my brother. As we were leaving the 
 house, we received each a message to attend a labour, Mrs. W., my 
 brother's patient, was attacked on the 8th, and died on the nth. 
 Mrs. T., the pei'son I attended, was also attacked on the 8th, but 
 recovered." 
 
 (15) Blackmobe (1. c), in his account of the epidemic of puerperal 
 fever at Plymouth in 1831, says : " Case I of my series was the second 
 of eight or more cases of puerperal fever that occurred in the practice 
 of one accoucheur within a fortnight ; during the next fortnight he had 
 seven more cases, which all ended fatally ; in the week following at 
 least three women delivered by him took the fever, of whom two died ; 
 and several cases occurred in his practice subsequently. I make out 
 that in the practice of this medical man at least eighteen cases of puer- 
 peral fever occurred in rapid succession, most of them at a time when 
 all the other practitioners of the town had not met with a single case 
 of the disease. Scarcely had the malady ceased among his patients, 
 when a second and a third accoucheur had cases of puerperal fever, 
 which were only the beginning of a long series. Between those three 
 series of cases there was no communication whatsoever ; none of the 
 three practitioners had visited the patients of any of his colleagues. 
 The accoucheur was the only medium, so far as was known, of spreading 
 the disease among his patients." 
 
 (16J Simpson ('Edin. Monthly Joum. of Med.,' 1851, July) relates 
 the following : In the winter of 1836-37, Dr. Sidey had five or six fatal 
 cases of puerperal fever in his practice in rapid succession, no other 
 practitioner in Edinburgh having had any. Simpson attended the 
 examination of the body in two of the cases, and took the diseased parts 
 into his hands so as to examine them more closely. The next four 
 women delivered by himself took puerperal fever, and these were the 
 fii'st cases of the disease that he had ever had in his private practice. 
 P(?ddie (ibid.) tells us fiirther that the communication of the disease 
 was not confined to the cases mentioned by Simpson ; a practitioner in 
 Leith, who had examined a piece of the uterus which Simpson had 
 brought home with him, had three cases of puerperal fever among his 
 patients directly after. Another instance given by Simpson is the 
 following: A doctor in Leith made a post-mortem examination of a 
 woman with pelvic abscess ; within the next fifty hours he was called to 
 five cases of midwifery ; in four of these puerperal fever came on ; and 
 in the single case which did well, the child had been born before be
 
 456 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 arrived. Another instance was told to Simpson by Dr. Patterson : A 
 doctor had several cases of puerperal fever in his practice one after the 
 other, whereupon he changed his clothes as a precaution ; the women 
 whom he delivered after that did well, until he happened to put on a 
 pair of gloves which he had been wearing at the time when he was 
 attending the first-mentioned cases, and immediately the disease 
 reappeared among his lying-in patients. 
 
 (17) Fenton ('Brit. Med. Journ.,' 1875, Feb., p. 208) gives an official 
 report upon a small epidemic of puerperal fever at Coventry, which was 
 due to the linen that had been used by lying-in women with puer- 
 peral fever at two charitable institutions having been given to two 
 other women about to be confined; these women took puerperal fever, 
 and the midwives who attended them carried the infection to other 
 cases. 
 
 (18) Punch (' Allgem. Annalen der Heilkunst,' 181 1, p. 329) observes 
 that most of the cases of puerperal fever observed in 1810-11 in the 
 small Saxon town of Landsberg happened in the practice of one mid- 
 wife ; after this woman ceased to attend midwifery cases, nothing more 
 was seen of the disease. 
 
 (19) LiTZMANN (1. c, p. 308) narrates the following in connexion 
 with the epidemic of 1841-42 in the lying-in hospital of Halle: "The 
 disease was not epidemic in the town itself nor in the vicinity ; but in 
 the month of February two women suddenly took it in the town and 
 died, and one woman in the country. All three were delivered by 
 myself, two with the forceps, and the other by accouclieinent force owing 
 to placenta previa. The symptoms and course of the malady corre- 
 sponded exactly to what had been observed at the Institution, and I do 
 not hesitate to assume a transmission of contagion. From that time all 
 the lying-in women escaped the disease, although operative interference 
 was required for several of them. Besides those three cases I could 
 learn of no case of childbed fever at that time outside the Institution." 
 
 (20) KiRCHOFF, in his account of a small epidemic of puerperal 
 fever at Leer in 1852, says that neai'ly all the cases occurred in his own 
 practice or in that of the district surgeon, no serioiis childbed maladies 
 having been reported by the third practitioner or by the midwives of 
 the district. 
 
 (21) Martin (' Monatschrif t fiir Geburtskunde,' x, 259) relates the 
 following incident in the epidemic of 1856 at the lying-in hospital of 
 Munich : '' For a considerable time, in January and February, there 
 had been a cessation of cases of serious illness among the patients in 
 the lying in hospital; when suddenly two women on the same day fell 
 ill with symptoms of the epidemic puerperal fever. They had been 
 delivered on the same day and almost at the same hour ; but for neither 
 of them could an obvious cause of the sickness be found, which would not 
 apply to the i-est of the inmates. At length, after prolonged inquiries 
 into this remarkable occurrence, it came out that an assistant, without 
 the knowledge of the director, had opened the body of a child in the 
 deadhouse some distance off; and, having carefully washed (as he
 
 PUERPERAL FEVEE. 457 
 
 said) "with clilorinatod water, he went and made an examination of 
 those two women, but of no others. As both of these women became 
 ill at an unusually early period after the labour, and as they were the 
 only two attacked of all the lying-in women in the house, the assistant 
 admitted that he was to blame. Ho added that he had done the same 
 thing in December, on the day when puerperal fever first appeared in 
 the institution ; and on that occasion also it was only those women 
 whom he had examined after making the post-mortem examination who 
 fell ill in the first instance." 
 
 (22) ScHULTEN (' Vii-chow's Archiv,' 1S59. xvii, 22S) gives an account 
 of epidemics of puerperal fever at two villages in Rhenish Hesse, where 
 the disease was carried by a midwife from one lying-in woman to 
 others ; in both instances the epidemic ceased as soon as the suspected 
 midwife gave up her duties for a time. 
 
 (23) WEGSCHEiDER('Monatscbr. fiir Gebui'tskde.,' iS64,Feb.) records 
 the following observations : A midwife in Berlin named L. delivered a 
 woman, who took puerperal fever and died. Three days after she 
 attended another woman in labour, who also took the disease and died. 
 After refi*aining from midwifery practice for a short time she undertook 
 three confinements in quick succession, which were all followed by 
 puerperal fever. She now gave up her work for several weeks, religiously 
 discarded her linen, clothes, and instruments, and replaced them with 
 new; and after that had no more of these cases in her practice. A 
 second series of observations is even more remarkable. A midwife 
 named R. delivered four women in one day, who all took inierperal 
 fever and died; on that day the midwife herself had been suifering from 
 commencing rose in the face, and she was afterwards so ill with it that 
 she had to keep her bed for a fortnight, and was not able to resume her 
 work for nearly a week longer. Dr. Wegscheider seriously cautioned 
 the woman not to begin practice again until she had provided herself 
 with new clothes and instruments. However, she gave no heed to this 
 counsel, and resumed work on the 21st October, or nineteen days from 
 the date of the first case that went wrong. Thereupon a woman de- 
 livered by her on Oct. 21st fell ill, then two women on the 25th, another 
 on the 30th, another on the 31st, two on the 2nd Nov., and two on the 
 4th; so that of twenty-two puerperse whom this midwife attended 
 between the 21st Oct. and the 4th Nov., nine fell ill and seven died ; and 
 of the thirteen who did well nearly all were multiparae, with whom the 
 midwife remained only a short time, or found the child born before she 
 came. In judging of that instance the following things should also bo 
 taken into consideration : the cases occurred over a very wide radius of 
 Berlin, in the most diverse parts of the city; at the same time, so far 
 as could be ascertained, only one other of the numerous midwives 
 practising in the same quarters had cases of puerperal fever (three in 
 rapid succession) ; so that there could nctt be the remotest idea of a 
 general diffusion of it throughout the city. 
 
 (24) Mair ('Bayer, arztl. Intelligenzbl.,' 1865, No. 19, p. 269) gives 
 the case of a midwife in Munich, who attended a woman with a severe
 
 458 GEOGRAPHICAL AND HISTOETOAL PATHOLOGY. 
 
 attack of puerperal peritonitis, and infected four puerperse within three 
 weeks. 
 
 (35) Weedmullee (' Monatsclir. fiir Geburtskunde,' 1865, p. 293) 
 narrates the history of an epidemic of puerperal fever in the commune 
 of Maur (Zurich), in which the first person to fall ill had probably been 
 infected through a woman just returned to her home from the lying-in 
 hospital, where she had suffered from childbed fever. The next case 
 was the sister-in-law of the former, and she used the same delivery- 
 stool and had the same nurse. The midwife went straight from this 
 patient to a crying woman in the neighbourhood, who was likewise 
 infected; and in this way the epidemic was prolonged for several 
 months by infection from one lying-in woman to another. 
 
 (26) Stehbeegee ('Monatschr. fur Geburtskunde,' 1866, April) 
 relates that the puerperal fever in Mannheim, which had been very rare 
 previously, and in sporadic cases only (one to three cases in the year), 
 rose to such a height in the spring of 1S65 that thirteen patients died 
 of it in four months. All these cases happened in the practice of two 
 midwives ; whereas the other twelve midwives in the town and the 
 whole of the medical practitioners had only one case of the disease at 
 that time among them, being a case in which ci'aniotomy had been 
 performed, and from which the puerperal fever did not spread. 
 
 (27) Kaufmann gives an account of a slight epidemic of puerperal 
 fever at Diirkheim in 1866 ; five women in childbed were involved in it, 
 who had been delivered by the same midwife one after the other within 
 the space of a few weeks. 
 
 (28) Hahnle says concerning the Schweningen epidemic of 1879, 
 that the whole of the fourteen cases (among thirty-four confinements) 
 occurred in the practice of one midwife, while the other midwife in the 
 place, Avho had just as much to do, had not a single case to report. 
 
 (29) HuGENBEEGEE (I. c, p. 49) writes: "Having made a post- 
 mortem examination immediately before, Dr. Etiinger (in 1847) infected 
 a woman in labour in the institution [St. Petersburg Obstetric Insti- 
 tute], and a lady in the city whom he had occasion to examine after 
 abortion ; both died of pyaemia. Twice, under the same circumstances, 
 I had myself the misfortune to infect lying-in women with cadaveric 
 poison in making an examination or in removing the after-birth. 
 Although we have taken the greatest care about the examination of 
 dead bodies at our institution since that time, it cannot be doubted 
 that many other casualties beyond our control have occurred thi'ough 
 the negligence of the service." 
 
 (30) Oadeeschjold (1. c.) points out, in his report on the epidemic 
 of 1825-26 at the Stockholm lying-in hospital, that Dr. Idstrom, having 
 made an examination of the body of a patient dead of puerperal fever, 
 saw that disease ensue in five successive cases of labour which he 
 attended outside the hospital. 
 
 (31) Cadeeschjold ('Svenska Lakare Sallskapets nya Handl.,' ii, 
 32) also narrates the following incident in connexion with the general 
 lying-in hospital of Stockholm in 1832: "On the 27th October a
 
 PUERPERAL FEVER. 459' 
 
 patient who had been delivered with the forceps took puerperal fever. 
 The midwife who attended this case delivered two women between the 
 28th and 31st October, both of whom took puerperal fever and died; 
 at the same time three women delivered by other midwives did well. 
 This incident gave new vitality to the idea that puerperal fever may be 
 propagated under certain circumstances by contagion; and in the 
 inquiry that followed, it came out that there had been neglect of a rule, 
 introduced several years before, to the effect that each patient should 
 be washed with her own sponge assigned to the particular bed, and dried 
 with her own towel, and that the sponge was to be boiled before it was- 
 used for another lying-in patient. This rule was now revived, and 
 there were no moi*e cases of the disease until the 17th of November." 
 An incident of vei-y much the same sort is related by Elliot (ib., iii, 238) 
 of the same lying-in hospital in 1839. 
 
 (32) Speyer, writing of the epidemic of childbed fever at Aalborg 
 in 1844, says that, of twenty-two women who were confined there 
 between the 6th Nov. and 12th Dec, eight took the disease and seven 
 died. Of the whole twenty-two cases, seventeen were attended by one 
 midwife and five by another ; all the cases of sickness and death occurred 
 in the practice of the former, following one another at intervals of from 
 three to fifteen days. Speyer lays special stress on the fact that this, 
 midwife paid the greatest attention to her puerperal-fever cases, re- 
 maining with them as long as her time permitted, and going straight 
 from them to other women in labour when she was called to them. 
 
 (33) Stage (' Undersogelser angaaende Barselfebern i Danmark 
 udenfor Kjobenhavn,' Kjiib., 1868) gives an account of a number of 
 small epidemics of puerperal fever in various towns and country 
 districts of Denmark. In 1850 an epidemic of that kind sprang up in 
 the vicinity of Aarhuus ; nine women Avere attacked, who had all been 
 delivered by the same midwife; whereas the other midwife of the place 
 did not have a single case. The same thing was observed in 1855 in 
 the case of five women at Skibby, in 1 859 on the island of Bogoe, at 
 Frederickshavn in 1862, and Erdboebrug in 1864. In the last of these,, 
 the infection probably started from a case with pyajmic abscesses, which 
 the midwife had tended with special care. On Langeland in 1864, all 
 the women delivered by one midwife between the 29th June and the 
 1 8th July, nine in number, were seized with j)uerperal fever. Besides 
 these, one other lying-in Avoman took the fever, having been attended 
 by another midwife, who liad administered an enema to one of the first 
 series of cases, and had directly after used the same syringe for her 
 own patient. On the first midwife ceasing from practice the epidemic 
 stopped. 
 
 (34) Grisar (' Bull de I'Acad. de med. de Belgique,' 1864, No. 7) has 
 the following: In the end of December, 1842, he attended a woman in 
 labour, who took puerperal fever and died. From that date to the 
 following March, out of sixty-four women delivered by him, sixteen had 
 the fever and eleven died of it; meanwhile there were no cases of 
 puerperal fever in the practice of his colleagues. The same thing
 
 460 GEOGRAPHICAL AND HISTOKICAL PATHOLOGY. 
 
 happened again in his practice towards the end of 1862 ; of nine women 
 whom he confined between the 5th Dec, 1S62, and 26th Jan., 1863, 
 eight had the disease and four died of it. 
 
 (35) VoiLLEMiER records the following : M. Depaul, interne in the 
 Paris Maternite, was called to attend a lady in the town, at a time when 
 there was an epidemic of childbed fever in the lying-in hospital. He 
 had made an examination of one of the dead bodies shortly before going 
 out to his patient, who took puerperal fever in due course and died. 
 
 (36) Arneth (' Ueber Geburtshi'ilfe und Gynjikologie,' Wien, 1853, 
 p. 52) mentions a case told to him by Dubois, in which a medical fi'iend 
 of the latter, who carried on a small lying-in hospital in the country, 
 infected two women with fatal puerperal fever, the reason of which was, 
 as he seemed to think established beyond all doubt, that he had pre- 
 viously made a post-mortem examination. Since that time Dubois 
 gets women from the town to come for the examination-practice by 
 paying them, so as to ensure that these examinations shall not be 
 made on women who are on the point of being confined. 
 
 (37) RoBOLOTTi (' Giornale della soc. italiana d'igiene,' 1879, No. 6, 
 p. 700) gives a number of instances at various places in Lombardy, in 
 which puerperal fever was epidemic among the patients of one medical 
 practitioner or of one midwife; as at Cicognolo in 1870-73, Rivarolo in 
 ■1874, Scandolara in 1878, and Olmeneta in 1879. 
 
 (38) RiGLER (1. c, p. 240), referring to the cases of childbed fever 
 which he had himself seen in Constantinople, says : " There has never 
 been a contagion of the volatile kind observed ; but we are inclined to 
 think that contact of the pudenda of a woman in childbed by hands 
 not absolutely cleansed from the discharges of a septic patient may 
 have serious consequences." 
 
 (39) Paley ('Med. Gaz.,' Dec, 1839, "^^l- h n- s., p. 397) writes as 
 follows from Halifax : " During my attendance [in consultation] on the 
 first case [gangrene of the scrotum] one morning, whilst the surgeon 
 was dressing the patient, the scrotum and penis being in a gangrenous 
 state, a messenger came to request him to go to a woman in labour, 
 wlio resided about half a mile from our patient; and he obeyed the 
 summons without loss of time. Four or five days after this, on meeting 
 again, he said, ' You will recollect that I was sent for to a woman in 
 labour on such a day.' I replied, ' Yes ; what of that ?' ' She is dead; 
 everything seemed to be going on well until yesterday, when she was 
 seized with violent pain in the region of the uterus, and she died before 
 I had time to do anything to relieve her.' In the course of two or 
 thi-ee days, on meeting again, he said, ' It is very odd, Dr. Paley, I have 
 lost another patient in the same unaccountable way as before;' and the 
 next morning, at our meeting, he stated that he had another patient, 
 about two miles off, seized in the same manner, whom he requested me 
 to visit along with him. After seeing his patient, I told him that she 
 was labouring under puerperal fever, and before we left the house he 
 was sent for to visit another woman whom he had attended in labour 
 in the same village. I accompanied him, and found her also the subject
 
 PUERPERAL FEVER. 46 i 
 
 of puerperal fever. I believe tbat lie liad in all six cases of this disease. 
 . . . There is not the slightest doubt on my mind that the surgeon who 
 was in attendance was the means of communicating something (call it 
 what you please) from the patient labouring under the disease of the 
 scrotum to the lying-in women, which in them produced puerperal 
 fever. ... I pointed out these circumstances to the surgeon, and, at the- 
 same time, advised him to go from home two or three weeks, and to 
 have his clothes washed and fumigated. He did so, and the plague 
 (for such it seemed) ceased." 
 
 (40) Warrington (' Transact, of the Coll. of Phys. of Philad.,'^ 
 1842) stated in the course of a discussion on the conveyance of puer- 
 peral fever by third parties, that he had confined three women in quick 
 succession after having made an examination of the body of a patient 
 dead of puerperal peritonitis, and they all took puerperal fever one after- 
 the other. In like manner West said that, under the same circum- 
 stances, seven patients delivered by Dr. Jackson all took puerperal 
 fever, and five of them died. 
 
 (41) Holmes ('New Engl. Pract. Journ. of Med.,' 1843, -April, 
 p. 503) gives the following cases : A doctor examined the body of a 
 man who had died of gangrene of the leg, and next day he attended a 
 labour ; this woman, and six others whom he delivered in the time 
 immediately following, took puerperal fever. Another doctor, who had 
 five cases of puerperal fever in quick succession, writes to Holmes that 
 he had occasion to treat a patient with malignant erysipelas just before 
 the first of these cases, and that he had probably been himself the- 
 medium of spreading the disease. 
 
 (42) Leasure ('Amer. Journ. of Med. Sc.,' 1856, Jan., p. 4,5) says^ 
 that when malignant erysipelas was prevalent at Newcastle, Pennsyl- 
 vania, in 1852, all the cases of midwifery in his own practice and in 
 that of another doctor got puerperal fever ; and he expresses his con- 
 viction that they had themselves carried infection to the women in 
 labour. Many other observations of the same kind are recoi'ded by 
 Holston, Galbraith, Minor, Ridley, and other American practitioners 
 for the period of the great erysipelas epidemic ; and to these I shall 
 return later on. 
 
 (43) Perkins ('New York Journ. of Med.,' 1852, May, p. 330), in his 
 account of the epidemic of 1850 at a New York lying-in hospital, says: 
 " As to the cause of the endemic, I have every reason to believe that a 
 post-mortem examination of the body of Mary Murray, who was brought 
 into the hospital on the 25th November, and who died in an hour after 
 admission of a peritonitis, which had resulted in a purulent efiusion, 
 was (through the necessities of the case) the prime cause of the endemic 
 which followed .... The first case which occurred was delivered by the 
 same hand which made the autopsy, on the afternoon of the day on 
 the evening of which the woman was delivered." 
 
 (44) Levergood ('North Amer. Med.-Chirurg. Rev.,' 1857) I'elates 
 that Dr. Lloyd, being then engaged in the surgical treatment of a case 
 of phlegmonous erysipelas, delivered three women, who took puerpei-al
 
 462 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 fever and died, although there was not the faintest trace of epidemical 
 influence to be discovered, nor anything amiss in the hygienic sur- 
 roundings; at the same time the patients delivered by other prac- 
 titioners passed through childbed without mishap. Dr. Lloyd, who 
 was in much request as an accoucheur, transferred his erysipelas case, 
 and had no misfortunes in his midwifery practice after that. 
 
 (45) Feris ('Arch, de med. nav.,' 1879, Oct., p. 253), in his account 
 of the disastrous prevalence of puerperal fever at Monte Video in 1875, 
 states that the number of cases diminished considerably after the mid- 
 wives in attendance on patients with childbed fever had been forbidden 
 to wait on other women in labour or lately confined. 
 
 (46) Hall (1. c), writing from Tasmania, says that if a practitioner 
 has had to treat a case of puerperal fever, he may expect, just as in the 
 Old World, soon to have other cases of the same disease in his practice. 
 
 All these observations, wliicli I could easily liave trebled, 
 are taken from the most diverse parts of the world, and they 
 all tell one way. The significance which they seem to me 
 unquestionably to possess is in proving experimentally the 
 ■origin of puerperal fever by direct conveyance of a noxious 
 substance, without any need or even justification for assuming 
 that there had been influences of a general kind at work in 
 the pathogenesis. It is the great merit of Semmelweiss, 
 as I have already mentioned, to have solved the problem in 
 this sense by exact research; and his merit will not be 
 lessened by the fact that, in forming his conclusions from 
 the data furnished by the lying-in hospital of Vienna, he 
 took up a one-sided point of view. 
 
 The statistics of confinements, and of deaths from childbed fever, in 
 the great Maternity Hospital of Vienna during a space of sixty-two 
 years (1800— 1S61), tend to show that the rate of mortality in that 
 time may be diff"erentiated according to three well-marked periods : 
 
 Deaths from Death-rate 
 
 Confinements. puerperal fever. per cent. 
 
 First period (1800— 1822) . 47,409 ... 683 ... 1-44 
 
 Second „ (1823— 1846) . 100,448 ... 6331 ... 6-30 
 
 Third „ (1847— 1861) . 113,710 ... 3509 ... 3-17 
 
 But a study of the figures brings out another point. In 1833 the insti- 
 tution was divided into two sections, one of which, the First Clinique, 
 was for the instruction of students, and the other, the Second Clinique, 
 for the training of midwives. Although the two divisions were separated 
 by thm partitions only, and were perfectly alike in all other respects, 
 the death-rate among their respective inmates showed the following 
 diiierences :
 
 PUERPEEAL FEVER. 463 
 
 
 First or Students' 
 
 Second or Midwives' 
 
 
 Clin'ique. 
 
 Training Wards. 
 
 1833-39 • 
 
 6' 2 2 per cent. 
 
 573 pel" cent. 
 
 1840-46 . 
 
 • 9'76 
 
 3-83 „ 
 
 1847-61 . 
 
 • 3'3i 
 
 2-92 
 
 From 1820 to 1822 the deatli-rate from cliildbed fever in the Vienna 
 Lying-in Hospital was nearly the same as in many other large maternity- 
 institutions. With the year 1823 a rise began, which reached an 
 enormous height; and from 1847 there was a decline, which brought 
 the mortality down nearly, if not altogether, to the level of the first 
 period. Comparing the death-rate in each of the two divisions which 
 had been formed in 1833, we find that from 1833 to 1839 it was nearly 
 the same in both ; while from 1840 to 1846 it rose more than fifty per 
 cent, in the first, and fell nearly fifty per cent, in the second; and 
 since 1847 it has fallen in the First Clinique to one third of its previous 
 maximum, thus bringing the death-rate to a uniform mean in the two 
 divisions. The conclusions may be stated as follows : For the period 
 ending with 1822, the sick-rate for puerperal fever in the Vienna 
 Lying-in Hospital depended on influences which were common, more or 
 less, to all similar institutions; after 1823 a new factor came into 
 force, which acted continuously down to 1846, and caused a vei-y 
 material increase in the number of cases and in the mortality; and 
 that factor was shown by Semmelweiss to be indirectly derived from 
 the flourishing state of morbid anatomy in the Vienna School during 
 those very years. " The anatomical vogue," says Semmelweiss, "brought 
 to the professors, assistants, and students many opportunities of coming 
 into contact with dead bodies. It is evident fi-om the cadaveric odour 
 which the hands will retain for some time, that the ordinary mode of 
 washing the hands with soap does not altogether sufiice to remove the 
 cadaveric particles clinging to them. In examining women in preg- 
 nancy, or during the labour, or in the course of the confinement, the 
 hand tainted with particles from dead bodies comes into contact with 
 the genitals, so that cadaveric matters have the chance of being absorbed 
 and of passing into the vascular system," and thereby of causing 
 septicajmia in the patient. In the following figures we have absolute 
 proof of the correctness of that doctrine : The enormous increase in the 
 mortality (to six per cent, average) which followed the rise of the fashion 
 of post-mortem inspection, lasted from 1823 to 1832, while the institu- 
 tion was undivided; and continued also from 1833 to 1839, after its 
 division into two, or for so long as doctors and midwives were assigned 
 for their instruction to both divisions in equal proportions. From 
 J840 to 1846 the gross mortality continued about the same; but there 
 is this distinction to be made between it and that of the former period, 
 that in the first division, now reserved for the instruction of practi- 
 tioners, who were the real agents of conveying the infection, it rose 
 just as much as it fell in the second division now set apart for the 
 training of midwives, who had nothing to do with morbid anatomy. 
 Coming to 1847, we see the death-rate in the first division falling almost
 
 464 OROGRAPHIC AL AND HISTORICAL PATHOLOGY. 
 
 to the level of that iu the second ; and we discover tlie explanation in 
 the practice introduced by Semmelweiss, who was then an assistant in 
 the first division. " Let ns assume it to be true," he says, " that 
 cadaveric particles clinging to the hand can induce the disease. Then 
 by completely destroying these particles through chemical means, and 
 thereby providing that the generative organs of pregnant or puerperal 
 women shall be touched by the finger merely, and not by particles 
 adhering to it, we ought to be able to prevent the disease — in so far as 
 it is due to dead-house matters introduced in the course of the digital 
 examination." Inspired by this idea, Semmelweiss in 1847 procured 
 the adoption of the rule that teachers and students should wash their 
 hands with chlorinated water before making an examination, or coming 
 in any way into contact with the sexual parts of women in laboxir or 
 in childbed ; and ever since that time the sick-rate and death-rate from 
 puerperal fever in the Lying-in Hospital of Vienna have fallen so 
 materially, that one cannot well hesitate to ascribe the remarkable 
 decrease in the disease to these preventive measures, just as we ascribe 
 its former prevalence in great part to those noxious influences. 
 
 In this way Semmelw^eiss founded the doctrine of the 
 septic nature of puerperal fever. At the same time he laid 
 emphasis on the local character of the infection, by proving 
 that the infective matter was conveyed by the hand of the 
 practitioner or midwife ; and thus he provided a basis for 
 the doctrine that child-bed fever is a traumatic septic process, 
 to which every puerpera is liable, because the mucosa on the 
 inner surface of the uterus is laid bare as if it were a 
 wounded surface ; while most puerperal women are further 
 predisposed on account of more or less considerable laceration 
 of the cervix or of the vagina or of the external parts, 
 caused either by unskilful handling or by the foetus in 
 transitu. The conclusion which Semmelweiss drew from 
 these facts was no doubt one-sided, inasmuch as he traced 
 the sepsis exclusively to transmission of the so-called 
 cadaveric poison: It is beyond question that the infecting 
 matter may come from putrefactive changes essentially 
 belonging to the puerperal process itself ; and it stands to 
 reason that these will make themselves the more felt the 
 more abundantly they are produced in overcrowded wards, 
 or under whatever circumstances cleanliness and ventilation 
 are rendered most difficult. Moreover, as we may gather 
 from many of the observations above quoted, the infecting 
 substance may come from the pus and ichor that are gene-
 
 PUEEPEEAL PEVEE. 465 
 
 rated iu various forms of disease. Again, transmission of 
 infection is by no means restricted to the hands of the 
 accoucheur or midwife ; experience teaches us that it may- 
 take place by means of their clothes, or through instruments 
 (catheters, syringes, &c.), by sponges, bedding, bed-linen 
 and the like, or, lastly, by the air entering with the finger 
 or instrument introduced into the vagina or uterus,^ perhaps 
 even by means of air entering by aspiration. Furthermore, 
 the observations given above afford a most interesting 
 explanation of the disease spreading, as it is known to 
 spread, from lying-in hospitals to women confined at their 
 own homes ; as well as of the so-called " epidemics " of 
 puerperal fever outside lying-in hospitals, which are really a 
 series of infections from case to case, the active media 
 being one or more practitioners or midwives, and the " epi- 
 demic '^ being confined, as has been often noticed, to the 
 practice of one practitioner or one midwife. 
 
 § 170. Relation to MicEo-oEaANiSMs. 
 
 Up to this point in the discussion of the question I have 
 used the current phrase of '' septic disease." The term has 
 still a use and meaning, in so far as it denotes the relation- 
 ship that may be discovered between putrefactive micro- 
 organisms and the morbific cause which underlies the devel- 
 opment and propagation of these diseases. In the morbid 
 pi'ocess itself there can be no thought of " sepsis ;" the 
 demonstrated fact that organic bodies (micrococci) are 
 uniformly found in the " septically '^ affected tissues warrants 
 us in concluding that the products of putrefaction are not in 
 themselves the excitants of disease, but that the micro- 
 organisms stand in some direct relation to the pathogenesis, 
 although for the present we are ignorant of its intimate 
 nature. And that conclusion is all the more justified, since 
 proof has been given experimentally, by artificial infec- 
 tion of animals, that these organisms have a disease-producing 
 action. From the researches of Recklinghausen,^ Waldeyer,^ 
 
 ^ See Spiegelbcrg, ' Bcrl. kl'ui. Wochonscli.,' 18S0, No. 22. 
 
 * ' Verliandl. der pliys.-med. Gescllsch. zii Wiirzburg,' 1871, Sitzuugsbjr., xi. 
 
 2 ' Arcliiv filr Gynakologle,' 1872, iii, 293. 
 
 VOL. ii. 30
 
 466 GEOGEAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Heiberg/ Bircli-Hirsclifeld/ Orth/ Ebertli/ Landau/ and 
 others, that proposition holds good for childbed fever among 
 other diseases of the kind. We should thus regard puer- 
 peral fever as being also a process of disease due to parasites, 
 although we should not therefore be justified in speaking, as 
 many observers do, of a specific virus of puerperal fever, 
 just as we speak of the virus of smallpox or of scarlet fever. 
 The facts that have been adduced in detail in the preceding 
 pages serve to show that this virus inheres equally in the 
 products of cadaveric decomposition, and in those of sup- 
 purating or ichorous tissues in diseases of all kinds ; while 
 the experience of lying-in hospitals teaches us that the same 
 virus can develop in the putrefying membranes and lochia 
 when brought into contact with the air, as well as in the 
 morbid products which arise in the course of childbed fever 
 itself. On the other hand, there are many observations to 
 prove that practitioners, midwives, nvirses, infants, and 
 others, who have come into close contact with puerperal-fever 
 patients, may be infected by the latter, such infection leading* 
 always to an attack of one or other of the so-called "septic" 
 diseases. 
 
 Accordingly, whether we regard puerperal fever from the 
 anatomical and clinical point of view, or from the etiological, 
 it ranges itself with the traumatic septic diseases ; and it is 
 distinguished from other forms of disease belonging to the 
 same group merely by having a special stamp impressed upon 
 it from the peculiar physiological state of those who are its 
 victims. 
 
 § 171. Causal Connexion with Eeysipelas. 
 
 I have one more point in the natural history of childbed 
 fever to discuss, which has a peculiar interest for practice. 
 
 ' In ' Vircliow's Arcliiv,' 1872, Ivi, 407, and 'Die puerperalen und pyamischeu 
 Processc,' Leipz., 1873. 
 
 ^ 'Arcliiv der Heilkde,' 1873, xiv, 193. 
 
 3 In ' Virchow's Arcliiv,' 1873, Iviii, 437, and 'Arch, fiir experim. Pathol.,' 
 1873,1,81. 
 
 * ' CentralW. fiir die mcd. Wissensch.,' 1873, Nr. 8. 
 
 '" ' Archiv fur Gyniikol.,' 1874, vi, 147.
 
 PUERPERAL FEVEE. 467 
 
 I mean the connexion between that disease and erysipelas. 
 Pouteau was the first, so far as I know, to describe puerperal 
 fever as " erysipelatous inflammation of the peritoneum/' 
 This is a view of the morbid process arising more out of the 
 nosological fashion of the time^ than from any anatomical, 
 clinical, or etiological facts. Among the English accoucheurs 
 of the end of last century, such as Johnstone^ and Home," 
 it found a ready acceptance, all the more so that the some- 
 what frequent coincidence of erysipelas — or of what the 
 profession in England called erysipelas — with puerperal fever 
 in epidemics gave support to the idea. At length it came 
 to pass that English practitioners hardly doubted the kin- 
 ship between childbed fever and erysipelas ; and Nunnelly^ 
 went even so far as to say : '^ This much at least I am sure 
 of, that many questions in medicine, which by common con- 
 sent are regarded as settled, do not rest upon stronger evi- 
 dence, if so strong, as that which has been now adduced in 
 favour of the identity of erysipelas and puerperal fever. ^' 
 
 The facts upon which the idea of an etiological connexion 
 between erysipelas and puerperal fever is based, are the 
 following : 
 
 (i) The coincidence in time and place of the two diseases in 
 epidemic form, hoth in lying-in institutions and among the 
 population at large. 
 
 Data on this point are furnislied by the following writers : Clai-ke, iu 
 liis account of the cbildbed fever of 1787-88 in the Ijing-in hospitals 
 of London; Gordon, in liis narrative of the disease in 1789-92 at the 
 lying-in hospital and in the New Town of A.berdeen ; Hey, from obser- 
 vations in Torkshh-e, 1808-12; West for Abingdon, 1 8 13-14 ; Douglas 
 for Dublin, 1819-20; Blackmore for Plymouth, 1831 ; Sidey for Edin- 
 burgh, 1825-26; Elkington and Ingleby for Birmingham, 1833; Beatty 
 for Dublin, 1830-37, and M'Clintock for the same, 1845-46; Ackerley* 
 for London, 1838 ; and Fox,' from the record of the lying-in charities of 
 London fi-om 1833 to 1858. Similar experiences are recorded by Hodge 
 and "Wilson for the lying-in hospital of Philadelphia, where numerous 
 cases of erysipelas had been noticed every time that puerperal fever 
 
 1 * Observationes de febre puerperal!,' Edinb., 1779. 
 
 2 'Clinical Experiments, Histories and Dissections,' Lond., 1780, 183. 
 * ' Treatise on the Nature . . of Erysipelas,' Lond., 1841, 89. 
 
 ^ ' Lond. Med. Gaz.,' 18.^8, June, 463. 
 
 « ' Transact, of the Obstetr. See.,' 1862, iii, 368.
 
 468 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 occurred, and by nearly all the practitioners wlio wrote ou the severe 
 epidemics of erysipelas in America in 184 1 and following years. 
 
 From the reports hy Schaffer and Jespersen on the childbed fever 
 of 1844 in the Sanitary District of Aarhuus, it appears that malignant 
 erysipelas had been widely diffused at the very same time ; and that was 
 also found to be the case, according to the official report, on the island 
 of Bornholm in 1848. From Germany we have accounts to the same 
 effect for the "Vienna Lying-in Hospital from iSi9toi86i;^ for Neuenhaus 
 1827-28 ; for the lying-in institution at Wiirzburg 1835 and 1846; the 
 Stuttgart Maternity 1849 5 ^^^ Lying-in Hospital of Prague, 1861 ; and 
 the midwifery wards of the Berlin Charite, 1879." In the Paris lying-in 
 hospitals many coincidences of the two diseases have been noticed, an 
 enumeration of which down to 1 848 is given by Masson.' The following 
 account, by Pihan-Dufeillay, of the epidemic of puerperal fever in 1861 
 at the Hopital St. Louis has a special interest : About the end of 
 January or beginning of February an epidemic of puerpei'al fever bi'oke 
 out among the patients in the lying-in wards. Notwithstanding the 
 excellent sanitary arrangements of the wards, it quickly assumed so 
 malignant a character that new admissions were stopped and the 
 patients (whether with puerperal fever or free from it) removed to other 
 wards. Into the wards thus emptied were transferred thirty-two women 
 suffering from chronic skin-diseases, among whom many cases of erysi- 
 pelas soon appeared, some of them being of a very severe type, and one 
 (in a syphilitic subject) ending fatally as rose in the face. Among 
 more recent accounts of the two diseases occurring together in French 
 lying-in hospitals are those relating to the Mafcernite of Lyons'* in 1866, 
 the Hopital de la Pitie* of Paris in 1S68, and the Hopital St. Antoine*' of 
 Paris in 1869. 
 
 (2) Tlie familiar fact that women in labour, attended by 
 doctors or midwives ivho ivore suffering themselves from erysi- 
 pelas or had come into contact with erysipelas patients, Jiave 
 tahen inierperal fever . 
 
 A number of instances of this will be found in the series of cases 
 above given (7, 8, 9, 10, 11, 13, 14, 44,), where doctors or midwives carried 
 
 ^ "As regards erysipelas," says Spiith, "it is impossible to deny that it has 
 some intimate connexion with puerperal fever ; although, during the epidemic 
 of the former in Vienna and the vicinity in 1853, the state of health among the 
 patients of the lying-in hospital was good. . . . In 186 1, erysipelas had been 
 seen from time to time in the Vienna Obstetrical Clinique for Midwives and 
 Pi-actitioners just before the epidemic of puerperal fever broke out in it." 
 
 " See Runge, 1. c. 
 
 ^ ' De la coincidence des epidemics des flevres puerperales et dcs epidemics 
 d'erysipMe, de I'analogie et de I'identite de ces deux maladies,' Paris, 1849. 
 
 * Fonteret, 1. c. 
 
 * Ref. in ' Gaz. des hopit.,' 1869, Nr. 33. 
 ^ Lorain, 1. c; Quinquaud, I. c, 32.
 
 PUERPERAL FEVER. _ 469 
 
 tlie infection. Many of the American authorities, such as Hall, Dexter, 
 Holston, Corson, Leasure, Galbraith, and Minor, are emphatic in saying 
 that cases of sickness among puerpera) during the great epidemics of 
 erysipelas occurred mostly in the practice of those who had erysipelas 
 patients and had gone direct from these to their patients in labour or 
 in childbed. The i-emarkable case recorded by Wegscheider has been 
 given already at p. 457. The slight epidemic of puerperal fever at 
 Reichenbach in 1872 arose in the same way, according to the account 
 by Kraus : the midwife of the place was attacked with erysipelas of the 
 face, and was still in the stage of scaling, when she delivered (Oct. 2) a 
 woman at Reichenbach, who fell ill in the course of two days and died 
 on the day following. During October and November this midwife 
 delivered nine other women, who all took puerperal fever, seven of them 
 dying of it. At that time erysipelas was epidemic in Reichenbach and 
 vicinity ; in Reichenbach itself there were eight persons suffering with 
 rose in the face, and in two of these cases the disease had a fatal issue. 
 The following case was communicated by Dr. Freer to Spencer Wells, 
 who quoted it in the discussion on puerperal fever at the Obstetrical 
 Society -.^ 
 
 " Two years since I was engaged to attend the wife of a clergyman in 
 her first confinement — a very fine healthy lady, aged 26. Upon entering 
 the bedroom, I found a nurse in attendance with an erysipelatous blush 
 and swelling upon the side of the face. Upon inquiry she told me that, 
 two days before, she had been in Liverpool Hospital to have a nasal 
 duct opened. My patient was seized with rigors at the end of thirty 
 hours and died of puerperal fever on the eighth day. The nurse died 
 of rapid erysipelas of the head and neck on the twelfth day." 
 
 (3) The converse fact to (2), i\\Vit doctors, midwives, nurses ^ 
 
 or other individuals tvho come into close contact with jpuerperal- 
 
 fever patients, suffer from erysipelas remarkahly often ; also 
 
 that the newhorn infants of mothers tvith puerperal fever die 
 
 of erysipelas in an unusually large ratio. 
 
 Of this also there is evidence in several of the observations already 
 given. Lee" mentions a case in which the doctor, the nurse and the 
 child, all took erysipelas from the puerperal fever of the mother. Sidey^ 
 speaks of a case in which five persons in the family of a lady with 
 puerperal fever were attacked with erysipelas a few days after the death 
 of the latter. Kraus concludes his account of the Reichenbach epi- 
 demic of childbed fever with the remark that four of the newborn 
 children whose mothers were seriously ill, took erysipelas when a few 
 days old, the inflammation spreading over the whole body and ending 
 fatal]y in two cases. Squire^ gives the following case : Having come 
 
 1 ' 13rit. Med. Journ.,' 1875, July, p. 105. 
 
 * ' Edinb. Monthly Journ. of Med, Sc.,' 1847, April, 793. 
 3 'Edinb. Med. and Surg. Journ.,' 1839, Jivu., 92. 
 
 * 'Brit. Med. Journ.,' 1875, May, 673.
 
 470 GEOGRAPHICAL AND HISTOIilCAL PATHOLOGY. 
 
 straiglit from visiting a patient witli traumatic erysipelas, he delivered 
 a woman who died on the sixth day ; two days later the husband died. 
 Shortly after, another woman, who had come out of the house where 
 the erysipelas patient was, took puerperal fever and died ; and then 
 there occurred in rapid succession eight more cases of erysipelas (three 
 of them fatal) among persons who could he shown to have visited either 
 the first erysipelas case or the second puerperal case, having themselves 
 some slight abrasions of the skin. 
 
 (4) The fact vouched for by many observers that childbed 
 fever itself has not unfrequently an erysipelatous character, if I 
 may so h;peak ; or in other words^ that the disease begins to 
 develop from an erysipelas ivhich mostly arises in the lacerated 
 vaginal mucous membrane. 
 
 I am aware that many of the above observations and 
 many more of the same kind (especially some of those from 
 English sources), which have been adduced to prove the 
 intimate or genetic connexion between childbed fever and 
 erysipelas, do not possess the value of evidence inasmuch as 
 they relate, not to erysipelas, but to diffuse phlegmon of the 
 connective tissues and such-like processes -, also that erysipelas 
 neonatorum is in many cases to be taken as not true erysi- 
 pelas, but as septic phlegmon of the connective tissue. But 
 there will always be a great many cases remaining in which 
 no such reserve is called for ; cases* where there had un- 
 doubtedly been " erysipele legitime " which had given rise to 
 childbed fever just as the infection from a patient with 
 puerperal fever has given rise to the same. Volkmann,^ who 
 shares the scepticism above referred to, and who is certainly 
 not open to the charge of using the term " erysipelas " in too 
 wide a sense, admits that " when simple erysipelas is abroad, 
 there is no doubt that there are sometimes influences at work 
 which generate puerperal fever, when women newly delivered 
 are exposed to them." Of the nature of these influences 
 I am unable for the present to form an opinion. I leave it for 
 discussion whether Tillmanns" is right when he says (as other 
 observers also say) that " it may be taken as jaroved that 
 many forms of so-called 'puerperal fever' are true erysipelas 
 which had started in lacerations at the entrance of the genital 
 
 ^ In Pitha and Eillroth's ' Handbuch der Clururgie,' Bd. i, Abth. ii, A, p. 161. 
 " L. c, p. 46.
 
 PUERPERAL FEVER. 471 
 
 passages;" or wliether Hugenberger^ is more correct in his 
 view of the relationship o£ the two diseases, when he says that 
 puerperal fever and erysipelas have one and the same cause, 
 namely, ^^ septic" infection, and are therefore to be regarded 
 as co-ordinate eifects. Before we can decide whether this 
 theory can be reconciled Avith the latest discoveries of 
 Pehleisen," we shall require to have the researches in that 
 direction continued. 
 
 List op Writers on Puerperal Fever.^ 
 
 Ablfelcl, in Schmidt's Jahrb. der Med., 1877, August. Armstrong, in 
 Edinb. Med. and Surg. Journ., 18 14, Oct., 444; and Facts and Observ. 
 relating to the Fever commonly called Puerperal. Lond., 1814 (2nd edit.), 
 1819. Aubinais, Journ. de mcd. du Depart, de la Loire inferieure, 1850, 
 xxvi, 210. 
 
 Baart de la Faille, in Nederl. Tijdsclir. voor Geneesk., 1854, Novbr. 
 Bang, Selecta Diarii Nosoc. reg. Friederic. Hafn., 1789, ii, 240. Barker, 
 in New York Journ. of Med., 1858, May, 377. Bartholin, Act. med. Havn. 
 Ann. 1671-72. Hafn., 1673, 65. Bartsch, in Oester. med. Jahrbiicher. 
 Neuesto Folge, x, 123. Bayrhofer, Bemerkungen iiber das epidemische 
 Kindbettfieber. Frankf. a. M., 18 12. Beatty (I), in Dtfblin Journ. of Med. 
 Sc, viii, 76. Beatty (II), ibid., xii. Baudelocque, Abhandlung iiber die 
 Bauclifellentziindung der Woclmerinnen. From the French. Potsd., 1832, 
 67. Berliner, in Deutsche Kliuik, 1855, Nr. 17. Berndt, Klinische Mit- 
 theilungen. Heft 3 and 4, 233. Bicker, Raadgeving voor den gemeenen 
 man, etc. Rotterd., 354. Bidault et Arnoult, in Gaz. med. de Paris, 1845, 
 Nr. 31, 481. Bischolf, in Abhandl. oster. Aerzte, iv, 107. Blackmore, in 
 Provinc. Med. and Surg. Journ., 1845, Nr. 12, 14 — 16, 21 — 26. Botrel, in 
 Archiv. gen. de med., 1845, April, 416. Bouchut, in Gaz. med. de Paris, 
 1844, Nr. 6, 7, 10. Bourdon, in Revue med., 1841, Juni 348. Bowen, in 
 Western Lancet, 1842, June, Nr. 2. Boysen, Observat. in nosocom. obstetr. 
 de febre puerp. maligna. Ilafa., 1792. Bradley, in London Med. and 
 Phys. Journ., xxv, 193. Brenan, Thoughts on Puei-p. Fever, etc. Lond., 
 1814. Bruu, in Seance publ. de la Soc. de Med. de Toulouse, 1830. Burck- 
 hardt, in Allgem. med. Annal., 1802, Correspondenzbl., 177. Burguet, in 
 Journ. de Med. de Bordeaux, 1853, Avril. Burns, Principles of Midwifery, 
 8th ed., Lond., 1832 (Germ, ed., p. 576). Busch, in Zeitschr. fiir Geburts- 
 kunde, ii, 637. Butter, Account of the Puerp. Fevers as they appear in 
 Derbyshire. Lond., 1775. 
 
 Campbell, Treatise on the Epidemic Puerp. Fever, etc. Edinb., 1822. 
 
 ' 'Archiv fiir Gynakol.,' 187,3, xiii, 387. 
 * !Seu above, p. 414. 
 
 3 The list contains only such writings as have a special interest for epidemio- 
 logy or are referred to in the table of epidemics.
 
 472 GEOGRAPHICAL AND HISTOEIOAL PATHOLOGY. 
 
 Cardiff, Dissert, de febre puerperarum. Edinb., 1815. Carus (I), in Salzb- 
 med.-chirurg. Zeitscbr., 1821, ii, 155. Carus (II),in Allgem. med. Annalen, 
 1825, 421. Caderscbjokl (I), in Svenslc. Liikar. Sallskap. Handlingar, vii,. 
 229. Caderscbjold (II), ibid., xi, 53, xii, 48. Ceely, in Lancet, 1835, Marz- 
 813. Cerri, Observat. quaedam de puerperar. morbis, etc. Mediolan, 1788. 
 Charrier, in Gaz. des bopitaux, 1856, Nr. 23. Cbevance, Des accidents 
 puerpcraux observ. ?i I'bdpital Beaujon, etc. Par., 1878. Jobn Clarke. 
 Essay on tbe Ej)idemic Disease of Lying-in Women, etc. Lond., 1788. Jos. 
 Clarke, in Edinb. med. Commentaries, Dec. ii, vol. v, i. Cliet, Compte- 
 rendu des observat. rec. dans la Salle des filles-meres de I'liopital gen. de la 
 Charite de Lyon, etc. Lyon, 1823. Collins, Treatise on Midwifery, etc. 
 Lond., 1836, 380. Crede, Cbarite Anual., 1857, Heft i, 38. Cruveilhier, 
 in Eevue med., 1831, Mai, 169. 
 
 Delamotte, Traitc complet des accoucbements, etc., lib. iv, cap. six. Leid., 
 1729, 582. Denbam, in Dublin Quart. Journ. of Med. Sc, 1862, Nov., 317. 
 Diel, in Baldinger's N. Magaz., ix, 304. Diemer, De pblebitide uterina, etc 
 Eostock, 1842. Disse, in Monatscbr. f iir Geburtskunde, 1855, v, 117. v. 
 Deeveren, Primae lineao de cognosc. mulier. morbis, cap. vi, § 194. Dommes,. 
 in Hannov. Annal. fxir Heilkundc, i, 235. Doornik, in Nederl. Tijdscbr. 
 voor Geneeskunde, 1859, iii, 207. Dor, in Gaz. bebdomad. de med., 1858, 
 Nr. 9. Doublet, in Journ. de med., Iviii, 502. Douglas, in Dublin Hospit. 
 Eeports, iii, 139. Dubois (I), in Gaz. des bopit., 1838, Nr. 37. Dubois (II), 
 ibid., 1 84 1, Nr. 85. Dubois (III), Bull, de I'Acad. do med. de Paris, 185S. 
 Dunn, in Edinb. IVied. and Surg. Journ., xii, 36. Duplay, in Journ. bebdo- 
 mad. de m6d., 1830, Mai. 
 
 Elkington, in Prov. Med. and Surg. Journ., 1844, 287. Elliot, in Svensk.. 
 Liikar. Sallskap. nya Handl., iii, 253. Elsasser (I), in Wiiiiemb. med. 
 Con-espondenzbl., xviii, 35. Elsasser (II), ibid., xxi, 10. Estcrle, in AnnaL 
 univers. di Medicina, 1858, October. 
 
 Eauken, Das in Wien in den Jabren 1771 and 1772 sebr viele Menscben 
 anfallende Fjiulungsfieber. Sammt Anbang einer bosartigen Ivrankbeit^ 
 welcbe im Jabre 1770 unter den Kindbotterinnen im Spitale zu St. Marx 
 gewiitbet hat. Wien, 1772, 61. Faye, Norsk Mag. for Laegevidensk, 1858, 
 xii, 1859, xiii, and Om puerp. febers diagnose og bebandling. Cbrist., 1859. 
 Eobei-t Ferguson, Puerperal Fever. Lond., 1S39 (Germ, ed., p. 241). Ficker, 
 Beitr. zur Arzneiwissenscbaft, etc.. Heft i. Milnster, 1796, 3. Foderc,. 
 Lemons sur les epidemics, iii, 216. Fonteret, Lyon medical, 1867. v. Franque 
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 Galicier, Journ. do mod. du Depart, de la Loire inferieure, 1850, xxvi^ 
 209. Geoffroy, in Hist, de la Soc. de Med. de Paris, ii, Mem. 25. Goetz,. 
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 Epidem. febr. puerp., annis 1824-5 i" nosodocbio Monac. observ. Monach,. 
 1825. Graff, im General-Bericht des Ebein. Med. Collegii fiir das Jabi- 
 1834,42, 106. Griinwaldt, in Petersb. med. Zeitscbr., 1861, Heft 7, 185.. 
 Guyenot, Lyon medical, 1869, 177.
 
 PUERPERAL FEVER. 47o 
 
 Haase (I), in Gemeinsame deutsche Zeitsclir. fiir Geburtskunde, vii, i. 
 Haase (II), in Nene Zeitschv. fiir Geburtskunde, xi, 257, 276. Haase (III)» 
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 Epidemiol. Soc, 1866, ii, 69. Hassing, in Bibl. for Laeger, 1850, ii, 95. 
 Hauner, De febre puerperali, etc., Diss. Monach, 1826. Heclcer (I), Klinik 
 der Geburtskunde, etc., i, 211. Hecker (II), ibid., ii, 200. Heiss, in Bayr. 
 arztl. Intelligenzbl., 1859, Nr. 7. Helm, in Oester. med. Jabrb. Neueste 
 Folge, XV, 223. Herrmann, in Scbweiz. med. Monatscbr., i860, Nr. 8. Her- 
 vieux, Traite clinique et pratique des malad, puerp., etc. Par., 1870. Hey, 
 Treat, on tbe Puerperal Fever, etc. Lond., 1815. Heymer, BeitrJige zum 
 Puerperalfieber, etc. Wiirzb., 1847. Hodge, in Amer. Journ. of Med. Sc, 
 1833, August. Hoffmann, Med. Eational Syst., pars i, sect, i, cap. ix, 0pp. 
 Genev., 1748, ii. 73-75. Holston, in Transact, of the Ohio State Med. Soc. 
 for the year 1854. Hugenberger, Das Puerperalfieber im St. Petersburger 
 Hebammen-Institute, etc. St. Petersb., 1862. 
 
 Ingleby, in Edinb. Med. and Surg. Journ,, 1838, April, 412. 
 
 Jager, in Osiander's Neue Denkwiirdigkeiten fiir Aerzte, i, Heft 2. Jes- 
 persen, in Sundhetskoll. Porhandl. for Aaret 1S45, 31. Jonas, De phlebitide 
 uterina, etc., Diss. Berol, 1841. Jungmann (I), in Oester. med. Jabrb. 
 Neueste Folge, xxii. Jungmann (II), ib., xxiv, 80. 
 
 Kaufmann, in Monatscbr. fiir Geburtskde., 1867, xxix, 246. Kayser, Den 
 kongel. Fodselstiftelse i Kjobenb. og den der hersk. ondart. Barselfeber. 
 Kjobenh., 1845. Kayser (II), Ugeskrift for Laeger, 1846, Nr. 15, 229. 
 Kehrer, in Monatscbr. fiir Geburtsk., xviii, 209. Kircbhoff, HaunoY. med. 
 Conversationsbl., 1852, Nr. 6, 41. Koch, in Neue Zeitschr. fiir Geburtskde., 
 xvi, 290. Kraus, in Archiv fiir Gyniikol., 1873, v, 562. 
 
 Lariiarque, in Journ. de Med., Ixxxiii, 179. Leake, Pract. Observat. on 
 the Childbed-Fever. Lond., 1772, 242. Leasure, in Amer. Journ. of Med. 
 Sc, 1856, Jan., 45. Lebmann, Verslag van het Genootsch. tot Bevorder. 
 der Geneesk. te Amsterdam, 1863, xii, 293. Lepecq de la Cloture, Med. 
 Topographie der Normandie, etc. From the French. Stend., 1794, 244. 
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 dem, etc.. Dissert. Bonn, 1833. Litzmann, Das Kindbettficber, etc. 
 Halle, 1844, 306. de Lingen, De phlebitide uterina, etc.. Diss. Berol, 
 1841. Lippich, Observ. de metritide septica in puerp. grassante. Vindob, 
 1823. Lorain, Gaz. des hopit., 1869, Nr. 148, 567. Loschncr, in Prager 
 Vierteljahrschr. fiir Heilkde., 1861, i, 145. Lusk, Amer. Joum. of Obste- 
 trics, etc., 1875, Nov., viii. 
 
 Mackintosh, Treatise on the Disease termed Puerperal Fever, etc., Edinb., 
 1822. Malouin, in Mem. de I'Acad. roy. des Sc, 1746, 160. Mars, Przgl. 
 lekarski, 1880, in Virchow-Hirscb's Jabresberieht, 18S0, ii, 596. Martin (I) 
 in Schmidt's Jabrb. der Med., xiii, 72. Martin (II), in Neue Zeitsch. fiir 
 Geburtskde., ii, 350. Martin (III) in Monatsclir. fiir Geburtskde, 1857, x, 
 253. Maiiin (IV), ibid., i860, xvi, 161. Martin (V), Epidemic de fievr. 
 puerp. observee a I'hopital St. Antoine, Par., 1S69. McClintock (I), Pract. 
 Observ. on Midwifery, &c, Dub., 1848. See also Dub. Jour, of Med. Sc,
 
 474 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 1845, May. McClintock (II), in Dubl. Quart. Joiirn. of Med. Sc, 1855, 
 May. Micbaelis, in Neue Zeitscbr. fiir Geburtskde., iv, 322. Miquel, in 
 Horn's Arcbiv filr medic. Erfalu-ung, 1829, i, 84. Miiller, Bidrag till 
 Puerperalfeber-Epid. Hist. Kjobenb., 1840. 
 
 Nagel, Charite-Annalen, x, Heft i. Niigele, Schilderung des Kindbett- 
 fiebers . . . 1811-12, zu Heidelberg, etc. Heidelberg, 1812. Naumann, 
 Monatscbr. fiir Gebnrtskde., 1866, Dcbr., 442. Nebel, in Loder's Journ. fiir 
 Cbir., iii. Heft 2. Netzcl, Hygiea, 1879, xli, 156. Neumann, in Siebold's 
 Joum. fur Geburtsbiilfe, vii, 53- Nolde, in ' Lucina,' iv, 375. Nonat, in 
 Eevue med., 1837, Mars, 329, Avril, 37, Septembre, 333, Novembre, 180. 
 
 d'Orbcastel, in Seance publ. de la See. de Med. de Toulouse, 1847, 149. 
 Osiander, Beobacbtungen, Abbandlungen, etc. Tubingen, 1787, 37. d'Outre- 
 pont (I), in Salzb. med.-cbir. Ztg., 1821, ii, 204. d'Outrepont (II), in Tex- 
 tor's Cbiron, i, 151, 350. d'Outrepont (III), Abbandlungen und Beitrage 
 geburtsbiilflicben Inbaltes. Wiirzb., 1822, i, 297. d'Outrepont (IV), in 
 Neue Zeitscbr. fiir Geburtskde, v, 456. Ozanam, Hist. med. des malad. 
 epidem., edit. ii. Par., 1835, ii, 32. 
 
 Parkins, in New York Journ. of Med., 1852, May, 328. Parry, Amer. 
 Journ. of Med. Sc, 1875, Jan. Patterson, in Dublin Journ. of Med. Sc, 
 iv, 170. Peu, La practique des Accoucbements, liv. vii, cap. i. Par., 
 1694, 268. Pfeufer, in Horn's Arcbiv fiir medicin. erfabrung, 1824, i, 246. 
 Pihan-Dufeillaj^ in Union med. 1861, Nr. 102-8, 371, ff. Pippingskjold, 
 in Notisbl. for Liikare ocb Pbarm., 1859, Marz. Pouteau, Melanges de 
 Cbirurgie. Lyon, 1760, 180. Puncb, in AUgemeine Annalen der Heilkunst, 
 1811,329. 
 
 Quadrat, Diss, sistens observat. circa febr. puei-p. annis 1833-35 epid. 
 Prag, 1835, and in Oester. med. Jabrb., neueste Folge, xiii, 112. Quinquaud, 
 Essai sur le puerpcrisme infectieux, etc. Par., 1872. 
 
 Eamsbotbam, in Lond. Med. and Pbys. Journ., 181 1, xxvi, 265. Eapp, 
 Ueber das Kindbettfieber, inauguralabhandlung. Bamb., 1835. Ref. 
 (I) in Journ. de Med., Iviii, 448. Eef. (II) in Journ. gen. de Med., 
 vii, 413. Eef. (Ill) in Fodere, Lemons sur les epidemics, etc., iii, 289. Eef- 
 (IV) in Oester. med. Jahrblicber. Neue Folge, i, 244. Eef. (V) in Bibl. 
 for Lfiger, 1839, i, 121. Eef. (VI) in tbe Sanitjitsbericbt von Westpbalen 
 fiir das Jabr 1840, 17. Eef. (VII) in Gaz. med. de Paris, 1841, Nr. 24, 370. 
 Eef. (VIII), ibid., 1842, 499. Eef. (IX) in Sundetskoll. Forhandl., Aaret 
 1845, 28. Eef. (X), ibid., Aaret 1850, 31. Eef. (XI) in Transact, of the 
 State Med. Soc of Pennsylvania, ii, 1852. Eef. (XII) in Gaz. med. de 
 Paris, 1846, Nr. 9, 161. Eef. (XIII) in Gaz. des bopit., 1869, Nr. ss- Ref. 
 (XIV), Brit. Med. Journ., 1873, Sept., 354. Eetzius (I), in Svensk. Lakar. 
 Siillsk. nya Handl., viii, 53. Eetzius (II), in Monatscbr. fur Geburtskde., 
 i86i,xvii, 191. Eeuss, Beitr. zur Statistik des Puerperalfiebers. Tiibingen, 
 1851. Eicker, Nass. med. Jabrb., 1853, ^h 167. Einck, in Stark's Arcbiv 
 fiir Geburtsbiilfe, vi, 67. Eitgen, in Gemeins. deutsche Zeitschrift fiir 
 Geburtskunde, vi, 562, vii, 66, 229, 571. Eoberton, in London Med. 
 Gazette, ix, 503. Eunge, Zeitscbr. fiir Geburtsb. und Gynakol., 1880, v. 
 195. Eupert, Das Puerperalfieber in der Gebaranstalt zu Jena im Winter 
 1861-62. Jena, 1864.
 
 PUERPERAL FEVER. 475 
 
 Salomonsen, Uclsigt over Kjobenhayns Epidemier, etc. Kjubenli., 1854, 
 123. Saztovpli, Om FoJselsvidensk, Tilvaext, etc. Kjobenh., 1782, 81. 
 Scanzoni, Verliandl. der Wiirzb. med. Gesellsch., i86o, x, app. xxxix. 
 Schaffer, in SuudbetslvoU. Porbaudl. for Aaret, 1845, S^- Scheider, in 
 Generalbericbt des Rhein. Med.-Collegii fiir das Jahr, 1844, 41. Schilling, 
 in d'Outrepont's Abhandlungen nnd Beitrjige, etc., i, 195. Schlesier, in 
 Preuss. med. Vereins-Zeitung, 1842, Nr. 40. Sclilogs, De peritouitide 
 puerp., etc., Diss. Berol., 1820. Schofl, AViener Spitalarzt, 1864, Nr. 9 — il. 
 ScboUer, in Oester. med. Jahrbiiclier, 1844, Sptbr., 281, Octbr., 38. Scbon- 
 Icin, Klinische Vortrjige, beransgegcben von Giiterbock. Berl., 1842, 256. 
 Sclmltze, FilUe wiclitiger Puerperalerkranknngen u. s. w., Diss. Berl., 1869. 
 Selle, Neue Beitrjige zur Natur- nnd Arzeneiwissenscbaft. Berl., 1782, i, 
 45, 60. Serre, Montpellier medical, 1869, Juill. 20. Sidey, in Edinb. 
 Med. and Surg. Journ., 1839, Jan., 91. v. Siebold, Versucb einer patbol.- 
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 SiefEermann, Descript. de I'epid. de ficvre puerper., etc. Strasb., 1862. 
 Sonderland, in General-Bericht des liboin. Med.-Collegii fiir das Jahr 1827, 
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 Acrzte, 1S64, Nr. 8. Speyer, in Sundhetskoll. Forbandl. for Aaret, 1845,32. 
 Spiegelberg, Ueber das Wesen des Puerperalfiebers. In Volkmann's Samml., 
 Nr. 3. Steblserger, Monatschr. fiir Geburtskde, 1866, April, 300. Stoll, 
 Ratio medendi, Ann., 1777, cap. ix, vol. ii, 67. Storrs, in Prov. Med. and 
 Surg. Journ., 1842, Nr. 15; 1843, Dccbr., 163. 
 
 Tanchon, in Gaz. des bopit., 1837, Nr. 8. Thijssen, Geschiedk. bescbouw, 
 der ziekten in de Nederlanden, etc. Amster., 1824. Tilanus, in Heije, 
 Arch, voor Goneesk., i, 1S41. Tode, in Ny Sundbetstidende, i, 99. Ton- 
 nelle, in Arch. gen. de Med., 1830, March to June. Reprinted as : Des fievr. 
 puerp. observ., a la Maternite pendant I'annce 1829, etc. Par., 1830. 
 
 Vernay, Do la fievre puerp. epidcm., etc. Paris, 1848. Virchow (I), 
 Gesammelte Abhandlungen. Frankf. a. M., 1856, 779. Virchow (II), in 
 Monatschrift fiir Geburtskunde, 1858, xi. Voillemier, in Journ. des con- 
 naiss. med.-chir., 1839, Dcbr., 1840, Jan., Mars. 
 
 Weber, in Monatschr. fiir Geburtskde., i860, Dcbr. West, in London 
 Med. Repository, iii, 103. White, Treatise on the Management of Lying-in 
 Women. Loud., 1773. Wilson, in Amer. Journ. of Med. Sc, 1843, 
 Januar3\ 
 
 Zandyk, in Revue med., 1S56, Fevr., Mars, Mai. Zengerlc, in Wiirt- 
 temb. med. Corrcspondenzbl., x, i.
 
 CHAPTER XIII. 
 
 HOSPITAL GANGRENE. 
 
 § 172. Historical Odtbreaks. Present Geographical 
 
 Range. 
 
 The third member of the series of traumatic infective 
 diseases whicli lias an interest for our particular subject is 
 hospital gangrene, a malady that connects in a general way 
 with the morbid conditions discussed in the two preceding 
 chapters, inasmuch as it also has been prevalent in all ages 
 over the whole globe. In the medical writings of antiquity 
 and the middle ages, such as the works of the Hippocratic 
 Collection,^ of Celsus," Galen,^ Avicenna,'* the School of 
 Salerno, Guide de Cauliaco^ and De Vigo,*' mention is made, 
 
 * See ' De locis in homine,' § 29 (ed. Littre, vi, 322), for an account of the 
 ulceration described under the name of " Btjpiov." 
 
 ^ Lib. V, cap. 28, § 3 (ed. Targa, i, 287), where this form of iilcer is described 
 as " ^t]piwfia," and another form, " (paytduva" (in other readings " ipTrtjg 
 iaQiofiivoQ," as in the edition by Almoloveen, Basil., 1748, 319), is mentioned as 
 follows : " vocant Graeci hoc ulcus (paykSsivav, quia celeriter serpendo, pene- 
 trandoque usque ossa, corpus vorat. Id ulcus inaequale est, coeno simile, 
 iuestque multus humor glutinosus (might not this suggest the so-called diph- 
 theritic deposit?), odor iutolerabilis, majorquc quam pro modo ulceris, inflam- 
 matio." 
 
 ' In lib. iii, ' De temperameutis,' cap. iii (ed. Kiihn, i, 664), and ' Comment, 
 in Hippocratis Aphorismos,' cap. xlv (e. c, xviii, a, 71), malignant destructive 
 ulcerations are spoken of as " ^aysSaiva K.71 tpTnjg dvo/St/^poffKo/uroe;' and in 
 lib. ii, ' De praesagitione ex pulsibus,' cap. i (e. c, ix, 273), "ulcera depascentia " 
 are mentioned, " ovq la^iofiivovc 'iTTTroKparjjg iovofiaZtv." 
 
 * Ref. to malignant progressive ulceration in ' Canon,' lib. iv, Fen. iv, Tr. iii, 
 cap. I ff. (ed, Venet., 1564, ii, 157). 
 
 ' ' Chirurgie magna,' Tract, iv, Doctr. i, cap. iii (Lugd., 1572,233: "Dum 
 ulcus non habet nisi sordem et saniem grossam et viscosam, dicitur sordidum ; 
 postquara autem augetur ipsius malitia, ita quod putrefacit et mortificat caruem 
 dimittendo sarra, a qua elevatur fumus foetidus, et cadaverosus, dicitur putridum 
 fraudulentuui. Et si ambulat ejus malitia, transit ad esthiomenum et ad hominis 
 mortem." 
 
 6 'Chirurgia,' lib. iv. Tract, vii, cap. i (Lugd., 1521, fol. cvii).
 
 HOSPITAL GANGRENE. 477 
 
 under vai'ious names, of malignant gangrenous ulcerations, 
 progressing rapidly, causing wide-spread destruction of 
 tissue, and sometimes endangering life ; and these may be 
 identified, in part at least, with the disease which afterwards 
 received the name of hospital gangrene. More precise 
 references to this disease are met with in the writings of 
 some of the sixteenth and seventeenth-century surgeons, 
 such as Tagault^ and Marcus Aurelius Severinus^, but more 
 particularly in Paracelsus and Pare. 
 
 In the " Grosse Wundartzney " of Paracelsus^ there is the following 
 interesting passage : " Be it further said that in times of pestilence, 
 the pestilence has appeared in wounds, unless there were no ulceration 
 The onset was with chills and heats, ?ind some died of it speedily, having 
 felt nothing else in all their body ; for that which brought it on issued 
 from the wounds. Sometimes, too, it has been noticed that a common 
 ci'oup (Brikme) has befallen the people in war, which also had all its 
 signs in the wounds, in suchwise that a thick skin came from them like 
 that which one peels from the tongue, the croup aifecting them just as 
 
 if their wounds and their mouths were the same Of such. 
 
 accidents there have been untold numbers." In his chapter on gun- 
 shot wounds, Pare* says, by way of combating the views of those who 
 attribute to some combustion or poisoning the untoward course which 
 such wounds often take, that it is a matter of corruption or " rotting 
 of wounds," under some pestilential constitution of the air that induces 
 the state of rottenness in them. He specially recalls the observations 
 that he made at the siege of Rouen in 1562, when the air was so tainted 
 that the slightest and scarcely noticeable wounds often took on a 
 malignant character. Relating also to hospital gangrene are the 
 statements about malignant ulcerations which he makes in the section* 
 on "neglected, untidy and filthy ulcerations;" he there speaks of a 
 thick tenacious exuvia, like the coating of the tongue in sick persons, 
 which forms upon the wound, while " a corruption and liquefaction of 
 the soft parts " sets in underneath. 
 
 The first thorough study of hospital gangrene is met with 
 
 1 ' De ulcere sordido et putri ' in lustit. cbir., lib, iii, cap. xvi (' De chirurg. 
 script.,' Tiguri, 1555, fol. 10.3 b. 
 
 - ' De efficaci cbirurgia,' lib. ii, cap. Iii (Frankf. 0. M., 1646, 107), on "Ulcera 
 putrescentia ;" also in ' Pyrotecbuia cbirurg.,' lib. ii, Pars, i, cap. viii (e. c, 264), 
 "de gangraenosis et putridis ulceribus," especially after gunshot-wounds ; and ib., 
 cap. X (e. c, 265), " de ulceribus cacoethis et malignis." 
 
 ^ Bucb, i, cap. vi, rd. Strassb., 1618, fol. 7. 
 
 ■* ' Llvres de la Cbirurgie,' Bk. x, in Offenbach's German edition, Fraukf. o. M., 
 1635, pp. 380-81. 
 
 ^ lb., Bk. xii, chap, ix, 434.
 
 478 GEOGRAPHICAL AND HISTOEIOAL PATHOLOGY. 
 
 in the works of Mauquest de la Motte/ wlio wrote iu tlie 
 middle of last century _, and who gained his experience of 
 the disease in the Hotel Dieu of Paris ; and in the writings 
 of Pouteau^ who himself came through an attack of the 
 disease at the Hotel Dieu of Lyons while he was a student, 
 and had many opportunities of observing it there subse- 
 quently. Shortly afterwards there appeared the monograph 
 on hospital gangrene by Dussaussoy/ Pouteau's successor 
 at the Hotel Dieu of Lyons ; and almost simultaneously the 
 observations by English surgeons, in particular by Gillespie'* 
 and Trotter/ on the endemic and epidemic prevalence of the 
 disease on board English ships ci'uizing in tropical ivaters 
 or stationed in the tropics. The wars that involved almost 
 all Europe in the end of last century and beginning of the 
 present, afforded abundant opportunities for studying hospital 
 gangrene ; and from that period we have many valuable 
 memoirs on the disease, including those of Boggie," Hennen,'^ 
 Blackadder^ and Gerson^ for the Peninsula j Boyer^^ and 
 Delpech^^ for France; Menzel,^" Volpi^^ and Eiberi^*for Italy; 
 Thomson^" for Belgium; Brugmans^^ for Holland; and 
 Busch^^ for Treves. Experiences collected under similar 
 
 1 ' ALliandl. von der elilrurgie,' Germ, transl., Ni'iniberg, 1762,111, 267. 
 
 * ' Oeuvres postluimes,' Paris, 1783, iii, 246. 
 
 ' ' Diss, sur le gangrene ties bopitanx,' Geneve, 1786. 
 
 * 'Lond. Med. Journ.,' 1785, vi, 373. 
 5 'Medicina nautica,' Lond., 1797, ii. 
 
 8 'Transact, of the Edinb. Med.-Chir. Soc.,' 1828, iii, i. 
 ' 'London Med. Repository,' 1815, iii, 177. 
 
 ^ ' Observations on tbc Phagedaena gangraenosa,' Edinb., 1818. 
 
 9 ' Uebcr den Hospitalbivand, u. s. w.,' Hamb., 1817. 
 10 'Traite du malad. cbirnrg.,' Par., 1818, i, 221. 
 
 1^ ' Mem. sur la complication des plaies et des ulceres, connue sous le nom de 
 pourriture d'bopital,' Par., 1815. (Transl. into German, along with the work of 
 Bruginans, by Kieser, Jena, 1816,85.) 
 
 12 In Hufeland's ' Journ. der Ileilkunde,' 1799, viii. Heft 4, 144. 
 
 13 < Saggio di osservazioui e di esperienze med.-chir. fatte nello spedale civico 
 di Pavia, Mllano, 1814. 
 
 ^•t' Sulla caiicrcna contagiosa uosocomialc,' &c., Torino, 1820. Also iu 
 • Repert. med.-chir. di Torino,' 1822, 2r4. 
 
 ^* ' Report of Observations made in the Military Hospitals of Belgium,' Lond., 
 1817. 
 
 16 'Natuurk. Vcrhandel. van der Holland. Maatsch. der Weelensch te 
 Harlem,' 1814, Aug., vii, St. 2 (Germ. Transl. by Kieser, Jena, 1816). 
 
 " In Rust's ' Magaz. der Heilkunde,' 1820, vii, 3.
 
 9 
 
 HOSPITAL GANGKENE. 479 
 
 circumstances were published by Surdun/ Lallour/ Tou- 
 rainne/ and Bourot* after the Crimean War in 1854-55; 
 by Goldsmith/ Pittinos/ Brinton/ Thomson/ Packard, 
 ^mpster/'^ Jones^^ and Carpenter^" after the War of Seces- 
 sion in the Untied States; and after the late Austro-Prussiau 
 and Franco-German Wars, by Lewandowzki^" for the military 
 ambulance of Weissenfels in 1866, by Ponfick^'^ for the 
 hospital of Heidelberg, by Konig^^ for the military hospitals 
 of Berlin in 1870-7 1, by Moty^^ and by Leroy^'^ for the military 
 ambulances at Maubeuge and Amiens in 1870-71 ; after the 
 Austro- Hungarian and Austro-Italian Wars, by Nagel^^ for 
 the hospitals at Temesvar, Festlt, and Fresshurg, by Rostolli^^ 
 for the ambulance at Alessandria in 1848, and by Demme"*^ 
 for the military hospital at Milan in 1859; and after the 
 Indian Mutiny by Moore"^ for Bind. 
 
 Besides these memoirs, we have reports of epidemics of 
 hospital gangrene on board ship, which connect with those 
 already mentioned. They come chiefly from Indian, Chinese 
 and other tropical 'waters, the authorities being Curtis,"" an 
 
 ^ 'Revue therap. du Midi,' 1856, Avril. 
 
 ^ ' De la pourriture d'hopital en general et de celle observee sur les blesses de 
 I'armee d'Orient,' &e.. Par., 1856. 
 
 ^ 'Mem. de med. milit.,' 1861, iii, ser. v, 303. 
 
 ■* 'Sur la pourriture d'bopital,' &c., Strasb., 1858. 
 
 * 'Report on Hospital Gangrene,' &c., Louisville, 1863. 
 
 ^ ' Amer. Journ. of Med. So.,' 1863, July, 50. 
 
 ' lb., 279. » lb., 1864, April, 379. 
 
 ^ lb., 1865, Jan., 114. 
 
 10 lb., 1866, April, 351. 
 
 1' 'New Orleans Journ. of Med.,' 1869, Jan., April. 
 
 1= 'Transact, of the Pennsylvania State Med. Soc.,' 1877, 736; and 'Transact, 
 of the Amer. Med. Assoc.,' 1878, xxix, 237. 
 
 '2'De patbol. et therap. gangraenac iiosocomialis,' Hal., 1866; also iu 
 'Deutsche Klinik,' 1868, 14, 15. 
 
 " ' Deutsche Klinik,' 1867, Nr. 20 ff. 
 
 ^5 In ' Virchow's Archiv,' 1871, Hi, 376; and ' Ueber Hospitalbrand,' Lelpz., 
 1872 (' Volkmann's Samnil. klin. Vortr.,' Nr. 40). 
 
 1^ ' Sur une epidemie de pourriture d'hopital,' Par., 1871. 
 
 1' ' Relat. d'une epidemie de poui-riturc d'hopital observ. a Amiens en 1870-71,' 
 Par., 1872. 
 
 ^8 ' Zeitschr. der "Wieu., Aertze,' 1852, viii, 116. 
 
 19 'Annal. univ. di med.,' 1849, Maggio, Giugno. 
 
 ^" ' Militiir-chir. Studien, u. s. w.,' Wiirzb., 1861. 
 
 =" ' Lond. Med. Gaz.,' 1846, ii, 1005 ; 1847, i, 187, 450. 
 
 -' ' Account of the Diseases of India,' Edinb., 1S07, 211.
 
 480 GEOGEAFHICAL AND HISTORICAL PATHOLOGY. 
 
 anonymous writer/ Hutchinson/ Smart/ de Lajartre* and 
 others. 
 
 Lastly, there are very numerous accounts of its occurrence 
 in hospitals in all parts o£ the world by the following among 
 others : Rust^ and Fischer^ for the Charite at Berlin ; 
 Schiiller^ for Greifswald, Fock^ for Magdeburg, Heine^ for 
 Heidelberg, Alle^*^ and Pitha^^ for Prague, Groh^^ for Brandeis, 
 Coote,^^ Hawkins^* and an anonymous writer^^ for hospitals 
 in London, Bobilier^® for Toulon, Chambolle^'^ for Dunhirh, 
 Faure^^ for 8'pain, Riglei'^^ for Constantinople, Pruuer"° for 
 Egypt, Baudens"^ for Algiers, K^?i,vo^" for Aden, Cui'tis (1. c), 
 Dunbar,""^ Walker/^ Chevers"^ and Sutherland"^ for various 
 parts oi India, Friedel for"^ China, Wright"^ for Baltimore, Gil- 
 lespie (1. c.) for the West Indies, and Lallemant"^ for Brazil. 
 
 ' 'Lond. Med. and Phys. Journ.,' i8iOj July 13. 
 
 * ' Pracfc. Observ. iu Surgei'y,' Loud., 1826. 
 •* 'Lancet,' 1870, October, 462. 
 
 * ' Consider, sur I'etat sanitaire de la f regatte rAudromaque pendant sa traversee 
 •de France en Chine,' Par., 1866. 
 
 ^ 'Magaz. der Heilkde" 1833, ^1> 539- 
 
 6 ' Charite-Annalen,' 1865, xiii. Heft i. 
 
 7 'Zeicschr. fiir Chir.,' 1878, viii, 540. 
 s 'Deutsche Klinik,' 1856, Nr. 25, 26. 
 
 9 'Handb. der Chirurgie,' by Pitha and Billroth, Bd, i, Abth. ii, A. 221 iT. 
 '" • Oest, med. Jahrb.,' Nste. F. iii, 594. 
 " ' Prager Vierteljahrschr. fiir Heilkde.,' 1851, ii, 28. 
 12 ' Wien. med. Wochenschr.,' 1858, Nr. 35, 36. 
 " ' Lond. Med. Gaz.,' 1847, 'h 729. 
 " lb., 1028. 
 
 ^^ 'St. George's Hosp. Reports,' 1866, i, 363. 
 '^ 'Mem. de med. Milit.,' 1854, xiv, 60. 
 '7 lb., 1843, liv, 247. 
 '* ' Souvenirs du Midi.' 
 
 " ' Die Tiirkei uud deren Bewohner, &c.,' ii, 85. 
 ^° 'Die Krankheiten des Orients,' 158. 
 ^^ 'Clinique de plaies d'armes a. feu,' Par., 1836. 
 ^" 'Transact, of the Calcutta Med. Soc.,' 1837, "'' M2. 
 '^ 'Ind. Journ. of Med. Sc.,' 1S42, New Scr., 1,630. 
 ^* ' Ind. Annals of Med. Sc.,' 1858, Jan., 83. 
 -* lb., i860, Nov. 
 "'^ lb., 1857, April, 471. 
 
 '^ * Eeltr. zur Kenntn. des Klimas und der Krankheiten von Ostasien,' Berl., 
 1863, 135. 
 -^ 'Amer. Journ. of Med, So.,' 1832, May, 47. 
 ^^ In Casper's 'Wochenschr. fiir die ges. Heilkde.,' 1845, 481.
 
 HOSPITAL GANGRENE. 481 
 
 Tlie facts contained in tliese various writings afford evidence 
 tliat hospital gangrene lias been a disease of all tinnes and 
 of every i:)art of tlie hahitahle globe. It has been found both 
 in high latitudes and in low^ on the coast and in the interior, 
 at elevated situations and at low-lying places, and on dry 
 soil as much as on wet. Although no climate enjoys any 
 notable immunity from it, there is almost complete unanimity^ 
 among such of the English and French naval and military 
 surgeons as had been for some time in the tropical parts of 
 Asia, Africa and America, that those are the regions most 
 scourged by hospital gangrene. The '^foul sloughing ulcers" 
 of the English surgeons in India, the Hed Sea ports, the 
 West Coast of Africa, Guiana, &c., and the " phagedenisme 
 tropical " of the French, observed as they have mostly been 
 in hospitals and prisons, take a prominent place among the 
 diseases of the tropics ; and in that group of diseases, of 
 which I shall have something more to say when I come to 
 speak of diseases of the skin, hospital gangrene plays the 
 principal part. 
 
 § 173. Dependence on Climate and Weather. 
 
 It is impossible to decide with certainty to what extent 
 the relative frequency of hospital gangrene in the tropics is 
 dependent on certain factors in the hygiene, to what extent 
 it is to be explained by meteorological influences, — by high 
 temperature and extreme moisture, or by the sudden changes 
 of weather which are so acutely felt in the tropics — and how 
 these influences bear upon the production of the disease. 
 Even with the aid of comparative experiences on the same 
 matter in higher latitudes, we can arrive at no definite con- 
 clusion. It is an undoubted fact that hospital gangrene may 
 occur at any season of the year and in all weathers ; but that 
 
 ^ Moinet (' De I'influence cles climats cliauds sur le triiumatisine chez I'Euro- 
 peeii,' Montp.,' 1866) is almost alone in his assertion that hospital gangrene is 
 much more rarely seen in the colonies than in Europe. He contradicts himself, 
 moreover, when he adds that the malady occurs there very often, and in severe 
 forms, when the hospitals are crowded, at a time of great epidemic sictness, or 
 when the hardships of living are felt in expeditions to distant places. 
 
 VOL. II. 31
 
 482 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 fact is far from warranting Fischer and others in peremptorily- 
 denying the influence of the weather on the oingination and 
 prevalence of the disease. The high or low level of the 
 thermometer is probably without significance in itself for 
 the development and diffusion of hospital gangrene ; at least, 
 there are as many observers to speak to very low temperature 
 at the time of the outbreak, as there are to attest that the 
 weather was particularly hot. 
 
 On the other hand there is a certain amount of agreement 
 among the authorities as to the influence of extreme fluctua- 
 tions of temperature on the pathogenesis, and so far also 
 of a higher degree of atmospheric moisture dependent 
 thereon ; or, in other words, of that kind of weather which 
 is especially characteristic of the changes of season in the 
 tropics. This is the position taken up by many of the 
 Anglo- Indian physicians. 
 
 Thus Curtis points to the prevalence of the disease in Madras in 
 October, 1782, during the monsoon, and its extinction on the setting in of 
 dry and cool weather. Adam tells us that hospital gangrene broke out 
 at Hussingabad (Kandeish) among the ill-clad and unprotected sepoys 
 in October, 181 8, when a cold and damp wind began to blow from the 
 north-east, although only a few cases occurred among the rest of the 
 troops. Chevers says that in Bengal and the N. W. Provinces the wet 
 season of the year is the proper season of hospital gangrene. The 
 epidemics observed by Moore and Dunbar happened in the I'ainy or 
 cold season. Dussaussoy had previously learned from his Lyons 
 observations that hospital gangrene was most frequent with high 
 temperature and a long prevalence of moist south winds ; and a similar 
 conclusion was come to by Boyer, Boggie, Larrey' and Hennen from 
 their experiences in the Peninsular War, Groh lays most stress, with 
 reference to Hungary and Italy, on variations in the amount of atmos- 
 pheric moisture associated with extreme fluctuations of temperature. 
 Oerson and Bobilier, and the United States' surgeons in the War of 
 Secession, found cold and damp weather to be favorable to the develop- 
 ment of the malady. 
 
 ' * Meinoires dc Chirurgie militaire ' (Germ, ed., i, 440).
 
 HOSPITAL GANGRENE. 483 
 
 § 174. Often associated with an Ovekcrowded and Un- 
 wholesome STATE OP THE HOSPITALS, BUT NOT ALWAYS SO. 
 
 Not less considerable than these differences of opinion 
 as to the influence of the weather, are those relating to the 
 significance of unhygienic conditions, such as overcrowding 
 of the wounded within doors, deficient ventilation and 
 cleansing of the crowded apartments, in short, the whole 
 of the noxious influences, chiefly met with in hospitals, which 
 it is the practice to group together under the name of 
 " hospitalism/' In the first place, it has to be said that the 
 disease has been by no means exclusively confined to hospitals, 
 as the name implies ; nor is it to be designated a hospital 
 disease pre-eminently. There is a not inconsiderable series 
 of observations serving to prove, not only that the disease 
 had been observed outside the hospitals at a time when it 
 was epidemic within them, but that it had even originated 
 outside the hospitals, the fii'st cases in these having been 
 such as were brought in. That such might be the case had 
 been shown by Moreau and Burdin,^ from their experiences 
 in the Napoleonic Wars ; and the same thing* was observed 
 by Moore in the Sind war in 1845-46. In the epidemic 
 of 1831-32 at the hospital of Prague, the first case, 
 according to Alle, came from the town ; and the same was 
 obsei'ved on a still larger scale, as Pitha tells us, in the epi- 
 demic of 1850. Whqn hospital gangrene was epidemic in the 
 Berlin Charite in 1856, and again in 1864-65, there were 
 cases at the same time in the town, having no connexion 
 with those in the hospital (Fock, Fischer). The same cir- 
 cumstance was noted at Heidelberg," in 1866-68, at Balti- 
 more in 1830-32 (Wright), and in London, where many 
 cases of hospital gangrene were admitted for treatment into 
 St. Bartholomew's and St. George's Hospitals in 1846 
 (Hawkins), and into St. George's again in i86g.* 
 
 Another argument against the influence of hospitalism in 
 
 1 In Sedillot, ' Journ. de ined.,' An. v, i, 353. 
 
 ' Heme, 1. c, p. 267. 
 
 ^ Leigh, ' Lancet,' 1869, Oct. 16.
 
 484 GEOGRAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 causing the development and diffusion of hospital gangrene 
 has been discovered in the fact that the disease has not un- 
 frequently appeared in newly-built, clean, airy, and far from 
 crowded wards ; while filthy and ill-ventilated wards, closely 
 packed with surgical cases, have escaped. Boggie, confirming 
 Bell/ pointed out that the malady had been prevalent during 
 the war in the Peninsula in thoroughly clean and well- 
 ventilated hospitals. Coote says that when the disease 
 appeared at St. Bartholomew's Hospital in 1846, the wards 
 were well aired, well lighted, clean, and in no wise crowded ; 
 and in the epidemic of 1863-65 at St. George's Hospital,, 
 hospital gangrene was most severe in one of the best wards, 
 while the surgical cases in two of the most unwholesome 
 wards were free from it ; even the most thorough ventilation 
 of the wards was of no avail. In the military hospital at 
 Antwerp the disease made progress, notwithstanding venti- 
 lation and the most scrupulous cleanliness.^ Speaking of 
 the epidemic at Prague in 1831-32, Alle says: '^ The 
 wards were neither overcrowded, nor were there many 
 patients with extensive and foul ulcerations. The keeping 
 of the air in the wards pure and the bandages clean was 
 attended to, as it always was ; in fact, after the hospital 
 gangrene showed itself, the upper casements of two windows 
 in each ward were left open day and night, even in the most 
 intense cold, a double quantity of fuel being served out to- 
 make up for the heat lost." It was the same when the dis- 
 ease broke out again in that hospital in 1850; the number of 
 patients was absolutely small, particularly the number of 
 operation cases, being less than in the previous three years ; 
 while there was no difference as regards ventilation and 
 cleanliness.^ Wright informs us that when the disease 
 broke out in 1830 in the hospital at Baltimore, the wards 
 were emptied as far as possible and everything done tO' 
 ensure the utmost cleanliness and adequate ventilation ; but 
 the malady continued to progress. Referring to the frightful 
 epidemics of hospital gangrene that occurred year after year 
 in the central prison at Agra, Walker says : " hygienic 
 
 I 'Principles of Surgery/ Edin., i8or, i, io8. 
 
 - Clements, ' Wiirzb. med. Zeitscbr.,' 1863, iv. Heft v. 
 
 * Pitha, 1. c.
 
 HOSPITAL GANGRENE. ■ 485 
 
 measures on a grand scale, resulting in tlie most scrupulous 
 •cleanliness, were found of no avail/' Clievers quotes a 
 statement by Brougham that, during the siege of Delhi, 
 although the hospitals were crowded, not a single case of 
 hospital gangrene ocqparred in them. In the epidemic of 
 1 85 1 at Brandeis, the disease occurred in the airy and 
 sparsely occupied rooms of the Imperial Schloss whicli had 
 been converted into a hospital. Under equally favorable 
 conditions of place, Marmy saw hospital gangrene in a villa 
 on the Bosphorus belonging to the Viceroy of Egypt. Fischer 
 says of the epidemic in 1864-65 at the Berlin Charite, that 
 it began in a room which had stood empty the whole summer, 
 and had then been thoroughly cleaned out and whitewashed 
 afresh. On the other hand, in two low-roofed wards on the 
 third floor, somewhat crowded and ill ventilated, not a single 
 case of hospital gangrene was seen. During the Secession 
 War in the United States, hospital gangrene was introduced 
 from Richmond into the hospital at Annapolis, although the 
 arrangements in the latter, as Pittinos tells us, were in every 
 respect excellent. Packard's experiences in the military 
 hospital of Philadelphia led him to the same opinion ; but he 
 is careful to add that overcrowding, filth, and other sanitary 
 defects were a material help to the disease spreading. In 
 the French military hospital at Maubeuge, according to 
 Moty, there was not a single case of hospital gangrene 
 during the autumn of 1870, despite overcrowding, want of 
 cleanliness, and lack of surgical aid; it was not until December 
 that the disease broke out, by which time the sanitary con- 
 dition of things had been very much improved. 
 
 Noteworthy as these and many other observations like 
 them are, there is a not less considerable weight of evidence 
 on the other side, which does not permit us to ignore the 
 influence of the above-mentioned defects of hygiene on the 
 origination and diffusion of the malady. As early as the 
 end of the sixteenth century (1597) the surgeons of the 
 Hotel Dieu of Paris had occasion to notice that hospital 
 gangrene occurred almost uniformly in a ward set apart for 
 the reception of injured persons, which was known by the 
 name of " Rang noir," and in which the beds were close 
 together and huug with curtains, so that there could bo no
 
 486 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 proper ventilation.^ The same tainting of the hospital 
 atmosphere is assigned by Dassaussoy as the most material 
 cause of the endemic prevalence of hospital gangrene in the 
 Hotel Dieu of Lyons. Bobilier found the reason of the 
 disease being endemic in the military* hospital of Toulon to 
 be the situation of the edifice in a narrow and ill-ventilated 
 street Avith high houses all around, where the air was loaded 
 with putrid products of decomposition from the badly con- 
 structed latrines and from the graveyards, which were in 
 badly chosen situations. The endemic of hospital gangrene 
 in the hospital of Dunkirk could be traced, as Chamboll 
 tells us, to water standing in an adjoining hollow ; when 
 that was removed the endemic came to an end. " So long,'' 
 says Rigler, " as the medical institutions of Constantinople 
 fell short of the admitted requirements in point of situation, 
 airiness, internal arrangements, and administration, wo saw 
 cases of hospital gangrene ; but it disappeared when the 
 inconvenient, low, damp and dark buildings were abandoned 
 and replaced by hospitals better situated, dry, well-lighted 
 and well-aired.^' Under the same circumstances as Eigler 
 in Constantinople, Pruner saw the disease prevalent in the 
 hospitals of Alexandria, Abou-Zabel, and other places in 
 Egypt. It stands to reason that the corresponding observa- 
 tions in times of war should have been on a much larger 
 scale. Wenzel states from his experience of the Italian 
 military ambulances that crowding of buildings, want of 
 ventilation, filth in the wards, and the like, very materially 
 helped to generate the disease. Brngmans concluded from 
 his observations, collected in the military ambulances of the 
 Netherlands, that *' the disease was first generated in low, 
 dull, damp and ill-ventilated apartments, and was more 
 difficult to combat in these than elsewhere." Hennen took 
 the same view in the case of the military hospitals in 
 Spain. Other evidence in this direction is given in the 
 account by Eostolli of the epidemic of hospital gangrene 
 from 1848 to 1849 i^ the overcrowded military hospital at 
 Alessandria, in that by Albespie relating to Genoa, as well 
 as by Bourot, Lallour, Marmy, and other French army 
 surgeons in the military hospitals in the Crimea and at 
 * Fodere, 'Lemons sur les epidemics/ &c., Par., 1824, iii, 495.
 
 HOSPITAL GANGRENE. 487 
 
 Constantinople during the campaign in the East ; which 
 latter experiences are summed up by Tourraine in these 
 words : " L'encombrement des hopitaux est, sans contredit, 
 la cause la plus commune, la cause occasionelle de la pourriture 
 d'hopital.'^ 
 
 In nowise different are the accounts given by several 
 United States^ surgeons, such as Goldsmith, Thomson, 
 Packard, and Kempster, concerning the state of matters in 
 the military hospitals during the War of Secession. And not 
 less telling are the observations on the endemic or epidemic 
 prevalence of hospital gangrene on board ships of war. 
 Keferring to the frightful havoc that the disease used to 
 make in the English navy,^ one of the authorities writes : 
 ^' In dirty ships (a comprehensive term, including the actual 
 impurities that may be suffered to accumulate in every 
 part, the want of ventilation, and inattention of the crew to 
 personal cleanliness) the disease was found most to prevail.^' 
 
 The French surgeons had the same experience during the 
 Crimean war on board transports crowded with the wounded ; 
 so also the United States' surgeons during the War of Seces- 
 sion. Of special interest in this respect is the report of 
 Brinton, who was sent on a visit of inspection to the hospitals 
 of the Confederate army in order to inquire into hospital 
 gangrene : 
 
 ^ Hutchinson (' Pract. Observ. in Surgery,' Lond., 1826) says that at the time 
 when he first entered the naval service (beginning of this century) cases of 
 hospital gangrene were of the commonest occurrence in the fleet ; so much so 
 that not unfrequently the greater number of the ships of a squadron were obliged 
 to return to port on account of it. In a paper written about that time (' Lond. 
 Med. and Phys. Journ.,' 1810, July, p. 13) the following passage occurs: "For 
 some years a species of ulcer, called the ship-, or contagious malignant ulcer, had 
 afflicted the British navy to an extent that was extremely alarming .... Some 
 idea may be formed of the ravages occasioned by this malady when it is stated that 
 in 1804 six hundred and twenty-one patients labouring under it were admitted 
 into a single hospital at Plymouth. In 1805, Sir Edward Pellew, Commander- 
 in-chief in India, stated to the Admiralty that so destructive was the ship-ulcer, 
 and so intractable under every kind of medical and chirurgical treatment, that 
 an apprehension was entertained of some of his ships being depopulated. In 
 1804 and 1805 it had made destructive inroads upon the health of the fleets ofl 
 Brest and Ferrol ; but the greatest fatality occurred in 1806 on board the 
 " Salvador del Mundo," then a receiving ship at the port of Plymouth. When 
 Dr. Andrew Baird . . visited the fleet off" Brest and the squadron at Ferrol, he 
 found in many ships the progress of this disease truly awful."
 
 488 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 "The disease occurred almost always in patients who had been 
 wounded at the battle of Murrfreesboro', and who had been retained in 
 crowded hospitals for some time previous to their transportation to 
 Louisville. I am informed by Surgeon Thurston, U.S.A., Medical 
 Director of the Nashville Hospitals, that no one upon whom the 
 gangrene had already appeared was ever sent from Nashville, and yet 
 many wei'e so infected when admitted to the Louisville hospitals. The 
 development of the disease on the route seems to have been owing to 
 the fact that the transportation of the wounded was effected by means 
 of crowded and ill- ventilated boats, and the trip by the Cumberland 
 and Ohio rivers frequently occupied several days. During this time 
 these patients, who had already undei-gone much suffering, were 
 exposed to all the influences most apt to engender this disease. In 
 contrast with this fact it was found that as soon as the Louisville 
 and Nashville railroad was opened, so that the wounded could be 
 conveyed from city to city in one day, all importation of gangrenous 
 sores into Louisville ceased. The development of hospital gangrene 
 during the boat transportation is a noticeable fact, and is strikingly 
 analogous with the same phenomena observed among our paroled 
 wounded prisoners from Richmond, received into the Annapolis General 
 Hospital some months since." 
 
 It is just tliis preponderant, i£ not absolute, association of 
 hospital gangrene with hospitals, prisons, ships, and such 
 like self-contained places, where every kind of sanitary 
 neglect has often been rampant, as well as the very notable 
 remission of the disease since those nuisances have been 
 abolished, or at any rate considerably lessened by the appli- 
 cation of rational principles of hygiene — it is just these 
 things that serve, in my view, to prove incontestably that 
 the development and diffusion of the disease are, if not 
 absolutely dependent on such injurious influences, yet very 
 materially favoured by them. It would be completely 
 inverting the natural order if we were to pass by these 
 latter facts unnoticed, or to deny their importance, because 
 of a too close attention to those other observations which 
 tend to show that hospital gangrene may develop under 
 conditions that are the reverse of these, or that it does not 
 always develop in surgical wards although such insanitary 
 conditions are present. The mistake made by the observers 
 who take up this point of view in their estimate of the facts, 
 partly arises from their hazy notions of the importance of 
 hygienic defects for the breeding of infective diseases in 
 general, and partly from their anxiety to have hospital gau-
 
 HOSPITAL GANGRENE. 489 
 
 grene characterised as an " epidemic contagious disease/' as 
 if there were such a thing as the epidemic of a disease by 
 itself, or as if by this way of speaking they gained anything 
 better than a phrase with no meaning of its own. But, 
 moreovei", that term must lose all meaning whatsoever when 
 we see how, in order to prove an " epidemic " origin for 
 hospital gangrene, they have mixed it up with various other 
 infective diseases prevalent at the same time, such as cholera, 
 typhoid, typhus, and diphtheria, whereby the homogeneous 
 character of the disease is completely lost. 
 
 § 175. A Communicable Disease due to a Morbid Poison. 
 
 There is no doubt that hospital gangrene is due to a 
 peculiar morbific cause, to a specijic morbid poison, for the 
 action of which on the body it is necessary that there should 
 previously have been a wound (Konig), and which induces in 
 the first instance a local infection at the seat of injury, as in 
 erysipelas and puerperal fever. Whether the above-men- 
 tioned influences of weather and insanitary conditions are 
 favorable to the development or the I'eproduction of this 
 morbid poison, or whether they merely increase the predis- 
 position of the individual to take the sickness (possibly by 
 changing the character of the wound), can hardly be decided 
 at present, the less so that there is nothing certainly known 
 of the nature of the poison, although it is probably of the 
 organised or parasitic sort.^ 
 
 The commioiicahility or contagiousness of the disease, which 
 has been called in question by AUe, Thompson, and the 
 writer on the epidemic at St. Greorge's Hospital (London) 
 in 1863-65, has been demonstrated by means of experimental 
 transmission of the infection to animals (Fischer), and proved 
 still better by means of intentional (Ollivier) or unintentional 
 infection of small abrasions in medical attendapits and nurses.^ 
 It has been shown that the virus of hospital gangrene can 
 
 ' Hiiter (' Centralbl, fiir die ined. Wissensch.,' 1868, No. 12, and ' Zeitschr. fiir 
 Cbiiurgic,' 1872, i, 91), in cases of " gangrena diphtheritica," has found spores 
 and fungi (micrococci) in the blood and in tlie gangrenous tissues. 
 
 * See the collection of facts on this point made by Heine, 1. c, p. 287.
 
 -490 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 be transmitted by bandages, instruments, or the surgeon's 
 or nurse's hands soiled by the gangrenous discharge, these 
 being the media of carrying it in a fixed state. It is still a 
 question whether it can be transmitted by currents of air. 
 
 § 176. Relation to Erysipelas, Puerperal Fever, and 
 
 Diphtheria, 
 
 As to the relation between hospital gangrene and the other 
 infective traumatic diseases of the same group, erysipelas and 
 puerperal fever, we can say no more with certainty than that 
 the production of them all alike is under the common influ- 
 ence of certain external factors, and that accordingly 
 they now and then coincide both in place and time. But I 
 should consider it altogether unjustifiable to conclude there- 
 from that the processes are identical, or that the specific 
 cause underlying them all is the same. In fact Pitha's view 
 of the analogy between puerperal fever and hospital gangrene 
 being so close that " it is not going too far to declare unre- 
 servedly for their identity '' (an opinion which he bases on the 
 coincidence of the two diseases in time), has found very few 
 adherents as yet. In like manner as regards erysipelas and 
 hospital gangrene most observers, such as Goldsmith, 
 Brinton, Riberi, Ponfick, Fischer, Schiiller and Carpenter, 
 content themselves with making good the fact that the two 
 diseases sometimes occur epidemically side by side, without 
 venturing to regard them as identical moi-bid processes.^ 
 
 A very lively controversy has arisen in recent times around 
 the question of the relation of hospital gangrene to diphtheria. 
 
 * In controverting Hiiter's theory of monads, Konig very justly asks, " What 
 is it that leads the monads at one time to attack wounds in epidemic fashion, 
 and in them to spend their activity, causing a diphtheritis of wounds; and 
 another time to leave the surfaces of wounds at peace, to offer no interference 
 with their healing, hut to wander into the skin and there cause erysipelas ; or, in a 
 third case, to choose the suhcutaneous connective tissue as the scene of their labours, 
 and there to set up diphtheritic phlegmon ? How is it that the contagion of gan- 
 grene is so transmitted as to produce only gangrene, and that of the rose so as to 
 set up merely the rose again in the person infected ? Why is it that we can 
 discover no other relationship between rose and hospital gangrene than that rose 
 may supervene on a wound attacked by gangrene, but neither more readily nor 
 lesg readily than on wounds not infected at all ? "
 
 HOSPITAL GANGRENE. 491 
 
 One idea is that of an anatomical,, clinical, and etiological 
 community in the two diseases ; and that idea has at length 
 come to imply that " hospital gangrene is nothing else than 
 diphtheria of wounds." Indications of the so-called diph- 
 theritic character of the wounds in hospital gangrene occur 
 as far back as Paracelsus and Pare ;^ in later times this 
 view was developed by Ollivier/ Robert/ and Nagel, and 
 quite recently it has found its more important defenders in 
 Heine* and Carpenter.^ I reserve my more special discus- 
 sion of this question until the chapter on angina maligna 
 (diphtheria of the throat). I will only remark here that the 
 theory rests upon a vague notion of what is " diphtherial " 
 (or, to use a barbarism, '^ diphtheritic ") ; and that there is 
 not the slightest ground, from the geographical, historical, 
 or etiological point of view, as I shall show at the proper 
 place, for identifying the diseases. They have nothing more 
 in common than the anatomical condition up to a certain 
 point. 
 
 1 See p. 477. 
 
 ■■' • Traite experimental tlu typhus trauinatique, gangrene ou pourriture des 
 Lopitavix,' Paris, 1822. I have no knowledge of this work except from extracts. 
 It is impossible that the word " diphtheritic " could have been used by OUivier, as 
 it was first introduced into medical terminology by Bretonueau in 1827. 
 
 3 'Bull. gen. de therap.,' 1847, Juli; ' Gaz. des hopit.,' 1847,^0. 85. 
 
 •* L. c, p. 207. 
 
 ' "Hospital gangrene and diphtheria are precisely similar" ('Transact, of 
 Amer. Med. Assoc./ 181 8, xxix, 245.
 
 CHAPTER XIY. 
 
 CHLOROSIS A^D ANEMIA. 
 
 § 177. Vague Statements on the Connexion of Anemia 
 
 WITH Civilisation. 
 
 *^ Poverty o£ the blood, green sickness, and allied coudi- 
 tionSj as the prevailing physical characteristics of our age " — 
 so runs the title of an address^ given by Politzer in 1856, 
 at the thirty-second annual meeting of the Deutsche Natur- 
 forscher-Versammlung. In this address he expressed with 
 much eloquence the old complaints of Hufeland and others 
 as to the " physical degradation of the human race/' the 
 " degeneration of mankind to simulacra/' and so forth ; and 
 as the characteristic mark of the degeneration he named 
 the group of morbid conditions which I have placed at 
 the head of this chapter under the general term " anasmia." 
 Evidence that his complaint was in any degree well-founded, 
 the orator did not adduce ; and if we follow the only 
 trustworthy road, that of statistics, there is no such 
 evidence to be had. After we have resolved that compre- 
 hensive term " poverty of the blood " into its elements, we 
 shall find infinite difficulties in the way of arriving at a safe 
 opinion whether any one of them has, as a matter of 
 fact, undergone so considerable an increase iu the extent of 
 its prevalence in modern or recent times as to warrant us in 
 speaking of it as characteristic of the period. 
 
 It is not to be denied that progressive cultivation and the 
 refinements of civilised life have introduced, and are intro- 
 ducing every day many things into our mode of living which 
 have a deteriorating influence upon the race, and are favor- 
 
 ^ Repi-iutedin the ' Zeitschr. der Wiener Acrzte,' 1857, Heft ii, 63.
 
 OHLOEOSIS. 495 
 
 able to angemia in particular ; and therein we may find an 
 a priori justification of the assertions made. On the other 
 hand, it should not be forgotten that the progress of culture 
 and civilisation has obviated or overcome many sins of 
 omission or commission in the lives of former generations, 
 which were not less injurious to nutrition and blood-making 
 in man's body. And thus the title of the address quoted at 
 the beginning of this paragraph must remain a mere idea, 
 resting on altogether general and very vague impressions — an 
 idea which has no more definite value than the maxim of 
 the melancholy philosopher, that " the world is always 
 growing worse." 
 
 Without entering upon this question, to which it seems 
 to me there can be no answer, I shall take as the subject 
 of a more modest inquiry two or three forms of anaemia, 
 which are of especial interest from the point of view of their 
 geographical distribution. 
 
 I. Chlorosis. 
 
 § 178. Eefeeences in Ancient and Medijival Writings. 
 
 To the practitioners of antiquity and the middle ages,, 
 chlorosis, like chronic disorders of nutrition in general, was 
 quite unknown as a peculiar and individual form of morbid 
 process. There arc, however, here and there in the writings 
 of the Greek physicians references to pallor {ayr^oiv) or a 
 yellow tint {y^'Xt^pa yr^pMnara) of the skin as symptoms of 
 illness, which may be supposed, in some instances at least, 
 to point to chlorosis. But we find more definite evidence 
 that the disease was not infrequent in those times, in the 
 
 1 Hippocrates, ' Praenot. coac.,' sect, ii, § 3:^3, ed. Littre, v, 656, and ' Prorrh.,' 
 lib. ii, § 31, e. c, ix, 64; also Galen, in 'Hipp. Prorrh.,' lib. i, comment, iii, 
 cap. ci, ed. Kiihn, xvi, 727; and in 'Hipp. libr. de alimento,' comment, iii, 
 cap. xvii, e. c, xv, 327, where we have a moi'e precise indication of chlorosis and 
 anaemia ex metrorrhagia : " we /*«>' ovv TroWa tVtrai ffvuirTwfiara ralg kTrnTxsfftffc^ 
 rijC sju/xjjvov ica3-ap(T6wc> ovno Kal afierpoic Ktrdjataiv iniyiviTai raSs axpoiaiKcu 
 ■KO^MV oUnfia Kal oXov vttoi^ov to aiofia." The word " x^wpwrrte " does not occur 
 in Hippocrates, or in any of the subsequent Greek writers on medicine.
 
 494 GEOGEAPHICAL AND HISTORICAL PATHOLOGY, 
 
 fact that Oi'ibasius, Aetius, Eliazes, Avicetina, tlie Salernians^ 
 and others dwell very particularly upon '^ general weakness 
 of body, trouble in breathing, and paleness of the skin '* 
 as symptoms of a disorder of menstruation (suppi'essio men- 
 struorum) which did not depend on disease in the uterus. 
 In the sixteenth century the malady was well known under 
 various names which described its characters well ; such as 
 '^ febris amatoria/'^ '^ foedus virginum color/^' " morbus 
 virgineus/'* and '^ febris flava/' " The term " chlorosis/' 
 in the sense in which it is now generally employed, I find 
 occurring first in Sennert,*"' and in several of the dissertations'^ 
 written at Basel in the beginning of the seventeenth century. 
 It forms one of the stock subjects in the compendiums of 
 medicine and treatises on diseases of women belonging to 
 that and subsequent periods, the first thorough handling 
 of the matter being in an essay by Friedrich Hoffmann,^ 
 in which use is made of the term "Bleichsucht," still employed 
 in German colloquial speech. This essay was the source of 
 numerous writings on chlorosis throughout the eighteenth 
 century. 
 
 § 179. Present Distribution: Remarkable Extension in 
 
 Sweden op late. 
 
 There can be no doubt, then, that chlorosis has been among 
 the subjects of medical observation at all times. But the 
 frequency of the disease at various periods of the past history 
 as compared with its present frequency is a question that we 
 
 ' See " De egritudinum curatione tract.," in De Renzi's ' Collectea Salerni- 
 tana,' Napol., 1853, ii, 331. 
 
 ^ In Lange, ' Epist. med.,' lib. i, epist. 2r. 
 
 ^ In Ballonius, ' De virginum et muliermn morbis,' cap. vli, 0pp. Genev,, 1762, 
 iv, 66. 
 
 '' In Rodericus a Castro, ' De univ. raulierum med.,' lib. ii, cap. v. 
 
 * In Mercado, ' De morbis mulierum,' lib. ii, cap. vi. 
 
 * 'Pract. med.,' lib. iv, tract, ii, sect, iii, cap. ii, Wittbg., 1760, p. 214. The 
 opinion referred to in this passage, that the word ■xXM^hioi.c, had been used by 
 Hippocnttes, rests, as we have seen, on an error. 
 
 ^ Flacht, • Diss, de chlorosi, s. morbo virginum,' Basil., 162 1. 
 
 * 'De genuina chlorosis indole, origine et curatione,' Hal., 1731, in 0pp. 
 Genev., 1748, suppl. ii, pars, ii, 389.
 
 CHLOROSIS. 495 
 
 have no answer for. Even in our inquiry into its present 
 geographical distribution, it is impossible to arrive at a definite 
 idea of the relative amount of the sickness at various parts 
 of the world, owing to the data of authorities being frag- 
 mentary as well as extremely vague. 
 
 In Central and Southern Europe, including Great Britain 
 and Ireland, Holland, Belgium, Germany, France, Italy^ and 
 Turkey," as well as in the countries of America within the 
 temperate zone, the malady appears to be common every- 
 where. From the northern regions of both hemispheres 
 we have accounts of its very considerable prevalence in 
 Miquelon {Newfoundland)^ and in Iceland and the Faroe 
 Islands.*' 
 
 Schleisner's'' statement that the malady is very rarely seen in Iceland, 
 is contradicted by Hjaltelin'' and Finsen^ in the most decided terms. 
 Hjaltelin found that 5 per cent, of all his patients there had chlorosis, 
 and I I'l per cent, of all the women patients. Finsen treated 316 cases 
 of chlorosis in ten years in a district with 10,000 inhabitants, and he 
 accordingly rates the amount of the sickness very high. 
 
 In the annual health reports of Norway,^ there is mention 
 of the exceedingly frequent occurrence of chlorosis for every 
 district of the country, from Christiansand up to Tromsoe, 
 in the interior as well as on the coast ; and in some districts 
 it is accorded one of the first places among chronic maladies. 
 These data are fully borne out in the most recent account 
 of chlorosis in Norway by Axel Lund.^ Of recent years the 
 disease has played a not less prominent, possibly a more 
 
 ^ See De Renzi ('Topogr. e. statist, med. della citta di Napoli,' Nap., 1845, 
 p. 321), on the commonness of chlorosis in Southern Ital}'. 
 
 * Rigler (' Die Tiirkei und deren Bewolmer,' ii, 412), in like manner, speaks of 
 the very considerable amount of the sickness in Tui key and adjoining countries 
 of the Levant. 
 
 3 Gras ('Quelques mots sur Miquelon,' Montp., i860, p. 35) says: "La 
 chlorose domine toute la pathologic de la jeune miquelonnaise." 
 
 ■* Martius, ' Revue med.,' 1844, Fevr. In Greenland, according to Langc 
 ('Gronland's Sygdomsforhold,' Kjobenh., 1864, p. 28), chlorosis would appear to 
 be very uncommon. 
 
 ^ ' Island uudersijgt fra et laegevidensk synspunkt.,' Kjobenh., 1849, 4. 
 
 *" • SundhedskoU. Forhandl. for aaret 1859,' 434. 
 
 " • Jagttagelser angaaende Sygdomsforholdeue i Island/ Kjobenh., 1874, 60. 
 
 * ' Beretninger om Sundhedstilstandeu i Norge.' 
 '■> 'Nord. med. Arkiv,* 1875, vii, Nr. i.
 
 49G GEOGliAFHICAL AND HISTORICAL PATHOLOGY. 
 
 prominent part in the sickness of Stveden. '*■ Within the 
 last twenty or twenty-five years," says Hnss/ writing in 1851, 
 " a form of disease that used to be rarely seen, has come to 
 be more and more domesticated among grown-up people in 
 Sweden. I mean the green sickness. At an earlier period 
 the malady had occurred in this country among those classes 
 whoso children, the girls in particular, had been more 
 delicately brought up, as well as among the poorer classes 
 in the towns ; but until thirty years ago or less, it was quite 
 unknown among the inhabitants of country districts. . . 
 . . The more general diffusion of the sickness has not 
 been a sudden thing with us, but gradual ; neither has it 
 been to the same extent in every region of the country, 
 being rather common in some, merely sporadic as yet in 
 others, while in still others it has not been observed at all 
 hitherto. Thus in Norbotten, chlorosis is still unknown as 
 a disease of the people, being rare even in the towns. The 
 most northern point where it can be definitely shown to have 
 become truly endemic is the parish of Skelleftea in the 
 province of Westerbotten. In Angermanland, Medelpad 
 and Jemtland, it was first seen about ten years ago [written 
 in 1 851] ; and since then it has become more general every 
 year. The same is true of Hclsingland and Gestrikland, 
 where chlorosis was quite unknown twenty or thirty years 
 ago j also of the southern parts of Dalarue and Westmanland, 
 whence we are told by Altin that preparations of iron were 
 dispensed by the chemist at Westerns from 1845-50 to the 
 amount of three hundred and seventy per cent, more than 
 in the five years preceding, and by Pallin, that old people 
 had often assured him that no one had ever heard of green 
 sickness in that part of the country twenty years ago. In 
 Upland, Sodermanland and Nerike the first appearance of 
 the disease dates from the fourth or fifth decade of the 
 century; and the importance that it has now attained in 
 some districts of these provinces will appear from the state- 
 ment of Klintberg, that in his practice (in the province of 
 Nerike) only a few of the young women between fourteen 
 and twenty-one years of age were free from chlorosis. On 
 the other hand, it is noteworthy that there is exemption 
 ' 'Om Sverges endem. Sjukdomar,' Stockb., 1852, 96.
 
 CHLOROSIS. 497 
 
 from the disease in the inland districts of Wermland and 
 Dahlsland, as well as in the coast district of Bohuslan. By- 
 far the greatest extension of the malady, both in town and 
 country, appears to have taken place in Westergothland^ 
 Ostergothland, Halland, Schonen and Blekinge ; and in those 
 regions also it is within the last twenty or thirty years that 
 chlorosis has become common. But in Smaland it is less 
 general, and on Gottland it is seldom seen. All the medical 
 accounts [that have been used by Huss for this summary] 
 are agreed in saying that chlorosis is to be regarded as a 
 disease newly arisen among the rural population of Sweden, 
 having first appeared twenty years ago in some of the districts, 
 and in others fifteen, ten or eight years ago, and having for 
 the most part become general in a district soon after it had 
 showed itself at one point. '^ 
 
 These statements as to the ever encroaching area and 
 the increasing number of cases of chlorosis in Sweden are 
 fully confirmed in the medico-topographical accounts of 
 Swedish practitioners, published in the ofiicial sanitary 
 reports for that country from 1852 to 1871 -^ so that chlorosis 
 may be described as a truly endemic malady of Sweden. 
 
 I find only a few accounts of the occurrence of chlorosis 
 in tropical and subtropical countries, and these are partly 
 contradictory and therefore not altogether trustworthy. On 
 the coast of Mexico, according to Heinemann's" experiences 
 during a six years' residence in Vera Cruz, it is very com- 
 mon ; so much so that it is spoken of as " one of the most 
 general diseases of the Vera Cruzan youth, especially those 
 of the female sex.'' In the West Indies^ it would appear to 
 be almost as common among women as it is in European 
 countries. According to Waddel* there is a good deal of 
 it in Brazil ; but Wucherer^ says that it was rarely to be 
 seen in Bahia. For the West Coast of Africa Chassaniol^ 
 
 ' ' SundliedskoUegii Berattelse.' Unfortunately in these reports since 1871 
 the medico-topographical accounts have ceased. 
 
 * ' VirchoVs Archiv,' 1873, Iviii, 178. 
 
 3 See Savaresy, ' De la fievre jaune,' &c., Napl., 1809, 88, and Eufz, 'Arch, 
 de med. nav.,' 1849, Novhr., 346. 
 
 * In Castelnau, ' Expedition,' II, 38 ; but it is doubtf al whether there is not 
 some confusion here with other forms of ansemia. 
 
 5 'Arch, fur klin. MeJ.,' 1872, x, 379. 
 
 * ' Arch, de med. nav.,' 1865, Mai, 508. 
 
 VOL. II. 32
 
 498 GEOGRAPHICAL AND HISTOETCAL PATHOLOGY. 
 
 observes that it is less common among the negresses than it 
 is among women in Europe ; and the opinion of Frank^ and 
 Pruner^ as regards Egypt is the same. On the other hand, 
 according to French authorities^ it is very common in Algiers 
 among women of Moorish descent. That it is a compara- 
 tively frequent malady in India we learn from Huillet's^ 
 account for Pondicherry, and from Curran's'* for the southern 
 slopes of the Himalaya. In the East Indies the cases of 
 chlorosis that Heymann^ has seen have been almost entirely 
 in European young women. In the maladies of women in 
 Cochin China, according to Beaufils/ chlorosis plays a promi- 
 nent part along with other forms of anaemia; and that it is 
 also true for China, according to Dudgeon^, and for Japan, 
 according to Wernich.^ 
 
 § 1 80. Independent op Climate, Soil, and Race. 
 
 Although our information on the history and geographical 
 distribution of chlorosis is fragmentary, there is enough of 
 it to warrant the conclusion that the malady has been 
 observed at all times, that its area of diffusion embraces a 
 large part, perhaps the larger part of the globe, and that no 
 kind of climate or soil precludes it. We ought not, pei'haps, to 
 dismiss absolutely the idea that extremes of temperature, such 
 as are found in the highest and lowest latitudes, are espe- 
 cially likely to generate the disease. In favour of that idea is 
 the considerable amount of the sickness in the polar and the 
 temperate cold zones, and its relatively common occurrence 
 in the tropics. As regards the latter, to which attention has 
 specially been called by Sullivan,® there is certainly much 
 more of it than would appear from the foregoing notices, for 
 
 ^ 'Neues Journ. der ausland. med.-cliir. Litteratur,' ix, Heft i. 
 
 ^ ' Krankheiteu des Orients,' 325. 
 
 3 'Arch, de med. nav.,' 1868, Fevr., 82. 
 
 ^ ' Dubl. Quart, Journ. of Med. Sc.,' 187 1, Aug., p. loi. 
 
 ^ 'Darstellung der Kraukheiten in den Tropeulandern,' &c., Wiirz,, 1855, 186. 
 
 « 'Arch, de med. nav.,' 1882, Avril, 272. 
 
 '■ 'Glasgow Med. Journ.,' 1877, July, 329. 
 
 ^ ' Geogr.-med. Studien,' Berl., 1878, p. 172. 
 
 « 'Med. Times and Gaz.,' 1875, Aug., p. 233.
 
 CHLOEOSIS. 499 
 
 tlie reason that I have disregarded all those accounts from 
 the tropics which relate to the enormous prevalence of anae- 
 mia in general without mentioning chlorosis in particular, 
 although there is no doubt that in many of them it is 
 chlorosis that is particularly meant. 
 
 Goldschmidt's^ opinion is that in Oldenburg the malady 
 occurs mostly on a sandy soil, while in the marshes it is so 
 seldom seen that an experienced practitioner from the marsh- 
 country assured him that he had had no cases of chlorosis 
 among his patients ; but I am unable to decide from the 
 recorded facts whether that experience expresses the general 
 case, or how far a swampy soil gives immunity from the 
 disease. In Norway, according to Axel Lund's observation, 
 the malady is much rarer in the mountain valleys than on 
 the level country ; but the explanation of that, he thinks, is 
 not to be found in the soil, but in the manner of life of the 
 inhabitants. So far as I can judge from authentic observa- 
 tions, it is not at all probable that racial or national pecu- 
 liarities create either a predisposition to chlorosis or an 
 immunity from it. 
 
 § 1 8 1. Mostly a Malady op Women leading an indooe 
 
 Life. 
 
 The morbid diathesis from which chlorosis develops, is 
 undoubtedly a congenital one in many cases, sometimes 
 associated with imperfect development of the vascular system 
 (Virchow^), sometimes perhaps traceable to a morbid habit 
 of body of the parents due to drinking, consumption, syphilis, 
 and the like (Lund). But there are other cases in which 
 the diathesis is acquired, having its basis in the individual's 
 manner of life. There is scarcely a single fault in the kind 
 of life that men, and more particularly women, lead both 
 socially and intellectually, that has not been regarded, either 
 by itself or in company with other things, as the cause of 
 the acquired chlorotic diathesis. That the social position of 
 the individual has, generally speaking, only an indirect in- 
 
 1 ' Haser's Arch, fiir die ges. Med.,' 1845, ™» i^i^ 
 
 2 'Ueber die CUorose,' &c.. Berlin, 1872,
 
 500 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 fluence at tlie most, may be inferred from tlie fact tliat 
 chlorosis is distributed somewbat uniformly among tbe poor 
 and the rich, among persons in all sorts of occupations, and 
 among the inhabitants of town and country. '' It is not on 
 increasing poverty," says Huss, " that the general diffusion 
 of chlorosis in Sweden depends ; for, although there too the 
 number of the poor has increased, that applies more to 
 towns than to the country districts ; while it is in the latter 
 that the malady has appeared as something new, and more- 
 over has shown itself more often among the moneyed classes 
 than among the poorer class and the labourers." 
 
 The preponderance of chlorosis in the female sex indicates 
 that there must be some factor predisposing to that type of 
 disease, which is inherent in the female organisation ; and 
 that there are certain harmful things in their manner of life- 
 which are calculated, where such predisposition exists, to 
 bring out those irregularities of blood-making which are the 
 fundamental thing in chlorosis. Many observers are agreed 
 that there is hardly any of these harmful influences which 
 plays so great a part as prolonged confinement indoors, or 
 want of exercise in the ojjen air. With reference to the dis- 
 ease in Sweden, Huss says : " One of the principal causes 
 is to be found in the completely changed mode of living 
 which has taken place among the women part of the popu- 
 lation in north country districts. Formerly the wife shared 
 with the husband almost all the labours of the field ; she 
 lived, accordingly, almost constantly in the open air, under- 
 took the most fatiguing kinds of work, and so became hardy 
 and strong of body. But within the last twenty or thirty 
 years, things have changed very much. The women now 
 occupy themselves, except in harvest time, with household 
 work almost exclusively ; and their children also they keep 
 for the most part shut up in their houses, where the cramped, 
 narrow and unwholesome rooms must of themselves 
 exert an unfavorable influence on the wellbeing of the 
 inmates. But the great importance of these circumstances 
 for the endemic existence of chlorosis is shown by the fact 
 that the malady is rare or altogether unknown in those 
 regions, such as Dalarne, Wermland, Dahlsland, and Smaland, 
 where the old customs continue to the present day ; while, on.
 
 CHLOEOSIS. 501 
 
 tlie other band, it is most widely spread in the province s, 
 such as Westergothland and Halland, where the women are 
 occupied almost entirely with household work.^^ In like 
 manner Lund, for Norway, would find the most potent 
 although not the only cause of the ever-increasing chlorosis 
 there, in the want of open-air exercise ; and he points out 
 that the difference in the amount of the sickness in the two 
 ■sexes is partly explained by the fact that the boys, after 
 their first childhood is over, are more in the open air than 
 tthe girls. The real cause of the chlorosis which is endemic 
 in the island of Miquelon, is stated by Gras to be " la 
 claustration presque absolue, a laquelle les jeunes filles se 
 condemnent volontairement." Rigler found the disease in 
 Turkey to be especially common among those Oriental women 
 who led an inactive and purely sensual life in the harems. 
 Pruner points out that chlorosis in Egypt occurs mostly in 
 women who lead an indolent life behind latticed windows, 
 such as the Jewesses in Cairo. In Algiers, also, according 
 to the French physicians, it is very common among the 
 Moorish women, who many early and spend their lives in 
 damp, closed- in houses, never leaving them except to walk in 
 the gallery overlooking the dank and ill-smelling courtyard. 
 Savaresy, speaking of the Creole women in the West Indies, 
 assigns their inactive and indolent mode of life, and the 
 nervous excitability dependent thereon, as the causes of the 
 chlorosis so common among them ; and a similar conclusion 
 is come to by Heinemann for Mexico and by Dudgeon for 
 China. 
 
 In discussing the etiology of chlorosis, I must confine 
 myself to a consideration of this one factor. It would carry 
 me far beyond the limits that I have imposed on myself in 
 this work, if I were to enter on a criticism of the many and 
 various opinions and conjectures that have been put forward.
 
 502 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 II, Aiisemia Intertropica. 
 
 § 182. The General Anemia op the Tropics. 
 
 All observers agree tliat ansemia is a characteristic morbid 
 phenomenon of tropical regions, and tliat as a symptom it is 
 found mostly among the white residents, although it maybe 
 observed to no small extent among the coloured races also. 
 As Sullivan says, anasmia constitutes " the foundation of 
 nearly all diseases of tropical climates.^' There seems to be 
 hardly any question that the peculiar influence of tropical 
 climate which is called "relaxing/' and which cannot be 
 otherwise defined in physiological terms, is, for white people 
 not habituated, a very material factor in the development of 
 this disorder of nutrition. But it is clear that malarial in- 
 fluences contribute not inconsiderably to it, and also nostalgia, 
 as Marchand^ makes out for the convicts transported to 
 Guiana from France. Experience shows, moreover, that the 
 anaemic habit of body in white residents of the tropics com- 
 municates itself to their ofi^spring ; and therein lies the chief 
 obstacle to the acclimatisation of the white race in the 
 tropics. 
 
 Among the coloured races of the tropics " pure " ana3mia 
 is mostly the consequence of deficient food, or of a diet poor 
 in animal substances, as well as of other debilitating influ- 
 ences such as the excessive use of spirits, bad dwellings, and 
 the insufficient protection afforded by their clothing against 
 the peculiarly trying tropical changes of weather. In other 
 respects the accounts of the prevalence of ana3mia among 
 the coloured races of the tropics, particularly the negroes, 
 are to be received with caution, for the reason that many of 
 them relate, not to idiopathic poverty of blood, but to 
 anemia caused by Anchylostoma duodenale or the so-called 
 " geophagia." 
 
 * ' Des causes et du traitement de I'anemie cbez Ics transportes a la Guayaue 
 fran^aise,' Montp., 1869.
 
 MOUNTAIN SICKNESS. 503 
 
 III. Ansemia montana [Mai des Montagues) . 
 
 § 183. Symptoms of Mountain Sickness. 
 
 Under these and various colloquial names^ there have been 
 described a group of symptoms apt to come on during the 
 ascent to more considerable elevations, or during any contin- 
 uous residence there by persons accustomed to live at lower 
 elevations or on the plains. They consist of a series of 
 phenomena, proceeding partly from disorders of the respira- 
 tory and circulatory functions, and partly from an affection 
 of the nervous system. 
 
 Usually the first thing noticed is a feeling of want of breath and of 
 pressure on the chest, the respiration becoming hurried and wheezy, and 
 there may even be a sensation of choking. It is clear that these pheno- 
 mena are not to be attributed to the exertion of climbing the mountain, 
 for they continue after the individual has arrived at pei-fect repose. 
 Associated with them are a quickened pulse, palpitation, attacks of 
 giddiness, pains in the head, sometimes even the feeling of going off in 
 a swoon, disturbed or lethargic sleep, sickness or even vomiting, and 
 usually a feeling of weakness or weariness which comes on in attempting 
 to walk or otherwise exert the bodily strength, and which sometimes 
 reaches so great a height that the slightest movement is torture. All 
 these symptoms quickly abate whenever the descent is made to lower 
 elevations ; but if the individual remain at his elevated station they will 
 persist, usually for a few days (two to four), but sometimes for several 
 weeks and even months, until he has been thoroughly acclimatised. 
 It is in the highest degree doubtful whether the seizure ever leads to 
 serious or fatal symptoms, or, as Jourdanet alleges, to a chronic state 
 of ill-health. Statements of that sort are probably based upon errors 
 of diagnosis, or, in other words, upon wrongly attributing the observed 
 morbid conditions to the effects of residence at a great height ; at all 
 events the severe forms of ansemia running a chronic course and with 
 permanent after-effects, which some observers have attributed to moun- 
 tain sickness, are due to quite other influences. MM. Gayraud and 
 Domec, writing from Qviito, say : " Nous avons vu arriver a Quito, et 
 venant de niveaux inferieurs, des enfants, des veillards, des femmes, des 
 personnes de toute race, de toute complexion et de tout temperament ; 
 jamais il ne nous a etc donne de constater le moindre etat morbide que 
 Ton pu mettre sur le compte d'une acclimatation plus ou moins 
 incomplete." 
 
 ^ In Peru and Quito these arc : mal de la Puna, soroche, veta, mareo {i.e. mal 
 de mer) de la Cordillera ; in the Himalaya, bies or bootie.
 
 504 GEOGEAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 It is only in cases of heart disease that the symptoms of mountain 
 sickness appear to be of a ratlier serious kind. According to Guilbert's 
 observations on the subject in Peru and Bolivia: " Quelques personnes 
 atteints d'afFectiou organique du cceur deja avancee, ont souffert beau- 
 coup plus longtemps et ont conserve pendant toute la duree de leur 
 sejour la gene de la respiration et de la circulation. Mais ce sont des 
 faits exceptionnels." 
 
 Lastly, it is a noteworthy fact that the phenomena of mountain 
 sickness have been observed also in beasts of burden (horses, asses, and 
 mules) which had come up from the plains to considerable elevations. 
 
 § 184. Localities wheee Mountain Sickness has Occurred. 
 
 The malady does not occur except at elevations more tlian 
 2000 metres (6500 feet) above the sea^ and it does not 
 manifest itself fully until a height of 3000 to 4000 metres 
 (10,000 to 13,000 feet) is reached. In this way we account 
 for the fact that the sickness has never been observed to 
 last for any length of time except in tropical countries, as it 
 is only in these that a somewhat prolonged or continuous 
 stay at so great elevations is possible. Most of the obser- 
 vations on mountain sickness, accordingly, and these the 
 most thorough, come to us from the Cordilleras of the 
 Western Hemisphere : from the Rochy Mountains,^ the 
 Tahle-land of Mexico^ [Anahuac), certain elevated points of 
 Central America, Ecuador^ {Quito), Bolivia,'^ and Feru} In 
 
 ^ Fremont, ' Narrative of the Exploring Expedition to the Rocliy Mountains,' 
 Lond., 1846. 
 
 * Glennie, 'Philos. Magazine,' 1828, June, 149; Wuillot, 'Presse med. beige,' 
 x866, Nr. 40; Jourdanet, Le Mexique et I'Amerique tropicale, &c.,' Par., 1864, 
 221 ; Coindet, 'Mem. de med. milit.,' 1866, Mai, 423. 
 
 3 Bouguer, 'Mem. de I'Acad. des sc.,' Annee 1744, Par., 1748, 261 ; de la Con- 
 damine, ' Voyage a I'Equateur,' &c.. Par., 1751, 34; Remy, ' Annal. de voyages,' 
 Par., 1857, clviii, 320; Gayraud et Domec,' Montpellier medical,' 1878, Juin, 491. 
 
 * Wadell, ' Voyage dans le Nord de la Eolivie, &c.,' Par., 1853; Burmeister, 
 ' Reise durch die la Plata-Staaten, u. s. w.,' Berl., 1861, ii, 263; Guilbert, 'De 
 la phtlnsie pulmonaire . . . au Pcrou efc en Bolivie,' Par., J862, 23. 
 
 * Jose d'Acosta, ' Histor. natural y moral de las Indias.' French translation. 
 Par., 1600, 90 (the first description of the malady, in which we find it already 
 spoken of as "mal des montagnes ") ; Ulloa, ' Physik. und histor. Nachrichten 
 vom sudl. Amerika,' i, 73, 2565 Cunningham, ' Lond. Med. Gaz.,' 1834, May, 
 August; Poppig, ' Rcise in Chile, Peru, u. s. w.,' Leipzg., 1836, 84; Smith, 
 ' Edinb. Med. and Surg. Journ./ 1842, April, 357; Tschudi, ' Oest. med, Wochen- 
 schr,,' 1846, 601 ; ' Wien. med. Wochenschr.,' 1859, ^r. 6.
 
 MOUNTAIN SICKNESS. 505 
 
 the Eastern Hemispliere tlie malady has been often observed 
 in ascents of the Higli Aljys,^ and of Arrarat^ (and Elburz) ; 
 still more often in ascents of the Himalayas^ and on the 
 Neilgherries'^ at elevations of no more than 2500 metres 
 (80Q0 feet). 
 
 § 185, Theories op the Cause op Mountain Sickness. 
 
 Regarding the cause of mountain sickness there was much 
 obscurity for a long time. Some thought that it was a kind 
 of narcotic effect produced by metallic or vegetable poisons. 
 Others sought for the reason of the phenomena in circulatory 
 disorders induced by the rarefied air in persons not habituated 
 to living in it ; as late a writer as Guilbert expressed the 
 opinion that the tension of the free gases of the blood was 
 increased under a lower weight of atmosphere, whereby 
 pressure was exercised on the walls of the vessels. The 
 most recent and generally received view is that the physio- 
 logical disturbances are a consequence of changes in the 
 •composition of the blood due to the diminished quantity of 
 oxygen which it receives, corresponding to the rarefied state 
 of the air, — '' diminution de I'oxygene dans le sang par 
 defaufc de pression/' as Jourdanet says in explaining the 
 name " anoxyhomie " which he has given to the disease,, — 
 and that the disorder of the functions is gradually overcome 
 by the respiration becoming deeper and more frequent. A 
 modification of this theory of what takes place in mountain 
 sickness has been adopted by Paul Bert.^ He has satisfied 
 himself J by experiments, that the co-efiicient of absorption 
 
 ' De Saussure, 'Voyage dans les Alpes; Forbes, 'Travels to tlie Alps of 
 Savoy,' Edinb., 184.3, 223, and many other travellers ; see Meyer- Ahrens, 'Die 
 Bergkrankbeit, u. s. \v.,' Leipzg., 1854, 40 S. 
 
 ^ Parrot, ' Keiso zum Arrarat,' Eerl., 1834, i, 133 if. 
 
 3 Moorcroft, ' Asiat. Researches,' Lond., 1818, xii, 413; Eraser, 'Journey 
 through part of the Snowy Range of the Himalaya Mountains,' Lond., 1820 ; 
 Jacquemont, 'Voyage dans I'Inde,' Par., 1841, ii, 260; Hoffmeistcr, 'Briefe aus 
 Indien,' Braunschw., 1847, 242; Drew, ' The Jummo and Kashmir Territories,' 
 Lond., 1875. 
 
 4 Collins, 'Ind. Annals of Med. So.,' i860, Nov., 7 ; Mackay, 'Madras Quart. 
 Journ. of Med. So.,' 1861, July, 29. 
 
 5 ' Compt. rend.,' 1882, torn. 94, No. 12, p. 805.
 
 506 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 of liaemoglobin for oxygen does not exceed lo to 12 per cent, 
 in animals living at the sea level, whereas in animals 
 domesticated to great elevations or under lower atmospheric 
 pressure — the animal's blood examined by him came from 
 La Paz, in Bolivia, at a height of 3700 metres or 12000 feet — 
 it rises to between 17 and 21 per cent. Probably the case 
 is the same with men ; and, in Bert's opinion, the acclimati- 
 sation of men and animals removed from the plains to great 
 elevations depends upon an increasing capacity of the haemo- 
 globin for absorbing oxygen, so that disorders caused by the 
 diminished quantity of oxygen in the air are gradually 
 overcome. 
 
 Another point, specially emphasised by Gayraud and 
 Domec, is that the malady known by the name of mountain 
 sickness is slight or severe according to the idwsync7-asy of 
 the individual. In their own persons they observed no sym- 
 ptoms of it on coming to Qviito ; and in the case of some other 
 strangers arriving in Quito they have eith er failed to observe 
 it altogether or have seen only very slight degrees of it.^ 
 
 ^ See also the earlier observations on the same subject by Meyer-Alirens, 1. c., 
 p. 128.
 
 CHAPTEE XY. 
 SCURVY. 
 
 § 1 86. Neglect op Historical Eesearch on Scurvy. 
 
 iC 
 
 It is a remarkable fact that, witli all the zeal which 
 historical students of medicine have applied to the more 
 important and more widely distributed forms of national 
 sickness, there has not been in recent times a single thorough 
 inquiry into the history of scurvy. It has in most cases been 
 thought sufficient hitherto to engage in unprofitable discussions 
 as to whether scurvy was known to the ancient and mediaeval 
 practitioners of medicine ; whatever the medical writers of 
 the sixteenth and seventeenth centuries had alleged of the 
 disease down to their own time has been allowed to pass 
 current without scrutiny as sterling coin ; and from those 
 materials a representation has been produced of the natural 
 history of survy, which has been copied and re-copied from 
 the one or two monographs on the subject into nearly all the 
 later compendiums of medicine. In the whole of the more 
 recent literature I know of only one author who has taken 
 the trouble to inquire into the history at first hand and to 
 subject an obscure heap of materials to the light of criticism. 
 I refer to Lind, whose admirable treatise^ still holds a fore- 
 most place among the writings on scurvy ; although all the 
 later authorities, with the exception of Sprengel,^ have paid 
 no attention to the important indications concerning the 
 history of scurvy which the book contains. It seemed all 
 the more necessary, therefore, that I should make this 
 
 ^ 'A Treatise ou the Scurvy,' Edin., 1752. An alphabetical list of authorities 
 quoted in the text is given at the end of the chapter. 
 2 * Geschichte der Arzneikunde,' iii, 93.
 
 508 GEOGKAPHICAL AND HISTORICAL PATHOLOGY. 
 
 matter the subject of a new and thorougli scrutiny, and 
 should exhibit it in a somewhat broader light ; and this was not 
 the less incumbent on me because the results of my inquiry 
 proved to be in many respects a good deal at variance with 
 the view of the facts hitherto accepted." 
 
 These are the words with which I began the chapter on 
 scurvy in the first edition of this work, by way of justifying 
 the detailed treatment of the subject from its historical side. 
 Since that was written several considerable works on scurvy 
 have appeared, in which the history of the malady has 
 received attention ; in these I find the results of my 
 researches reproduced, and no material exception taken or 
 contradiction given to them. I think myself warranted, 
 therefore, in using them as the basis of the historical survey 
 of the disease in this second edition, all the more so that the 
 facts which have come to my knowledge in the interval have 
 only served to confirm me in my original opinions. 
 
 § 1 87. Criticism ojp the supposed references to Scurvy in 
 
 ANCIENT writings. 
 
 The writings that have come down to us from antiquity 
 and the middle ages give no help towards deciding whether 
 scurvy occurred, or was known to medicine, in those times at 
 all ; or, if so, to what extent. In order to make out that 
 the Graeco-Roman and Arabian physicians were acquainted 
 with scurvy, special emphasis has been laid on a form of 
 disease described under the name of " lienes magni " by 
 Hippocrates,^ Celsus,^ Areteeus,^ Cselius Aurelianus,* Paulus 
 -^gineta/ Avicenna*' and others. 
 
 ^' Okoooi §£ (jirXrji'a tj^ovai luiyav,'' says the Hippocratic 
 writer in one of the treatises, " oaoi fxtv ilai y^oXw^eeg, kuko- 
 y^pooi re y^vovrai Kal KaKiXKkg /cot BvacoBe^g eK rov arof-iaToq 
 
 ' Sec the passages quoted in the text. 
 
 " Lib. ii, cap. vii, ed. Targa, i, 54. 
 
 ^ ' De causis morb.,' lib. i, cap. xiv, ed. Kuhn, no. 
 
 '' ' Morb. chron.,' lib. iii, cap. iv, ed. Amman, Amstelod., 1755, 448. 
 
 ^ Lib. iii, cap. xlix, ed. L«igd, 1551, 222. 
 
 ^ ' Canon,' lib, iii. Fen. xv, Tract, i, cap. iv, ed. Venet., 1564, i, 790. 
 
 ^ 'De affectionibus,' § 20, ed. Littre, vi, 228.
 
 SCURVY. 509 
 
 Kal XsTTTol. Kai o (TTrXrji' a\r]po^, Kai a'ui 7rapa7r\i]<yiog to fiey^^oQ. 
 Kai ra aiTia ov ^la^^w^la." And in another passage,,^ " ovXa 
 ^£ irovr]pa Kcti aTOf.iaTa ouawoEa oiai (TttAjji'EC fx^'yaXoi. Okocjol 
 
 Sf eyoucri cxTrAjji'oc f.uya\ovQ, jurjTe aifxoppayiai yivovTtn juriTe 
 arofxa SuCTwSf^, Tovritov a'l Kvrjinai tX/CEa irovrjpa 'icf^ovai Kai 
 
 owAac fxsXaivag. 
 
 There is, in my view, but little reason to take that group 
 of symptoms, characteristic of the " lienes magni,'^ as point- 
 ing to scurvy ; firstly because swelling of the spleen, which 
 was undoubtedly a constant occurrence in that malady 
 according to the descriptions of observers,^ is by no means 
 one of the more commonly noted phenomena of scurvy ; and 
 secondly because the Hippocratic writers themselves^ refer 
 the origin of the malady in question to its true source — the 
 malarial cachexia. This view of mine is further supported 
 by the fact, to be afterwards adduced, that scurvy and 
 malarial cachexia have often been confounded in later times. 
 
 Other authorities* have detected scurvy in the form of a 
 disease mentioned by several writers of antiquity under the 
 name of " stomakake " and " skelotyrbe,^' supporting their 
 contention by a reference to Pliny's^ account of a disease 
 which was prevalent in the Low Countries among the Roman 
 army under Germanicus, and to Strabo's^ narrative of an 
 outbreak in the Roman army under ^lius Gallus in Arabia^ 
 
 " In Germania trans Rlienum castris a Germanico Caesare pit)- 
 motis," says Pliny, " maritimo tractu fons erat aquae dulcis solus, qua 
 pota intra biennium dentes deciderent, compagesque in genibus sol- 
 verentur. Stomacacen medici vocabant et sclerotyrben ea mala. 
 Reperta auxilio est berba, quae vocatur Britannica, non nervis modo 
 et oris malis salutaris, sed contra anginas quoque et contra serpentes . . 
 Frisii qua castra erant, nostris demonstravere illam ; mirorque nominis 
 
 1 ' Praediction,,' lib. ii, § 36, ad. Littre, ix, 66. 
 
 " See the excellent description in Aretaeus. 
 
 3 For example, in the genuine Hippocratic treatise, * Be acre, aquis et locis,* 
 § 7, ed. Littre, ii, 26, where it is stated that the disease of <j:r\ijvsg fisyaXoi is. 
 most frequent in damp and marshy situations, and that dropsy usually super- 
 venes on the general wasting. See also ' Lib. de affect, intern.,' §§ 30-34, ed. 
 Littre, vii, 245, seq. 
 
 * Such as Guyon in still recent times (' Compt. rend.,' 1846, Juin, 29 ; ' Gaz. 
 med. de Paris,' 1846, No. 27, p. 533. 
 
 * ' Hist, nat.,' lib. xxv, cap. vi, ed. Franz, Lips., 1788, vii, 64J. 
 ' ' Geogr.,' lib. xvi, towards the end of the book.
 
 510 GEOGEAPHICAL AND HISTORICAL PATHOLOGY. 
 
 causam, nisi forte confines Oceano Bi-itanniae, veliit propinquae, 
 dicavere." 
 
 Some have gone still fartlier, and have deduced from this recom- 
 mendation of the herba Britannica as a remedy for " stomakake " and 
 "skelotyrbe" the conclusion that a diseased state of the mouth, men- 
 tioned by Max-cellus' under the name of " oscedo," was also scurvy, the 
 remark of Marcellus being, " oscedinem herba Britanica viridis sumpta 
 in cibo, lactucae modo, sanat." 
 
 Of the nature of this " stomakake/^ there is nothing to be 
 learned except from Pliny's account, which has a somewhat 
 romantic ring. It is not impossible that this affection of 
 the mouth was a symptom of scurvy ; but it is just as pro- 
 bable that the disease in the Eoman army was the same that 
 has been seen in modern times and described under the 
 name of " stomatite ulcereuse/^ as an endemic or epidemic 
 malady among the troops of more than one European power, 
 and particularly often among the French troops. 
 
 As to the nature of the " skelotyrbe " and its connexion 
 with the affection of the mouth, I am unable to form any 
 opinion. 
 
 Galen^ gives the following definition of it : — " Skelotyrbe species est 
 paralyseos, qua quis recte ambulare non potest et latus alias in rectum, 
 quandoque sinistrum in dextrum, aut dextrum in sinistrum circumfert, 
 interdum quoque pedem non attoUit, sed attrahit velut iis, qui 
 magnum quid adscendunt." 
 
 In this description we are reminded somewhat of the gait of 
 tabetic patients. So far as relates to the recommendation of herba 
 Britannica, nothing can be inferred either regarding " stomakake," 
 or regarding " oscedo " (which is mentioned by no other author), 
 for the reason that it is not known what plant is meant. Euricius 
 Cordus^ conjectured that it is Bistorta which is intended, but he after- 
 wards gave up that opinion. Agi-icola'* does not commit himself to an 
 opinion of his own, and merely states the view of Cordus. 
 
 The idea, started in modern times by Seidlitz,^ and 
 adopted by Hecker, that the disease described by the 
 physicians of antiquity under the name of " morbus cardiacus 
 
 ^ 'De medicamentis,' cap. xi, in Stephani, ' Collect.,' 291. 
 
 " ' Definit. med.,' § 293, ed. Kiihn, xix, 427. 
 
 ^ ' Botanologicon,' Colon., 1534, 137. 
 
 * 'Med. Herbariae,' lib. ii, Basil., 1539, 56. 
 
 ^ In Hecker's ' Wissenschaftl. Annalen der Heilkde.,' 1835. xxxii, 129.
 
 SCURVY. 511 
 
 s. cocliacus " corresponded to pericarditis scorbutica (found 
 mostly in Russian practice), has been completely overtlirown 
 by Landsberg.^ 
 
 After a close scrutiny of the ancient and mediaeval 
 medical writings, I have found only one description of a 
 form of disease which so far corresponds to the picture of 
 scurvy, that the identity of the two may be hazarded. I 
 refer to the malady spoken of in the Hippocratic collection" 
 under the name of iiXeog m/^iariTtjg ; of which it is said : 
 
 '' TaSf §£ £v rw voay]j.iaTi TrpoayivsTai' £/c tov (TTOjuaTog kukov 
 oCei, Kai OTTO T(i)V o6ovT(x)i' Ta ovAa acpiaTarai, Kai airo twv pivu)V 
 aijLia pUi. Ert'oTf o£ Kai £ic tojv oksXhov tXKea eKc^Xwcaveij Kat 
 ra ^t£i' vyiaiverai, ra o£ aWa irpoayiv^Tai, Kai i] vponi /neAaiva, 
 Kai XEVToSepiiiog' Trepi(l>oiTrjv Se Kai raXanrtopEeiv ov TTpoS-u^to?. 
 
 It is a priori highly probable that scurvy had been epi- 
 demic fi'om time to time in antiquity under the same 
 circumstances that have given rise to it in the modern 
 period or in recent times. It certainly follows from the 
 account given by Jacques de Vitry^ of a disease called by 
 him the plague, which ravaged the army of the crusaders 
 before Damietta in 1218, and from Joinville's* description 
 
 ' 'Janus,' 1847, ii, 53. 
 
 * * De affect, intern.,' § 46, ed. Littre, vii, 280. 
 
 ' Liv. iii, § 351, 'Collect,' Guizot (quoted by Marchand, 'Etude histor. et 
 nosol. sur quelques epidemics et endemies du moyen age,' Par., 1873, 17) : " Un 
 grande nombre d'hommes de notre armee furent en outre saisis d'une certaine 
 peste centre laquelle les medecins ne pouvaient trouver aucun remede dans leur 
 art. Une douleur soudaine s'emparait des pieds et des jambes : aussit6t apres 
 les gencives et les dents etatient attaquees d'une sorte de gangrene, et le naalade 
 ne pouvait plus manger. Puis I'os de la jambe devenait horriblement noir et 
 ainsi apr^s avoir souffert de longues douleurs pendant lesquelles ils deployerent 
 une grande patience, an grand nombre de chretiens all^rent se reposer dans le 
 sein du Seigneur. Quelques-uns etant parvenus a gagner le printemps se gu^ri- 
 rent alors par I'effet des chaleurs." 
 
 * ' Histoire de Saint-Loys,' Par., 161 7, 121. "Nousvint une grant persecu- 
 tion et maladie en I'ost ; qui estoit telle que la chair des jambes nous dessechait 
 jusqu'i I'os, et le cuir nous devenoit tanne de noir et de terre h, la resemblance 
 d'une vielle houze, qui a ete longtemp mucee derriere les coffres. En oultre, k 
 nous autres qui auions cette maladie, nous venoit une autre persecution de 
 maladie en la bouche, de ce que nous auions mengie de ces poissons, et nous 
 pourrissoit la chair d'entre les gencives, dont chacun estoit orriblement puant de 
 la bouche. Et a la fin guesres n'en enchappoient que tons ne mourussent. Et le 
 signe de mort que Ton y congnolssoit continuellement estoit quand en se prenoit 
 a saigner du neys, et tantoust on estoit bien asseuro d'estre mort de brief."
 
 512 GEOGEArHICAL AND HISTOEIOAL PATHOLOGY. 
 
 of the sickness that broke out in 1250 among the army o£ 
 Louis IX at the seige of Cairo, that scurvy had existed 
 long before we have any medical recognition or description 
 of it as a peculiar form of disease. 
 
 § 188. Historical Epidemics. The '^ Scoebutic Constitu- 
 tion " OP FoRMEii Times a Myth. 
 
 The history of scurvy as an epidemic malady well known 
 to the medical profession does not begin before the fifteenth 
 century, or the period of the Renascence — a movement 
 which touched every relation of life, and by exciting an in- 
 terest in foreign countries, gave occasion to sea voyages on 
 a scale never before known. 
 
 As early as the middle of the fifteenth century we find in 
 the history of maritime commerce accounts of expeditions to 
 remote regions which had only a partial success or even 
 proved total failures owing to scurvy breaking out among 
 the crews. One of these was the great expedition of Vasco 
 de Gama, on board whose ships the disease appeared off the 
 African coast in January, 1498, in so malignant a form that 
 he lost fifty-five of his fellow-adventurers in a short time.^ 
 Other exam-pies are Cartier's unfortunate expedition" in 
 1535, the expeditions to Canada under v. Monts, Pontgrave 
 and Poutrincourt^ towards the end of the sixteenth century, 
 the French naval expedition to India under Dellon,* Admiral 
 Anson's voyage round the world with an English fleet from 
 1740 to 1744 (during which the disease broke out at various 
 times in different latitudes^), the voyage of Ellis® in 1746-47 
 to Hudson's Bay to discover the North-West Passage, the 
 expedition of the English fleet to the coast of Algiers''' in 1773, 
 the cruise of the Channel Fleet in 1 780^ under Admiral Geary, 
 
 ' Ramusio, ' Raccolta delle navigaz. e. via^gi/ i, 119. 
 
 ' Hakluyt, ' Principal Navigations, &c.,' Lond., 1598, iii, 225. 
 
 ^ ' Collection of Voyages/ iii, 808. 
 
 * 'Voyage aux Indes orient.,' quoted by Lind, 557. 
 
 * Walter and Robins, ' Voyage round the World,' &c., Lond., i ;48. 
 
 6 Ellis, ' Voyage to the Hudson's Bay,' &c., Lond., 1748. 
 
 7 Aaskow, 'Diarium nied. uavale,' Lond., 1774. 
 
 * Armstrong, L c, 4.
 
 SOUEVY. 513 
 
 ■vvlien he was obliged to put back to England with two thousand 
 four hundred men down with scurvy, and the voyage of a con- 
 voy of English ships round the Cape of Good Hope in 1781.^ 
 
 It was not until the end of last century that attempts 
 were made by the naval powers chiefly concerned, particularly 
 England, to carry out such rules in the fitting out of ships 
 for great naval enterprises, as experience had shown to be 
 best adapted to prevent the outbreak of the malady ; and, as 
 a matter of fact, scurvy on board ship, and especially in 
 ships of war, has been seen during the present century much 
 more rarely than in former times, although there have not 
 been wanting epidemics at sea even in the most recent 
 times, under circumstances to be afterwards mentioned. 
 
 Of somewhat later date are the first authentic accounts of 
 the epidemic occurrence of scurvy on land. The earliest 
 mention of the nosological term " Scharbock " is to be found 
 in Cordus,^ who, in speaking of the healing virtues of the 
 Ohelidonium majus, refers to its efficacy in scurvy, the herb 
 being known among the " Saxones '' (Low Saxons or in- 
 habitants of the North German plain)^ as " Scharbocks- 
 Kraut ;" but it does not appear that he had ever seen the 
 disease itself. Shortly after there appeared the statements 
 of Olaus Magnus,'* concerning the often observed epidemic 
 prevalence of scurvy in the Scandinavian kingdoms, espe- 
 cially in times of famine ; and about the same time, or a little 
 later, the writings of Echthius, Eonsseus, Wier, Dodonaeus 
 and Brucaeus, which testify to the comparatively common 
 occurrence of the disease along the littoral of the North Sea 
 and the Baltic (as Brucaeus says : " Morbus maris Baltici, 
 Finnici et Bothnici sinus accolis, iisque qui Germanico 
 Oceano adjacent, Saxonibus, Phrygiis, Batavis, totique 
 Scaniae sive Scandinaviae, quae Danes, Norwegos, Suecos 
 complectitur, familiaris '') . 
 
 These excellent descriptions of the malady, more especially 
 by Echthius, Ronsseus and Wier, leave no doubt as to its 
 nature. Also in the epidemics of 1556 and 1562 in the 
 
 1 Curtis, 1. c, 9. 
 
 2 L. c, p. 94. 
 
 3 It is clear from the treatise of Brucaeus, quoted in the text below, that it is 
 the inhabitants of that tract of country who are meant. 
 
 "^ ' De gentium septentrional, condititiouibus,' &c., Romre, 1555, lib. xvi, cap. 51. 
 VOL. II. 33
 
 514 GEOGEAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Netherlands, whicli are mentioned by Dodonaeus^ the disease 
 was certainly scurvy and not ergotism, as some have been 
 inclined to think from a remark of the chronicler as to the 
 injurious effects of damaged grain which had been imported 
 from Prussia. On the other hand, it remains a question 
 whether the disease at that time was an important one among 
 the national maladies of those countries ; the fact that so 
 experienced and widely consulted a physician as Foreest^ 
 betrays only a slight acquaintance with scurvy, warrants us 
 in concluding that the epidemic outbreaks of it, at least, had 
 reached no very great extent. 
 
 These observations had hardly become known to the 
 medical profession at large before the dogmatism of the 
 schools laid hands upon them. A succession of medical 
 treatises came out, in every page of which one may discover 
 that their authors had in all probability never had an oppor- 
 tunity of seeing a single case of scurvy ; and thus there was 
 initiated in the course of a few years one of the most foolish 
 episodes in the whole history of medical science or practice. 
 '' Scurvy " became the Alpha and Omega of professional 
 routine, the catchword of the day, " the asylum ignorantiae 
 of the practical man," as Baldinger excellently puts it. 
 And although a few of the more sensible observers, like 
 Willis, Sydenham, Hoffmann and Kramer strove against that 
 misuse of the word and idea, yet it persisted long into the 
 eighteenth century ; until at length an impartial scrutiny and 
 correct estimation of the facts brought the empire of scurvy 
 within narrower and narrower limits. Then it happened, as 
 it has often happened in similar revolutionary movements 
 in the subject-matter of our science, that scepticism fell into 
 the opposite extreme. The reality of facts well authenticated 
 began to be doubted altogether, and it was a question 
 whether scurvy should not be struck out absolutely from the 
 list of specific forms of disease. Into this chaos the first 
 beams of light fell when Lindas classical work appeared. 
 In the end scurvy was secured its rightful place in the 
 nosology through the extremely careful way in which the 
 observations on it had been made, especially in the Baltic Pro- 
 
 ^ ' Observ. et curat, med.,' lib. xx, obs. xi, Lugd. Batav., 1595, p. 347. In this 
 passage he even speaks of scurvy as " uiorlus rariis."
 
 SCURVY. 515 
 
 "vlnces of Russia. But that old-world phantom of a Scorl^utic 
 Constitution still continues to haunt the brains and books 
 of a good many practitioners. For the reason that the disease 
 has occurred comparatively seldom in recent times, they dis- 
 cover that scurvy is declining or gradually dying out, not 
 being aware that the decline is for the most part only an 
 apparent one, brought about in the way already adverted to. 
 A few references to the literature of the subject in the 
 seventeenth and eighteenth centuries will suffice to prove 
 that the view here taken is a correct one, although it is in 
 almost direct opposition to opinions hitherto current. 
 
 The earliest information of the prevalence of scurvy in other coun- 
 tries besides the coast regions above mentioned dates from the year 
 i486, when " Scharbock," according to several chroniclers, would appear 
 to have shown itself in some parts of Saxony, Thuringia, and the adja- 
 cent country as a malady previously quite unknown there. It is not 
 difficult to follow up this assertion to its source if we compare among 
 themselves the various chronicles which record the fact. We find the 
 first indications of it in the ' Annales urbis Misnicae ' of Fabricius, 
 who died at Meissen in 1571 in the office of rector of the Filrsten- 
 schule ; the passage runs : " Grassatus est hoc anno novus et inauditus 
 in his terris morbus, quern nautae Saxoniae vocant den Scharbock, qui 
 est inflammatio in membris partium carnoarsum, cui quo^ celerius 
 adhibetur medicina, eo citius malum restinguitur. Sin mora accedit 
 pauUo tardior, sequitur membri afFecti mortificatio, quam siderationem 
 nostri, Graeci a(paKt\ov dicunt, ultimum gangraenae malum. Nam caro 
 ab ossibus defluit et continua quoque a lue corrumpuntur." 
 
 In my view it is not so clear that the disease here is scurvy, and not 
 rather ergotismus gangraenosus ; for even in much later times we meet 
 with the same confounding of the two diseases. We shall readily 
 understand how Fabricius came to use that nomenclature when we 
 reflect that he, like the members of the medical profession itself ^in his 
 time, was still altogether unacquainted with the nature of ergotism ; 
 whereas the treatises on scui-vy by Echthius and Ronsseus' hadj^already 
 appeared, as well as Lange's historical researches." Fabricius, there- 
 fore, was ready to identify by its name the pestilence of i486 with the 
 disease which had lately come to knowledge, all the more so that a remote 
 resemblance between certain of the phenomena of disease will satisfy the 
 lay mind even in a question of fact. 
 
 In 1589 Brunner" published a tractate on the scurvy which does little 
 more than reproduce the statements of Wier. Whether he had ever 
 
 ^ Antwerp., 1564. 
 
 2 Basel, 1554- 
 
 3 ' De Scorbuto,' tract, ii, appended to Brucacus, ed, cit.
 
 516 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 seen scurvy does not appear from anything in his work ; still less is 
 there anything in it to justify the inference that scurvy had been en- 
 demic or epidemic in his own country of Saxony. A few years after 
 came the work of Albertus' who, in giving the distribution of scurvy, 
 enumerates the coast lands of the German Ocean and Baltic Sea, as 
 stated by Brucaeus and others, and then adds that the malady had 
 begun to spread into the adjoining inland territories, " quibus hactenus 
 insolens fuit " (wherein he contradicts the assertion of Fabricius), and 
 that it had shown itself in particular in Silesia, Bohemia, and Saxony. 
 Whether he had himself ever seen cases of scurvy his book does not 
 make clear. If neither of the works already mentioned may be said to 
 possess any original value, they are none the less good compilations. 
 But in the next book that came out, the treatise by Eugalenus," we are 
 introduced to a piece of make-believe which is, in two respects, without 
 a rival in the whole literature of medicine : firstly, in the ignorance of 
 its author, and secondly, in the results which the book achieved notwith- 
 standing. For more than a centiary it continued to be the canonical 
 book for the doctrine of scurvy, even the best physicians of the time 
 being unable to keep themselves free from its tyrannical influence. 
 There can be only one explanation of this fact — that the disease was 
 on the whole rare, occurring only within small circles, and coming 
 under the notice of those practitioners least who wrote about it most. 
 Eugalenus took from the writings of his predecessors the name of the 
 disease, and from Wier he took a brief epitome of the clinical cha- 
 racters ; but beyond that he developed his notion of scurvy in the most 
 arbitrary manner out of his own head, and applied it so generally to 
 diseases that in the end the whole nosology was received therein. This 
 theory, founded on the crassest of dogmatism, he built up with an 
 afrbitrariness of assertion and assumption beside which the fabrication 
 of the Galenic doctrine of the Qualities is mere child's-play. 
 The real phenomena of the disease — the affection of the gums, the 
 ecchymoscs, hasmorrhages and the like — vanish for diagnostic purposes 
 before the truly pathognomonic symptoms which he discovered in 
 cei'tain characters of the urine and of the pulse ; by these he recognised 
 the disease, altogether in-espective of the presence or absence of those 
 casual accompaniments, which are essentially the scorbutic symptoms. 
 One can understand how a production of that sort might exert much 
 influence at a time when science had not yet shaken off its stiff chains of 
 dogmatism, and when the opportunities of observing the disease itself, 
 few at any rate, were for that reason but little turned to account in test- 
 ing the theory. Thus it is that we actually find the men who then led 
 the tone in the German medical world, such as Horst^ and Sennert,* 
 
 ^ ' Scorbuti liistoria,' Wittbg., 1594. Printed in Senncrt, Tract. 354. 
 
 ' 'Do morbo scorbuto liber,' Hngae-Com., 1658. 
 
 ^ ' Obsei'v. uied.,' lib. vii, 34; 0pp. Norimb., i6k6o, ii, 364. 
 
 * 'Tract, de Scorbuto,' Wittbg., 1624; also in ' Pract. Med.,' lib. iii, part v. 
 
 sect, ii, Wittbg., 1648, 542.
 
 scuEvy. 517 
 
 coming forward as faithful benclimen of Eugalenus : " Tanta omnino 
 morborum et symptomatum faiTago in hoc affectu concurrit," cries 
 Sennert, " ut vix alius sit tarn TroXv/xopipoQ et qui sub tot morborum 
 speciebus latitat, ac Medicos, etiam cum cavisse maxime videntur, saepe 
 decipiat et deludat." 
 
 Shortly after comes Drawitz' with a doleful book, in the preface to 
 ■which he declares that all mankind will soon be scorbutic, for most 
 children are conceived in scurvy and born with it. He breaks out 
 violently upon those of the more sensible of his contemporaries who had 
 pronounced " Scharbock " (as interpreted by himself and Eugalenus) to 
 be a nonentity ; while, among other paradoxes, he speaks of the scor- 
 butic gout (p. 3) and of the scorbutic " Kriebelkrankheit " (p. 73). The 
 next is Moellenbroeck," who observes in the introduction to his ti-eatise : 
 " Immo nullus fere jam morbus est, cui se non adjungat scorbutus, unde 
 nisi antiscorbutica interdum reliquis admisceat medicamenta, vix eos 
 curabit medicus." 
 
 After him comes Giildenklee,^ who certainly had opportunities of 
 seeing scurvy somewhat frequently at Colberg, on the Baltic, where he 
 resided ; but who betrays in many passages'* so complete mystification 
 as to what is implied in the notion of scurvy that one can place no 
 reliance on his statement :^ " Inter omnia, quibus corpus humanum 
 expositum est, morborum KoXaarijpia nullum scorbuto, oris hisce mari- 
 timis endemio, frequentius." 
 
 A later author, George Gottlieb Richter," is still found writing entirely 
 in the Eugalenian sense : " Scoi'butus non tam morbus est, quam 
 morborum iilas, certe ob symptomatum copiam et versatilem indolem 
 tam multiplice facie apparet, ut earn inter lineamenta, periti etiam 
 manibus ductu, non nisi aegre agnoscas ;" and elsewhere as well he 
 follows Eugalenus closely. C. J. Lange'' makes the same profession of 
 faith : " Faciem hujus affectus quod attinet, impossibile est illam accu- 
 rate depingere ; tam varias enim formas assumit, et nullus pene 
 affectus detur in tota j)raxi, sub cujus pallio non quandoque personam 
 suam agat." 
 
 The doctrine of scurvy fared hardly any better in the Netherlands, 
 where the views of a Eugalenus or a Sennert found favour more readily 
 than the unbiassed observations of an Echthius or a Wier. Barbette^ 
 describes scurvy in terms which betray the influence of the German 
 school. Beverovici^ does not hesitate to declare that in his time (first 
 
 ^ ' Unterriclit vom Schmerz-machenden Scharbock,' Lcipz., 1647. 
 " ' De varis seu arthritide vaga scorbutica tract.,' Lips., 1672. 
 3 ' 0pp.,' Lips., 1715. 
 
 ■* ' Epist.,' lib. iii, quaest. xx, ed. cit., 569, epist. xxiii, p. 585, &c. 
 ^ ' Casuum medic.,' lib. iii, cas. 34, ed. cit., 143. 
 
 ^ 'Diss, de Scorbuto,' Getting., 1744; iu ' Opuscul. mod., Frankf., 1780, i, 
 160. 
 7 ' Prax. med./ cap. vii, § 4 ; ' 0pp.,' Lips., 1 704, ii, 38. 
 ^ ' Prax. med.,' iv, cap. 3 ; ' 0pp.,' Geiiev., 1688, ii, 153. 
 9 'Opp.,'i, 91.
 
 518 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 half of the seventeenth century) there were few persons free from scurvy. 
 In tlie same way was the subject dealt with by Linden,^ and by Bontekoe,^ 
 who designates scurvy as "radicem et causam omnium morborum ;" 
 and even Boerhaave by no means attained to an unprejudiced view of 
 scurvy, although he admits that the malady in his day (beginning of 
 the eighteenth century) occurred more rarely in the Netherlands than 
 would seem to have been the case formerly. 
 
 In Scandinavian countries the state of matters was little different, 
 as we may learn from the report of the Academical Council of Health, 
 published in 1 645 ; and I can only regard it as the result of superficial 
 research that Ilmoni, speaking in his " Nordens Sjukdoms-Historia " of 
 the state of healtli in the sixteenth and seventeenth centuries should 
 say : " This much may safely be alleged, that scurvy during those two 
 centuries was the predominant chronic national malady of the northern 
 countries, the fundamental dyscrasia which characterised that period in 
 Scandinavian lands, and imparted to every form of sickness there a uni- 
 form specific background of its own colour." As evidence of the extent to 
 which men could carry the idea of scurvy even in much later times, I 
 quote the following fact relating to the year 1808 from Arnold, who was 
 at that time a surgeon in the English fleet which had joined the 
 Swedish fleet for a cruise in the Baltic. On information being sent 
 that scurvy was raging in a disastrous form on board the Swedish 
 men-of-war, Arnold was transferred to them in order to accompany 
 them home. He soon satisfied himself, however, that there was not a 
 single trace of scurvy, but that the crews were suffering from well- 
 marked typhus. 
 
 Finally in England the doctrine of scurvy fared little better. We 
 find Lister, for example, holding strictly to the point of view of 
 Eugalenus, whose services to the State and to science he could not extol 
 highly enough ; and even in Bisset, who wrote about the middle of the 
 eighteenth century, we read : " The diseases induced by more or less of 
 the scorbutic cacochymy in these different circumstances are chiefly the 
 following : viz. an habitual land-scui'vy or scorbutic affection of the first 
 class ; slow scorbutic or nervous little fevers of long duration which 
 are often attended with hypochondriac and hysteric symptoms ; scor- 
 butic or erysipelatous defluxions; scorbutic rheumatisms; scorbutic 
 eruptions of various soi'ts ; the gout ; the sciatica ; palsies ; hypochon- 
 driac and hysteric affections ; cachexy and dropsy ; or an ati-ophy." 
 
 The medicine of France and Italy from the sixteenth to the eighteenth 
 century concerned itself with scurvy on the whole very little ; the slight- 
 
 ^ 'Medulla Med. Pars, patliol.,' Franecker., 1642,35, 112. 
 ■^ '0pp.,' Amsterd., 1689, ii, 138 
 
 2 In Bartholini, ' Cist, med.,' Hafn, 494. 
 
 * 'Bidrag till Nordens Sjukdoms-Historia,' Helsingfors, 1853, iii, 4. 
 
 ^ ' Lond. Med. and Phys. Journ.,' 1809, xxi, p. 17. 
 
 ® ' Tract, de morb. cliron.,' 1696, p. 71. 
 
 ^ 'Medical Essays and Observations,' Newcastle, 1766, p. 197.
 
 SCURVY. 519 
 
 ness of tlie knowledge of it in those countries may be inferred from tlie 
 pathological inquiries of Fracassini,' who designates scurvy as a variety 
 of hypochondria, a view that was taken of many things by the solidist 
 school of pathology in those times. 
 
 There were bound to be, as we have said, a few sensible and observ- 
 ant men who saw through the abuses that were being practised in this 
 manner with names and notions. A reaction at length set in, which 
 went so far as to deny altogether that scurvy existed as a specific form 
 of disease. That much we may infer from the replies to their opponents 
 by those implicated in the scurvy mystification. The reactionary party is 
 but scantily represented in the literature of scurvy ; although there are 
 among them men whose word should have weighed heavily in the scale, 
 and whose testimony remains of special importance for the purposes of 
 the historian. Sydenham- says : " Licet non dubitem, quin Scorbutus 
 in his plagis Borealibus revera inveniatur, tamen eum morbum non tarn 
 frequentem, quani fert vulgi opinio, occurrere persuasum mihi habeo ; 
 multos autem ex iis aflfectibus, ne pluribus dicam, quorum nomine 
 Scorbutum incusamus, vel morborum Fientium, nondum vere Factorum, 
 quique nullum adhuc certum induerunt typum, effecta esse, vel etiam 
 infelices reliquias morbi alicujus nondum j)enitus devicti, a quibus 
 sanguis ceterique humores contaminantur . . . Et sane nisi hoc 
 concedamus, Scorbuti nomen, uti hodie fit, in immensum crescet et 
 omnem fere morborum numerum absolvet," — an apprehension which, 
 as we have seen, the sequel fully warranted. HoifmannV language is 
 almost the same, and he adds a warning against the good being re- 
 jected with the bad and the existence of scurvy altogether denied. 
 Mead^ says : " Scorbuti nomen apud auctores medicos morbum designat 
 tarn multiplicem et facie diversum, ut non idem, sed alius atque alius 
 esse videatur." 
 
 Kramer,* who has a very good description of scurvy from cases which 
 he himself saw, (although the disease, as he expressly tells us, was rare,) 
 observes : " And accordingly it (scurvy) is so little known to these 
 persons, particularly the acidists, that they turn the word ' scorbutus,' 
 to a monstrous use, and incl^^de therein all kinds of ' sordes caco- 
 chymiae,' even the lues venerea, not knowing how to discriminate one 
 thing from another. In this way every Dutchman and Zeelander, every 
 Dane and Swede, and in fact all the Northmen, arc bound to be all 
 alike scorbutic from their birth, or at least so constituted that in all 
 their diseases scurvy is ever an ingredient." 
 
 So far, then, as relates to tlie data of sixteentli and seven- 
 teentli century writers concerning the prevalence of scurvy 
 
 1 ' Opuscula pathol.,' part iii, cap. ii. Lips., 1758, 368. 
 ' Obscrv. mcd.,' sect, vi, cap. v, ' Ojip.,' Genev., 1736, i, 172. 
 Med. ration, syst.,' torn, iv, part v, cap. i, § i, ' 0pp.,' Genev., 1748, iii, 369. 
 '' ' Monita et praccepta med.,' Lond., 1751, p. 123. 
 * ' Medicina castrensis,' Niirnberg, 1735, p. 77.
 
 520 GEOGEAPHIOAL AND HISTOEICAL PATHOLOGY. 
 
 during tliat period, it seems to me to be quite obvious, accord- 
 ing to the foregoing account of the matter, tliat we have small 
 warrant to conclude from them that scurvy was universally 
 diffused. But in judging of this matter, we have another 
 and very notable circumstance, namely, that remarkably few 
 records of epidemics of scurvy have come down to us. If 
 we exclude all those data, in the chronicles or the epidemio- 
 logical writings of the sixteenth and seventeenth centuries, 
 which are obviously errors of diagnosis, such as confounding 
 scurvy with ergotism^ and malarial sickness,^ there remains 
 only a small number of epidemics of scurvy for that period, 
 as the following table shows ; and this is all the more note- 
 worthy, that the period is far from poor in epidemiological 
 records in general. Without taking this fact as absolutely 
 conclusive, I think that it should at any rate confirm the 
 impression derived from the foregoing criticism, that scurvy 
 in fortner centuries had hy no means that importance as a 
 universal malady ■which is assigned to it hy contemporary 
 and later writers ;^ although, for reasons to be afterwards 
 given, it is probable that the malady was more common, 
 perhaps also more widely distributed, in former times than 
 during recent years. 
 
 ^ Errors of that sort occur in Sennert's book (p. 60 1), where he speaks of 
 gangraena scorbutica; in Bonet's ' Sepulchretum ' (ii, 338); and even in Hoffmann 
 (1. c, § 8). 
 
 ^ In this second category are to be reckoned the notices by Sylvius (in the 
 ' Tract, de affect, epid. anni, 1669/ § 471, ' 0pp.,' Amstel., 1679, P- 842), by Fonesca 
 (' Consult. med.,' Frankf., 1625, i, cons, ii, p. 3 r), and by Morley (' De morb. epid. 
 observ.,' Lond., 1686). Morley describes, under the name of febris epidemicus 
 scorbuticus, an epidemic of malarial fever in 1679, which was widely spread over 
 England and the Netherlands. From this Ozanam (1. c, iv, 184) has made out 
 an epidemic of scurvy ; it is clear that he had read the book, but only in that 
 uncritical temper which makes his own work of so little use. Others also have 
 described it as such, faithfully following him. This laxity must appear all the 
 more incomprehensible, inasmuch as we have another and excellent account of 
 the same epidemic by Sydenham (Greenhill's ed., pp. 275, seq.). 
 
 ' Rotenbeck and Horn (1. c, p. 27), writing at the beginning of the seven- 
 teenth century, explicitly state that scurvy occurred vei:y rarely as an epidemic 
 in Germany, France, and other European countries, apart from war times and 
 other circumstances leading to scarcity.
 
 SCURVY, 
 
 521 
 
 [Chronological Table of Epidemics of Scurvy. 
 
 Time. 
 
 1556] 
 1562 j 
 
 1625 
 I63I 
 
 1632-33 
 
 1699 
 1703 
 I73I 
 
 1732 
 1733 
 
 1735 
 
 1738 
 
 1739 
 1740] 
 
 i74ii 
 
 1742 
 
 1749 
 1750 
 
 1751 5 
 1752 
 
 1758 
 
 1760") 
 1761] 
 1760 
 
 1762 
 
 1776 
 
 1783 
 
 1784 
 
 1785) 
 17865 
 
 Summer 
 
 Winter — 
 Summer 
 
 )> 
 Summer 
 Spring — 
 Summer 
 Summer 
 Winter — 
 Summer 
 Spring — 
 Autumn 
 
 Winter — 
 Spring 
 Winter- 
 Summer 
 
 Autumn 
 Winter 
 
 Winter 
 
 Winter — 
 
 Autumn 
 
 Spring 
 
 Autumn 
 
 Winter — 
 Summer 
 
 Place. 
 
 Coast Provinces of the Netherlands 
 
 Breda (hesieged fortress) 
 
 In the Swedish Army before Niu'n- 
 
 berg 
 
 Augsburg after its occupation by 
 
 the Swedes 
 
 Paris, in the Hotel Dieu 
 
 Thorn (besieged by the Swedes) 
 
 > Cronstadt 
 
 Wiborg 
 
 Cronstadt 
 
 St. Petersburg, among troops from 
 
 the Ukraine , 
 
 Temesvar, in the Imperial Army ... 
 
 ] 
 
 Voronej, among soldiers and sailors 
 
 C Stockholm, on board the men-of- 
 (_ war 
 
 Authority. 
 
 rWier, 
 < Ronsseus, 
 C Dodonaeus 
 
 V. d. Mye. 
 
 Rotenbeck 
 and Horn. 
 
 Hochstetter. 
 
 Poupart. 
 
 Bachstrom. 
 
 Sinopeus. 
 
 Nitzsch. 
 
 Sinopeus. 
 
 Nitzsch. 
 Ki'anier. 
 
 Cork. 
 
 St. Petersburg. 
 
 Finland... 
 
 Riga, among the troops 
 
 Corregliano, and other places in 
 Venetia 
 
 Riga, among the troops 
 
 In a few localities near Verona 
 
 Breslau, after occupation by the 
 
 Prussians 
 
 C Lower Silesia, in the Austrian 
 
 (_ Army 
 
 Canada, among the troops in the 
 
 Ports 
 
 Bremen, among the English troops 
 
 Evreux, in the prison 
 
 Copenhagen 
 
 ") Jemtland, Angermanland (Swe- 
 5 den) 
 
 St. Petersburg, Cronstadt, among 
 soldiers and in the navy ; after- 
 
 wards general . 
 
 ]u 
 
 LinniBus. 
 
 Buddeus. 
 
 Nitzsch. 
 
 Cork. 
 
 Agostiui. 
 
 Cork. 
 
 Targa. 
 
 Baldinger. 
 I Chmelsky. 
 
 Monro. 
 Monro. 
 
 Lepecq. 
 Bang. 
 
 Salbcrg. 
 Guthrie, 
 Bache- 
 racht. 
 
 !
 
 522 
 
 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 1785] 
 1786) 
 
 1787 
 1789 
 
 1793 
 1798 
 1799 
 1800 
 1801 
 
 1803 
 
 1806 
 
 1807 
 1808 
 
 1820 
 
 1822 
 
 1823 
 1824 
 
 5> 
 
 1828-29 
 
 1830 
 
 I83I 
 
 1832 
 5> 
 
 1833-34 
 1836 
 
 Spring 
 Summer 
 
 Spring 
 Summer 
 
 Spring 
 Summer 
 
 Spring — 
 Winter 
 
 Winter 
 
 Rainy season 
 
 Winter 
 
 Winter and 
 
 Spring 
 
 Autumn 
 
 Summer 
 
 Spring 
 
 Spring 
 Autumn 
 
 Autumn- 
 Spring 
 
 Summer 
 
 Spring 
 
 Braila 
 
 Finland, among the Russian troops 
 Braila,duving the Russian occupation 
 ") Copenhagen (to a moderate ex- 
 
 5 tent 
 
 Bombay, among the English troops 
 Alexandria, among the French troops 
 
 Hungary, in the Eastern Division of 
 Upper Hungary 
 
 Reggio (Modena), among the Fi-ench 
 troops 
 
 Prussia, among the French troops... 
 
 Spalato, among the French troops... 
 
 In Fort Council Bluffs (Iowa) among 
 U. S. troops 
 
 the 
 
 Moorshedabad (Calcutta), in the 
 Asylum for the Insane 
 
 Rutnagherry (Bombay), in 
 prison 
 
 Southern Russia (NicolajeflF, Cher 
 son, &c.) 
 
 London (Millbank Penitentiary) 
 
 1837 
 
 Rangoon, among the English troops 
 
 Turkey, among the Russian troops 
 
 London (slight outbreak) 
 
 Prague, in House of Correction 
 
 St. Petersburg, in House of Refuge 
 Cannanore (Madras), among the 
 
 troops 
 
 India, throiighout the west 
 
 Masulipatam (Madras), among the 
 
 troops 
 
 Rutnagherry (Bombay), in the prison 
 Nusserabad (Bengal), among the 
 
 troops 
 
 Prague, in the House of Correction 
 
 England, in a number of poor-houses 
 Iceland, in Westerland 
 
 Adelaide (Cape Colony) among the 
 English troops , 
 
 England, in a number of poor-houses 
 
 Oloflf. 
 
 Enneholm. 
 
 Oloff. 
 
 > Bang. 
 
 McGregor, I. 
 Larrey, 
 Frank. 
 
 Schraud. 
 
 Lamothe. 
 
 ChaiUy. 
 
 iGale, 
 Mower, 
 Forry. 
 
 Burt. 
 
 Bouchier. 
 
 Lee. 
 Latham. 
 
 Waddel, 
 Ref I. 
 Seidlitz. 
 McMichael. 
 Popper. 
 Doepp. 
 
 Henderson. 
 Panton. 
 
 Murray, I. 
 Bourchier. 
 
 Ross, Mac- 
 nab. 
 
 Cejka, 
 Popper. 
 
 Copland 
 
 Ref. II. 
 
 {Murray, II, 
 Minto, 
 Morgan. 
 Copland.
 
 SCURVY. 
 
 i23 
 
 Time. 
 
 1837 
 1838 
 
 1S39 
 
 1840 
 
 1846-47 
 
 Spring 
 
 Spring 
 Spi-ing 
 
 I84I 
 1842 
 
 
 3J 
 
 37 
 
 Spring 
 Summer 
 
 1842-43 
 1843 
 
 Winter — 
 
 Summer 
 
 Spring 
 
 1844 
 
 Spring and 
 Summer 
 
 1845 
 
 ... 
 
 S) 
 
 
 1846 
 
 Summer 
 
 J) 
 
 )j 
 
 Winter 
 
 Place. 
 
 Iceland, in Westerland 
 
 England, as in 1 837 
 
 Finnmark, very extensively 
 
 Cronstadt, in the navy 
 
 Aden, among tlie English troops ... 
 London (Milbant Penitentiary) ... 
 Clairvaux, in the prison 
 
 Russia, widely spread (Cronstadt, 
 Moscow, Orenburg, &c.) 
 
 Agra (N. W. Prov. of India), very 
 
 extensively 
 
 Algiers, in a number of localities . . . 
 Prague, in prison and garrison 
 
 Sulajew (Gov. Viatka) 
 
 Kurnaul (N. W. Prov. of India), in 
 
 Military Hospital 
 
 Leipzig, very extensively 
 
 Prague, general 
 
 Christiania, in the prison 
 
 Alessandria, in the military prison 
 
 Algiers, in several districts 
 
 Russia, in many governm , 
 
 Christiania , 
 
 Alessandria 
 
 Algiers 
 
 Perth (Scotland), in the prison 
 
 Copenhagen (frequent cases) 
 
 Christiania , 
 
 Algiers 
 
 Edinburgh, Glasgow, and other 
 places in Scotland, very cxten 
 sively 
 
 Exeter, Bath, Kent, Liverpool, York, 
 Cumberland, and other places in 
 England 
 
 In Ireland, generally 
 
 Authoi'ity. 
 
 Ref. II. 
 
 Copland. 
 
 Walter. 
 
 Kerewajew. 
 
 Malcolmsen. 
 
 Baly. 
 
 Ref. III. 
 /'Samson, v. 
 \ Himmel- 
 1 stiern,I,II, 
 V^ Schiitz. 
 ■) McGregor, 
 
 5 n. 
 
 Guyon. 
 Cejka, 
 
 Popper. 
 Jonin. 
 
 McGregor. 
 Radius, May. 
 
 Cejka, 
 
 Popper. 
 Boeck. 
 
 Novellis. 
 Maupin. 
 Lin gen. 
 
 !Same as in 
 1844. 
 
 Christison, I. 
 
 Ref. IV. 
 
 ") Same as in 
 
 3 1884. 
 
 fChristison, 
 I II, Ritchie, 
 -{ Ref. IV, 
 Lonsdale, 
 Anderson. 
 ' Shapter, 
 Laycock, 
 Barret, 
 Sibbald, 
 Lonsdale, 
 Turnbull. 
 McCormack, 
 
 Popham, 
 Bellingham, 
 Curran, 
 Donovan. 
 
 I
 
 524 GEOGEAPHIOAL AND HISTORICAL PATHOLOGY. 
 
 Time. 
 
 Place. 
 
 Authority. 
 
 1847 
 
 Spring 
 )> 
 )) 
 
 Winter — 
 Spring 
 Spring 
 
 Spring 
 
 Winter — 
 Summer 
 
 Summer 
 
 Summer 
 
 Summer 
 j> 
 
 Winter and 
 
 Spring 
 
 Summer 
 
 Spring 
 
 3> 
 
 Summer and 
 Autumn 
 
 Sj)ring — 
 Autumn 
 
 Paris, in the Salpetriere 
 
 Fauvel, I. 
 
 Givet, in the garrison 
 
 Scoiitetten. 
 
 5> 
 
 Copenhagen, slight epidemic 
 
 Hannover, 
 
 
 St . Petersburg, very common 
 
 Ref. IV. 
 LichtenstJidt. 
 
 
 Christiania 
 
 ") Same as in 
 j 1844-46. 
 Smellie. 
 
 Rigler. 
 
 
 Algiers 
 
 1847-48 
 1848 
 
 York Factory (Hudson's Bay) 
 
 Constantinople, in workhouse 
 
 Algiers 
 
 Same as in 
 
 
 St. Petersburg, Cronstadt 
 
 1844-47. 
 Lichtenstadt, 
 
 1848-49 
 
 In Southern Russia (Bessarabia, 
 CharkoflF, Poltava, Kieff, Voronesh, 
 Kursk, Podolia, Pensa, Yolhynia, 
 Tambov, Kasan, Jekaterinoslav, 
 Astrakhan, Simbirsk, Yiatka), 
 generally ditfvised 
 
 Lang. 
 
 "1 Ref. YII, 
 Heinrich, 
 > Grimm, 
 Heine, 
 
 Guttceit. 
 
 1850 
 5> 
 
 In Melrose (Scotland), among navvies 
 
 Ludwigsburg (Wiirtemberg), in the 
 
 workhouse 
 
 Ref. YIII. 
 
 Dicenta. 
 
 I85I 
 
 Fort Mcintosh, and other stations of 
 the U. S. troops in Southern Texas 
 
 Ludwigsburg (Wiirtemberg), in the 
 workhouse 
 
 Perrin. 
 Dicenta. 
 
 1852 
 
 RiTssia, shores of the Black Sea 
 (Dagestan, Lescin) 
 
 Ref. IX. 
 
 
 LudwitrsbursT 
 
 Same as in 
 
 » 
 
 Rastatt, among the Austrian gan-i- 
 son 
 
 1850-51. 
 Opitz. 
 
 Crawford. 
 
 J> 
 
 Fort McKavit, &c., on the western 
 frontier of Texas, among the U. S. 
 troops 
 
 1853 
 
 In the Army of the Caiicasus 
 
 Ref. X. 
 
 Ludwigsburg 
 
 Same as in 
 
 5J 
 
 1854 
 
 J) 
 
 Strasburg, in the prison 
 
 [ Aix, in the lunatic asylum 
 
 1850-52. 
 Forget. 
 
 Routier. 
 
 Wartenberg (Prussia), in the House 
 of Correction 
 
 Wald. 
 
 »> 
 
 Breslau, in the penitentiary and the 
 deaf-and-dumb asylum 
 
 Gilnsburg. 
 
 yj 
 
 Strasburg, in the prison 
 
 Schiitzen- 
 
 » 
 
 Wallachia, very extensively in the 
 Russian Army of the Danube 
 
 berger. 
 1 Sokoloff.
 
 
 
 SCUIiV5r. 
 
 525 
 
 Time. 
 
 Place. 
 
 Authority. 
 
 1854-56 
 
 Spring on- 
 wards 
 
 Spring 
 Summer 
 
 Summer 
 )> 
 
 Winter 
 Spring 
 
 Spring 
 
 Winter and 
 Spring 
 
 Summer 
 
 Autumn- 
 Winter 
 
 Winter and 
 Spring 
 Spring 
 
 In the Crimean War, espcially in 
 the French, English, and Turkish 
 Armies 
 
 "Leudes- 
 
 dorff, Per- 
 
 rin,Scrive, 
 
 Fauvel, 
 
 Rollin, 
 
 18557 
 18565 
 
 1855-56 
 1856 
 
 Aix, In the lunatic asylum 
 
 Maugin, 
 ^ Macleod. 
 ") Same as in 
 i 1S53-54. 
 Tholozan. 
 
 Lavirotte. 
 
 In the Military Hospitals of Paris . . . 
 Roanne, in the prison and beggars' 
 refuge 
 
 jj 
 
 Nicolai on the south-east coast of 
 Siberia 
 
 Dawidoff. 
 
 1857 
 i860 
 
 Ludwigsburff, in the prison 
 
 Cless. 
 
 Lucknow (India), during the siege... 
 Lille, in the garrison 
 
 Greenhow, 
 Villemin. 
 
 1 861 
 )> 
 
 1862 
 
 Camp Bull, among the U. S. troops 
 
 Port Blair (Andaman s), to a fright- 
 ful extent among the convicts ... 
 
 In the army of the Potomac, TJ. S.. . . 
 
 St. Petersburg, in the Obuchow 
 Hospital 
 
 McBride. 
 
 Gamack. 
 Herr. 
 
 Herrmann. 
 
 1868-70 
 1869 
 
 Prague, in the House of Correction 
 
 Iceland, in the fishing districts 
 
 Bengal, among native troops 
 
 Popper. 
 Ejaltelin, I. 
 Ref XI. 
 
 1870-71 
 1871 
 
 Paris, during the siege 
 
 'Delpech, 
 Hayem, 
 Legroux, 
 Leven, 
 Lasegue, 
 ■{ Bucquoy, 
 Boisgard, 
 Charpen- 
 tler, Geor- 
 gesco, Jar- 
 
 ^dln, Roche. 
 
 Doring. 
 
 Ingoldstadt, among French prisoners 
 of war 
 
 
 B u cliarest 
 
 Felix. 
 
 1873 
 1873-74 
 
 Prague, in the garrison hospital . . . 
 
 Algiers (in Cherchell), slight epi- 
 demic among workmen 
 
 Clrchen- 
 berger. 
 
 Benech. 
 
 1875 
 1875-76 
 
 Abo (Finland) , in the prison 
 
 Hildebrand. 
 
 Moringen, In the convict prison and 
 In the town 
 
 Kiihn. 
 
 1877 
 
 Paris, slight epidemic in the Mazas 
 prison 
 
 Besnier, de 
 
 
 
 Beauvais.
 
 526 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 § 189. Present Area op Prevalence. 
 
 This chronological table of all the epidemics of scurvy 
 known to me will at the same time serve to show approxi- 
 mately the georjra])}iical distribution of the disease in recent 
 years and at the present date. Of the 143 epidemics in the 
 table^ 35 belong to Rtissia alone_, not counting the outbreaks 
 in the Crimean War ; and among these there were three^ in 
 1840, 1845, ^^^^ 1848-9^ which extended over a great part of 
 the empire. It follows, accordingly, that E-ussia is one of the 
 chief seats of scurvy at the present date, although less 
 so than in former centuries ; the malady is still endemic 
 in the Baltic provinces,^ and in St. Petersburg/ where 2680 
 cases of it have been treated within the last eighteen years 
 in the Obuchow Hospital alone.^ It is endemic also in the 
 governments of Olonetz and of Novgorod (mostly in the 
 circles of Beloserki, Kiriloff, Borovitsch and Tichvin*), along 
 the shores of the Arctic Ocean and other parts of the Siberian 
 littoral/ such as the Amoor region (10*9 per 1000 of the 
 troops quartered there in 1875-78 having been attacked with 
 scurvy®), and in Kamtchatka.'^ We have other accounts of its 
 endemic prevalence in Asiatic Russia from the districts on 
 the Chinese frontier,^ and from Tomsk .^ Also, for Russia 
 in Europe, from the government of Kasan,^° but more espe- 
 cially from the southern provinces of the empire-— Jekateri- 
 noslav,''^ tho Steppes of Saratov,^^ the Ukraine and adjoining 
 districts of Western and Little Russia,^^ and the Crimea.^* 
 Mention is made also of endemic scurvy in Kutais (Traus- 
 
 ' Krebel ; Lang, 1. c. 
 
 2 Liclitenstiidt, in ' Hecker's wissenscli. Annal. der Heilkde.,' 1834, xxx, 76; 
 Heine, ' Med.-topogr. Skizze von St. Petersburg,' St. P., 1844, Amburger. 
 
 ■■^ Hermann. ■• Bardowsky. 
 
 5 Sclirenk, Castren, 'Nordisclic Reise,' &c., Petersb., 1854, 271; SoUaud, 
 'Arab, de med. nav.,' 1882, Juin, 435. 
 
 ^ Seeland. 7 Bogorodsky. 
 
 8 Stubendorfp, 'Med. Zeitung Russl.,' 1846, 34. » Rex, ib., 1859, 408. 
 
 1" Erdmann, * Topogr. des Gouvernements und der Stadt Kasan,' Riga, 1822, 
 igi, 251 ; Blosfeld, ' St. Petersb. Zeitschr. fiir Natur- und Hellkae.,' Nr. 4, 151. 
 
 " Sacbs. 
 
 1'^ Erdmann, ' Reisen im Innern Russlands,' Leipz., 1825, ii, 224. 
 
 13 Boulgakof, ' BulL des sc. med.,' xxiii, 205. 
 
 !•» Heiurich, 'Med. Ztg. Russl.,' 1845, 379.
 
 scuEVY. 527 
 
 Caucasia^). The focus of scurvy in Southern Russia joins on^ 
 as Felix tells us, to the endemic of it in the adjoining dis- 
 tricts of Roimiania. 
 
 The part played by scurvy in North-Western Europe is 
 very much less. In Iceland, it is true, the malady has several 
 times broken out as a sequel of famine (last in 1836 and 
 1837") ; but for more recent times scurvy does not deserve 
 to be spoken of as endemic in that country j^ and the same 
 holds good for the Faroe^ and Shetland Islands} As regards 
 Sweden, Dalb erg/ writing in 1777, says that scurvy was much 
 less common there than was generally supposed ; Huss, in 
 his medico-topographical account of the country, makes no 
 mention of it ; and Berg'^ speaks of it as being somewhat 
 frequent only about Umea, the district of Udewalla, and 
 Jemtlandslan. For the most recent period there is only one 
 notice of scurvy in Sweden known to me, that by Heyman, 
 referring to its prevalence in Swedish prisons ; according to 
 this there were, among 151,384 prisoners, from 1848 to 1877, 
 5188 cases of scurvy, or 34*3 per 1000, the percentage dimin- 
 ishingfrom 52*5 in the period of 1848-57 to 32-9 in 1858-67 and 
 to 17*0 in 1868-77. For Norway there is mention (by Walter) 
 of its somewhat frequent occurrence among the Finnish and 
 Lapp population of Finnmarken. In Benniarh, where it used 
 to be rather common, it is now met with almost exclusively 
 in prisons.^ The same applies to England, Scotland, and 
 Ireland,^ where scurvy during the present century has occurred 
 either in prisons, or in occasional epidemics, some of which 
 were no doubt very extensive. The case is the same, too, 
 with Holland^^ and. Belgium (193 cases officially reported from 
 
 ' Krebel, ib., 1858, 76. 
 
 ^ Holland, ' Ediab. Med. and Surg. Jonrn.,' 18 12, April, 202, Schleisner, 
 ' Island, &c.,' 48. 
 
 3 ' Finsen (' Jagttagelser angaaende Sygdomsforholdene i Island,' Kjobenh., 
 1874, p. 56) saw only thirteen cases during a ten years' residence. 
 
 ^ Manicus, 'Bibl. for Laeger,' 1824, Jan. 15. 
 
 ^ Sexby, in ' Dobell's Reports,' 187 1, ii, 225. 
 
 6 ' Tal om nigra det Svenska Climatats FormSncr, &c.,' Stockh., 1777. 
 
 7 ' Bidrag til Sveriges mod. Topogr., &c.,' Stockh., 1853, 17, 22, 89. 
 
 8 Otto, ' Transact, of the Prov. Med. Assoc.,' 1839, ^'^'h 211; Salomonseu, 
 'Udsigt over Kjobenbavns Epidemier,' Kjcib., 1854, 126. 
 
 9 Currau, 1. c, 109; Wylde, ' Edinb. Med. and Sur::, Journ.,' r8!5, July, 13, 
 ^^ Guislain, ' Annal. de la ^'oc. de med, de Gand.,' i^'42, Jan.
 
 528 GEOGEAPHIOAL AND HISTOlilOAL PATHOLOGY. 
 
 1853 to 1862^), with Germany and Austria (accounts of occa- 
 sional epidemic outbreaks mostly of small extent), with. 
 France^ and Itah/ (somewhat common in fortresses and 
 prisons, especially in Venetia and the Emilia along the 
 valley of the Po), and with TurlceyJ' 
 
 From Asiatic countries we have accounts of endemic scurvy 
 on the Yemen coast of Arabia,^ particularly in Aden f also 
 from some parts of India^ such as the North- West Provinces, 
 Rajpootaua and Malwa -^ from Cochin Ghina^ the northern 
 part of China, especially Pekin^° (where it is the poor that 
 suffer, as is usual in other countries as well), and Japan, 
 where cases of a milder type (here, too, among the portionless 
 classes^^) are to be seen remarkably often.^^ 
 
 The Continent of Australia is notorious for the severe 
 epidemics of scurvy which have broken out time after time 
 among the exploring parties in the interior. Pechey^^ men- 
 tions the disease as occurring endemically, mostly among 
 the shepherds on the Darling downs, in the north-west of 
 
 ' Meyune, ' Topogr. med. de la Belgique,' Bruxell., 1865, 204. 
 
 ^ According to Le Gendie ('Etude sur la topogr. med. du Medoc,' Par., t866, 
 p. 29) scurvy is eoinmon along the bill-zone of Medoc. I have found no other 
 accounts of scurvy being endemic in France. 
 
 ^ Sormani, ' Geogr. nosol. dell' Italia,' Roma, 1881, p. 169. For the years 
 1874-76 the mortality from scurvy was o'i3 per 1000 among the civil population 
 of Italy, and o'o7 per 1000 among the military. 
 
 ^ Oppeuheim, ' Ueber den Zustand der Heilkunde . . in der Tiirkei,' Hamb., 
 ^'^?>i^ 77 ; Riglcr, ' Die Tiirkei,' &c., ii, 405. 
 
 * Pruner, ' Die Krankbeiten des Orients,' 334. 
 
 ^ Mulcolmsen; Courbon, ' Observ. topogr. et med., &c.,' Par., 1861, 59. In 
 another chapter I shall deal with the malignant ulcers which are known as 
 Yemen or Aden sores, and which occur in many other parts of the tropics as 
 well. Some of them, at least, are plainly of a scorbutic nature. 
 
 ' Particularly common in prisons (Porter, ' Madras Quart. Journ. of Med. Sc.,' 
 J872, Ap., p. 253). In the East Indies, according to "Van Leent ('Arch, de med, 
 nav.,' 1867, Oct., p. 241 ; 1868, Sept., p. 163), scurvy is rare, being mostly found 
 in sailors admitted into the naval hospitals. Morehead has seen it in Bombay 
 under the same circumstances (' Clin. lies, on Diseases in India,' Loud., 1856, 
 ii, 680). 
 
 s McGregor, 1. c. ; Moore, ' Lancet,' 1882, June, p. 1048 ; Lucas, ib., Aug., p. ^z^. 
 
 ^ Blancbard. 
 
 1" Morache, ' Annal. d'Hyg.' 1870, Janv., p. 54. 
 
 ^1 Sollaiul, 'Arch, de med. nav.,' 1882, Juin, 435. 
 
 1- Wernich, ' Geogr.-med. Studien, &c.,' Bcrl., 1878, 172. 
 
 12 ' Med. Times and Gaz.,' 1867, Nov., 509.
 
 SCURVY. 529 
 
 New South Wales. In Tasmania it is not met witli as an 
 endemic.^ There are no accounts of it from Oceania. 
 
 Among the native population of the Coj^e (Hottentots), 
 scurvy would appear to be quite unknown, according to 
 information by Murray (II), Morgan, and Minto dating from 
 1836. For Eguijf and Algiers there are only a few refer- 
 ences to epidemics (see table), and no endemic cases have 
 been observed. In Abyssinia, according to Blanc,^ scurvy is 
 found almost exclusively aniong foreigners, or slaves from 
 the Shankalla country, the native population being free from 
 it despite the use of brackish water and the want of vege- 
 tables in their food. On the other hand, in the Eastern 
 Soudan as well as throughout the whole of the rainy zone 
 of Africa, it would appear to be very common (especially 
 during the overflow of the Nile) amoug natives and foreigners, 
 such as travellers, hunters, camel drivers, and soldiers.* On 
 the West Coast of Africa, also (Benguela, Gold Coast, &c.), 
 scurvy is mentioned as a common disease among the natives.^ 
 In Senegambia it has decreased considerably of late owing to 
 the improved hygiene.^ 
 
 In the Western Hemisphere, the worst centres of scurvy 
 are in the most northern latitudes — in Greenland,'' Alaska,^ 
 and among the lumbermen of the Ottawa district [Canada) f 
 in these cases the disease is nearly always among the 
 strangers, the natives enjoying an almost complete immu- 
 nity.^" In the United States of America scurvy to any 
 considerable extent has not been seen in recent times except 
 
 1 Hall, * Transact, of the Epidemiol. See.,' 1865, ii, 85. 
 
 * Pruner, 1. c. 
 
 3 'Brit. Med. Journ.,' 1869, March, 278. 
 
 * Hartmann, 1. c. 
 
 * Magyar, ' Eeisen in Siid.-Afrika,' &c., from the Hungarian, Pesth, 1859, 
 i, 450; Clarke, 'Transact, of the Epidemiol. Soc.,' i860, i, 107; Chassaniol, 
 'Arch, de med. nav.,' 1865, Mai, 508, 
 
 ® Borius, ib., 1882, Mai, 371. 
 
 7 Lange, ' Bemaerkn. om Gronlands Sygdomsforhold,' Kjobcnh., 1864, 28. 
 
 ^ Blaschke, ' Topogr. med. port. Novi-Archangelccnsis,' Petropoli, 1842, 67. 
 
 9 Grant, ' Med. Times and Gaz.,' 1863, Dec. 
 
 1'^ Lange writes in this sense as regards Greenland. Blaschke says that he did 
 not see a single case among the Kulosks and Aleutians during a residence of 
 several years at New Archangel. Gras says that it is quite unknown in the small 
 island of Miquelon, Newfoundland (' Quelqucs mots sur Miquelon,' Montp., 1867, 
 P- .S9)- 
 
 VOL. IT. 34
 
 530 GEOGEAPHIOAL AND HISTORICAL PATHOLOGY. 
 
 among bodies of troops wlio had been exposed to great 
 privations during the war or quartered at outlying stations ;^ 
 also at the time of the "gold rush" in California" among 
 immigrants who suffered in much the same way. In the 
 West Indies it appears that on some of the islands it is very 
 rare. Lempriere^^ after six years^ observation of the diseases 
 of Jamaica (1792-97), gives it as seldom occurring there; in 
 Martinique, according to Rufz/ it is quite unknown. As 
 against these statements we have the assertion of Levacher'' 
 that scurvy is prevalent in the Antilles to a great extent ; 
 but the silence of other observers in those regions makes it 
 impossible to decide how far that is true only for particular 
 localities. 
 
 From South America there are no accounts relating to 
 scurvy that are at all trustworthy. Sigaud^ mentions it as 
 occurring in Brazil among newly imported negroes ; but 
 from a later account it would appear that the malady had 
 been already developed among these unfortunates during the 
 passage. 
 
 § 190. OUTBEEAKS AT SeA. 
 
 Particularly interesting for the etiological inquiry con- 
 cerning scurvy are the observations of recent date on the 
 epidemic occurrence of the disease on hoard ships ; inasmuch as 
 they present an easily surveyed and obvious field of obser- 
 vation, and therein furnish valuable materials for judging of 
 the circumstances that determine the existence of the 
 malady, or at any rate are likely to favour it. 
 
 Scurvy at sea has become much rarer since the end of 
 
 1 Hammond (' Amer. Jouru. of Med. Sc.,' 1853, Jan., 102), for tlie Mexican 
 war; Perin and Crawford (11. cc.), for several forts in the west of Texas ; Madison 
 (' Statist. Reports on the Sickness and Mortality of the U. S. Army, 1855-60,' 
 Wash., 1861, 40), for Fort Randall (Dakota Terr.); Johns (ih., 45), for Fort 
 Laramie (Nebraska Terr.); Bartholow (' Amer. Journ. of Med, Sc.,' i860, April, 
 330), for Fort Bridger (Utah Terr.). 
 
 ^ Logan, in ' Southern Med. Reports,' ii, 468. 
 
 ' ' Pract. Observ. on the Diseases . . in Jamaica, &c,,' Lond., 1799, i 50, 
 
 ■* *Arch. de med, nav.,' 1869, Nov., 349, 
 
 5 'Guide med. des Antilles,' Par., 1840, 145, 
 
 « ' Du climat et des malad. du Bresil,' Par., 1844, 133
 
 8CURVT. 531 
 
 last century, tlie period when tlie hygiene of ships under- 
 went great improvement, the provisioning of ships more par- 
 ticularly being looked after with all possible care as regards 
 adequacy and suitability, especially in the case of long 
 voyages. It is hardly ever met with now except where 
 unforeseen difficulties in suitably providing for a ship's 
 company arise through misadventure. In these reforms 
 England has set a brilliant example to other seafaring 
 countries. In 1795 there were introduced into the English 
 navy those admirable regulations for provisioning ships of 
 war which Blane drew up ; and since that time scurvy has 
 been so rare with them that the number of cases over the 
 whole fleet during the years 1856-61 did not amount to 
 more than 1*05 per 1000 men.^ It is on the Australian 
 Station and on the West Coast of Africa^ that the disease is 
 oftenest seen. 
 
 The following are tlie more considerable outbreaks of scurvy in ships 
 of tbe Englisb navy tbat have been recorded during the last fifty years : 
 
 1838 in the Palinurus^ cruising on the North-East Coast of Africa; 
 
 1839 in the Alligator,'* ordered from England to the North Coast of 
 Australia, the disease having broken out four months after sailing from 
 the home port ; 1 854 in the British fleet in the Black Sea^ during the 
 Crimean War ; same year in a troopship" on the voyage to India ; and 
 1866, a severe epidemic among the soldiers on board a troopship^ 
 returning from India, the vessel being overcrowded as well as short of 
 provisions. 
 
 Until not very long ago the state of matters was less 
 
 satisfactory in the ships of the British mercantile marine, 
 
 particularly in those sailing to or from ports east of the Cape 
 
 of Good Hope, which had to be long at sea, the first cases 
 
 of scurvy occurring when they were sixty to eighty days 
 
 out. During the period from 1852 to 1863, the cases of 
 
 sickness of all sorts in the English mercantile marine 
 
 reported to the authorities amounted to 25,486 j and of 
 
 1 Friedel, 'Die Kraukheiteu in der Marine,' Berlin, 1866, 271. 
 " Bryson, ' Ophthalui. Hosp. Reports,' 1859, July. 
 
 3 Hardy, 'Transact, of the Bombay Med. Soc.,' 1839, ii, 256. 
 
 4 See 'Statist. Report on the Health of the Navy, 1837-43,' Lend., 1853, 
 pt. ii, 2 1 . 
 
 5 Rees, ' Med. Times and Gaz.,' 1854, Sept., 233. 
 " Morgan, ib., Dec., 586. 
 
 ' Wrench, ib,, 1867, March, 317.
 
 532 GEOGEAPHIOAL AND HISTORICAL PATHOLOGY. 
 
 ttese 1058 or 4*2 per cent, were cases of scurvy. Of 372- 
 cases of the disease admitted from merchant ships into the 
 Seamens' Hospital, Greenwich, from 1863 to 1866, 316 
 belonged to vessels that had sailed from ports east of the 
 Cape. One reason of this comparatively frequent occurrence 
 of scurvy in the mercantile marine is undoubtedly careless- 
 ness in the provisioning of the ships for the voyage, the 
 blame resting not unfrequently with the captain. Another 
 reason is the difficulty of procuring fresh provisions during 
 the voyage ; in which connexion attention has been called 
 to the state of matters at the port of Aden, where fresh 
 vegetables were particularly hard to get.^ 
 
 The care with which the English Government has endea- 
 voured to cope with scurvy on shipboard since the beginning 
 of the century has been emulated by the other seafaring 
 countries of Europe and America ; and since that time the 
 malady in their ships also, and especially in their ships of 
 war, has been considerably lessened. In the Austrian navy 
 the cases of scurvy from 1863 to 1870 were i per cent, of the 
 ships' companies; in 1871 and 1872 they had fallen to 0*34 
 per cent.^ In the German navy from April 1875, to March 
 1880, there were only sixteen cases of fully developed scurvy, 
 besides seventy-six cases of scorbutic affection of the gums f 
 taking the cases of both kinds together, the sick-rate was 
 o"475 per cent. ; and in only three ships did the malady 
 attain to slight epidemic diffusion. 
 
 I am acquainted with only a few casual notices of scurvy 
 on board ships of the Dutch,* Italian^ and United States^ 
 
 1 See 'Brit. Med. Journ.,' 1867, Jan., 89, Feb., 147; 'Lancet,' 1867, April, 
 463; and Dickson, 'Transact, of the Epidemiol. Soc./ 1867, ii, 440. 
 
 * 'Statist. Sanitiitsbericlit der Kaiserl. oster. Kreigsmarine fiir das Jahr 1872/ 
 Wien, 1874, 26. 
 
 ^ ' Statistische Sanitatsberichte der Kaiserl. deutschen Marine vom April, 
 1875, bis Marz, 1880.' 
 
 ■* Lilienfeld (in ' Casper's Wochenschr. fiir Heilkde.,' 185 1, Nr. 1-3) gives an 
 account of an outbreak in 1849 on board a Dutch man-of-war, ordered from 
 Batavia to China and California, after her arrival in the bay of San Francisco. 
 
 * Report by Vieira (' Revist. med. fluniin.,' 1838, p. 318) on the scurvy on board 
 the Sardinian frigate Euridice in 1836 during a voyage from Para to Rio de Janeiro. 
 
 ^ See Coale (' Amer. Journ. of Med. Sc.,' 1832, Jan.), on the epidemic of scurvy 
 which broke out in a United States' frigate off the coast of China during a voyage 
 round the world; also Foltz (ib., 1848, Jan., p. 38), on the epidemic of 1846 in 
 the flotilla in the Gulf of Mexico.
 
 souEVT. 533 
 
 navies. In the Frencli sliips-o£-war it lias been epidemic 
 comparatively often. 
 
 Thus in 1827-28, in tlie Mediterranean blockading squadi'on;^ 1842, on 
 board the frigate Heroine"^ cruising on the coast of New Zealand ; 1 846-47, 
 in the Belle Poule^ cruising betweeen Bourbon and Madagascar; 1854- 
 55, in the French squadron in the Black Sea during the Crimean War 
 {so severe that the strength of the ships' companies was quickly 
 reduced by scurvy to one half) ;'' 1859, on board a ship-of-war on the 
 passage from France to China, the disease appearing when they were 
 120 days out and invaliding 230 out of 716 persons on board f 1864, in 
 the fi'igate Andromaque,'^ also from France to China ; same year, in a 
 <5orvette^ cruising in the Gulf of Mexico (Bay of Matamoras) ; same 
 year, in the fi'igate JVemcZe^ on a voyage round the world; 1867, in a 
 frigate** from Mexico to France ; same year, in a ship-of-war'" on the 
 voyage back to France after a four months' cruise round Iceland. 
 There have also been very severe epidemics of scurvy on board ships of 
 the French navy employed in transporting convicts to New Caledonia : 
 namely, in the frigates Sibylle^^ and fyhigenie^^ in 1866-67, and in the 
 Orne^'^ and Var^* in 1873. 
 
 Lastly^ particular attention is due to the very severe out- 
 breaks of scurvy tliat have been often observed on board 
 whalers which have had to endure the want of px^ovisions, 
 especially fresh vegetables, owing to their being long beset 
 in the ice or kept back by contrary winds. ^^ Under the 
 
 ^ Levicaire, * Gaz. ined. de Paris,' 1832, 735. 
 
 * Dutroulau, ib., 1850, 627. 
 3 Id., ibid. 
 
 ■• Arnaud, 'Gaz. med. d'Orieut,' 1857, Juiii; Beuzelin (see Bibliogr.). 
 
 * Lagarde, 1. c. (Bibliogr.). 
 
 '' Lajartre, ' Consider, sur I'etat sanitaire de la fi'egatte I'Andromaque, &c.,' 
 Par., 1866. 
 
 7 Piiiou, 'Arch, de med. nav.,' 1865, Nov., 415. 
 
 8 Bernes-Lasserre, ' Relat. med. de la campagnede la fregate laNereide,' Par., 
 1866, 21. The reader will be astonished to find from this report that there were 
 cases of scurvy on board immediately after the ship left Brest. 
 
 " Leon, 'Arch, de med. nav.,' 1868, Avr., 290. 
 w Galliot, ib., 1877, Mai, Jiiin. 
 
 11 Normaud (see Bibliogr. ). 
 
 12 Caurant (1. c). 
 
 13 Ay me (1. c). 
 '■* Ledraiu (1. c.). 
 
 '^ Instances within recent times are given by Williamson (' Lond. Me.l. Gaz.,' 
 1836, April, xviii, 136) and Smith (' Edinb. Med. Journ.,' 1868, March, 859), 
 for Hudson's Bay. A French authority (' Arch, de mod. nav.,' 1867, Mai, p. 274) 
 speaks of the numerous cases of scurvy that have been admitted into the hospital 
 at St. Pierre (Newfoundland) iu Frenchmen engaged in the whaling, or in
 
 534 GEOGEAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 same circumstances scurvy lias become epidemic among the 
 crews of ships engaged in Arctic discovery ; as in the 
 Investigator^ in 1852, the malady appearing after the vessel 
 had been two years and three months out; and in the Alert 
 and Discovery (under Nares) in 1876.^ 
 
 This sketch of the histoiy of scurvy and of its geo- 
 graphical distribution at the present time can lay no claim 
 to completeness ; on the one hand there are doubtless many 
 records that have escaped my notice ; and, on the other 
 hand, many persons who have observed epidemics of scurvy 
 have neglected to report them. But the most serious gaps 
 in our knowledge of the incidence of scurvy pertain to those 
 regions which are somewhat remote from ordinary traffic and 
 whose general health-conditions have been very deficiently 
 observed and recorded. So far as our information goes, we 
 may at least conclude that scurvy, although no longer so 
 common as in past centuries, can by no means be said to be 
 extinct ; on the contrary, that it still threatens to break out 
 among bodies of people the moment they begin to experience 
 those hardships and mishaps of living which I shall have to 
 deal with in the paragraphs following. 
 
 § igi. Question op the Influence of Cold and Wet. 
 
 The records of scurvy both in former centuries and in 
 recent times teach us that the malady is not dependent for 
 its existence and extension on any particular climate, or on 
 the geographical position of the place or country ; but that 
 it has been found all over the world, equally in temperate 
 latitudes and in the coldest and hottest. No doubt when 
 we compare the amount of scorbutic sickness in various parts 
 of the world, we shall find that there is a small excess for 
 
 working at the cod-liver oil manufacture. Under similar circumstances the 
 disease has often appeared, according to Lallemand (' Casper's Wochenschr. fiir 
 die ges. Heilkde.,' 1848, pp. 25, 385), among the crews of guano ships, particu- 
 larly when exposed to extreme want after shipwreck on the Patagouian coast. 
 
 * Armstrong, 1. c, 13, 36. 
 
 2 Donnet and Fraser (Bibliogr.) ; see also Leach (' St. Barth. Hosp. Kep.,'" 
 1878, xiii); and Kochefort (♦ Arch, de med. nav.,' 1877, Juill, Aout, Septr.), fol- 
 lowing Donnet.
 
 SCURVY. 535 
 
 regions within the cold zone ; and that fact, taken along with 
 a number of observations on the season of prevalence of the 
 malady, has given rise to the often expressed opinion that 
 states of the weather, particularly cold and wet weather, are 
 a principal factor in the production of the disease, and that 
 its maximum falls, accordingly, in the seasons to which such 
 states of weather mostly correspond. The following analysis 
 should show how far this opinion is justified by the facts : 
 
 Of 73 epidemics of scurvy in cold and temperate latitudes, 
 of which the date is given with tolerable precision, 24 
 occurred (or reached their highest point) in winter, 34 in 
 spring, 13 in summer, and 2 in autumn. Of 10 epidemics 
 in tropical and sub-tropical regions, i falls in the cold 
 season, while 4 fall in the hot and 5 in the transition- 
 seasons corresponding to our spring and autumn. Accor- 
 dingly, for the cold and temperate zone, spring would be the 
 proper season of scurvy, and next to it would come winter. 
 In agreement with StoU^ who says that " constatissima causa 
 (scorbuti) est mador atmosphaerae continuus, maxime fri- 
 gidus,^' many who have observed^ these winter and spring 
 epidemics or endemics have laid special stress for the patho- 
 genesis upon the cold and wet weather which had been 
 prevalent at the same time as the disease. In like manner 
 the outbreaks of scurvy on board ship have been traced in 
 many quarters to the direct influence of the weather. Such 
 was the view that Lind very decidedly took ; he pointed to 
 the kind of life led by the common sailors, to the frequent 
 drenchings of their clothes and their forecastle, and to the 
 dampness of their sleeping-bunks. He then contrasts the 
 exemption from scurvy that the officers in most cases en- 
 joyed, explaining it by their being less exposed to hardships 
 or better protected against them. A similar opinion was 
 held by Rouppe,^ who dwelt upon the fact that scurvy usually 
 breaks out on board a ship as she passes from the tropics to 
 higher latitudes ; and by Macmichael, Pirion and others. 
 But, against these observations adduced in favour of the in- 
 
 1 ' Praelect. in diversos morbos clironicos,' ed. Eyerel, i, 7. 
 " Bacberacht, Nitzsch, Monro, Radius and May, Curran, Routier, Opit.i 
 Perrin, Jouin, Heinrichs. 
 
 3 ' De morbis navigantium,' Lugd. Batav., 1764, 118.
 
 536 
 
 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Huence of cold and wet, there is a uofc less extensive series 
 of well- authenticated facts which afford evidence, both of a 
 negative and positive kind, that this factor plays only a 
 secondary part in the production of the disease, if indeed it 
 come into account at all. All the localised epidemics of 
 scurvy mentioned by Lavirotte in the penal institution at 
 Eoanne, by Dicenta and Cless in the prison of Ludwigsburg, 
 and by Popper and Kirchberger at Prague, occurred in 
 summer. Chrastina^ observes that, in the Charitable Insti- 
 tution at Alserbach (Vienna), where there is scurvy every 
 year, a few cases occur as early as February and March, but 
 that the number increases in the months following, and 
 reaches the highest point in July. Of the 2680 cases of 
 scurvy observed at the Obuchoff Hospital of St. Petersburg 
 during eighteen years, the percentages in the several months 
 were as follows (according to Herrmann) : 
 
 January . 
 
 . 3-06 
 
 May . 
 
 . 21-86 
 
 September 
 
 - i"97 
 
 February . 
 
 . 5'o7 
 
 June 
 
 . 20-55 
 
 October . 
 
 . 1-52 
 
 Marcli 
 
 • 9*32 
 
 July . 
 
 . 14-70 
 
 November 
 
 . 1-49 
 
 April 
 
 . i2gi 
 
 August 
 
 • 5'26 
 
 December 
 
 . 2-23 
 
 Here the maximum is in May and June, and the minimum 
 from October to December. Amburger arrived at nearly 
 the same result on comparing the states of the weather at 
 St. Petersburg for each month from 1867 to 1880 with the 
 number of scorbutic cases admitted into the hospitals of the 
 city : " The evidence is plain, '^ he says, " that scurvy is not 
 dependent on meteorological influences." Almost all the 
 epidemics in Swedish prisons from 1848 to 1877, according 
 to Heymanu, have begun in summer, and mostly towards 
 the end of it, and have terminated about the close of the 
 year ; in these cases the influence of cold and wet weather 
 on the pathogenesis is absolutely excluded. From the 
 reports of the army surgeons on the prevalence of scurvy 
 among the French troops during the Crimean war, we find 
 that the monthly returns of the sickness from October 1854 
 to June 1856, including a total of 23,365 cases, are as 
 follows : 
 
 1 c 
 
 Oest. Zeitschr. fur Heilkde.,' 1859, Nr. 12.
 
 
 SCURVY. 
 
 537 
 
 1 854 October 
 
 20 1855 September 
 
 1388 
 
 November 
 
 So October 
 
 707 
 
 December 
 
 800 November 
 
 718 
 
 1855 January 
 
 1575 December 
 
 1248 
 
 February 
 
 789 1856 January 
 
 3980 
 
 March . 
 
 452 February 
 
 4341 
 
 April 
 
 348 Marcb . 
 
 1787 
 
 May 
 
 132 April 
 
 785 
 
 June 
 
 350 May 
 
 275 
 
 July . 
 
 1 140 June 
 
 50 
 
 August 
 
 2400 
 
 
 According to this, the epidemic reached its first maximum 
 in the summer of 1855 and its second maximum in the 
 winter of 1855-56. From ti'opical and sub-tropical regions 
 there are other observations in entire agreement with these 
 facts. In the Indian gaols the epidemics of scurvy reach 
 their greatest height in the months of July, August, and 
 September (Porter) j^ and McGregor confirms this when he 
 tells us that the disease is most inveterate in the North- 
 West Provinces during the hot season, having been so in 
 1839 at Agra and in the hospital at Karnaul, where the air 
 was at the same time very dry. 
 
 Wernich says that in Japan scurvy is most commonly seen 
 in summer. Logan, after describing* the kind of weather at 
 the time when scurvy broke out among the gold diggers in 
 California, goes on to say : "If the facts here given have 
 any value at all, they should certainly serve to prove that 
 cold and wet, which have hitherto been regarded as the two 
 most powerful predisposing causes of scurvy, were altogether 
 unconcerned in producing the malady in this country.'^ 
 
 In a much more equivocal light than in the case of land 
 scurvy, does this etiological factor exhibit itself in connexion 
 with scurvy on board ship. Kouppe^s assertion that it 
 develops for the most part as the vessels pass from low 
 latitudes into higher, is altogether unfounded. If we are to 
 have a general rule of that sort at all, it would be much 
 more correct to express it in exactly the converse way ; for, 
 as Bampfield^ had previously pointed out, scurvy on board 
 ship has occurred much more often in the tropics than in 
 
 ' 'Madras Monthly Jourii. of Med. Sc.,' 1872, April, p. 253. 
 - * Treatise on Tropical Dysentery,' Lond., 1823, p. 239.
 
 538 OEOOEAPHIOAL AND HISTORICAL PATHOLOGY. 
 
 higher latitudes. We have, besides, the evidence of nu- 
 merous authorities such as Leon, Lascade, Lejartre and 
 others, based upon the systematic observations made during 
 long voyages (from France to the East Indies or the Pacific), 
 that scurvy occurs on board ship altogether independently of 
 meteorological influences. The slight dependence of the 
 malady under given circumstances on the coldness of the 
 season, is further shown in the statistics published by 
 Duchek^ of the sick-rate from scurvy in the Austrian Navy, 
 the same having been o'og per cent, of the full strength in 
 winter, 0*13 in spring, 0*17 in summer, and o"o8 in autumn. 
 Again, the opinion sometimes expressed that the outbreaks 
 of scurvy, which used certainly to be common in former 
 times in ships making the voyage round Cape Horn, were to 
 be attributed to the prevailing bad weather, is shown by an 
 interesting observation of Logan^ to have little general 
 relevancy. In the worst season of the year they were 
 beating about for four months in a small schooner trying to 
 double Capo Horn ; during all that time the crew were never 
 out of their wet clothes, the ship with everything in it was 
 saturated with water, the cabins had to be kept shut and 
 were accordingly full of all kinds of emanations ; and yet 
 not a single trace of scurvy showed itself on board.^ It is 
 not the fact of sailing in high or low latitudes, and not one 
 season more than other, but solely the length of the voyage 
 in relation to the store of suitable provisions, that really 
 gives rise to an outbreak of scurvy on board ship. And 
 this is the explanation, as we shall afterwards see, of the 
 material decrease of scurvy at sea in recent times, although 
 ships' crews are liable as much as ever to have the weather 
 both foul and fair. 
 
 In the etiology of scurvy, diet is the Alpha and Omega ; 
 but inasmuch as weather and season do come into play 
 directly or indirectly, we must think of these factors as 
 
 1 L. c, p. 279. 
 
 * ' Southern Med, Keports,' ii, 474. 
 
 3 [In the voyage made classical by Dana in his ' Two Years before the Mast/ 
 the experience of Cape Horn weather was much the same, only less protracted. 
 The single case of scurvy which he mentions (noteworthy also for the almost 
 miraculously quick cure by the juice of raw potato) occurred when the ship was 
 in the warmer latitudes.]
 
 SCURVY. 539 
 
 always able to exert a modifying influence on the disease in 
 one direction oi' anotlier. Moreover, it cannot be denied 
 that weather-influences which lower the resistance power of 
 the organism by disturbing the normal course of its func- 
 tions, may predispose it to an attack of scurvy ; but this 
 applies not only to cold and wet weather, but also to the 
 relaxing effects of a prolonged residence in a warm tempera- 
 ture, as Foltz and other observers have pointed out. 
 
 § 192. The Kind op Soil op no Account. 
 
 Again the significance of the kind of soil for the occurrence 
 of the scurvy must be judged in this and no other way. 
 The exceptionally frequent prevalence of the disease at sea 
 is itself an evidence that its production is altogether inde- 
 pendent of strictly telluric influences ; and any direct influ- 
 ence of the soil upon the pathogenesis is excluded not less 
 by the very narrow limitation of epidemics, especially in 
 recent times (often to a few rooms), as well as by the material 
 decrease of the malady under the blessings of rational hygiene, 
 and, above all, of sufiicient and wholesome food, A number 
 of observers have attached special importance to the morbific 
 effects of a wet soil in scurvy ; such as Oloff for the epidemics 
 in Wallachia, Monro for Bremen, Scoutetten for Givet, 
 GUnsburg for Breslau, Perrin for the Crimea, Novellis for 
 Alessandria, Opitz for Rastatt, Doring for Ingolstadt, Blan- 
 chard for Cochin China, and Seeland for the Amoor region. 
 But the conclusion that they draw from the facts is valid only 
 in so far as relates to a possibly injurious effect of residence 
 on a damp soil, or to an increased personal predisposition to 
 scurvy thereby caused. It is the more necessary to be 
 cautious in judging of these circumstances in the causation, 
 for the reason that many other harmful things besides a wet 
 soil come into account in all such cases, most of all the food. 
 When Grimm alleges " that territories traversed by great 
 rivers, or situated on the estuaries of rivers, or on the sea- 
 coast, have a visitation of scurvy every spring, whenever 
 there has been a cold and wet winter preceding," he commits 
 an inexcusable exaggeration and a gross error, inasmuch as
 
 640 GEOGEArHICAL AND HISTORICAL PATHOLOGY. 
 
 scurvy lias been as often upon dry ground as on wet, on 
 elevated land as on low levels, on rocky soil as on porous 
 and pervious. Lastly, when some observers (including See- 
 land among recent writers) speak of a scorbutic miasma 
 developing from the wet ground, and would class the malady 
 among infective and even communicable or contagious dis- 
 eases (a point to which I shall recur), I can see nothing 
 more in this than a misdirection of the etiological inquiry, 
 of the same kind that has found abundant expression lately 
 in the speculative theorising and in the rage for parasites 
 which have taken possession of the medical world. 
 
 § 193. Influence of Ovekcrowding and of Impure Air. 
 
 There is one factor in the history of scurvy which has 
 been uppermost in every age and in all countries, namely, 
 the close association of the disease with defects of hygiene 
 and ahove all of diet ; and that factor must in reason 
 become the point of departure in the inquiry into causes. 
 
 In the first place, we meet in this connexion with the 
 noteworthy fact that of the 144 epidemics on land in the 
 above table, only 42 were general, and of these 42 only 26 
 extended to more than one locality and very few to large 
 tracts of country. On the other hand, there were 55 observed 
 in besieged fortresses, or in the besieging armies,^ or in 
 garrisons ; and 47 in prisons, poor-houses, and refuges, or 
 under such like circumstances. In all the cases where scurvy 
 has appeared outside these circumscribed ai'eas, it is only 
 the needy part of the poi^ulation, wanting the barest neces- 
 saries of life, and in particular a sufficiency of proper food, 
 that have suffered ; the better off classes have been altogether 
 exempt or have been touched by the disease only in so far 
 as the same wants have made themselves felt among- them also. 
 This applies to the incidence of the disease among bodies 
 of troops both on shore and afloat ; for it is usually only the 
 common soldiers or sailors and the petty officers that suffer, 
 while cases among the officers have been the exception and 
 
 ' Glaus Maguus says of scurvy, " Est morbus castrensis qui vcxat obscssos et 
 inclusos."
 
 SCURVY. 541 
 
 have occurred only under such exceptional circumstances, 
 (particularly in Arctic expeditions) as made the privations 
 general.^ 
 
 It stands to reason that in all these cases we are concerned 
 with an aggregate of influences injurious to health. The 
 question then arises whether the disease ensues as a conse- 
 quence of their combined effect, or proceeds from influences 
 of one particular category. In framing an answer to this 
 question we must above all bear in mind that the misery of 
 living, with its consequences, has at all times existed over the 
 whole world ; whereas scurvy as an epidemic malady has 
 been a phenomenon of comparatively rare occurrence, and as 
 an endemic has played a very subordinate part, especially in 
 recent times ; and accordingly that the noxious thing which 
 has arisen out of the hardships of living and has become the 
 proper cause of the malady, must have had something of a 
 specific character in it. 
 
 It has been thought probable that the tainted atmosphere 
 caused hy overcrowding may have been a material factor in 
 the etiology, perhaps the one decisive thing ; some observers 
 have even gone so far as to allege that a specific scorbutic 
 miasma has developed under these circumstances. This con- 
 jecture supports itself on the fact that there has not unfre- 
 quently been overcrowding at the time of an outbreak of 
 scurvy in one of those self-contained institutions before men- 
 tioned ; and that on board ship, especially in transports, 
 scurvy has attacked those of the crew, or of the troops or 
 convicts, who have passed the greater part of the time, or per- 
 haps in bad weather the whole of the time, in the overcrowded 
 and insufficiently ventilated ^tween decks or lower hold. One 
 cannot, a priori, deny that close confinement in an atmo- 
 sphere of that kind, little suited as it is to the needs of 
 respiration, and the absence of exercise in the open air, are 
 
 ' The following instances are recorded : by Kramer, for the Imperial army in 
 Hungary 1734-35, when none but the common soldiers were affected; by Monro,, 
 for the English troops in Bremen in 1762, when not merely the officers and staff 
 escaped, but also the sergeants ; by Forry, for the epidemic among the United 
 States' troops at Council Bluffs in 1820, when only one officer took scurvy; by 
 Coale, for the U.S. frigate Columbia on a voyage round the world, only three 
 out of the twenty-eight officers being affected, and these the officers wlio had 
 shared in the diet of the scurvy-stricken crew.
 
 542 GEOGRAPHICAL AND niSTORIOAL PATHOLOGY. 
 
 not without their effect on the composition of the Wood and 
 the nutrition of the body, and may accordingly become a 
 predisposing- cause of an attack of scurvy. 
 
 The following remarks by Armstrong^ on the influence of foul air upon 
 the condition of patients with scurvy, are selected from a large number 
 of observations to the same effect : " It is impossible to deny some degree 
 of influence to the effects of pure air in this disease. I have found, 
 where the ventilation was occasionally rendered less perfect than usual 
 for a few days (from iinavoidable causes), and the escape of impure air 
 was thereby interfered with, that those who were labouring under the 
 disease always experienced more or less aggravation of their symptoms. I 
 think that the existence of a vitiated atmosphere always tends to impart 
 a more aggravated character to scurvy. Hence, attention to ventilation 
 in this disease, as in every other, should always be an object of our 
 greatest care." 
 
 But we shall keep the importance of this noxious agent within due 
 limits when we reflect that the outbreak of scurvy in places of confine- 
 ment, especially prisons, poor-houses, and the like, has never been more 
 than an occasional incident notwithstanding their incessant overcrowd- 
 ing ; and that in some instances, as, for example, the convict prison at 
 Ludwigsburg, the disease has been prevalent year after year altogether 
 irrespective of the greater or smaller number of inmates ; or that, in 
 one and the same place, there have been two centres of disease (as in 
 1854 at Breslau, in the House of Correction, and the deaf-and-dumb 
 institution) of which one had been overcrowded, and the other not only 
 not so but even admirably ventilated and a pattern of cleanliness. We 
 have to bear in mind, also, that epidemics of scurvy have broken out in 
 prisons where there could be no question whatsoever of overcrowding, 
 as at Eoannein 1856 (Lavirotte), Exeter in 1847 (Shapter), the Paris 
 House of Correction in 187 1 (Delpech, Georgesco), as well as very often 
 on board ship ; and that the malady has several times decimated the 
 expeditions sent out to explore the interior of Australia, breaking out, 
 that is to say, among persons living constantly in the open air. It has 
 further to be said that most of the observers who are inclined to lay 
 special stress on overcrowding, cannot but admit that other hardships 
 of living, and most of all a deficient diet, are contributories in the 
 pathogenesis. Ifc is clear then, that this factor, like the bad weather 
 and wet soil already mentioned, and like bodily fatigue, thwarted 
 feelings, such as home-sickness, and other things that some writers 
 have specially dwelt upon in the causation, has no other importanee 
 than as a causa prcsdis2wnens. 
 
 ' L. c, p. 32. 
 
 %
 
 SCURVY. 543 
 
 § 194. Caused by want op Fresh Vegetables. 
 
 No single one of these tilings^ nor the whole group of them 
 together, has ever yet given rise to an epidemic or endemic 
 of scurvy. There must always have been at the same time 
 in action one particular noxious influence, an influence which 
 has produced scurvy quite independently of these, and not 
 unfrequently under hygienic conditions that were in other 
 respects as good as can be conceived — I mean something 
 ivanting in the food. It is in that then, that we must seek 
 for the most material if not the exclusive cause of scurvy. 
 There are few points of etiological doctrine about which 
 so much agreement has been expressed among observers of 
 every period and in all countries, as the power of an in- 
 adequate diet to determine an outbreak of scurvy ; although 
 opinions differ as to whether it is want of food in general, 
 or the absence of certain elements of the food, chiefly of a 
 vegetable kind, or a monotonous diet limited to one kind of 
 nutriment, especially salt meat, or finally something positively 
 harmful or unsound in the food or drink, which furnishes 
 the real cause of the malady. 
 
 Against the notion of deficiency of food in general (irre- 
 spective of the quality) being of itself productive of scurvy, 
 there is first of all the fact — and to my thinking the un- 
 answerable fact — that the severest of famines, due to failure 
 of the crops or other elemental causes, or to the calamities 
 of war, have only in very rare instances been attended by 
 or followed by epidemics of scurvy ; that the great and 
 proper types of famine-sickness, as seen of late in Algiers, 
 India, and other parts of the world, have never been the 
 scorbutic, and that scurvy is as far as possible from bearing 
 the stamp of a disease of inanition. Conversely, and still 
 telling against the same notion or at least against the 
 general application of it, we have the fact that in very many 
 instances, both on sea and land and among people living in 
 the open air as well as those in confinement, scurvy has 
 broken out although there has been no absolute want of food 
 at the time. No doubt there have been some epidemics of 
 scurvy in consequence of bad harvests or famines from other
 
 544 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 causes: as in Sweden in 1784, at St. Petersburg, Cronstadt 
 and other places in Eussia in 1785, Braila in 1787 and 
 1793, Hungary in 1803, Southern Russia in 1823, 1845, and 
 1849-50, Iceland in 1836, Moscow in 1840, Prague and 
 Leipzig in 1843, Great Britain and Ireland in 1846-47, and 
 Paris in 1871. But for most of these cases it can be proved, 
 as we shall see in the sequel, that it was not the want of 
 nutritive articles absolutely, but of a certain kind of them, 
 that occasioned the sickness. 
 
 There is equally little justification for the idea that it is 
 the immoderate or almost exclusive use of salt meat which 
 creates the real occasion of the malady. Much of the evidence 
 that passes current in support of this rests upon a loose sort 
 of criticism ; inasmuch as it is always a question when scurvy 
 breaks out under these circumstances, whether the disease 
 is indeed the effect of that kind of diet, and not rather of 
 the want of other nutritive substances, namely, vegetables. 
 Further, there have been a number of outbreaks of scurvy 
 observed, in which the affected persons had certainly suffered 
 from no lack of fresh meat : as in the Imperial army in 
 Hungary in 1735; in Lord Anson's fleet in 1741, which 
 left the Mexican coast provisioned , with fresh meat ; at 
 Millbank Penitentiary, Loudon, in 1823 ; among the English 
 troops at the Cape in 1836; among the Austrian troops at 
 Rastatt in 1852; in Ireland in 1846 (Curran) ; in Burke's ex- 
 pedition through the heart of Australia in 1861 ; in Paris 
 and among the French prisoners at Ingolstadt in 187 1. 
 Lastly, against any scorbutic effect due to a full diet of 
 salted meat or fish, there is the fact that many of the peoples 
 of the far north, such as the Finns, Lapps, Koriaks, 
 Tchoukchi, and Eskimo, will subsist often for months on 
 pickled flesh or salted fish without having any visitation of 
 scurvy, or at the most only one now and then. 
 
 Beckler, in his interesting account of the outbreak of 
 scurvy among the members of Burke's exploring party in 
 the interior of Australia, points out that the provisions Tvhicli 
 the expedition took with them from Melbourne were unex- 
 ceptionable, and that scurvy appeared, none the less, when 
 they were obliged for want of fresh water, to drink the 
 standing water in the half-dried creeks, fouled by worms
 
 SCURVY. 545 
 
 and weeds. Beckler is all the more disposed to regard that 
 as the true aud only cause of the malady^ for the reason 
 that the expedition which was sent out subsequently to 
 bring back the scurvy-stricken explorers from the interior to 
 the Darling river, and which took with them only such pro- 
 visions as remained over from the outfit of the original party, 
 continued free from the disease ; the reason being, as Beckler 
 observes, that they were so fortunate as to obtain pure water 
 from the rains that had meanwhile fallen in the interior. 
 Well founded as this conclusion of Beckler's may at first 
 sight appear, there are some very considerable objections 
 to it, as we shall see in the sequel. Furthermore, it can by 
 no means be denied that a monotonous and innutritions diet 
 (salted meats and fish being in the first rank of such) or 
 unsound food, may act on the organism just like absolute 
 want of food, so as to lower its powers of resistance and 
 thereby mcrease its predisposition towards the attack of 
 sickness. 
 
 The central point of interest in the problem of the real 
 cause of scurvy is undoubtedly how far the want of fresh 
 vegetable food, or rather of a pai'ticular kind of it, is of para- 
 mount importance in the pathogenesis. Even if this notion 
 were not supported by an overwhelming body of experience 
 as to the usual circumstances under which it has always 
 appeared in all parts of the world both ashore and afloat, 
 among those leading a free life as well as among those living 
 under some restraint, it would be sufficiently established by 
 the one fact that there is no more cex^tain means of obviating 
 an outbreak of scurvy, and no more speedy means of sup- 
 pressing it, than a diet of fresh vegetables of the right kind, 
 or the medicinal use of their principles. 
 
 The importance of this matter, and the doubts about it 
 which are still raised here aud there, will justify me in 
 giving briefly a few of the more remarkable among many 
 experiences that have been collected to illustrate the point. 
 
 The first to express an opinion as to the morbific influence of a want 
 of fresh vegetables was Bachstrom,' who thus summarises his experience 
 in the matter during the epidemic of scurvy at Thorn in 1 703 .- 
 
 "Probe itaque pensitatis omnibus circumstantiis, qiias superius in 
 
 ^ 'Obscrv. chxascorbutuin,' Lugd. Bat., 1734, p. 95. 
 
 VOL. II. 35
 
 546 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 historia et cura hujus morbi narravimus, imo pluribus aliis quas hie 
 ob brevitatem omittimus, concludendum nobis esse videtur: causam 
 veram et primariam scorbuti nullam aliam esse, quam abstinentiam 
 diutumiorem a quocumque genere recentiura vegetabilium, sive ilia 
 climatis indoli, sive coactioni et necessitati, sive neglectui sit tribuenda." 
 The epidemic of scurvy in Hungary, in 1734, led Kramer^ to the 
 same conclusion; he noticed that it was almost always the common 
 soldiers, and not the officers, who sickened ; the reason being that " the 
 former had nothing but farinaceous substances and legumes to eat, 
 while the latter had often green esculent vegetables ; when some of the 
 officers neglected these, which did not happen often, they took scurvy 
 also." Monro," in his account of the scurvy in Canada, in 1760, and at 
 Bremen, in 1762, says that the disease is most frequent in those northern 
 countries where fresh vegetables are scarce, and the inhabitants obliged 
 to live much on salted provisions during the winter. That was the 
 reason why the malady was so common in Quebec during the first 
 winter of its occupation by the English, as well as in several other 
 forts in America which were captiired so late in the season that the 
 troops had no time to lay in a store of vegetables and fresh meat, and 
 were obliged to live mostly on ships' stores. At Bremen the disease 
 was seen among the soldiers only, the reason being that they (although 
 not the officers, civilians and others) were unable to procure vegetables 
 or fruit in the market. In reference to the epidemic of scurvy in 
 Hungary in 1803, Schraud lays most stress for the etiology upon the 
 want of food, and especially of fresh vegetables, during the winter. 
 Still more definite is Guthrie's opinion as to the cause of the epidemic 
 of 1785, among the naval and military forces at St. Petersburg and 
 Cronstadt. The cause was found to be the want of those vegetables 
 upon which the maintenance of health depends ; cabbage, carrots, beet 
 and turnips ran short, and the small supply sent the price up much too 
 high for the pockets of the troops. It was just among them that the 
 disease became prevalent; while the laboui-ing class and the country 
 people understood better how to provide for themselves. Lee, in his 
 account of the severe epidemic of 1823 in Southern Russia, says, with 
 reference to the laying waste of the fields by swarms of locusts, "It was 
 precisely at this period that the disease commenced, and there can 
 be little doubt that it ought to be attributed to a want of the 
 usual supply of the sour crout and prepared cabbages and other vege- 
 tables for the winter . . . All green vegetables had attained an unusual 
 price at this period, and it was in the power of few to make the usual 
 provision. In all the hospitals the patients were supplied, as they 
 usually are, with fresh animal food, bread and grits for gruel, yet the 
 disease was not arrested." 
 
 Under the same circumstances of a scarcity of fresh vegetables, the 
 malady became prevalent in 1840, in Orenburg (Schiitz) and in Moscow 
 (Samson v. Himmelstiern, 2nd ref.) ; also in 1842 in Viatka, where the 
 
 ' L, c, p. 80. L. c, p. 204.
 
 SCURVY. 547 
 
 real cause, as alleged by Jonin, was " the absolute want of the kind of 
 vegetables that are indispensable for preserving the right composition 
 of the body's juices;" again, in 1854 among the Turkish and French 
 troops in the Crimean War, while the English army suffered little, 
 having better provisions. Leidesdorf remarks, in his account of the 
 scurvy in the Turkish army, that those who suffered most were the 
 Tartar regular cavalry, whose food was often only a few handfuls of rice, 
 some rancid fat and mouldy biscuit, eked out, at the best, with damaged 
 beans or peas and salted mutton, while of fresh vegetables there were 
 absolutely none. Regarding the outbreak among the French troops 
 also, Perrin, Fauvel, RoUin, and most of all Scrive,' lay stress chiefly 
 on the entire want of vegetables, of which there are never any in that 
 region during the winter, while all the esculent plants of the summer 
 season had been burned up around the camp before Sebastopol by the 
 excessive heat. The epidemic of scurvy at Prague in 1843 is referred 
 by Cejka to the failure of the harvest the year before; vegetable growth 
 of every kind was poor, but potatoes in particular were deficient both 
 in quantity and quality ; so that not merely the soldiers and the poor, 
 but even the residents in better circumstances, had to put up for a long 
 time with bread and coarse pastry. 
 
 There is absolute unanimity among the English, Irish, and Scotch 
 practitioners, that the epidemic of scurvy in the United Kingdom during 
 1846-47 was due to the bad harvest, and particularly to the failure of the 
 potato crop. Lonsdale's conclusions, from the observed facts during 
 the epidemic in the South of Scotland are : " That scurvy originates 
 from an error of diet, — the occupation, dwellings, &c., sometimes viewed 
 as collateral causes having little or no influence, — and that a deficiency 
 of potatoes constitutes the chief error of diet, and is the main cause 
 of the present epidemic, whilst the absence of variety and deficient 
 quantity of food hastened the development of scurvy." 
 
 BelHngham summarises the results of observations in Ireland as 
 follows : " That this disease did not make its appearance until after the 
 people had been deprived of their accustomed diet for several months, 
 that the disease prevails only among that class of the population whose 
 diet consisted formerly, in a great measure, of the potato, and who, as 
 long as they had that vegetable in abundance, enjoyed a perfect 
 immunity from it ; the subjects of the preceding cases appear all to 
 have had a sufficiency of bread, others had meat in addition, with some- 
 times wine or porter ; none suffered from an absolute deficiency of food, 
 but all agreed in not having used fresh vegetables from the period of 
 the failure of the potato crop of last year." " In four fifths of the cases 
 reported to me," says Curran, for Dublin, "bread and tea or coffee, 
 was what the patients had been living on when attacked ; the others 
 had been using grains of various kinds, or grains and flesh or fish, but 
 in no single instance could I discover that green vegetables or potatoes, 
 had formed a part of their regular dietary." 
 
 1 L. c, p.427.
 
 548 GEOGEAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 Sibbald, who studied the epidemic in tlie Kent County Asylum, says 
 that as soon as potatoes were procured, "although at an exorbitant 
 price," and the aiHng and healthy began to have them at meals, the 
 former soon got well and no new cases occurred among the latter. 
 The same conclusion was come to by Ritchie, Shapter, Anderson, 
 Christison, and others. It is the opinion of nearly all the authorities^ 
 on the epidemic of scurvy in Paris during the siege by the German 
 troops in 1870-71, that the cause of the malady was neither over- 
 crowding (in such places as prisons, barracks or military hospitals), 
 nor cold and wet, nor the use of salt meat ; neither was it scarcity of 
 food in general that was to blame ; but it was when the supply of fresh 
 vegetables, and particularly of potatoes failed, that the disease broke 
 out. 
 
 In nearly all the epidemics of recent years among the British and 
 native troops in India — at Rangoon in 1824, Nusserabad in 1834, 
 Cannanore in 1832, and during the siege of Lucknow in 1S57 — the 
 cause of the sickness could be ti-aced to the want of fresh vegetables, 
 either from failure of the crop or the difficulty of introducing supplies. 
 " Little or no fruit has been procurable in Rangoon," we read in one 
 of the accounts,^ " and the only vegetable available to the troops has 
 been wild spinach or country greens, and that even in a very limited 
 quantity." 
 
 The real cause of the epidemic at Cannanore in 1832 is stated by 
 Henderson to have been " the scarcity and high price of good vege- 
 tables;" and of the epidemic in Lucknow, Greenhow says: "Con- 
 sidering the total want of vegetables and the absence also of lemon- 
 juice and vinegar, the wonder is that more persons did not suifer in this 
 way. Rice was served out latterly, of course, in very reduced quantity ; 
 but rice cannot be considered a good substitute for good vegetables, 
 a fact proved indeed by the experience of this siege. The best treatment 
 for the complaint, and an evidence too, if such were needed, of its real 
 origin, was the poi'tating again of fresh vegetables. When the su^Dply 
 of these was opened up, scorbutic disease began to disappear." 
 
 Under the same cii'cumstances scurvy appeared in 1862 in the Army 
 of the Potomac in the American Civil War. There also fresh vege- 
 tables failed altogether, and it was only with the greatest difficulty that 
 a small quantity of potatoes and cabbage could be procured, "the 
 beneficial effects of which were marvellous," as Herr says in his repoi't. 
 The same consequences of the want of fresh vegetables, and the same 
 curative effects of them in scurvy when they were procurable, had often 
 been experienced before by the surgeons of the United States Army 
 at remote posts in the Western States, and in Texas and New Mexico. 
 Thus Madison, speaking of the scurvy at Fort Randall, Dakota, in 1857, 
 says : " During the last winter the whole command was more or less 
 affected before we received the Irish potatoes, which had left St. Louis 
 
 ^ Delpech, Georgesco, Bucquoy, Charpcntier, Lustigue, &c. 
 2 'Madras Quart. Med. Jouru.,' 1839, '> 209.
 
 SCURVY. 549 
 
 in tlie fall and had to be deposited one hundred miles below, and after- 
 wards hauled up, frozen, in waggons. They did not reach us before 
 the first week in January. As soon as a liberal issue was fairly com- 
 menced, and tlie men compelled to eat them raw as well as cooked, 
 their convalescence was most rapid and recovery complete. After the 
 potatoes gave out, the supply of which was not abundant, the disease 
 showed a strong disposition to return." 
 
 Johns,^ for Fort Laramie, Nebraska, and vai'ious other^ authorities, 
 have come to the same conclusion. Again, Logan points out that 
 scurvy aj^peared among the gold-diggei's in California when they were 
 entirely without fresh vegetables or the corresponding vegetable juices, 
 having to live on flour and half-putrid meat which had become hard 
 in the pickKng and drying. The epidemics of scurvy that have been 
 observed time after time in Russia have been shown to depend on the 
 etiological factors of which we are speaking; and in the Crimea, 
 accoi'ding to HeLurich, in Jekatermoslav, according to Sachs,^ and in. 
 other of the southern governments, the endemic prevalence of the 
 malady has been essentially connected with the want of fesh vegetables 
 in the winter and spring seasons. From Finmark we have it stated by 
 Walter that scurvy is rarely seen among the Finnish and Lapp popula- 
 tion of the country, who collect large quantities of sauerkraut (Rumei 
 acetosa) during the autumn and eat it with milk in the winter; whereas 
 the malady is very common among the Quaens and Northmen who &o 
 not follow the same practice. 
 
 In Sweden, says Dalberg (1. c), the disease used to be prevalent in 
 those districts where the inhabitants suffered from the want of fresh 
 vegetables. Under those circumstances, also, it has occurred time after 
 time in Iceland, according to Holland,^ Schleisner^ and Hjaltelin, and, 
 according to Sexby,*' in the Shetland Islands, especially in seasons 
 when the potato crop was a failure. 
 
 The unusually frequent, and even endemic, occurrence of scm-vy in 
 Rajpootana, Malwa, and other parts of north-western Hindostan, is 
 explained, as Moore and Lucas think, by the fact that these tracts of 
 country, which are very barren of every kind of growth, produce no 
 anti- scorbutic plants ; but the malady breaks out all the sooner and 
 spreads the farther, the greater the want of vegetable food in general. 
 From information furnished by Pechey, scurvy is not uncommon among 
 the shepherds in the interior of Australia, who live mostly on bread 
 and salt meat. Whenever there is a fall of warm rain, many juicy 
 plants at once shoot up, which, although not agreeable to the taste, 
 
 1 ' Statist. Report on the Sickness and Mortality in the Army of the U. S-, 
 1859-60,' Washington, i860, 45. 
 
 2 See Forry, for Council Bluffs (Iowa); Perin, for Fort Mcintosh (Texas); 
 Bartholow, for Fort Bridger (Wyoming) ; McBride, for Camp Bull, 11. cc. 
 
 3 'Med. Ztg. Russl.,' 1848, 37. 
 
 * ' Edinb. Med. and Surg. Journ.,' 1812, April, 202. 
 
 * ' Island uudersogt, &c.,' 48 . 
 •5 In Dobell's ' Reports.'
 
 I 
 
 550 GEOGliAPniOAL AND HISTORICAL PATHOLOGY. 
 
 are nutritious ; and tliey would appear, from the language which the 
 writer uses, to have a good effect as antiscorbutics. Unfortunately, 
 i-ain seldom falls in any quantity, and the supply of these plants is 
 never more than a scanty one.^ 
 
 There are extremely plentiful materials for forming an opinion on the 
 question before us, to be found in the experience acquired in prisons 
 and on board ships as to the influence of a want of fresh vegetable food 
 on the production of scurvy. Classical instances of the first kind are 
 the epidemic of 1840 in the prison of Clairvaux, where potatoes were 
 withheld from the prisonei's, and herrings supplied instead ; also the 
 observations of 1823 and 1840 in Millbank Penitentiary, where it was 
 only the prisoners sentenced by court martial, whose diet contained 
 hardly any vegetables, and in particular the very smallest allowance 
 of potatoes, that took scurvy, the other inmates of the prison, who had 
 a better diet, remaining well. Baly, who reports these facts, adds that 
 scurvy had occurred time after time in many other English prisons, 
 where " potatoes or green vegetables were given only occasionally on 
 Sundays, when the prison garden would furnish them." Scux'vy broke 
 out also, \inder these or similar circumstances, in the military prison 
 of Alessandria in 1840, and in the prison of Christiania in the years 
 1844-47. 
 
 Regarding the occurrence of scurvy in Swedish prisons from 1848 
 to 1877, Heyman gives the following interesting details: — In the fii'st 
 ten years (1848 — 1857) the number of cases of scurvy was 52*5 per 1000 
 prisoners; in the second ten years (1858 — 1867) it was only 32*9; and 
 in the third period (1868 — 1877) it fell to lyo. From 1848 to 1877 there 
 had been two diets in force; the one (down to 1862) contained succulent 
 
 ^ This leads me to recur to the above-mentioned (p. 545) account of Beckler 
 on the outbreak of scurvy among the members of Burke's exploring party, an 
 outbreak, which was caused, according to Beckler, by the drinlcing of bad water. 
 If we examine more closely the list of things provided for the expedition, we 
 find that besides twenty gallons of lime-juice, which, as we learn from Beckler, 
 was left behind before they came to the Darling river, the only antiscorbutic 
 food was preserved vegetables, as to which our authority himself writes : " Of 
 our preserved vegetables there is little good to be said. We had only a few 
 packages of di-ied assorted vegetables, the properties of which had been so pre- 
 served by the mode of preparation that we were justified in expecting them to 
 make up in a measure for the want of fresh vegetables. By far the most of our 
 supply consisted of unassorted vegetables of various kinds, dried and pressed, 
 which I am bound to say, without bias, that I consider to have been useless." 
 Taking this into consideration, along with the fact that the explorers had to 
 endure great fatigue, it becomes far from improbable that the bad water was 
 only a predisposing cause, although it may have been a potent one, in the out- 
 break of the malady. There may be another explanation of the fact that the 
 relief-expedition which was sent out, and which took the same provisions with 
 them, escaped the disease ; they began their journey after the rains, and they 
 would not only find good water, but would also be able to use with their food 
 those juicy plants mentioned by Pechey. However, there is nothing said on that 
 point in Beckler's account.
 
 SCURVY. 551 
 
 vegetables for each prisoner in tlie proportion per week of a pint and a 
 lialf of potatoes, two pints and a half of carrots, &c., and a pint of 
 sauerkraut; the other (after 1862) contained three pints more of 
 potatoes. BiTt those vegetables were supplied only in winter, the 
 equivalent diet in summer being bread, flour, barley and peas. Now, 
 the remarkable thing is that nearly all the epidemics in the Swedish 
 prisons began in summer and died out towards the end of the year. 
 Further, since 1865, the prisoners have had leave to buy food with 
 the wages that they earned; and during the summer months they 
 have made use of this permission chiefly to buy potatoes. Lastly, the 
 most efficient means of combating an epidemic has been found to be 
 the addition of potatoes to the rations ; and of late years that has always 
 been done the moment any indications of scurvy showed themselves 
 According to Porter, epidemics of scurvy in Indian (Madras) gaols 
 mostly occur at the time of the monsoon (July to September), that is 
 to say, at the time of the year of all others, " when the months preceding 
 are most likely to have had a scanty supply of fresh vegetables." 
 
 Of the production of scurvy on board ships in consequence of a 
 deficient supply, or no supply at all, of fresh vegetables for the crew, 
 there were two striking instances as early as the first half of last 
 century, in Admiral Hosier's disastrous expedition^ with the English 
 fleet against Porto Bello, in 1726, and in Lord Anson's expedition to 
 the Pacific in 174 1. In the latter part of that century we have the 
 hardly less instructive instance narrated by Curtis, of the outbreak on 
 board the fleet during a voyage from England to India in 1781; the 
 fresh vegetables taken on board at St. Jago (Cape Verd Islands) having 
 been exhausted after a voyage of several months, the men refused to eat 
 the pickled cabbage that remained, and scurvy broke out among them ; 
 but it vanished a few days after, when the sick were landed on 
 Johanna Island (in the Mozambique Channel) and supplied with fruit 
 and vegetables. Hardy" says of the outbreak of scurvy in 1838 on 
 board the Palinurus frigate cruising on the East Coast of Africa, 
 that " none of the obvious causes of scurvy were present except the 
 want of fresh vegetables, for the ship's company had abundance of good 
 dry food, fresh meat and good water." The U. S. frigate Columbia 
 having been cruising for several months in tropical waters, had an out- 
 break of scurvy on board after the meat went wrong and the fresh 
 vegetables ran short ; but the sickness very soon ceased when the vessel 
 arrived at a Chinese port and the crew were supplied with fresh vege- 
 tables. Of twenty-eight officers, only three took scurvy, and these had 
 shared the diet of the crew.^ 
 
 ^ [" Sent in this foul clime to languish. 
 
 Think what thousands fell in vain. 
 Wasted with disease and anguish. 
 Not in glorious battle slain." 
 
 ballad of Admiral Hosier's OTiostJ] 
 2 ' Transact, of the Bombay Med. Soc.,' 1839, "» 256. 
 •■* Coale, 'Amer. Journ. of Med. So.,' 1842, Jan.
 
 552 GEOGBArHICAL AND IllSTOT^TOAL rATIIOLOGY. 
 
 A very interesting contribution to the matter under debate, is given 
 by Foltz in liis account of the outbreak of scurvy in the U.S. blockading 
 flotilla in the Gulf of Mexico, in 1846. To show the influence of a 
 deficient vegetable diet on the production of scurvy, he adduces the fact 
 that he had often seen the disease on board whalers ; and whenever he 
 had seen it, it had always been after the best antiscorbutic elements of 
 their food, namely, fresh potatoes, had been used up, while, on the other 
 hand, the malady never appeared so long as these held out. This is 
 confirmed by a statement in Morgan's^ account of the scurvy on board 
 the troop-ship Lismoyne, on a voyage to India; among the recruits 
 which she carried those only took the disease who did not eat their ration 
 of potatoes but exchanged it with their messmates for salt beef. Lilien- 
 feld's" experience of an outbreak of scurvy onboard a Dutch man-of-war, 
 during a voyage round the woi'ld in 1849, leads him to the conclusion 
 that " the deprivation of fresh vegetable food is the principal cause of 
 scurvy in ships." 
 
 Even in recent times the ships of the French navy have several times 
 suflfered severely from scurvy owing to the want of fresh vegetables. Of 
 special interest is the account by Leon, of the epidemic on board the 
 transport Castiglione, which was one of the vessels employed in conveying 
 the French troops back fi-om Mexico, in 1867. The first symptoms of 
 the epidemic appeared as early as the twentieth day out from Vera Cruz, 
 and in the course of the next ten days it had extended so much that, of 
 the whole crew (who were the only class on board to suff"er), one third 
 were more or less ill. Notwithstanding that fresh meat, acidulated 
 drinks, and lime-juice wei'e served out, the epidemic did not come to an 
 end; and it became necessary to make for the Azores, where large 
 quantities of fresh vegetables, potatoes, cabbages, and the like were taken 
 in. From the day when these were served out to the healthy and the 
 sick, new cases ceased to occur among the former, and convalescence 
 proceeded so rapidly among the latter that, when the ship arrived at 
 Toulon a fortnight after, all the more considerable signs of illness had 
 disappeared. Leon points out that neither the weather nor the hard- 
 ships of the service, nor any depression of the feelings had occasioned 
 the epidemic, but solely the want of fresh vegetable food, which was not 
 to be got at Vera Cruz. It is worthy of note, at the same time, that 
 cases occurred only among the crew, who had been already exposed in 
 part to the same deficient diet during the voyage out from France to 
 Vera Cruz ; and that not a single case of scurvy occurred in any of the 
 other ships of war or transports, none of which sailed direct to France 
 Irom the Mexican coast, but touched at the West Indies, where they 
 received abundant supplies of fresh vegetables. 
 
 Again the disease has several times broken oiit under the same influ- 
 ences on board Fi-ench ships of war carrying convicts from France to 
 New Caledonia, as, for example, in 1S66 on board the frigate Sijhille^ 
 1867 in the fi-igate Iphigenie* and 1873 in the transport Orne? Ayme*"' 
 
 ' L. c, p. 25. 2 ^ ]\ipjj Times and Gaz.,' 1854, Dec, p. 586. 
 
 * Normand. * Caurant. ^ Aynie. " L. c, pp. 26, 31.
 
 SCURVY. 553" 
 
 says : " La privation d'aliments vcgctaux (frais), est la seiile cause puis- 
 sante, decisive, que nous puissions invoquer pour explicer I'epidemie de 
 rOrne . . . toutes les autres conditions restant les memes aprcs 
 notre relaclie a Melbourne, la presence de vivres et de vegetaux frais 
 dans la ration de I'equipage et des dcportes, a suffi pour arreter, d'une 
 manicre brusque, les progres de la maladie." 
 
 Lastly, it should be stated that scurvy has not unfrequently appeared 
 in vessels of the mercantile marine and in whalers, just as in ships 
 of war, when their crews have been without fresh vegetables for a con- 
 siderable time. Under the same circumstances, several of the Arctic 
 expeditions have suffered from scurvy ; for example, the crew of the 
 Investigator in the spring of 1852, when the ship had been out, as Arm- 
 strong tells us, two years and a quarter and the rations of fresh vege- 
 tables, potatoes in particular, and of lime-juice had been reduced 
 considerably; and, again, in 1875 in the Alert and Discovery, the cause 
 of the outbreak in their case being assigned, upon evidence given by 
 experts at an oflBcial inquiry, to not using lime-juice as a sabstitute for 
 fresh vegetables. 
 
 In consideration of tliese and many otlier observations of 
 the same tenour, it is impossible witli any sliovr of reason to 
 deny the importance of a scarcity or absolute want of fresh 
 vegetables in the diet as the real cause of scurvy ; and we 
 should perhaps not err if we were to find in that view of the 
 causation the explanation of a fact which ^ it seems, is not to 
 *be denied, namely, that scurvy was not only of more frequent 
 occurrence in former centuries than it has been of recent 
 years, but also more widely spread, especially in the higher 
 latitudes. Besides the enormous extension and multiplication 
 of the means of transit, which makes it much easier than 
 formerly to compensate for the failure of fresh vegetables in 
 regions remote from traffic, there is, first and foremost, the 
 benefit that has accrued to the peoples of the Eastern Hemi- 
 sphere daring the last two centuries in the cultivation of the 
 potato, the most effective anti-scorbutic in the dietary. 
 There is also the more systematic and more general cultiva- 
 tion of all kinds of vegetables, an industry which even in the 
 sixteenth century was in so backward a state in Northern 
 Europe that Catharine of Arragon, queen of Henry VIII, 
 desiring to have a salad for the table, had to send her gardener 
 to the Low Countries to procure it. 
 
 Garrod was led by the consideration that scurvy came to so great a 
 heiglit in the United Kingdom during the potato famineof 1846 and 1847,
 
 554 GEOGRAPHICAL AND niSTOEIOAL PATHOLOGY. 
 
 to analyse tlie most usual articles of diet so as to ascertain tlieir propor- 
 tion of carbonate of potasli, a substance in whicb potatoes are unusually 
 rich. He arrived at tbe results in tbe following table, wliicL. shows the 
 number of grains of carbonate of potash in an ounce of each substance : 
 
 Grains Grains 
 
 per ounce. per ounce. 
 
 Large potatoes (boiled) . i"875 Pease 0*529 
 
 Small „ (raw) . . 1-310 Beef (salted) o'394 
 
 Lime-juice 0-852 Onions o'333 
 
 Lemon-juice o'846 Wheaten bread .... 0*258 
 
 Unripe oranges .... 0-675 Cheese (Dutch) .... 0-230 
 
 Mutton (cooked) . . . .0-673 Flour (best) o-ioo 
 
 Beef (raw) 0'599 Oatmeal 0-054 
 
 Salt beef (slightly salted). 0-572 Rice o-oio 
 
 It follows from this table that all those articles of diet which have 
 been especially apt to devolop scurvy when used exclusively, contain car- 
 bonate of potash in smaller quantity, sometimes in much smaller quan- 
 tity, than those which are never followed by scurvy and have been 
 proved to be the best antiscorbutics (potatoes and lime-juice). Having 
 regard at the same time to the fact (not altogether certain, however) 
 that the blood in scurvy is characterised by a deficiency of potash salts, 
 Garrod draws the conclusion that the cause of the malady is to be 
 attributed to a diet poor in carbonate of potash. 
 
 § 195. Scurvy under ExcErTiONAL Circumstances. * 
 
 Higlily as we must always rate this etiological factor in 
 the production of scurvy, it is at the same time not to be 
 denied that the malady has developed now and again under 
 circumstances which make it at least improbable that the 
 cause had been an error in diet, or more particularly the 
 want of fresh vegetables. It is true, indeed, that the ob- 
 servations adduced in proof of this are not all of equal value, 
 and we shall have to reserve our opinions as to their trust- 
 worthiness. On board French and English ships-of-war, 
 such as the frigate on the voyage from L' Orient to China 
 mentioned by Lagarde, and the ship of the English navy 
 bound for Calcutta quoted by Wrench,^ outbreaks of scurvy 
 have occurred although the crews were supplied with lime- 
 juice and preserved vegetables; and although these observers 
 draw the conclusion that the disease may originate indepen- 
 
 1 'Med. Times and Gaz.,' 1867, March, p. 317.
 
 SCURVY. . 555 
 
 dently of the want of fresh vegetables, yet it should be kept 
 in mind that lime-juice is perhaps not absolutely trustworthy 
 in its prophylactic action, that it is often adulterated/ that it 
 spoils easily, especially in the tropics, that it is not unfrequently 
 administered in too small doses, and that preserved vege- 
 tables are by no means a substitute for fresh vegetables. 
 Other instances which have been adduced to show that there 
 was no cause of scurvy discoverable in the dietary of those 
 who took it, such as the case of the lunatic asylum at 
 Moorshedabad (Bengal) mentioned by Burt, and Maupin's 
 cases in Algiers, want the force of conviction, inasmuch as 
 it does not appear from the evidence what these observers 
 understand by a '' suitable " diet. In still other papers 
 written with the object of proving that scurvy has developed 
 apart from defects of diet, the want of clearness and of 
 critical acumen on the part of the observers is conspicuous. 
 Thus Le Vicaire traces the epidemic of scurvy among the 
 French blockading squadron in the Mediterranean in 1827- 
 29 to the amount of tobacco-smoking among the crews, 
 although he tells us besides, that they lived upon biscuit, 
 salt meat, and dried vegetables. In his account of the 
 scurvy in 1872 on board the steam transport Var carrying 
 convicts to New Caledonia, Ledrain lays the stress upon 
 the confinement of the convicts in damp, dark, and ill-ven- 
 tilated berths; but he adds, "quant aux vegetaux frais nous 
 ne pouvions en prendre qu'une faible quantite, la place 
 manquant pour les loger." The cause of the epidemic of 
 scurvy in the garrison hospital of Givet in 1846 was attri- 
 buted by Scoutetten to the low and damp situation of the 
 building; but he mentions also that the food oE the troops 
 was insufficient, they having been put on short allowance to 
 the extent of one-third or one-half.^ Seeland also, who is 
 inclined to see '^miasma^' in so many things, denies the influ- 
 ence of diet upon the production of scurvy in the regions of 
 the Amoor; for, as he assures us, the store of greens usually 
 
 1 " The lime-juice of commerce," says Bccldei- (1. c, p. 239), " is ouc of those 
 articles adulterated in so many ways, that we can hardly depend upon it." 
 
 6 On Moreau asking the reason for this lowering of the rations, Scoutetten 
 stated that he was uotahle to speak out on the matter : " Je serais oblige pour y 
 repondre," he adds, " de produire des chiffrcs qu'il ne m'appartient pas de faire 
 connaitre ici."
 
 556 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 holds out tlirough the winter and spring — he does not say 
 what happens when it does not hold out — and it is only 
 now and then during the latter half of winter and during 
 the spring that the potatoes fail from going wrong in the 
 damp cellars. 
 
 There is one other point that I must call attention to, 
 which does not seem to me to have been estimated at its full 
 importance in considering the influence of diet, and vegetable 
 diet especially, in the problem of scurvy. I mean the pre- 
 disposition to, or immunity from the malady, howsoever 
 brought about, among some people as compared with others 
 living under the same circumstances. How do we explain 
 the fact that, cieteris 'paribus, one group becomes subject to 
 scurvy, while others remain free from it ? In the epidemic 
 among the British troops in Cape Colony at the time of the 
 Kaffir War of 1836, there was only one regiment that really 
 suffered, although all the regiments were equally in want of 
 vegetable food. The explanation is, as Morgan has pointed 
 out, that that regiment had to undergo particularly great 
 fatigue in making long marches during very bad weather, 
 and it was the one, therefore, in which the deficient diet 
 made its effects most felt. In the slight epidemic of 1873 
 among the garrison of Prague, according to Kirchberger, 
 it was only the troops from Bohemia that suffered, the 
 Galizian regiments remaining exempt although they had the 
 same rations. The explanation may be found, as that writer 
 suggests, in the fact that the Bohemians are on the average 
 much better fed at home than when on service, whereas the 
 contrary is the case with the Galizians. We are not in- 
 formed, however, of the extent to which this lowering of the 
 rations relatively to the usual allowance of food, affected 
 the actual quantity of fresh vegetables in the diet. But this 
 factor of a predisposition to scurvy, or immunity from it, 
 acquired by being habituated to a particular diet, appears to 
 me to come out very decidedly in the circumstances under 
 which the disease attacks people in high latitudes, as in 
 Kamschatka,^ Greenland,^ and Hudson's Bay Territory.^ 
 In these latitudes scurvy occurs solely among sti'augers, 
 whenever they suffer the want of the fresh vegetables to 
 ' Bogorodsky. 2 Lans?e. => Smcllie.
 
 SCURVY. 557 
 
 wliicli they liave been accustomed ; wliile tlie natives, wlio 
 have been accustomed from their birth to live principally, if 
 not altogether on animal food, bread and the like, remain 
 quite free from the disease. 
 
 But besides these observations, which are still capable of 
 being interpreted in favour of the theory that the malady 
 is caused by the want of fresh vegetables, we have a series 
 of epidemics of scurvy, the origin of which, as credibly 
 alleged by those who observed them, cannot be referred to 
 want of fresh vegetables, or to erroneous or deficient diet 
 at all. Such are the outbreaks narrated by Dicenta and 
 Cless for the prison of Ludwigsburg from 1852 to 1858, by 
 Opitz among the Austrian garrison of Rastatt in the winter 
 of 1851-52, by Coring among the French prisoners of war 
 at Ingolstadt in 1871, by Klihn at the penitentiary of 
 Moringen (magistracy of Hildesheim) in the winter of 1875- 
 76, and several of the epidemics on board ships of the 
 English, French and German navies. Such instances, rare 
 though they be, serve to show that the disorder of nutrition 
 which underlies the scurvy, may as an exceptional thing 
 originate under the influence of other debilitating factors, 
 mostly associated with a life spent in prisons, barracks or 
 ships. But the rarity of these cases is, to my thinking, 
 a proof that all those commonplace injurious influences, such 
 as damp soil, cold and wet weather, bad air from overcrowd- 
 ing and want of ventilation, and bad drinking-water, which 
 are incessantly in operation without any epidemic of scurvy 
 breaking out, are not to be reckoned as real factors in the 
 pathogenesis. In the rare instances referred to, wo have 
 rather to assume some peculiar modification of hygienic 
 defects of that kind, or perhaps a certain ensemble of them, 
 concerning the nature of which the published records tell us 
 nothiug ; and that is an assumption which we might make 
 without going so far as to postulate a specific virus of scurvy.
 
 558 GEOGRAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 § ig6. Attempts to prove a Miasmatic^ Infective or 
 Contagious Origin foe Scurvy. 
 
 There has certainly been no lack of hypotheses of a mias- 
 matic cause for scurvy. In the last century the doctrine 
 was maintained by Poissonier-Desperrieres/ and others, that 
 scurvy was allied in its causation to the malarial diseases ; 
 and in these days of the malaria-craze there have been many 
 attempts made to construct some such hypothesis as would 
 secure for scurvy a place among the infections, or even 
 among the communicable and contagious diseases. Besides 
 Scoutetten and Deve, who are also in favour of the malarial 
 nature of the malady (Deve would have it that malaria occurs 
 on board ship), we have had within the last twenty years 
 such writers as Kriigkula, Villemin, Kiihn, Petrone, and 
 Seeland pronouncing in favour of the miasmatic or infective 
 character of scurvy. The noxious influences which have 
 hitherto passed current as the cause of the malady do not 
 fulfil, says Kriigkula, the requirements of real causes; scurvy 
 is chiefly found in localities which are known to be the 
 breeding-places of the acute infective diseases, and it fre- 
 quently shows itself in company with the latter; it has often 
 happened that scurvy has broken out as the immediate 
 effect of substances directly involved in the processes of 
 decomposition, such as stinking fish, foul water, and the 
 like; and in the majority of cases its production can be 
 explained much more naturally by infection than by any 
 of the hypotheses hitherto current. In its origin scurvy is 
 associated with typhus, and in respect of its being non- 
 contagious it connects with intermittent fever. (Dr. Kriig- 
 kula does not appear to be familiar with the large body of 
 facts which furnish, I may almost say, a mathematical proof 
 of the origin of the disease from those errors of diet which 
 I have entered into in detail ; and that is perhaps the reason 
 why he finds his explanation of the disease to be a more natural 
 one than that of other inquirers, whose theory rests not 
 upon assertions but on observations, and who have accordingly 
 set up no mere hypothesis, as he has done.) Villemin also, 
 ^ ' Traite des maladies des gens de mer/ Par., 1767.
 
 SCUKVT. 550 
 
 with a veritable profusion of arbitrary and erroneous assump- 
 tions, seeks to prove that scurvy is allied in its causation to 
 tbe typlious diseases, and, in contrast to Kriigkula, he claims 
 contagious properties for it as well. Like typhus, he says, 
 scurvy has primary foci on the shores of the German Ocean, 
 the Baltic, and the Black Sea; and from these it is carried 
 abroad by the shipping. With this prodigy of a theory, he 
 couples the statement that epidemics of scurvy very often 
 run their course parallel with epidemics of typhus, and that 
 the best way to obviate the spread o£ the disease is removal 
 to a distance from the morbific centre. This doctrine of 
 Villemin has met with a truly brilliant refutation at the 
 hands of Le Eoy de Mericourt, whose ample experience and 
 sound literary training have enabled him to exhibit the 
 reasons advanced by Villemin as untenable, and whose un- 
 hesitating conclusion is that a deficient diet, and especially 
 the want of fresh vegetables, is the essential factor in the 
 causation of scurvy. Shortly after, it was pointed out by 
 Galliot also, that the epidemic of scurvy which sprang up on 
 board a French ship-of-war on the voyage back from Iceland 
 was not due to a " miasma scorbuticum," but to the want 
 of fresh vegetables, and that the disease ceased abruptly as 
 soon as fresh provisions were procured. 
 
 The hypothesis of the miasmatic nature of scurvy has been 
 expounded after another fashion by Kiihn, with greater skill 
 perhaps but, in my opinion, with just as little success. The 
 notion of " scurvy ^' is enlarged by him, so as to include the 
 macular disease of Werlhof, which is a totally different thing* 
 from scurvy, as well as "^ stomacace,^' which has nothing* else 
 in common with scurvy except that it is an affection of the 
 gums. Next, he distinguishes between a scurvy of inanition, 
 as he calls it (or one that is induced by errors of diet), and 
 an infective scurvy, which is nearly related to the former in 
 symptoms but is quite different in its etiology, being caused 
 by a miasma ; and to the latter he ascribes contagious pro- 
 perties, just as Villemin does. If we examine more closely 
 his type of infective scurvy, filling in details from his clinical 
 histories, it is impossible to escape the impression that he 
 has widened the idea of " scur\^ '^ to an inordinate extent, 
 taking as signs of a scorbutic affection slight reddening or
 
 ^60 GEOGRAPHICAL AND HISTOEIOAL PATHOLOGY. 
 
 swelling of tlie gums, even in persons witli decayed teetli. 
 On that wide basis he makes his diagnosis of scurvy ; and 
 then he creates a number of forms of scurvy, such as scor- 
 butic peritonitis, bronchitis, angina, pneumonia, and rheu- 
 matism (reminding one of Sydenham's ^'febris dysenterica 
 sine dysenteria," or his " febris variolosa sine variolis ^'), 
 for which he assumes a miasmatic infection, probably by the 
 agency of putrefactive bacteria, inasmuch as he would connect 
 the origin of the malady with the fact of the patients living 
 in overcrowded and unventilated places. Finally, Seeland 
 has gone one step farther — he has seen the bacteria. Accord- 
 ing to him the cause of scurvy along the shores of the 
 Amoor is a fungus, which grows luxuriantly in the houses of 
 the better-off class of officials, owing to the dampness of the 
 soil ; while the natives, whose huts are made of hard-baked 
 clay, are exempt from the malady. 
 
 But the doctrine of the contagious nature of scurvy, asserted 
 by Echthius, Horst, Poupart, Trotter, and other writers of 
 the eighteenth century, and lately revived by Villemin, Kiihn, 
 Murri, and Cantu, is quite untenable, inasmuch as it goes 
 against all historical and clinical experience. Villemin's 
 assertion that the disease is indigenous on the coasts of the 
 German Ocean, Baltic and Black Sea, whence it has spread 
 by maritime commerce after the manner of a contagious 
 disease, such as typhus, is so fanciful that it does not require 
 to be seriously met ; and the other evidence which he brings 
 forward in support of his view, rests, as Le E-oy de Mericourt 
 has shown, upon an erroneous reading and stating of the 
 facts. There is jiist as little reason to find any evidence of 
 the communicability of the disease in Kiihn's observations of 
 scurvy occurring in those who had come into close contact 
 with scorbutic patients, the less so that the scurvy in the 
 cases in question was of the ambiguous kind. Inspired by 
 Kiihn's writings, Murri made experiments on four rabbits to 
 produce infection by means of blood drawn from the vein of 
 a scorbutic patient. After subcutaneous injection of the 
 blood, small ha3morrhagic spots appeared on the ears of the 
 animals, febrile symptoms (rise of temperature) having some- 
 times preceded them; and the anatomical examination 
 revealed slight effusion of blood on the dura mater and
 
 SCURVY. 561 
 
 pleura, and in one of the rabbits on tlie peritoneum also, and 
 in the liver and spleen. Murri does not go so far as to con- 
 clude that these phenomena have any significance in the way 
 of proving the communicability of scurvy. Cantu also, who 
 has repeated Murri's experiment on two rabbits, and with the 
 same result, is equally cautious, contenting himself with veri- 
 fying the facts. That these animals really acquired a 
 scorbutic disease follows neither from the account of the 
 symptoms nor from the conditions found post mortem. 
 
 Summing up briefly the facts and arguments of this chapter, 
 I am led to conclude, as regards the genesis of scurvy, that 
 the disease is most of all associated with want of fresh vege- 
 tables in the diet, perhaps with the insufficient supply of salts 
 of potash (combinations with the vegetable acids) ; that it 
 breaks out the more promptly and the more severely, the 
 greater the antecedent action of other debilitating things on 
 the organism, predisposing it to sickness ; that there are 
 certain other errors of hygiene, for the present not to be 
 more accurately particularised, which induce the disorders 
 of nutrition that underlie scurvy, although they do so much 
 more rarely than the first mentioned ; but that there is no 
 warrant to speak of a miasmatic or infective origin of the 
 disease, while a contagious property is to be denied of scurvy 
 in the most absolute terms. 
 
 The Fonos {or " Pain") of the Islands of 8pezza and Hydra. 
 
 § 197. Clinical Chaeactees and Morbid Anatomy of 
 " Pongs " — a Constitutional Disease op Infancy. 
 
 In connexion with scurvy I have to speak of a peculiar 
 disease affecting young children only, which is endemic in 
 the Greek islands of Spezza and Hydra on the eastern side 
 of the Peloponese, off the coast of Argolis. It is only recently 
 that the attention of the profession in Greece has been drawn 
 to this malady, which is known by the hardly distinctive 
 name of Ponos or " paiu." It is undoubtedly to be viewed 
 
 VOL. 11. 36
 
 562 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 as a constitutional affection deeply rooted in errors of nutri- 
 tion ; but tlie clinical and pathological studies hitherto made 
 of it have not yielded any definite information as to its 
 nature.^ 
 
 Clinical history. — The onset and course of the disease are always with 
 fever, which has an intermittent or irregular type and exhibits many 
 fluctuations from first to last, assuming the character of hectic when the 
 issue is unfavoi-able, as it usually is. The commencement of the malady 
 is indicated by some change in the child's strength and spirits ; it loses 
 its sprightliness, betrays feebleness in its gait, becomes sad, and dis- 
 inclined to play. The skin acquires a pale or straw-coloured tint ; and 
 progressive emaciation becomes noticeable, although the appetite keeps 
 up for the most part, not unfrequently indeed becoming ravenous, with 
 a peculiar craving for highly seasoned dishes and for spirituous drinks. 
 Meanwhile the belly enlarges owing to the gradvial swelling of the spleen, 
 which often attains so enormous a size as to reach the middle line of the 
 abdomen. In many cases the spleen is painful or tender to the touch, 
 whence the name given to the disease ; but it oftener happens that the 
 tenderness is wanting, notwithstanding that the organ is much enlarged. 
 As an exceptional thing, there may be slight enlargement of the liver ; 
 and swelling of the lymphatic glands in the neck has been noticed in 
 a few rare cases. The digestion is always out of order, and it is not 
 uncommon for vomiting to come on after food. At the outset of the 
 disease there is usually constipation, but later on the dejecta assume 
 the character of diarrhoeal or dysenteric. A very characteristic sign is 
 the penetrating odour of the urine, which becomes noticeable from the 
 very beginning of the illness and continues all through it ; usually there 
 is a sediment in it (possibly urates), but rarely or never albumen. One 
 of the most fi-equent symptoms throughout the disease is bronchial 
 catarrh. 
 
 At a later stage a variety of exudative phenomena occui' — the profuse 
 intestinal discharges already mentioned, dropsy (cedema at first and then 
 ascites), and colliquative sweating ; thereafter, haemorrhages in the form 
 of petechia3 or extensive ecchymoses of the skin, bleeding from the nose 
 and from the bowel, and above all bleeding from the gums. The latter 
 at length show the signs of a scorbutic affection ; an ichorous discharge 
 comes fi'om them, the teeth become loose and drop out in the end, and 
 in some cases even necrosis of the jaws has been observed. These are 
 the incidents, along with general marasmiis, that usher in the fatal 
 result, if it have not been now and then anticipated by intercurrent 
 local disease, such as broncho -pneumonia, meningitis, or peritonitis. 
 
 1 The account that follows in the text is based upon the papers of Karamitsas 
 ('Gaz. des hopit.,' 1880, No. 19, p. 147), and Stephanos (' Gaz. heb. de med.,' 
 1881, Nos. 47 and 51, pp. 750, 813). These papers make reference to the notices 
 of the malady which have appeared since 1835 ^^ the medical journal, ' Va\i]voc^ 
 published at Athens.
 
 SCURVY. 563 
 
 The illness lias usually a fatal termination ; it is only in exceptional 
 cases, when a suitable diet and tonic remedies (quinine, ii'on, and iodide 
 of iron) ai'e employed that a cure results, and then only if the disease 
 liave been treated in its early stages. In the case of very young children 
 the best hope, although that is not much, lies in the choice of a good 
 nurse. There are many remissions and exacerbations in the course of 
 the malady, which usually lasts from one to two years. Sometimes it 
 runs its course under very intense symptoms, and ends fatally in two or 
 three months. 
 
 Morbid anatomy. — Only one post-mortem examination has been made 
 hitherto, of which an account is given by Stephanos. There were no 
 traces of leuksemic or pseudo-leuksemic, or of tubercular or malarial 
 lesions. The capsule of the spleen was very firm, and the trabeculae a good 
 deal thickened ; the substance of the organ was swollen, but there was no 
 actual pigmentation and no excess of colourless corpuscles . In the right 
 lung there was an abscess reaching to the pleural covering ; there was 
 also commencing cirrhosis of the liver (the child had received alcoholic 
 drinks during its illness) ; the kidneys were congested, and the bronchial 
 and mesenteric glands normal, although some of them were slightly 
 enlarged. 
 
 This disease occurs, as we have said, only during the first years of 
 childhood, usually covering the period between the first and second 
 dentition ; in most cases it begins to develop as early as the eruption of 
 the first incisors. Only in very rare instances are children attacked at 
 the age of four or upwards. It is said (by Stephanos) to be rather more 
 common in boys than in girls. 
 
 § 198. History of ^' Ponos/^ 
 
 Our mformation about the " ponos " goes no farther back 
 than 1835, in which year Eoser directed attention, in an 
 address before the Medical Society of Athens, to enlarge- 
 ments of the spleen in young children on the island of 
 Spezza, the cause of which he traced to the use of water 
 from cisterns. Reference was afterwards made to it by 
 Pallas,^ who pointed out the hasmoi-rhagic phenomena and 
 their resemblance to those of sciirvy. It was not until 187 1 
 that this malady received general recognition at the hands 
 of the profession in Greece. 
 
 The disease, as we learn fx'om the most recent inquiries, 
 is endemic nowhere but in the islands of 8pezza and Hydra; 
 in other parts of Greece it has never been seen hitherto. 
 ^ ' Annali iiuiv. di med.,' 1842, c. ii, 61
 
 664 GEOGRAPHICAL AND HISTOEIOAL PATHOLOGY. 
 
 It used to be commoner formerly tliau it is now ; even at the 
 date o£ Pallas's article, there were few families in Spezza 
 but had lost one child at least by it. There have, indeed, 
 been considerable fluctuations in the number of cases from 
 time to time : according to the latest accounts, there were 
 twenty to twenty-five children with '' ponos " in Spezza out 
 of a population of 7500, and ten to fifteen in Hydra out of a 
 population of 7300. 
 
 § 199. Circumstances undee which "Pongs" occurs. 
 
 Glimate and season have no influence on the production 
 of the disease. Neither has the kind of soil ; for it occurs 
 equally on high and low ground, on rocky and damp soil, on 
 the chalk soil of Hydra and on the volcanic (gompholithic) 
 formation of Spezza. 8ocial ranh also would appear to be 
 of no real significance ; the cases of it are uniformly dis- 
 tributed through all classes from the rich downwards, and 
 in all kinds of dwellings, from the larger sort of well-kept 
 and well-aired residences to the hovels of the poor. Neither 
 is there any real causative element to be discovered in the 
 food, which differs in no respect from that used in other 
 parts of Greece where the disease is unknown. It follows 
 also that the much-blamed tise of rain-water is not the cause, 
 for the malady has been found in families who take their 
 water-supply from deep wells. The view adopted by 
 Jeanakopulos, that it arises from malarial infection, is quite 
 untenable ; for on neither of the islands is there any malaria 
 at all, and the disease is one that affects a time of life when 
 malaria is least apt to be felt. Moreover, it is limited to 
 certain families. 
 
 It is this last-mentioned fact, together with the fact that 
 the parents of children with " ponos " had suffered from 
 serious diseases, especially pulmonary consumption, that so 
 far bears out the opinion generally current among the inhabi- 
 tants of Spezza, that the question is one of hereditary condi- 
 tions or of a congenital predisposition. We are completely 
 m the dark as to the actual disease-producing agent ; and 
 Stephanos, in view of the fact that the malady cannot be
 
 SCURVY. 565 
 
 brought into causal connexion witli any of tbo influences 
 before mentioned, throws out the suggestion whether in- 
 fection or parasitism may not be at the bottom of it ! Lastly, 
 it should be said that the opinion held by Karamitsas of the 
 disease being a kind of splenic leukaemia, does not find the 
 smallest support either in phenomena observed during life, 
 or in the post-mortem appearances, or in the examination of 
 the blood (that author himself found the coloured corpuscles 
 considerably fewer and only some traces of leucocytes left) ; 
 and therefore Stephanos thinks himself warranted in decidedly 
 rejecting the idea of an affinity between the disease and 
 leukcEmia or pseudo-leukeemia. 
 
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 Wadell, Transact, of the Calcutta Med. Soc, 1828, Hi, 272. Wald, in 
 Casper's Vierteliahrssebr. fiir gerichtl. Med., 1857, Jan. Walter, Norsk. 
 Magaz. for Laegevidensk., 1840, i, 48. Wier, Observ. med., lib. i. Basil., 
 1567, 7. In Opp. Amstelod., 1660, 883.
 
 CHAPITER XVI. 
 BERIBERI. 
 
 § 200. Clinical Characters. The Paralytic and the. 
 
 Dropsical Form. 
 
 The malady known under the name of " beriberi " or 
 other colloquial designation/ -which is endemic in many 
 tropical and sub-tropical parts of Eastern Asia, was till not 
 very long ago a riddle in its pathology and causation. And 
 although the latest observations of English, German, Dutch, 
 and Brazilian practitioners have thrown much light upon it, 
 we are still far from being able to assign to it a definite and 
 undisputed place in the nosological system, to characterise- 
 its nature with precision, and least of all to come to any 
 positive conclusion as to its genesis or the causes that under- 
 
 ' The etj'inology of the word " beriheri " has not been explained. Its origin 
 is certainly not Ai-abie, but Hindustani or Malay. In the Malay language 
 " biribi" means an "abrupt and tripping gait" (Platteenu, ' Geneesk. Tijdschr. 
 voor Nederl. Indie,' x, 665). According to Bontius, who was familiar with the 
 disease in Java, the word is derived from " bharyce," meaning " sheep." Marshall, 
 on the other hand, derives it from the Cingalese word " bhargee," or " feeble 
 gait," and Herklots from the Hindustani word " bharbari," meaning "swelling," 
 i.e. ccdeuaatous swelling. In Eanka the disease is called " binas " or " apooi," as 
 well as " pantjakit niloe " or " siloe ;" in Java " loempoe ;" on the coast of New 
 Guinea "pantjakit papoca." In Japan it is known under the name of "kak-kc," 
 a term of Chinese origin, derived from the words " kiakn," meaning "leg," and 
 " ka " or " ki," meaning "disease," and equivalent therefore to " disease of the 
 legs " (Scheube). In the French Antilles it is called " mahidie des sucreries ;" in 
 Cuba, "hinchazon" (dropsy) "de los negros ;" in the Brazilian province of Matto- 
 Grosso, "perneiras" (disease of the feet); and in Minas Geracs " inchacao " 
 (oedema). The term "barbiurs" is undoubtedly a French corruption of "beri- 
 beri." Vinson (I) however, who was born in Keunion, and became familiar with 
 the disease, says that it is another disease which is denoted by "barbiers;" but it 
 would appear from the description of that other malady, that it is itself the 
 acute pernicious form of beriberi.
 
 570 GEOGEAPHIOAL AND HISTORICAL PATUOLOGT. 
 
 lie it. The recently published works of Wernich^ and 
 Scheube on the disease in Japan, where it is known as 
 "kak-kc" have made the profession in Germany more 
 intimately acquainted with it ; and as I am able to refer the 
 reader to the very comprehensive and thorough writings of 
 those authors for the morbid anatomy and pathology of the 
 disease, I shall limit myself here to an epitome and survey 
 of certain aspects of the pathology of beriberi which have a 
 special bearing on the etiological questions that will arise 
 in the course of this chapter. 
 
 Clinical history. — The disease,^ as we find it, is a complex of a number 
 of symptoms pointing to affections of tbe periplieral nerves and vessels, 
 which present themselves in the form of disorders of movement and sensi- 
 bility, particularly in the extremities, of dyspnoea, of scanty secretion of 
 urine, and finally of dropsical efi"usions. These effusions, however, are not 
 constant; in many cases there are only faint indications of them; some- 
 times they appear at the very outset of the illness, at other times they 
 are a late addition to the group of symptoms ; and thus it is possible 
 to distinguish a paralytic form, a dropsical form, and a mixed form, 
 according as dropsy is wanting altogether or as it comes on late or 
 early. The progress of beriberi is usually chronic ; it is rare for it to 
 run an acute course, and when it does so, it is mostly of a pernicious 
 type. 
 
 The onset of the first characteristic symptoms is usually preceded for 
 a considerable period (weeks or months) by a well-marked stage of 
 persistent weakness, low spirits, listlessness and unfitness for work. 
 When the outbreak is to take the paralytic foi'm, the onset is shown by 
 a difficulty in moving the lower limbs, which gradually increases to 
 paresis and paralysis; in many cases the upper exti'emities are attacked 
 with the same weakness, becoming paralysed in the end, and the patient 
 is then placed in a very melancholy situation, being unable to make 
 the slightest movement and requiring even to be helped to his food and 
 drink. At the same time there will have been disorders of sensibility, 
 in many cases commencing as perverted sensations (tickling or creeping 
 feeling, and the like), or as hypera3sthesias (burning, particularly in the 
 feet and legs, the "burning of the feet" of English writers), or as 
 muscular tenderness on pressure (especially in the muscles of the calf). 
 
 ^ The authorities quoted throughout the chapter are given in alphabetical 
 order at the end. 
 
 On comparing the accounts given of its symptoms and course by observers 
 in India, the East Indies, Japan, Brazil, and other countries, we find so perfect 
 au agreement in the morbid phenomena that we may regard the process as a 
 whole to have had everywhere the same character ; at all events there are no 
 fundamental differences in the type of the disease at the various points of its 
 distribution-area.
 
 BERlBEEi. 571 
 
 Later on the sensory disorder takes tlie form of anassthesia, and is 
 specially distinguished by loss of the sense of pressure, and of heat and 
 cold; these symptoms also are noted earliest and most uniformly in 
 the lower limbs, extending afterwards in a smaller proportion of cases 
 to the upper extremities. 
 
 Besides these nervous phenomena, there are observed disorders in the 
 blood-making and in the circulation. The patients have the look of 
 anaemia, complaining of palpitation which is not imfrequently very 
 troublesome, and of dyspnosa. , Auscultation of the heart discovers 
 blowing murmurs at the apex and over the semilunar valves ; percussion 
 shows the area of dulness increased (either from dropsy of the pericar- 
 dium or dilatation of the heart) ; the pulse is small, very compressible, 
 slow, or sometimes quickened. The urine is always diminished (in con- 
 sequence of lowered pressure in the aortic system), but it never contains 
 albumen. 
 
 To the phenomena above mentioned, which are characteristic of the 
 so-called paralytic or dry form of beriberi, dropsy is often added in the 
 further course of the malady. In another class of cases dropsy is 
 among the earlier symptoms, and the disease then assumes the so-called 
 dropsical type. Usually the oedema shows itself first in the ankles and 
 legs, extending gradually until it at length becomes general anasarca ; 
 tben follow dropsical effusions into the serous cavities — always into the 
 pericardium, more occasionally into the pleura or pei'itoneum, and 
 rarely, as would seem, into the cerebral and spinal arachnoid. 
 
 The acute form of beriberi develops either out of the above-described 
 chronic illness ; or the disease is acute from the first, with a violent 
 onset of the symptoms, such as has been already mentioned, and with 
 vomiting often added, which, according to some, is specially charac- 
 teristic and of evil omen. In the worst cases of this variety, the 
 dyspnoea reaches an extreme degree, the patient becomes cyanotic, 
 and dies a few days from the first appearance of the symptoms in a 
 state of asphyxia and with paroxysms of choking. In the chronic form, 
 the issue is not unfrequently towards recovery, the malady often dragging 
 on for months and, with remissions and exacerbations, even for years. 
 Even when the characteristic symptoms are all gone, there are not 
 rarely emaciation and feebleness of the lower limbs remaining over for 
 a long time or even for good. The fatal issue of the chronic form is 
 either by gradual aggravation of the symptoms, particularly the dropsical 
 effusions, accompanied by wasting and general marasmus; or suddenly 
 from asphyxia and paroxysms of choking, as in the distinctive manner 
 of the acute form. 
 
 Morhid anatomy. — The anatomical examinations of persons who have 
 died of beriberi have been few hitherto, and they have afforded no 
 certain clue to the nature of disease; or, in other words, they have 
 disclosed nothing uniform in the morbid anatomy. 
 
 Among the conditions most commonly found are the following: 
 Remarkably dark colour and extreme fluidity of the blood; serous 
 infiltration of the subcutaneous connective tissue; more or less con-
 
 
 GEOGRArniCAL AND HISTORICAL PATHOLOGY. 
 
 siderablo dropsical effusion into the pleura and peritoneum, b^^t most 
 of all into the pericardium, and now and then into tlie membranes of 
 the brain and the cord ; congestion and often oedema of the lungs ; the 
 heart often in a state of " excentric hypertrophy " or simple dilatation, 
 and in many cases soft, pale and f attily degenerated ; the inner coat of 
 the aorta and coronary arteries thickened at certain points from fatty 
 degeneration (Lodewijks and Weiss) ; the brain and spinal cord mostly 
 normal (the softened spots sometimes foimd in the central organs of 
 the nervous system should perhaps be regarded as post-mortem, phe- 
 nomena). In four bodies which they examined, Baelz and Scheube 
 found inflammatory changes in the peripheral nerves, going on to 
 induration and cirrhosis, and similar changes in the muscles — a sub- 
 acute neuritis and myositis reminding us of the cases of multiple 
 neuritis with inflammatory atrophy of muscles, lately described by 
 Eisenlohr, Geoffroy and Leyden, and in v/hich, accoi'ding to the 
 observers above named, the disease really consists and has its origin. 
 
 § 201. Historical Keperences. 
 
 The Jdstory of beriberi may be followed^ so far as the 
 present state of researcli enables us to decide^ as far back as 
 the second century of the pi'e- Christian era. Inquiries made 
 at the instigation of Dr. Scheube by a number of scholars 
 conversant with the ancient medical writings of China and 
 JapaUj with a view to discover whether the malady had existed 
 in those countries^ have succeeded in proving that the word 
 " kak-ke " occurs in a Chinese work dating from about 200 
 B.C., and that there is an unambiguous description of the 
 disease in another work of some one hundred and thirty years 
 later date. Other references to beriberi in China occur in 
 writings of the third, seventh and eighth centuries of the 
 present era ; and in a medicine book belonging to the end of 
 the tenth century, there is already a distinction drawn between 
 a " dry ^' or paralytic kak-ke and a " wet '^ or dropsicaL 
 Of the disease in Japan the earliest record is in a medical 
 treatise of the ninth century of our era ; but in that, as well 
 as in subsequent Japanese medicine books, the malady is often 
 confounded with other morbid conditions (heart disease, rheu- 
 matism, dropsy^). 
 
 Even in recent times there has been a good deal of confusion between beriberi 
 and the malarial cachexia on the one hand, and the cachexie aquense (the auchy- 
 lostoma-disease) on the other.
 
 BERIBERI. 573 
 
 For the East Indies tlie first notice of it occurs in tlie 
 medico-topographical treatise of Bontius^ who was acquainted 
 with the disease there in the seventeenth century under its 
 colloquial name " beriberi/' Belonging to the same period 
 is a note upon it by the Dutch physician Tulpius, who had 
 an opportunity of observing the malady in a person returned 
 from India (Coromandel coast). Then follow, in order of 
 time, the accounts by Paxmann, Lind and Fontana, for the 
 Malabar coast, and for the East Coast of the Indian penin- 
 sula the important and in some respects fundamental work 
 on beriberi by Malcolmson. Of much more recent date 
 is the appearance of beriberi at various parts of the New 
 World. At what time it first showed itself in the West 
 Indies I have not been able to make out from the accounts 
 before me. In Brazil it was not observed, at least in its 
 more general or epidemic diffusion, until after the year i860 ; 
 and its first appearance in Guiana would appear to fall about 
 the same time. 
 
 § 202. Present Area op Distribution. 
 
 The geograijliical distribution of beriberi extends over a 
 
 large part of the tropical and subtropical zones of the Eastern 
 
 and Western Hemispheres ; but the more important foci of 
 
 the disease are within comparatively narrow limits. One of 
 
 its chief seats is the Em^jire of Japan,^ in which the malady 
 
 is prevalent from Nagasaki (in the Kiushiu island) to Hako- 
 
 dade (in the Yezo island). Confined until some forty or fifty 
 
 years ago to the trading ports, it has appeared more recently in 
 
 the interior as well — in the central provinces of Kodzuke and 
 
 Osliiu, and even in the mountainous province of Shinano ; and 
 
 it not only affects the larger towns as formerly but the smaller 
 
 villages also.^ The want of statistical returns of disease in 
 
 Japan prevents us from forming an opinion as to the amount 
 
 of beriberi in that country ; but we have an approximate 
 
 estimate in the number of cases of it returned by physicians 
 
 in Kioto, wMch were 2273 from 1875 to 1879 in a population 
 
 ' Friedel, Pompc van Meulervort, Eef. (V), Miigct, WiTuicli, Anderson, Godet, 
 Simmons, Sollaud, Scheube, B; elz. 
 ^ Baclz, 1. c, 7.
 
 574 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 of some 229^000^ and of whicli 1093 occurred in the single 
 year 1878. In the army the number of cases in 1877 was 
 2687 among a total strength of 19,600 men, or 14 per cent. ; 
 the year after it was 13,629 in a force of 36,100, or 38 per 
 cent.^ In Gliina, where the disease would appear, from the 
 historical data above mentioned, to have been formerly one of 
 the prevalent diseases of the people, it now occurs very seldom.^ 
 In addition to the account^ of an epidemic of beriberi in an 
 English regiment in 1852, there is a notice of an epidemic 
 outbreak of it in 1870 in the Cocos Islands (in 12° S. in the 
 Indian Ocean), which came to an end when the patients 
 were sent to the adjoining Keeling Island.* For Lower 
 India we have information of its being endemic in Burmah, 
 where it does not appear to have been domesticated until 
 after the outbreak among the British troops in 1824/ also 
 at Singapore,'' and in the islands of Pulo-Condo (Calabash 
 Islands) lying off the coast of Cambodia.'^ On the mainland 
 of Saigon it is very rare, to say the least. ^ On many islands 
 of the Malay Archijoelago^ it is as widely spread, in endemic 
 or epidemic form, as in the Japanese Empire ; thus, in 
 8umatra,^^ the Dutch troops suffered from it severely during 
 the war in Acheen,^^ and there are more particular accounts 
 of its endemic prevalence among the natives of the Lampong 
 States.^^ It is found also in Banka}^ especially in the 
 mining districts ; and in Borneo, not only in the maritime 
 regions^* and in the English island of Labuan^^ off the north- 
 western coast, but also in the interior.^^ Also in Celebes}'^ 
 particularly in the Government of Macassar,^® and in several 
 islands of the Molucca group, such as Saparua;^^ but in 
 
 1 Scheube (II), 8. ^ Wernich (I), 293. ^ Eef. (II). 
 
 * Leudesdorf. * Mouat, Kearney, Arokeuui. 
 
 *• Ref. I; Ward and Grant. According to Russell, 1174 cases of beriberi 
 occurred in the Singapore gaol from May, 1875, to May, 1880. 
 ^ Beaufils. 
 
 * Richard, • Introd.,' vii. In the medico-topographical writings of French prac- 
 titioners in Cochin China nothing is said of the disease excepting in the note by 
 Beaufils already quoted. 
 
 ^ Schneider, Oudenhoven, Overbeck de Meijer, Swaving, van Leent (I). 
 '0 van Leent (VII). n Gelpkc. '- Eisinger. 
 
 '3 Lindman, van Kappen, van Leent (V). i'* Heymanii, Schneider, Rupert. 
 
 '5 Roe, Barry. ic van Leent (III, IV). " SchmidtmiiUcr, de Meijer. 
 
 ■^'''^*^^'- '^ Heymann, Robinow.
 
 BEEIBERI. 57 
 
 i> 
 
 Ambonia^ wLicli used to be very mucli affected by beriberi/ 
 it is now rarely seen.^ It exists also on the west coast of 
 New Guinea. In Java it would appear to be rare ou 
 the whole -^ but we have accounts of its endemic prevalence 
 in the Residency of Banjuwangi/ in the extreme east of the 
 island^ and in the prisons of Batavia f also^ notices of a 
 severe epidemic in the Residency of Passuruan in 1841, the 
 number of the sick being returned at 8000/ and of epidemics 
 in 1864 and 1865 at the Protestant Orphanage of SamarangJ 
 In India the principal seat of the malady is the strip of 
 coast, belonging to the Madras Presidency, from Gandjam to 
 Masulipatam, known as the Circars ;^ from the coast this 
 disease-focus extends with diminishing intensity for about a 
 hundred miles inland.^ It is met with very much less 
 frequently on the Coromandel coast/*' in the plain of the 
 Carnatic,^^ and on the Malabar coast. ^^ In Lower Bengal 
 beriberi became epidemic for the first time in 1877—80 at 
 Calcutta and at various places in the provinces of Dacca and 
 Assam. ^^ There is not a single reference to its endemic or 
 epidemic occurrence on the western littoral within the Bombay 
 Presidency, or in the greater part of the Deccan, or in the 
 North-West Provinces, or in any part of the Plain of the 
 Ganges, excepting the above-mentioned epidemic at Calcutta. 
 In Ceylon there is a good deal of it, more at some points 
 (Trincomalee, Kandy) than at others (Colombo)^^ and of a 
 more malignant type ; but the most recent information that I 
 have of it in that colony dates from 1849, and I am unable 
 
 ^ Lesson. ^ van Hattem, van Leent (II). ^ Heymann. ■* Clapbam. 
 
 5 Ref. (VI); Swaving. Frona January, 1857, to July, 1870, there were 2069 
 patients with beriberi in Batavia and on Onrust, w'ho were provided for at the cost 
 of the Government, most of them being in the prisons. 
 
 ^ Brockmeijcr. ' van Dissel. 
 
 8 Marshall (II), Hamilton, Malcolmson, Thomson, Hutchinson, Balfour, 
 Waring, Evezard. 
 
 ^ Kearney informs us that the disease exists in Sumbulpore, Kampti, &e. 
 
 '0 For the city of Madras and its vicinity there is not a single reference to 
 beriberi. Huillet says that in Pondicherry he had seen only a few imported 
 cases. 
 
 11 Dick. 
 
 '2 Wright. According to I),iy, beiibcri is very rave in the Cochin di strict. 
 
 '3 Fayrer, from information suppliel by MacLci d. 
 
 '4 Hunter, Rogers, Davy, Marshall (T, II), Ridley, rriilhiin.
 
 576 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 to say wliat may be the state of matters at present. It is 
 altogether doubtful, owing to the absolute silence of the 
 authorities on the point, whether the malady occurs in other 
 parts of the continent of Asia or in the adjacent islands. 
 There is, indeed, a statement by Moore, that beriberi has 
 been seen in sailors at Bassadur (on the island of Kishin, 
 Persian Gulf), but it is most probable that these cases do 
 not imply the prevalence of the sickness on shore but on 
 board vessels frequenting the Gulf. Of which more anon. 
 
 In African territory, so far as I can learn, the disease has 
 been found hitherto at three points — Mauritius, where it 
 was epidemic in 1813 among the British troops ;^ in Beunion, 
 where it has broken out epidemically in 1805, 1821, 1838, 
 and 1 847 -^ and on the small island of Nossi-Be, situated 
 north-west of Madagascar, where it occurs from time to 
 time.^ 
 
 In the Western Hemisphere, as we have seen, beriberi 
 has not been observed until recent times. In the French 
 Antilles, according to a report of Dumont published by Larrey, 
 there are occasional cases of it among negroes and Chinese, 
 which are known as " maladie des sucreries,^' and there are 
 epidemics of it now and then. It was prevalent on 
 Guadeloupe in 1859 among negroes imported from the Congo 
 Coast. It has been observed also in Cuba,* particularly in 
 1873, when it raged with great virulence among the negroes 
 on two plantations near Palmira, causing a mortality of from 
 60 to 75 per cent, of those attacked.^ In Cayenne it showed 
 it showed itself for the first time in 1865 among imported 
 coolies i^ but it does not appear to have recurred^ there until 
 
 ' Ref. (III). The epidemic of "acute anaemic dropsy," which occurred in 
 Mauritius in 1878-79, according to Davidson (' Ediu. Med. Journ.,' 1881, Aug., 
 p. 118), and Pelleran ('Arch, de med. nav.,' 188 1, Avril, p. 298), and which was 
 prohably imported from India, is not one thst I can regard as beriberi, judging 
 by the symptoms. 
 
 - Vinson (I). 
 
 ■'• Guiol. Fayrer's opinion, tliat the disease on the West Coast of Africa 
 known as " negro lethargy " corresponds to beriberi, rests upon some misconcep- 
 tion which I cannot explain. 
 
 ■* Hava. 5 Mintcguiaga. ^ Hemeury, Duraud. 
 
 ' The epidemic among the workmen in the gold mines of Siunarnary, described 
 by Dorvan (These, Montp., 1876), was probably an affair of anchylostoma disease 
 ((;ache.\ie aqueusc). At all events it was not beriberi.
 
 EERIBEEI. 577 
 
 October, 1877, when several coolies suffering from beriberi 
 were admitted into tlie hospital of Cayenne from neighbour- 
 •ing settlements.^ One of the most considerable centres of 
 the disease has been established of recent years in Brazil,^ 
 where its general outbreak belongs to the same period as 
 the first cases of it seen in Guiana. Some Brazilian prac- 
 titioners are of opinion that there had been occasional epi- 
 demics before ; as at Ceara in 1 825 and at Mariauna 
 (province of Minas Geraes) in 1858 and 1861. But it was 
 not until 1866 that the general attention of the profession 
 was drawn to it, particularly at Bahia, where there had been 
 sporadic cases a few years before, about the diagnosis of 
 which opinions differed. The point from which beriberi 
 started to overrun the greater part of Brazil was the Bahia 
 province ; shortly after, it broke out on the banks of the 
 Rio Anajas in Para; in 1869 it was in Santa Catharina 
 (according to Bey) ; at Pernambuco in 187 1 (according to 
 Beringer) ; in the Maranhao province in 1872, Ceara in 1873, 
 San Paolo and Rio Grande do Sul (according to Betoldi) in 
 1874; as well as in the provinces of Alagoes, Sergipe and 
 Espirito Santo, — thus extending over the whole Brazilian 
 seaboard. It has shown itself also in the interior in other 
 provinces besides Para, such as Matto Grosso and Minas 
 Geraes ; and at many places it has assumed the character of 
 an endemic disease. From the statements of Brazilian 
 army surgeons who had made the campaign against Paragiiay, 
 it appears that beriberi had been epidemic in that country 
 at the time of the war, at Humaita, Passo da Patria and 
 other places. Lastly, it has to be mentioned that a few cases 
 have lately occurred at San Francisco, but under what cir- 
 cumstances, or among what nationality, does not appear from 
 the very brief notice^ of the fact. 
 
 The epidemic outbreaks on hoard ship form episodes in 
 the history of beriberi that are full of interest in several 
 respects. It has been observed oftenest under those circum- 
 stances in Dutch men-of-war, transports, and coasting vessels 
 frequenting those parts of the Indian Ocean which encircle the 
 
 ^ Hemeurj, Fran9ois. 
 
 ' Compare the extremely exhaustive woi'k of Feris (I). 
 
 ' Eef. (V). 
 
 VOL. 11. 37
 
 578 GEOGEAPHIOAL AND HISTORICAL PATHOLOGY. 
 
 Malay Arcliipelago,^ and next to tliese in Britisli men-of-war 
 and transports in the Bay of Bengal and elsewhere in the 
 Indian Ocean." There are also a few notices of its occur- 
 rence among the crews of ships in the Sea of Japan/ the 
 Persian Gulf/ and the Eed Sea.^ In the Atlantic, naval 
 surgeons^ have seen cases of it among the crews of Bi-azilian 
 men-of-war during the war with Paraguay. Guy witnessed 
 an epidemic of it on board a French vessel carrying coolies 
 from Madras to Guadeloupe, the disease having appeared 
 when they were between the Cape and the West Indies and 
 some four weeks previous to their arrival at Guadeloupe. 
 On board another French ship carrying time-expired coolies 
 back from the West Indies to India, beriberi broke out 
 among the coolies when they had got as far through the 
 Indian Ocean as 91° E. and 14° N.^ Among other 
 instances of epidemics on board coolie ships from India to 
 the French Antilles, or returning, are those of the Nicolas 
 Foussin in 1864 and the Mario Laure in 1878. One of 
 the worst cases is that of the Parmentier in 1861-62 ; 
 she was carrying 401 coolies back from Martinique to 
 Pondicherry, and after a voyage of five months she landed 
 only 281 coolies alive. In ships navigating the Southern 
 Ocean or Australian waters,^ beriberi has never occurred, so 
 far as I know. 
 
 § 203. Influence op Climate and Season. 
 
 As regards the manner of its occurrence, beriberi has at 
 some places within its distribution area the character of an 
 
 ^ See the accounts of Schneider (1. c, 14), Heymaun (II), Pop, van Leent (I, 
 III, IV), Steendyk, Zuur, Schutte, WesthofP, Rupert. 
 
 - Hunter, Carter, Morehead (I). ^ Anderson. 
 
 ■* Moore. s Wellstead, Pruner, Carter. 
 
 ^ Ribeira de Almeida, ' Estudo sobre as condi9oes hygienions das navios encou- 
 ra9ados.' Rio de Janeiro, 187 1 ; Saraiva, ' Quaes os melhores meios de combater 
 o beriberi ?' Bahia, 1871. (Quoted by Feris.) 
 
 ' Ricbaud. 
 
 ^ The outbreak of an " epidemical dropsy," described as having occurred iu 
 1856 on board H.M.S. Jmwo, while cruizing off the Australian coast (' Statist. 
 Rep. of the Health of the Navy for the year 1856/ p. 161), is, in my opinion, 
 referred to beriberi on insufficient grounds.
 
 BERIBERI. 579 
 
 endemic malady, as in many islands of the Malay Archipelago 
 in the northern division of the Madras Presidency (Circars), 
 in Ceylon, at Singapore, in the Japanese Empire, and in 
 many parts of Brazil ; whereas at other places it shows itself 
 only in epidemics separated from one another by more or 
 less considerable intervals of time. To the latter class its 
 outbreaks on board ship belong very characteristically. 
 
 The influence of climate does not account for these differ- 
 ences, any more than it accounts for the existence of the 
 disease at all. No doubt the area of beriberi is almost ex- 
 clusively within tropical and subtropical regions ; but the 
 endemicity of the disease at Hakodade (Yezo), with a climate 
 nearly corresponding to that of the temperate zone of Europe 
 and America, and the outbreaks on board ships in somewhat 
 high latitudes, are evidence that the malady may develop or 
 persist, even as an endemic, beyond those regions. That the 
 tropical or subtropical climate does not of itself determine 
 the endemic or epidemic existence of the disease, follows 
 from the fact that the several centres of beriberi are often 
 narrowly circumscribed within its distribution area, while 
 the regions nearly adjoining them and subject to the same 
 climatic influences escape the disease ; as well as from the 
 fact that it is quite unknown in Arabia, on the East and 
 West Coasts of Africa, and in other regions with a pro- 
 nounced tropical climate ; and that in Guiana and Brazil, it 
 is only recently that it has, I will not say occurred, but at 
 all events become general, although we cannot account for 
 that by anything in the climatic conditions. 
 
 But we must none the less admit that the development of 
 the disease into an epidemic stands in very definite relation 
 to the influence of season, or of the corresponding weather 
 conditions. Observers in all parts of the world where beri- 
 beri has been observed hitherto are unanimous in saying 
 that the largest number of cases, or the epidemic outbreaks, 
 fall in the season which is meteorologically characterised, 
 first of all by the high degree of atmospheric moisture, and 
 next by great vicissitudes of temperature. This is the 
 opinion expressed by Bontius, v. Oudenhoven, Hej^mann, 
 Schneider, v. Dissel, Rupert and others for the East Indies ; 
 by Hamilton, Malcolm son, Waring, Kearney, and others for
 
 680 GEOGEAPHIOAL AND HISTORICAL PATHOLOGY. 
 
 the Circars ; by Dick for the Carnatic ; by Lind^ Fontana, 
 Wright and Day for the Malabar coast ; by Marshall for 
 Ceylon ; by the authority for Singapore ; by Wernich, 
 Simmons^ Scheube and Baolz for Japan ; and by da Silva 
 Lima, Pacifico Pereira and others for Brazil. Proof of this 
 is afforded by the statistics of sickness given by some of the 
 observers. 
 
 The following table shows the distribution according to season of 572 
 cases of beriberi, admitted into the military hospitals from among the 
 native troops in the northern division of the Madras Presidency during 
 a period of three years.' 
 
 Table of Admissions for Beriberi in the several Seasons. 
 
 Hot Season. 
 
 Rainy Season. 
 
 Cool Season. 
 
 March 
 
 . 19 
 
 July . 
 
 34 
 
 December 
 
 . 54 
 
 April 
 
 . 27 
 
 August . 
 
 . 68 
 
 January . 
 
 . 25 
 
 May 
 
 • 13 
 
 September 
 
 99 
 
 February 
 
 • 17 
 
 June 
 
 • 27 
 
 October . 
 
 90 
 
 
 
 
 
 November 
 
 99 
 
 
 96 
 
 
 86 
 
 
 390 
 
 
 
 or 1 5" 03 per 
 
 cent. 
 
 or 68"2 per car 
 
 It. 
 
 or 167 per cent. 
 
 The cases at Totio from 1879 to 1881, to the number of 2224, were 
 distributed as follows :^ 
 
 January . 
 
 • 37 
 
 May . 
 
 February . 
 
 • 23 
 
 June . 
 
 March 
 
 • 39 
 
 July . 
 
 April 
 
 . 124 
 
 August 
 
 2 1 2 September 
 
 341 October . 
 
 632 November 
 
 537 December 
 
 194 
 64 
 
 17 
 4 
 
 The approach of the cold and dry season has almost alwaj^s 
 had a good effect on the type of the attack, as well as in 
 bringing an epidemic to an end. Observations as to the 
 weather at the time of an epidemic outbreak, bearing out 
 those above mentioned, have been repeatedly made at sea 
 by Hunter, Lindmann, Eichaud, and others. 
 
 Warin^ 
 
 2 Baelz.
 
 BBEIBERI. 581 
 
 § 204. Intimate Association with the Sea Coast. 
 
 Whether the occurrence of beriberi, and its diffusion_, are 
 independent of particular kinds of soil cannot be decided 
 with any approach to certainty. One noteworthy fact is, 
 that the malady has been mostly prevalent on the sea-coast, 
 the shores of great rivers, and the plains adjoining ; while 
 it has shown itself seldomer in the interior, and has for the 
 most part avoided high tablelands and mountainous country. 
 Hamilton, Marshall, and others among the earlier observers, 
 were of opinion that a distance of forty to sixty miles from 
 the coast was sufficient to give immunity from beriberi; and 
 several of the more recent authorities have expressed the 
 same opinion. Malcolmson found this idea confirmed by his 
 experience in the Circars; but he thought it advisable to add 
 that "this law will, I have no doubt, require to be greatly 
 modified as our information is extended " — a wise reserve 
 which has been justified by subsequent experience. As early 
 as Balfour's report on the cases of beriberi among the troops 
 in the Madras Presidency from 1829 to 1838, we find con- 
 siderable exceptions to the rule in question. The cases to 
 the number of iii 6 were distributed as follows : 
 
 Stations on tlie coast .... 394 
 
 Stations on the plain, between eight and forty miles from 
 
 the coast ..... 537 
 
 Stations on the plain, between forty and one hundred 
 
 miles from the coast . . . -132 
 
 Stations on the high ground, more than 1300 feet above 
 
 the sea . . . . . '53 
 
 It should be kept in mind, also, that there were only two 
 stations of the last kind, viz. Secunderabad and Kampti ; 
 and that the troops quartered in them were a comparatively 
 small force. 
 
 But we find still better evidence that the area of the 
 disease is by no means absolutely associated with the condi- 
 tions obtaining on coast-lands, in the latest experiences from 
 those same districts of India (Kearney), from Assam (Fayrer), 
 and from Burmah (Kearney), where beriberi has occurred 
 hundreds of miles up country ; also in the observations on
 
 582 GEOGEAPHICAL AND HISTORICAL PATHOLOGY. 
 
 its extension in Japan^ from tlie coast into the interior; and, 
 most of all, in the fact that it has been found to be epi- 
 demically prevalent in one of the western provinces of Brazil, 
 Therefore, although the preponderance of beriberi on the 
 coast is still unmistakable, the explanation of the fact lies 
 perhaps more in the meteorological conditions than in any 
 peculiarities of soil. 
 
 With reference partly to the preponderance of beriberi 
 on sea-coasts and river banks, some^ have laid special 
 emphasis in the etiology upon the wetness or swampiness of 
 the ground, and have deduced therefrom the conclusion that 
 the disease partakes of a malarial character. I shall after- 
 wards show that beriberi has not the very smallest point in 
 common with malarial diseases. For the present, I shall 
 merely meet the theory of an influence derived from wet or 
 swampy soil by directing attention to the fact, that the 
 principal seat of the malady is that very region of India 
 which is comparatively well oif as regards the moderate 
 saturation of the soil ; whereas, the regions that are most 
 damp and most abounding in swamps, such as Orissa, the 
 plain of Lower Bengal, and the plain of Cambodia are almost 
 exempt from beriberi. Further, that the disease has risen 
 to a more or less important place within the last thirty or 
 forty years at various points, both in the Eastern and Western 
 Hemispheres, where it used to be either rare or altogether 
 unknown, while there have been no concomitant changes in 
 the soil ; that beriberi is met with much more commonly in 
 towns than in country districts ; and last, but not least, that 
 it can spring up and become epidemic on board ship, where 
 there can be no question of an influence of soil in the 
 ordinary meaning of the term. 
 
 § 205. Occurs mostly in Adult Males, Native and 
 Acclimatised, and in those op Good Physique. 
 
 Inquiring into the influence upon the production of beri- 
 beri exerted by things prejudicial in the mode of living, we 
 
 ^ 1 For example, Swuving, Bary, and Kupert for the East Indies; Anderson anu 
 Simmons for Japan j Uetoldi, Rey, and Pereira for Brazil,
 
 BEEIBEKI. 583 
 
 have in the first instance to consider as factors in the etiology 
 a number of personal things, such as age, sex, nationality 
 and constitution. 
 
 As regards the amount of the sickness at various ages, 
 there is absolute unanimity among the authorities that cases 
 of beriberi are the exception in children or young persons 
 under the age of fifteen, no such cases being met with in 
 many of the epidemics ; that old age is also exempt for the 
 most part ; and that most of the cases are in people in the 
 prime of life. On board the ship VIndien the emigrants 
 numbered 575, among them 54 children up to fifteen years 
 of age; there were 118 cases of beriberi, but only one of 
 these was in a child (Gruy), On board the Jacques Goeur, 
 the whole of the 55 children of the coolies escaped the disease, 
 while of the 332 adults, 44 took it (Richaud). In the epi- 
 demic of 1869-70 in Labuan, the age of childhood was found 
 to be quite protected (Barry). Of 35 fatal cases in the 
 hospital of Tokio, only one was in a person under fifteen ; 
 of 581 beriberi patients treated by Scheube at Kioto, only 
 35 were children; of 933 patients at Tokio, 15 were between 
 ten and fifteen years of age, 753, or 80 per cent., were 
 between sixteen and thirty years, and the remaining 165 
 cases were over thirty years, 89 of them being between thirty 
 and forty. That the rule is not without exceptions, is 
 proved by the epidemics occasionally observed in orphanages 
 and training institutions. Thus in the Protestant Orphanage 
 at Samarang in 1864 and 1865, there were 98 cases among 
 235 children, and 9 of these fatal ; and in the Missionary 
 Schools at Toukiji in Japan, a large number of girls between 
 the ages of ten and sixteen were attacked with beriberi, of 
 whom one died. 
 
 A difference in the liability to beriberi, not so pronounced 
 perhaps as that which distinguishes childhood from the prime 
 of life, but still a considerable difference, exists between the 
 female sex and the male. In Ceylon, Christie did not see a 
 single case in a woman, and Kupert says the same for Borneo. 
 According to Heymann and others for the East Indies, 
 Wernich and Simmons for Japan, l^ereira, Betoldi, Rey and 
 others for Brazil, and Larrey for the West Indies, the cases 
 of beriberi in the female sex are rare. On board the
 
 584 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 emigrant sliip VhuUen, there were 1 1 1 cases among 385 
 men, or 29 per cent., (of whom 40, or 10-4 per cent, died), 
 while there were only 6 cases among 118 women, or 5*5 per 
 cent., of whom 2 died (Guy). But on board the coolie ship 
 Jacques Coeur, the proportion of cases among men and 
 women was as 12 to 7. Among 584 patients with beriberi, 
 Scheube gives only 50 females ; and among 2224 cases treated 
 in the hospital of Tokio from 1879 to 1881, there were, 
 according to Baelz, only 68 women, or i to 31*7 men. 
 Agreeing with Simmons, Baelz is of opinion that pregnancy 
 and childbed make the liability considerably greater. 
 
 A third personal factor in the pathogenesis consists in the 
 nalionality of the indindual. At every endemic or epidemic 
 seat of beriberi where there is a mixed population, it is mostly 
 the natives or immigrants belonging to the dark races who 
 are attacked, the Europeans and Americans enjoying, par- 
 ticularly in the first period of their residence, an immunity 
 which, if not absolute, is still a very pronounced one. In the 
 East Indies and on board the ships of war on the Dutch East 
 Indian Station, according to the unanimous opinion of v. 
 Oudenhoven, van Leent, Praoger, Kupert and others, the 
 malady occurs principally among natives. Only in exceptional 
 instances has it been seen to any considerable extent among 
 Europeans, as in Amboina among very poor people, according 
 to van Hattem, and on board a Dutch man-of-war, where 
 the epidemic, according to Heymann, was strictly limited to 
 the Europeans of the ship's company. The extent to which 
 the malady is prevalent among- the Malay crews of the Dutch 
 East Indian squadron, is shown in van Leent's statistics^ for 
 the years 1870-77, according to which the proportion of cases 
 in Malays and Europeans was as 60 to i. In the earliest 
 accounts of beriberi in India, those by Fontana and Lind, 
 mention is no doubt made of somewhat frequent cases in 
 Europeans ; but all the more recent authorities are agreed 
 that the latter suffer very much less than the natives (and 
 than Mohammedans, in particular, according to Malcolmson) . 
 From 1829 to 1838 there were only two cases of beriberi 
 among the European troops in the Madras Presidency 
 (Balfour) ; Waring estimates the proportion of native cases 
 ' ' Gencesk. Tijdschr. voor Nedcrl. Indie/ 1880, ix, 297.
 
 BERIBERI. 585 
 
 and European as 6 to i ; during tlie epidemic of 1878-80, in 
 Calcutta and its suburbs, there was not a single case in a 
 European (Fayrer). In Ceylon, Marshall has seen beriberi 
 only in the blacks ; and Ridley, for the same colony, says 
 that Europeans are certainly subject to the disease, but much 
 less commonly than the natives. In Japan, the Europeans 
 and Americans enjoy an almost absolute immunity; among 
 two thousand foreigners in Yokohama, Simmons could learn 
 of only one well-authenticated case in a European ; in the 
 foreign colony at Tokio, Wernich saw only two cases, one in 
 an Italian and the other in an American woman ; according 
 to Anderson, not a single case of beriberi had occurred among 
 the British and French troops formerly stationed at Yoko- 
 hama; in his own experience Scheube knows of only two 
 authentic cases in Europeans ; and Baelz says that Europeans 
 in Japan hardly ever take beriberi. In the West Indies, 
 according to Larrey and Minteguiaga, the malady has been 
 seen hitherto only in negroes and Chinese ; in Guiana, 
 according to Fran9ois and Hemeury, only among imported 
 coolies, with the exception of a case which the latter saw in 
 a European sailor. In Brazil, also, the accounts given by 
 practitioners show that the natives suffer much more than the 
 foreign immigrants. 
 
 It is a noteworthy fact, already adverted to, that the pre- 
 disposition to an attack of beriberi increases with the length 
 of time spent at the focus of disease, or with the degree of 
 acclimatisation. Calhoun^ was the first to point this out when 
 he wrote as regards Ceylon : " It would appear that a stay 
 for some months on the station is almost essential for the 
 production of the disease, and that the gi-eatest predisposition 
 to it exists when troops have been about eight or twelve 
 months in the settlement. 
 
 Hamilton and Malcolmson afterwards took the same view, 
 from their experience in the Circars (Madras) . Subsequently 
 the fact was confirmed by observations made in Japan. 
 Simmons' statement is that among the Japanese who have 
 come from the interior to the coast (the proper seat of the 
 malady) , it never appeared until after they had resided some 
 time ; but that then the cases became more frequent among 
 
 ^ Quoted by Hunter, 1. c, p. 96.
 
 586 GEOGEAPHICAL AND HISTORICAL PATHOLOGY. 
 
 tliem than among natives of the coast (in which opinion Baelz 
 agi'ces) ; and that therein hes the explanation of the large 
 number of cases among sailors, soldiers, policemen, students 
 and others, who had come to the seaports from the interior. 
 The period required for acclimatisation, or, in other words, 
 for becoming predisposed to the sickness, is estimated by 
 Baelz at from a few months to a year ; and the same period 
 is fixed by practitioners in Brazil, where strangers are exempt 
 from attacks of beriberi for six or twelve months after they 
 have come to reside at one of the indigenous centres of the 
 disease. One attack makes a greater liability to others ; so 
 that those who have suffered from beriberi once may have 
 attacks recurring at regular intervals for years after, as 
 Hamilton had shown to be the case in India, and Wernich, 
 Scheube and Baelz in later times have proved for Japan. 
 
 The last consideration in the question of individual pre- 
 disposition, is that in the experience of the East Indies, Japan 
 and Brazil, people of strong physique take beriberi much 
 oftener than the weakly. " Evidence that it is not the 
 weakest who take the disease soonest and most severely,'^ 
 says van Overbeck de Meijer, " is furnished by the experience 
 of the new State Prison of Batavia, during the epidemic of 
 beriberi ; for it was just the strong people who took the 
 disease and died.'^ The same fact has been established by 
 Lindmann for Banka, by Mohnicke for Amboina, and by 
 Rupert for Sumatra. " So far as relates to constitution,^^ 
 says Rupert, " the fact was brought out that there were no 
 doubt a few weakly individuals among the patients, but that 
 the great majority were strong persons between the ages 
 of twenty and thirty, and that it was often actually the 
 strongest and best nourished who were attacked.'^ To the 
 same effect are the accounts from Japan by Simmons and 
 Baelz : among 626 out-patients treated by the latter for beri- 
 beri at the hospital of Tokio in 1881, there were 593 of 
 robust constitution, 27 of moderate strength and 6 weakly 
 persons. Such is the view, also, of many of the authorities 
 in Brazil -^ among others of Caire, who says that all the cases 
 of beriberi which he had to treat at the Sailor's Hospital of 
 Rio, were in strong, athletic individuals. It is only the 
 ' Feris, 'Arch, de med. nav.,' 1882, Juin, p. 476.
 
 BERIBERI. 587 
 
 previous attacks of exhausting diseases^ sucli as dysentery 
 and protracted agues, that appear to increase the predispo- 
 sition to beriberi ; and that is perhaps what van Leent (I) 
 refers to when he says that invalids are particularly liable to it. 
 
 § 206. Sedentary Occupations predispose to it. 
 
 With a special exception in favour of the very numerous 
 outbreaks of beriberi among bodies of troops and on ship- 
 board, particularly in men-of-war and transj)orts, the various 
 classes and callings of the population would appear to be 
 subject to it somewhat unifoi'mly; at all events no class 
 enjoys immunity by virtue of its wealth or its social position. 
 Feris in his summary of the Brazilian writings on the 
 subject says : " On voit quelqaefois Paffection attaquer les 
 personnes qui sent dans une position elevee ; ou pent dire que, 
 jusqu^a present, aucune position sociale n^i ete respcctee." 
 The accounts are the same from Japan, where, as Baelz says, 
 people in comfortable circumstances are attacked actually 
 oftener than the working classes and the proletariat. Scheube 
 is of the same opinion, and he adds that even the upper and 
 very highest ranks of -Japanese society are not exempt from 
 beriberi ; according to his observations, the great bulk of the 
 patients is made up of scholars, priests, teachers, pupils, 
 merchants, artists and handicraftsmen. Of 333 male patients 
 treated by him in 1877 and 1878, there were 261, or 78 per 
 cent., belonging to those callings; and of these again, 168, 
 or 46 per cent., were scholars, priests, teachers, pupils or 
 writers, while 106, or 41 per cent., were in business, and 37, 
 or 13 per cent., were artists or artificers. The conclusion 
 which Scheube draws is, that those occupations predispose 
 specially to the disease which involve a sedentary life -^ and 
 that is also the conclusion which the Brazilian practitioners 
 have come to, according to Feris, when he says : " Signalons 
 
 ^ This fact disposes of the suggestion thrown out by v. Leeut (' Geneesk. 
 Tidjschr. voor Nederl. ludie,' 1880, ix, 306), that the compavative freedom of 
 the female sex from beriberi may be due to their having less physical exertion 
 
 to undergo than men.
 
 588 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 la vie sedeutaire comme une cause secondaire de la maladie ; 
 c'est pour cela, sans doute, qu'elle se developpe si facilement 
 cliez les individus qui appartieunent a la classe lettree." 
 
 § 207. Influence of Overcrowding and Want op Venti- 
 lation. 
 
 It seems to me to be extremely doubtful whether the want 
 of physical exorcise is in itself a factor in the etiology, inas- 
 much as soldiers and sailors, who are particularly often 
 attacked by beriberi, have certainly no lack of exercise. A 
 much more likely suggestion is that long confinement in more 
 or less crowded and hadly ventilated places, so oitemxssocisbted 
 with the mode of life of those classes, plays a leading part 
 in the production of the disease ; and that is the opinion 
 held by many of the authorities. Noteworthy in this con- 
 nexion is the exceedingly frequent occurrence of beriberi in 
 the gaols of British India and the Dutch Bast Indies, as well 
 as in schools and boarding institutions, the defective ventila- 
 tion of which has been specially dwelt upon by van Dissel in 
 treating of the epidemics of Samarang ; and his observations 
 are all the more deserving of attention for the reason that they 
 relate to young girls who are not often subject to beriberi under 
 other circumstances. The same is true of the outbreaks of 
 the disease on board transports and coolie-ships ; for Hunter, 
 Guy, Richaud and others are agreed in saying that the one 
 obvious cause of the outbreaks has been the insufficient 
 ventilation of the ^tween decks occupied by the troops or 
 emigrants, the want of fresh air becoming all the more press- 
 ing when the hatches had to be kept closed for a length of 
 time in consequence of bad weather. Swaving, also, with 
 whom many observers in India agree, lays special stress in 
 the etiology of beriberi, upon prolonged and frequently 
 recurring confinement in small, overcrowded and ill-ventilated 
 places, more particularly if they be used also for sleeping in ; 
 and he shows, from facts observed, that the degree to which 
 the disease develops is in proportion to the seriousness of the 
 nuisance in question and to the duration of it. In like 
 manner Eupert is of opinion that "fouling of the air by
 
 BERIBERI. 589 
 
 noxious uiatters_, sucli as investigation cannot discover with 
 precision/' is one of the more intimate causal factors ; and 
 Scheube concludes from the facts before him that " persons 
 who live together in large numbers in small rooms are quite 
 peculiarly liable." In this we may find a partial explan- 
 ation of the frequent occurrence of beriberi among the crews 
 of men-of-war, and among troops in garrison. 
 
 § 208. Evidence of a Dietetic Causation. 
 
 The point most keenly debated in the etiology of beriberi 
 is the question of the influence of deficient or im'pro'per food 
 and di'inJc on the pathogenesis. As in all such cases of 
 obscure causation, there has been no lack of assertion that 
 the true and proper cause of the malady is to be looked for 
 in the use of tainted or hracMsh drinking water. This doc- 
 trine, which was put forward first by Wright and afterwards, 
 brought into currency by Evezard, has been contradicted 
 by the experience of other observers (Malcolmson, Richaud 
 and others) ; and, according to the most recent facts from 
 Japan and Brazil, it has now lost all importance. 
 
 It is otherwise with the question of an influence exerted 
 by an insvfficient diet or a diet not corresponding to the meta- 
 holisrns and hloodmahing, or to the needs of the body ; such 
 would be the exclusive or preponderant use of rice, which 
 is especially poor in nutritive matters, and of dried fish 
 (deficient in albuminous substances and fat) ; and these are 
 in many parts of Eastern Asia the principal articles of food 
 not only among the lowest of the population but also in the 
 middle classes. The Anglo-Indian physicians had at an 
 early period pointed to this harmful influence as a cause of 
 the malady ; and by many of the recent observers in the 
 Dutch East Indies and in Japan it has been assigned the 
 first place in the etiology. " Whenever beriberi appears 
 among a ship's company," says Overbeck de Meijer, " it is 
 always in consequence of their having to live exclusively on 
 salt meat owing to circumstances beyond our control ; and 
 whenever the troops employed in military expeditions in 
 certain parts of the Dutch East Indies are obliged to live
 
 590 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 exclusively upon tlie ordinary food of the country, they are 
 almost always attacked by beriberi ; " and Pop had pre- 
 viously spoken in the same way of the disease as it occurs on 
 board Dutch ships-of-war on the East Indian station. Van 
 Kappen draws attention to the fact that those of the Chinese 
 employed in the mines of Banka who live well, are exempt 
 from beriberi, and that the persons attacked by the malady 
 are those who become anaemic in consequence of insufficient 
 food, Stendijk's opinion was that beriberi appeared on 
 board ship whenever the food ran short or became spoiled. 
 A similar view is taken by Westhof, who complains of the 
 bad provisions (rice and dried fish) supplied by the river- 
 passenger companies to their vessels in the Dutch East 
 Indian service ; and by Schutte, who says that he had seen 
 the disease in the gaol of Paramaribo under the same cir- 
 cumstances (diet of rice, salt fish, and boiled green bananas) . 
 Not less decidedly has van Leent adhered to that opinion on 
 every occasion when he has had to advert to the occurrence 
 of beriberi in the Dutch East Indies, and at greatest length, 
 in his latest article on the subject.^ " The dietetic error," 
 he says, to translate literally, " which I regard as the one 
 and only cause of the morbid composition of the blood in 
 beriberi, consists in the too small proportion of albuminous 
 substances and fat.''^ In proof of this he gives the experi- 
 ences of the disease in the Dutch East Indian fleet from 
 1870 to 1878, particularly during the war in Acheen, both 
 among the native and European members of the crews. 
 Until 1873 there existed, in consequence of the extremely 
 inadequate rations of the natives, that marked difference 
 between the number of cases in them and in Europeans 
 which has been already referred to (p. 584), a difference that 
 was represented in 1873 by the ratio of 60*37 ^o o'88. 
 From 1874 onwards the Japanese sailors got the same rations 
 as the Europeans, whereupon the proportion of sickness from 
 beriberi among the two races became as 7"o6 to 0*07. ^^I 
 can say positively," he adds, " that there was not the 
 slightest alteration in any of the circumstances, apart from 
 the radical change in the rations supplied to the native part 
 of the crews." This experience confirms van Leent in the 
 ^ 'Geneesk. Tijdsclir. voor Nedevl. Indie/ 1880, ix, 295.
 
 BERIBEEI. 591 
 
 conclusion that he had come to from former observations, a 
 conchision formulated by him in these words :^ " Le beriberi 
 reconnait comme cause principale une alimentation trop uni- 
 foi'me, insuffisante et de mauvaise qualite ; I'organisation, 
 privee des elements indispensables a I'entretien de la com- 
 position normale du sang et par suite a la nutrition, s'appauvrit 
 peu a peu/' 
 
 The same view of the influence of improper diet in pro- 
 ducing beriberi has been taken up by Maget and Wernich, 
 two of those who have studied the disease in Japan. " The 
 kak-ke/' says Wernich/ " is a chronic constitutional disorder 
 of blood-making and of the vascular system. Rice as the 
 exclusive food of the people is answerable for it in a quite 
 especial way. Not, however, as some have thought, because 
 it is used in a decomposed state, but because it is used in 
 such quantities that the power of assimilation is gradually 
 lost for other kinds of food ; and even the large quantity of 
 rice is unable to render the nutrition and blood-making 
 adequate. Although the Japanese diet contains albuminous 
 elements in the form of fish and bean cheese,^ these are not 
 sufl&cient. Fat in an easily digestible form, as the Northern 
 Chinese have it in considerable abundance in their fat pork, 
 mutton and duck, and the Southern Chinese and Malays in 
 palm-oil, is almost wanting in the diet of the Japanese." 
 
 To this reading of the importance of certain deficiencies 
 or errors in the diet for the development of the malady, 
 considerable objection has been taken; and, in so far as 
 these objections are directed against the exclusiveness of 
 the doctrine, I think them entirely justified. Malcolmson, 
 criticising the earlier views on the influence of diet held by 
 Anglo-Indian physicians, wrote as follows : '' Much has been 
 said of the efi^ects of various kinds of food, and Dr. Herklots 
 enumerates a number of articles, whose use he considers 
 injurious ; but when we reflect that these are standard ali- 
 ments all over India, we cannot carry our deference to his 
 experience so far as to admit that they can produce, in these 
 districts only, so singular a train of symptoms. What effect 
 
 * 'Arch, de med. nav.,' 1867, 1. c. 
 ^ ' Geograpbisch-medicinisclie Studien,' p. 193. 
 
 ^ The Japanese " tofu," a kind of porridge made from old and dried beans, 
 and consisting mostly of the legumin. (See Weruich, 1. c, p. 85.)
 
 592 GEOGEAPHIOAL AND HISTOEICAL PATHOLOGY. 
 
 the extensive use of fish may have, in combination with other 
 influences, I am not prepared to say ; but the comparative 
 cheapness of all kinds of grain in the Circars, and the easy 
 circumstances of many of the native soldiers who suffered, 
 are fatal to any supposition of the disease depending on defi- 
 cient and unhealthy diet/' 
 
 The slight influence of deficient diet on the production of 
 the malady is further shown in the fact stated by Waring, 
 that during the frightful famine which visited the South of 
 India in 1833 and 1834, not a single case of beriberi was 
 observed in those gaols of the Madras Presidency which had 
 been free from the disease before, although it was epidemic 
 during that period in the gaols of Bellary and Cuddapah. 
 In the account of the epidemic of 1878-80 at Calcutta, 
 drawn up by Fayrer, it is stated that the disease was 
 prevalent mostly among the poorer classes of Hindus and 
 Mohammedans, but that Eurasians and well-to-do natives 
 were by no means exempt from it, and that dearness of pro- 
 visions or improper diet could by no means be made out to 
 be causes of it, inasmuch as well-fed persous and flesh-eating 
 Mohammedans suffered along with the poor. 
 
 The observations of Rupert in Borneo form a specially 
 interesting contribution to the discussion of this matter. 
 When beriberi was epidemic among the troops and the crews 
 of men-of-war, these had twice a week fresh beef, poultry, 
 eggs and coffee in their rations besides fish, salt meat, potatoes 
 and rice ; at the same time the labourers of the country, 
 whose food for long periods was nothing but rice and a piece 
 of dried fish, were entirely free from the disease. Rupert's 
 opinion is very much that of Malcolmson. " If the notion 
 were correct," he says, " that an improper diet, or a prepon- 
 derance of amylaceous and vegetable food and deficiency of 
 animal, plays the chief part in the production of beriberi, the 
 disease would have to be a very general one, inasmuch as 
 rice is the staple diet of the people of India and the East 
 Indies, remarkably little animal food being used by the 
 natives excepting in the case of a few hunting tribes in the 
 interior of Borneo and Sumatra. But the fact is that it is 
 restricted in the Dutch East Indies to certain regions and 
 spots, mostly on the coast or in immediate proximity to it."
 
 BERIBERI. 593 
 
 Simmons, who admits tliat rice is an inadequate kind of food, 
 ill suited to anyone suffering from beriberi, expresses a doubt 
 wlietlier the excessive use of it is to be held as the cause 
 of the malady in Japan. Scheube and Baelz enter the 
 lists very decidedly against that doctrine ; the former point- 
 ing to the existence of the disease among the hunters and 
 fishermen of the Ainos (in Yezo) , whose diet is far superior to 
 that of the Japanese in albumen and fat ; and the latter 
 pointing out, as Rupert had done for the East Indies, that in 
 Japan the disease is commonest where there is most animal 
 food in the diet, that is to say, at the sea-side. 
 
 Finally, Brazilian authorities are most decided, and almost 
 unanimous, in disputing all connexion in the pathogenesis 
 with deficient or improper diet, for the reason that beriberi 
 is common among the proprietary classes of that country, 
 surrounded by all the comforts of living. '' Comment se 
 fait-il," asks Feris, in his summary of the facts about beri- 
 beri in Brazil, "que les individus les plus atteintes soient 
 ceux de la classe elevee plutot que ceux de la classe inferieure 
 qui, luttant avec la misere, s'alimentent mal ou insuffisament, 
 et pourtant sent preciseraent ceux qui payent le moindre 
 tribut a I'epidemie ?" 
 
 In the Brazilian fleet it was epidemic on one occasion, 
 when there was actually a superabundance of provisions. 
 Guy and Richaud also state that there could be no question 
 of short rations or bad provisions in those instances of beri- 
 beri outbreaks which came under their own notice on board 
 French transports. One more proof that beriberi, in its 
 endemics or epidemics, is altogether independent of this 
 etiological factor, I find in the circumstance that there has 
 been no general diffusion of it in Brazil until recent times, 
 Avhile there has been no such change in the staple food of 
 the people as would render its phenomenal outburst in- 
 telligible. 
 
 § 209. Various Theokies op the Nature of Beriberi. 
 
 Impartially summing up the results of the foregoing 
 inquiry into the connexion between beriberi and certain con- 
 VOL. II. 38
 
 594 GEOGRAPHICAL AND HISTOEIGAL PATHOLOGY. 
 
 ditions of climate, weatlier, soil, constitution, mode of living, 
 and of diet, we find nothing which supplies an answer to the 
 question. Where are we to look for the true and proper cause 
 of the disease ? What we do learn is that it must be some- 
 thing over and beyond those influences. The difficulties which 
 we encounter in trying to solve this question are considerably 
 increased by the obscurity that surrounds the nature of the 
 disease itself, an obscurity which the most recent observations 
 and researches have not dispelled. At the present day, just 
 as in the earlier part of the century, the most various opinions 
 obtain as to the nature of the disease, and as to the disease- 
 producing factor ; so that we can very aptly express the 
 present standpoint of our knowledge in the phrase, " autant 
 d'auteurs, autant d^ opinions diverses." It would be beyond 
 the limits of my task to go at all deeply into the disputed 
 nature of heriheri ; I must therefore content myself with 
 touching upon it only in so far as it affects our critical 
 estimate of the opinions held by various authorities in regard 
 to the causation. 
 
 One of the oldest theories starts from the point of view 
 that beriberi is a rheumatic process ; or, to put it more 
 generally, a chill-disease brought about by hot and damp 
 weather with great fluctuations of the temperature. To this 
 doctrine Feris^ has lately given his adhesion ; he denies, 
 indeed, the rheumatic character of the disease (in the ordinary 
 meaning of the term) as well as its specificity (" entite 
 morbide ") ; but he takes the " cause determinante '^ to be 
 " ^influence des phenomenes meterologiques, a savoir: chaleur 
 humide et transitions brusques de temperature,^^ and the 
 " cause predisposante " to be " afPaiblissement des vaso- 
 moteurs et du grand sympathique." This theory of the 
 origin of beriberi, like every other theory which would refer 
 the disease to a cause in general operation, without taking 
 into account the fact that the malady is confined within small 
 and definite areas, is, in my opinion, to be set aside as 
 erroneous on the face of it. Even if we admit, in considera- 
 tion of the facts above given, that states of the weather are 
 not without an influence on the development of the disease, 
 and more particularly that the frequent occurrence of beri- 
 ^ 'Arch, de med. nav.,' 1882, Aoiit, 1. c.
 
 BERIBERI. 595 
 
 beri on board ship and among troops is connected therewith ; 
 we should still bo unable to understand how it is that a 
 harmful influence of so common a kind as that sort of weather, 
 distinctive as it is of the climate of many tropical and sub- 
 tropical regions, should give rise to outbreaks of disease of a 
 most definite and peculiar type at only a few points on the 
 globe, and these far apart ; why in India, for example, where 
 the meteorological conditions in question make themselves 
 felt with equal force over a great part of the country, the 
 spots of beriberi should be so few, and confined within so 
 sliort a radius. Furthermore, the existence of " aifaiblisse- 
 ment du grand sympathique •" is an assumption for which 
 there is not the smallest warrant in the previous histories of 
 the patients, the larger number of whom were of strong 
 physique and otherwise in good health. 
 
 The view entertained by Christie, Morehead, Carter, van 
 Overbeck de Meijer, Praeger and others, that beriberi is a 
 disease closely allied to scurvy, is based on the fact that the 
 two diseases have sometimes been prevalent together, and on 
 tbe assumption that the morbific causes of both belong to th.e 
 same group, namely, defects or errors of diet. Against this 
 doctrine it has to be said that a coincidence in time observed 
 now and then between two diseases, does not warrant a con- 
 clusion as to their general identity; that a comparison of the 
 aggregate symptoms peculiar to each disease does not bring- 
 out the smallest resemblance between them ; and that the 
 food-factor in the genesis of beriberi plays, as we have seen, 
 by no means so conspicuous a part as to warrant us in 
 explaining the production of the malady by reference to it 
 alone. 
 
 The same objection has to be taken to the theory first put 
 forward by Evezard and Lodewijks, afterwards stated more 
 precisely by Wernich and adopted in its later form by 
 Schutte, the theory, namely, that beriberi is a kind of 'perni- 
 cious anfeviia, or, as Pacifico Pereira puts it, that it is a 
 " dystrophic " depending upon insufficient oxidation of the 
 blood, induced by a variety of debilitating influences, and 
 having its real cause in errors of diet. It seems to me to 
 be beyond question that a state of anaemia brought on by 
 disordered nuti'ition is an essential part of the morbid
 
 596 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 plienomcna ; but it is still a doubtful point wlietlier this ab- 
 normal nutrition constitutes tlie primary factor, the starting- 
 point of the malady/ or whether as Simmons thinks, it is a 
 secondary development in the course of the disease. Cer- 
 tainly beriberi occurs both endemically and epidemically, 
 where no error of diet can be discovered as the morbific 
 cause ; and on the other hand, poor diet in every possible 
 form and with all its consequences has been common in all 
 ages and in all parts of the world without any epidemic or 
 endemic of beriberi developing from it. Those who would 
 cling to the idea that this etiological factor is the true cause 
 of the malady, will have to find evidence that the bad food 
 acts in some such peculiar and specific way as would account 
 for the specific character of the disease ; but this has not 
 been done as yet in a satisfactory manner* 
 
 Lastly, beriberi has not escaped the fate of being counted 
 among the malarial diseases, in the opinion of many observers 
 such as Heymann, van Hattem, Swaving, Clapham, Roe, 
 Barry, Russell and others in India, Ceylon and the East 
 Indies, of Simmons in Japan, and of many of the authorities 
 in Brazil.^ The evidence for this consists partly in the 
 prevalence of both diseases together in endemics or epidemics, 
 and in the fact that persons who had suffered from malarial 
 fever sometimes take beriberi ; and it is partly derived from 
 the occurrence of beriberi on wet or marshy soil. Apart 
 from the consideration that there are scarcely two other dis- 
 eases which show so great difl^erences in their type and 
 evolution as beriberi and malarial disease (the enlargement of 
 the spleen, which is characteristic of the latter, being never 
 found in beriberi), and that the coincidence of two diseases 
 in time or place, (far from constant, moreover, in the present 
 instance,) is not of itself enough to show their identity, 
 there is the objection to be taken above all others to this 
 theory that the most intense foci of malaria in India, although 
 they immediately adjoin the beriberi districts — I have 
 specially in mind Orissa and the delta of the Ganges — are 
 
 '■ V. Lcent, who holds this opinion (' Geneesk. voor Nederl. ludie,' 1. c, p. 
 307), expresses himself very decidedly against identifying the anajmia of beriberi 
 with the so-called " pernicious anajmia." 
 
 2 See Feris, ' Arch, de med. nav.,' 1882, Aout, p. 83
 
 BERIBERI. 597 
 
 absolutely free from tlie latter disease, that the coast of 
 China, which is one of the chief seats of malaria, is but 
 slightly affected with beriberi, that Davy, although he in- 
 clines to the view of beriberi being a form of malarial sick- 
 ness, did not meet with a single case of it in Ceylon during 
 four years medical service there, and that beriberi has never 
 been seen in the great malarious countries of tropical Africa. 
 It is a hardly less telling fact against the malarial theory 
 that beriberi is endemic in many regions where malarial 
 disease is rare, as at Singapore and at a number of moun- 
 tainous places in the East Indies ; and still more decisive 
 facts are that epidemics of beriberi may develop on board 
 ship, that women enjoy an exemption, and that the non- 
 acclimatised are spared, although they are the very subjects 
 to suffer most from the influence of malaria wherever it is 
 endemic. 
 
 § 210. The Cause of it a SrECiPic one. 
 
 That beriberi is a specific morbid process, a disease sui 
 generis, is proved, not only by the ensemble of symptoms and 
 the whole type of the malady, which presents no clear analogy 
 to any other disease known to us, but also by its history in 
 place and time, by its epidemic outbreaks, and by its esta- 
 blishment as an endemic. From these facts we must con- 
 clude that there is a peculiar and specific cause ; and inasmuch 
 as the specific cause is not discoverable, according to the 
 present state of our knowledge, either in conditions of climate, 
 weather and soil, or in the general manner of living and 
 dieting among the inhabitants of the affected parts of the 
 globe, it must reside, as we have already indicated, in some 
 pathogenetic influence over and above these latter, which cannot 
 themselves be made out to be of importance for the development 
 of the disease except only in so far as predisposing or afford- 
 ing an opportunity. But altliough that assumption appears 
 to be justified, no one has succeeded as yet in coming to any 
 definite conclusion on the nature of the "morbid poison." 
 
 The conjecture that the morbid poison is some specifically 
 noxious thing in the food, brought about by the local condi-
 
 598 GEOGRAPHrCAL AND HISTORICAL PATHOLOGY. 
 
 tions, is a probable one, and tliere has been no lack of hypo- 
 thesis in that sense. At an early period the question was 
 propounded, whether it might not be some poisonous property 
 of {decomposed) rice that represented the cause of the malady ; 
 and that doctrine has recently found a defender in Kearney, 
 who, like Malcolmson at an earlier date, points to the 
 resemblance in particular symptoms between beriberi and 
 ergotism, although he brings forward no other positive evi- 
 dence to support his opinion. 
 
 Other observers think that the disease is of parasitic 
 origin. This hypothesis, worked out by Gelpke, makes a 
 very odd impression, and I give it in the author's own words : 
 
 " It is only a living poison, sucli as can lie long latent in the body, 
 and, perhaps, undergo sexual development therein, that can generate 
 beriberi; and in this sense I may compare beriberi with trichinosis. 
 Let no one misunderstand me, however. I claim for this beriberi-trichina 
 neither the size nor the sexual natural history of Trichina spiralis. But 
 the host of the parasite, at all events, is the dried fish upon which 
 prisoners are fed. These fish do not live in the waters of the Malay 
 Archipelago .... and I have ascertained as a matter of fact, 
 through my inquiries on the subject, that the fish is imported from 
 
 China The diffusion of the disease extends to every place 
 
 where the fish is caught and eaten ; it breaks out in epidemics wherever 
 the fish comes in its migrations .... or wherever its poisoned 
 flesh is introduced by commerce." 
 
 The evidence that Gelpke brings forward to support his 
 theory is little likely to create confidence in it. The same 
 remark applies to the writings of Erni, who believes that 
 he has discovered the cause of the malady in an aifection of 
 the intestinal mucous membrane due to the presence of 
 Trichocephalus dispar. Having had his attention drawn to 
 blood in the dejecta in the course of an attack of beriberi 
 (a phenomenon which has not been seen by other observers 
 except on the very rarest occasions),^ he found on post- 
 mortem examination of the congested mucous membrane of 
 the lower end of the ileum and of the caDCum, small defects 
 
 1 Among a very large number of patients with beriberi, Schenbe has found it 
 in only two cases, both of them the rapid and malignant form of the disease. 
 Simmons has found it only as a dysenteric complication. Other observers do 
 not mention it at all.
 
 BERIBERI. 599 
 
 of substance/ and in the intestinal canal large numbers of 
 Trichoceplialus dispar^ some of which, he thought, had bored 
 into tlie mucous membrane and caused those breaches of the 
 surface. Besides that parasite he found a species of small 
 round worm about 4 mm. long, his description of whicli is 
 very obscure. Erni is of opinion that the nervous symptoms 
 in the course of the malady are reflex phenomena, due to 
 irritation of the intestinal mucous membrane, and that the 
 complications of anemia and dropsy are to be explained by 
 the loss of blood caused by the parasites (as in the cachexia 
 aquosa of Anchylostoma duodenale). Having these state- 
 ments in view, Stammeshaus paid particular attention to the 
 condition of the intestine in the cases of beriberi which came 
 under his notice in the deadhouse. With a single exception 
 lie found Anchylostoma duodenale in the small intestine in 
 all the cases (forty-eight in number), but mostly in very 
 small numbers and far apart ; but he found these parasites 
 also in a fatal case of tropical dysentery, and in a case of 
 cancer of the uterus. On the other hand, he never found 
 Trichocephalus dispar. He concludes from his observations 
 tliat Anchylostoma duodenale is very widely diffused in tbe 
 Dutch East Indies ; that that parasite is not the proper cause 
 of beriberi ; although it is not to be denied that it may have 
 some influence in producing the characteristic anaamia. 
 Wucherer and da Silva Lima have also found in the intestine, 
 *' small worms resembling Anchylostoma duodenale " in the 
 bodies of several persons who had died of beriberi in Brazil. 
 
 * Wernich, who obtained ouly one post-mortem examination, found " extreme 
 hyperffimia in the ileum, and at the lower end of it dark spots like haemorrhages, 
 which also occurred in the caecum ; in the colon the vessels were a good deal 
 injected, but nothing else remarkable." Anderson, who had likewise only one 
 post-mortem examination, found submucous ecchymoses at a few places in the 
 upper part of the small intestine. Scheube, who examined three cases after 
 death, found in one of them " a cluster of punctiform htemorrhages in the ileum 
 just above the valve, of various sizes up to 3 cm. long ; the mucous membrane of 
 the small intestine more or less injected at various points, and here and there 
 swollen or oedematous ;" in the second case, " the intestinal mucosa more or less 
 injected over most of its extent, punctiform hajinorrhages at a few spots." The 
 third case was complicated with typhoid, so that no conclusion could be drawn 
 from the changes in the intestine, which might have belonged in part to the one 
 disease and in part to the other.
 
 600 GEOGEAPHIOAL AND HISTORICAL PATHOLOGY. 
 
 § 211. Leading Indications for the Etiology — No Evi- 
 dence OF COMMUNICABILITY. 
 
 It must be obvious that none of tliese hypotheses and 
 observations, although I have thought it necessary to repro- 
 duce them here as fully as possible, have dispelled the- 
 obscurity in which the nature of the morbific cause is shrouded,, 
 or have brought us any nearer to a solution of the problem ; 
 and it is a task reserved for the future to continue the search 
 after the specific element of the disease in one or other of 
 the directions indicated. In this inquiry there are, it seems 
 to me, four things to be specially kept in mind and attended 
 to : firstly, the comparatively rare occurrence of the disease 
 in childhood, in the female sex, and among the European 
 part of the population ; secondly, the unusual frequency of 
 cases among the crews of ships, or in bodies of troops quar- 
 tered in localities where there is little or nothing of beriberi 
 among the ordinary population ; thirdly, the rapid recovery 
 of the patient on leaving the focus of disease, or on changing 
 his mode of living ; and fourthly, the epidemics on board 
 ship. That the true cause in these last cases, and others 
 like them of which particulars have been given above (p. 588), 
 is not merely an affair of " mephitism " developed from the 
 crowding together of a number of persons in a small and ill- 
 ventilated space, is shown by the fact that the same hard- 
 ships occur every day on board transports and ships-of-war 
 without beriberi developing, as well as by innumerable other 
 instances of the same kind in all parts of the world. 
 
 If there should be any desire to speak of the unknown 
 morbific agent under the name of " miasma," there can be no 
 objection so long as nothing more is implied in the term 
 than an unknown factor, and no prejudice entertained in 
 favour of its telluric origin. At the same time it appears 
 to me to be doubtful at the present date of writing (that is 
 to say, in view of the observations published since i860), 
 whether the disease is to be reckoned among the infective 
 diseases properly so called ; and I hold it to be still less 
 justifiable, in regard to the etiology, to give way precipitately 
 to the modern craze for bacteria in this particular field of 
 inquiry, or to seek to establish the commiinicahility of the
 
 BERIBERI. 601 
 
 disease on the ground of casual and ambiguous facts. From 
 India and the Malay Archipelago we have not a single fact 
 affording certain proof that the disease is transmissible ; while 
 against the idea, there is the fact that beriberi continues to 
 be endemically prevalent in India at the present day within 
 the same narrow limits to which it was confined at the 
 beginning of the century. When it has broken out on board 
 ship among Indian coolies, it has never spread to the atten- 
 dants of the sick, the sailors and others ; and the observations 
 of practitioners in Brazil are just as decidedly opposed to 
 the importation or transmission of it by means of individuals 
 or by goods.^ 
 
 List op Writers on Beeiberi. 
 
 Kibeira de Almeida, Estudo sobre as condi9oes bygienicas das navios en 
 coura^ados. Eio de Janeiro, 1871. Da Costa Alvarenga, Gaz. med. de 
 Lisboa, 1874, ii, 133 il, 1874, iv, 29 ft". Anderson, Lectures on Kak-ke. 
 Yokobama, 1879. Armand, Gaz. med. de Paris, 1861, N. 15, 237, Feuill. 
 Arokeum, Madras Quart. Journ. of Med. Sc., 1863, July, 159, 
 
 Baelz, Infectionskranklieiteu in Japan u. s. w. Yokobama, 1882. (Ee- 
 printed from tbe Mittbeil. der deutscben Gesellscb. fiir Natur- und Volker- 
 kunde Ostasiens, Heft 27.) Balfour, Edinb. Med. and Surg. Joum., 1847, 
 July, 33. Bankier, Essay on tbe Origin . . of Cbolera. Witb Eemarks on 
 Beriberi, etc. Madr., 1835. Barry, Brit. Army Eeports for tbe year 1870, 
 xii, 490. Baur, Geneesk. Tijdscbr. voor Nederl. Indie, i860, viii, 472, 477 
 Beaufils, Arcb. de med. nav., 1882, Avril, 274. Beringer, Annuaire de la 
 Soc. meteorol. de France 1878, xxvi. Betoldi, Annal. univ. di med., 1878, 
 Giugno 526. Bontius, De medicina Indoi'um. Lib. iii, cap. i. Lugd. Bat., 
 ^758) 59. Brockmeyer, Arcb. de mod. nav., 1868, Dcbr., 416. 
 
 Carter, Transact, of tbe Bombay Med. Soc., 1847, viii. Cbristie, quoted 
 by Hunter. Clapbam, Med. Times and Gaz., 1872, Aug., 293. Clark, Obs. 
 on Diseases in Long Voyages, etc. Lond., 1792. Collas, Eevue coloniale 
 1852, viii, 402. 
 
 Davy, Account of tbe Interior of Ceylon, etc. Lond., 1821, 495. Day 
 (I), Madras Quart. Journ. of Med. Sc, 1861, Oct., 256. Day (II), Madras 
 Quart. Journ. of Med. Sc, 1862, Jan., 31. Dick, Edinb. Med. Commentar., 
 1790, X, 207. van Dissel, Nederl. Tijdscbr. voor Geneesk., 1866, x, 497. 
 Durand, Des alterations anat.-patbol. dans I'intoxication palustre a la Guyane 
 fran^. Montp., 1868, 9. 
 
 Eisinger, Geneesk. Tijdscbr. voor Nederl. Ind., 1863, x, 443. van der 
 Elst, Geneesk. Tijdscbr. voor Nederl. Indie, 1879, n. s., ix, 112. Erni, 
 Geneesk.' Tijdscbr. voor Nederl. Indie, 1882, n. s., xi, 97. Evezard, Madras- 
 Quart. Journ. of Med. Sc, 1862, Jan., 44. 
 
 ' See Feris, 1. c, Juin, p. 467.
 
 602 GEOGEAPHIOAL AND HISTORICAL PATHOLOGY. 
 
 Fayrer, Med. Times and Gaz., 1880, June, 631. Feris, Arch, de med. nav., 
 1881, Juin, 466, Juill, 50, Aout, 81 (he gives a full list of the Brazilian 
 writings on beriberi). Fontana, Bemerk. iiber die Krankheiten , . in 
 warmen Himnielsstrichen, etc. From the Italian. Stend., 1790, 90. 
 Francois, Arch, de mod. nav., 1878, Oct. Friedel, Beitrage zur Kenntniss 
 des Klimas und der Krankheiten Ostasiens. Berlin, 1S63, 7, 33. 
 
 Gelpke, Geneesk. Tijdschr. voor Nederl. Indie, 1878, n. s., viii, 256. 
 Godet, Etude sur I'hygiene au Japon. Par., 1880, 57. Guiol, Arch, de 
 med. nav., 1882, Oct., 273. Guy, Etude sur le beriberi epid. observe sur le 
 convois indien du trois-mats Vlndien. Montp., 1864. 
 
 Hamilton, Transact, of the Med.-Chir. Soc., 1826, ii, 12. Also in Lond. 
 Med. and Phys. Journ., 1828, March, 197. v. Hattem, Nederl. Tijdschr. 
 
 voor Geneesk., 1858, ii, 538. Hava, An. real. Acad, de cienc. med 
 
 de la Habana, 1S65, ii, 158. Hemeury, Etude sur le beriberi observ. a 
 I'hopital de Cayenne en 1876. Par., 1879. Heymann (I), Darstellung der 
 Krankh. in den Tropenlandern. Wiirzb., 1855, 175. (II), in Virchow's 
 Arch., 1859, xvi, 331. Hoffmann, Mittheil. der deutschen Gesellsch. fiir 
 Natur- und Volkerkuude Ostasiens, 1873, Heft 2, S. 16. Huillet, Arch, de 
 med. nav., i867, Dcbr., 401. Hunter, Essay on the Diseases Incident to 
 Indian Seamen or Lascars on Long Voyages. Calcutta, 1804. Hutchinson, 
 Madras Quart. Med. Journ., 1839, i, 364. 
 
 V. Kappeu, Geneesk. Tijdschr. voorNederl. Indie, 1863, x, 510. Kearney, 
 Madras Monthly Journ. of Med. Sc, 1872, Feb., 108. 
 
 Larrey, Arch, de med. nav., 1867, Aout, 150. v. Leent (I), Arch, de 
 med. nav., 1867, Octbr., 241. (II), ib., 1869, Sptbr., 176. (Ill), ib., 1872, 
 Jan., 9. (IV), ib., 1872, Fevr., 95. (V), ib., 1875, Fevr., loi. (VI), 
 Geneesk. Tijdschr. voor Nederl. Indie, 1880, n. s., ix, 272. (VII), Arch, de 
 med. nav., 1877, I'evr. (VIII), Allgem. Wien. med. Ztg., 1879, Nr. 41, 
 seq. Lesson, Voyage med. aixtour du monde. Par., 1829,98. Leudesdorf, 
 Nachrichten iiber die Gesuudheitsverhaltnisse in verschiedenen Hafen- 
 platzen, 1874, x, 28. Lind, Diseases Incidental to Europeans in Hot 
 Climates. Germ. Transl. Leipz., 1773, 245. Lindman, Geneesk. Tijdschr. 
 voor Nedcrl. Indie, 1854, iii, 130. Lodewijks, Geneesk. Tijdschr. voor 
 iSTederl. Indie, 1878, n. s. viii, 17. Lodewijks en Weiss, Geneesk. Tijdschr. 
 voor Nederl. Indie, 1881, n, s., x, 589. 
 
 Maget, Arch, de med. nav., 1877, Mai, 376. Malcolmson, Pract. Essay on 
 the History and Treatment of Beriberi, etc. Madr., 1835. Marshall, Notes 
 on the Med. Topogr. of the Interior of Ceylon. Lend., 1822, 161. And 
 Edinb. Med. and Surg. Journ., 1832, Oct., 332. Maze, Notice sur la fievr. 
 icterique grave et sur le beriberie. Montp., 1862. de Meijer, Geneesk. 
 Tijdschr. voor Nederl. Indie, 1861, xi, 441. v. Overbeck de Meijer, Geneesk. 
 Tijdschi-. voor de Nederl. Zeemagt, 1864, iii, i. Minteguiaga, Gaz. med. de 
 Paris, 1874, Nr. 3- Moore, Assoc. Med. Journ., 1856, Nov., 996. More- 
 head (I), Transact, of the Bombay Med. Soc, 1855, n. s., ii, 87. (II), 
 Clinical Researches on Disease in India. Lond., 1856, ii, 684. Mouat, 
 Transact, of the Calcutta Med. Soc, 1835, vii, 243. 
 
 Oudenhoven, Nederl. Tijdschr. voor Geneesk., 1858, ii, 577. 
 
 Paxmann, Observ. de Indorum morbis et med. Eintel., 1735. Pacifico
 
 BERIBERI. 603 
 
 Pereira, Gaz. med. da Baliia, iSSi, Jul. Sodre Pereira, These iiber Pai-a- 
 lysen. Bahia, 1867. Pompe van Meedervort, Geneesk. Tijdschr. voor 
 Nederl. Indie, 1862. Pop, Nederl. Tijdschr. voor Geneesk., 1859, iii, 23. 
 Praeger, Geneesk. Tijdschr. voor de Nederl. Zeemagt, 1864, ii, i. Pridham, 
 Historical . . Account of Ceylon, etc. Lond., 1849. Pi'uner, Krankh. des 
 Orients. Erlang., 1847, 309. 
 
 Kef. (I) in Madras Quart. Med. Journ., 1839, i, 70. Eef. (II) in Revue 
 coloniale 1852, Mai, 402. Ref. (Ill) in Statist. Reports of the Brit. Army, 
 1840, 14. Ref. (IV), Arch, de med. nav., 1866, Avi-il. Ref. (V) in New- 
 York Med. Record, 1881, Jan., loi. Ref. (VI) in Nederl. Tijdschr. voor 
 Geneesk., 1862, vi, 514. Rey, Arch, de med. nav., 1877, Jan v., 33. 
 Richaud, Epidemie de beriberi au bord du navire d'emigration le " Jacques 
 Coeur." Montp., 1876. Ridley, Dublin Hosp. Reports, 1818, ii, 227, 
 Robinow, Geneesk. Tijdschr. voor Nederl. Indie, 1863, xi, 492. Roe, Brit. 
 Army Reports for the year 1869, xi, 312. Rogers, Diss, de hydrope asthma- 
 tico. Edinb., 1808. Le Roy de Mcricourt (I), Arch. gen. de med, 1861, 
 Sptbr., 257. (II), Diet, encycl. du sc. med. Paris, 1869, Art. Beriberi, ix, 
 129. Rupei-t, Arch, fiir klin. Med., 1880, xxvii, 95, 499. Russell, Med. 
 Times and Gaz., 1881, April, 635, 
 
 Scheube (I), Beitr. zur Geschichte der Kak-ke. Yokohama, 1881. (Re- 
 print from the Mitth. der deutsch. Gesellsch. fiir Natur- und Volkerkunde 
 Ostasiens, Heft 24.) Scheube (II), Die japanische Kak-ke. Lpz., 1882. 
 (Reprint from Arch, fiir klin. Med., xxxi und xxxii.) Schmidtmiiller, Hamb. 
 Zeitschr. fiir Med., 1849, xli, 79. Schneider, Prager Vierteljahrschr. fiir 
 pract. Heilkde., 1857, ii, Miscell. 11. Schutte, Beriberi beschouwd als per- 
 nicieuse anaemic. Utrecht, 1879. da Silva Lima (I), Siglo medico, 1867, 
 April, 28. (II), Ensaio sobre o beriberi no Brazil. Bahia, 1872. Sim- 
 mons, China Customs Med. Reports for the Year 18S0. (Transl. in Arch, de 
 m^d. nav., 1S81, Avril, 257, and Geneesk. Tijdschr. voor Nederl. Indie, 
 1881, n. ser., x, 511.) Sollaud, Arch, de med. nav., 1882, Juin, 435. 
 Stammeshaus, Geneesk. Tijdschr. voor Nederl. Indie, 1882, n. s., xi, 117. 
 Stendijk (I), Geneesk. Tijdschr. voor de Nederl. Zeemagt, 1871, ix, 378. 
 (II), Geneesk. Archiv voor de N. Z., 1872, i, i. Swaving (I), Geneesk. 
 Tijdschr. voor Nederl. Indie., 1870, xiv. (II), ib., 49. 
 
 Tarissan, Essai sur le Beriberi au Bresil. Par., 1881. Thomson, Madi-as 
 Quart. Med. Journ., 1839, i, 467. Tulpius, Obsei'vat. med.. Lib. iv, cap. v. 
 Lugd. Bat., 1739, 286. 
 
 Vinson (I), Mem. de la Soc. de Biologic, 1853, v, 287. Vinson (II) 
 rUnion med., 1870, Nr. 14. 
 
 "Ward and Grant, Official Papers, etc. Pinang, 1831. Waring, Ind. 
 Annals of Med. Sc, 1856, April, 490. Wellsted, Travels in Arabia. Lond., 
 1838, ii, 252. Wernich (I), Geogr.-med. Studien, etc. Berl., 1878, 177, 
 293. (II), in Virchow's Arch., 1877, ^^'^'h 290. (Ill), Arch, fiir klin. Med., 
 1877, xxi, 108. Westhoff, Geneesk. Tijdschr. voor Nederl- Indie, 1879, 
 n. s., ix, 179. Wright, Edinb. Med. and Surg. Journ., 1834, April, 323. 
 
 Young, Transact, of the Calcutta Med. Soc, 1826, ii, 337. 
 
 Zuur, Geneesk. Arch, voor de Nederl. Zeemagt., 1873,1!, 266.
 
 CHAPTER XVII. « 
 
 SCROFULA. 
 
 § 212. HlSTOEICAL REFERENCES TO ScROFULA. 
 
 The word " scrofula " or '' scrophula " denoting an in- 
 flammatory kind of tumour, more particularly in tlie neck 
 but also in other superficial parts of the body where there 
 are many lymph-glands, such as the armpits and groins, is 
 first met with in the medical writings of the school' of 
 Salerno.^ 
 
 1 Scrofula or scrophula is derived from scrofa or scropha, a pig. It may seem 
 to correspond etymologically to the word ^otpaj, as derived from xoTpoc. a suck- 
 ing pig; at all events Leonides says (in Aetius, lih. xv. cap. v, ed. Basil., 1535 
 m, 72): "Choerades nomine a suibus mutuato apellantur: circa suum enim 
 mandibulas adenosi quidam glohuli inveniuntur, quibus struma, (choerades) assi- 
 milantur; sunt qui a copioso animulis partu nomen sumpsisse putent, quoniam et 
 copiosa eorum propago est." Whether this derivation of the word xoip&e is the 
 rightone, or whether it should not rather he taken in a figurative sense (yotpac 
 meanzng primarily « a stone »), appears to me to he open to question. Leonides 
 IS no trustworthy guide, inasmuch as he lived 600 or 700 years after the Hippo- 
 cratic period, when the word first became a technical term. The latter explanation 
 IS certamly more promising than the former; and it may be supported by state- 
 ments made xn several passages of the writings of Galen ('Lib. de tumoribus 
 praeter naturam ' cap. xv. ed. Kiihn, vii, 739, and ' Method, med./ lib. xiii, cap. v, 
 ed. cit., X, 881) to the eflect that the inflamed glands are named ^o^^ih^ when 
 
 term «''""f ^ ^^'if T ''''"'""' (-'PPwe..r.. o.o;u„). In constructing the 
 erm scrofula the school of Salerno followed the interpretation of Leonides ; 
 the first of them to use the word was Constantinus Africanus, who employs it in 
 several passages of his writings (< De morbis cognose. et curand.,' lib. vii, cap. 
 t2,?^^' ^ '^^' ""^'"' *^' expression is "scrophulae sunt dura apos- 
 
 ^C lee sT > ■*"" ""' '^ '''''''''''''' 'P^--*'-' l^b. H (in De EeSi's 
 
 tione' ib ^'^. r'' 7' '^^^'' """ "^ '^"' 'Tractatns de aegritudinum cura- 
 
 dk on Ea"'/ ^^' ' ty Rolando, ' Chirurgia,' lib. ii. cap. xii (in Abulcasim'. 
 
 the explanation is « unde dtit scVon^^^^^^ ' ^"^ / ''""'^ '^""■' "' '''^' ^^'^"'^ 
 unae aicit sciophula a scrofa, quoniam sicut scrofa parit
 
 SCROFULA. 605 
 
 It corresponds in meaning to tlie y^oipag of tlie Greeks, 
 and to the " strnma " of the Latin writers of antiquity, and, 
 with some restrictions to our notion of scrofulous glandular 
 tumours. As early as the Hippocratic collection there are 
 indications pointing to the particularly common occurrence 
 of these tumours in children, from which it may be inferred 
 that the disease of y^oipag was for the most part the same as 
 that which we have here to consider. The references are 
 still clearer in the writings of the later Greek physicians, 
 who associate the tumours with the glands in the neck, axilla 
 and groin, characterising them as inflammatoiy swellings of 
 the latter and dwelling upon the sluggish nature and pro- 
 tracted course of the inflammation. 
 
 In one passage of tlie Hippocratic writings^ we read : " Trpea-fivripoiai 
 ^£ yivojxevoKn {i.e. in the somewhat older class of children) xo'P«'^fC Kat 
 TaWa (pvfiara jidXurra Si rd Trposiprjix'sva." and in another^ : " 7r«pi St 
 j/XtKiwj/, fvpara /itv tjUTTua /cat rci y^oipwSta, ravra TrXelcrra ra TraiSia Icrxovai 
 KCLi fj^ara t? avriuiv d-iraWdacrti' Tvlai Se yepaiTepoiai r£ TtHv TraiSiuv Kal 
 viijvlaKoiai (pvETai fiiv iXdaerw, ■^aXtirwripov Se IK avTsiov aTraWacrcrovcri. 
 In the post-Hippocratic treatise ' De glandulis,' it is stated in regai-d 
 to the inflammation of the cervical glands:^ "(cai v (pXtyfioi'tj, a-Tuainov 
 ibv vypov, xoipuStg iyyivovrai." Galen in several passages'* says that, if 
 the inflamed glands {(iovfiiovsc) take on a scirrhous character, or become 
 hard, they are then known by the name of xo'pa'oef." {a-KippioOivTwv ovo/ua), 
 and that these are not prone to suppurate {tig t/iTrijjo-ij/) inasmuch as 
 they x^roceed, not v-n-6 Oepnijg vX»;c (ex calida materia), but from " a 
 mucous and cold dyscrasia."^ Leonides" wi'ites to the same effect: 
 
 multiplices fetus, ita liujusmodi passio generat semper inultas scrophulas." In 
 the medical writers of the latter part of the middle ages, such as Gordon (' Lilium 
 medicmn.' De apostematibus frigidis., Practic. i, rubr. 2, Lngd., 1574, p. 90), 
 John of Gaddesden ('Rosa Anglica,' Aug. Vindel., i595,p. 981), Guido ('Chirurg. 
 Tract.,' ii, cap. iv, Lugd., 1572, p. 77), and Valescus de Tharanta (' Philonium,' 
 lib. vii, cap. 29-30, Lugd., t490, foL 337 b), we continue to meet with the term 
 " scrophula." It is not until the sixteenth century that it begins to give place more 
 and more to " struma," which now got to be used by medical writers indiscrimi- 
 nately for scrofula and goitre, and continued to have this double significance until 
 the eighteenth century, wlicn scrofulous disease was thoroughly investigated, and 
 the old name was revived to distinguish it fi-oui goitre. It is only in England 
 that the adjective "strumous" is still applied to cases of scrofula. The term 
 " scrofulosis," to signify tlie process underlying the disease, is of recent date. 
 
 ^ ' Aphorism.,' sect, iii, § 26, ed. Littre, iv, 498. 
 
 - ' Predictor.,' lib, ii, § 11, ed. cit., ix, 30. 
 
 ^ § 2 and 7, ed. c. viii, 556, 562. 
 
 ■* LI. cc. and ' De locis afl'cctis,' lib. i, cap. iii, cd. c. vlii, 31. 
 
 5 ' Comment, in Hipp. Aphor.,' cap. xxxvi, cd. c. xvii, B. 637. ^ L. c.
 
 606 GEOGRAPHICAL AND HISTOEIOAL PATHOLOGY. 
 
 " Sunt autem strumte (i.e. xo^pa^^s) carnes subcandidse auctu faciles, 
 intra membranam contentse, utque sammatim dicam glandulse indnratse, 
 unde et in collo, axillis, inguinibus fere generantur, ubi glandulae vasis 
 substrataj collocantur." 
 
 The same conception and description of the form of dis- 
 ease is met with in tlie works of such of the later Greek and 
 Eoman^ writers on medicine as treat of the subject at all_, 
 including Paulus ^gineta^ and Theophanes Nonnus ;^ also 
 in those of the Arabian school,* the school of Salerno,^ and 
 in other physicians of the middle ages.^ And although the 
 diagnosis of the tumours in question in all these authorities 
 is by no means a very precise one, although they have 
 plainly confounded with them various other forms of tumour 
 (particularly syphilitic glandular swellings) not only in the 
 naming but also in fact ; it is none the less certain from 
 their accounts that glandular swellings played the chief part 
 among those yotpaSf c? '^ scrofulas " and " strumas '' ; and we 
 may find evidence that even the specific character of the 
 disease was to some extent correctly recognised, in the refer- 
 ences to its especial frequency in childhood, to the " cold and 
 mucous nature " of the tumours, and to the special features 
 in the course of the malady dependent thereon, whereby it 
 was distinguished from ^^ phlegmonous ^' inflammations. 
 
 This acquaintance with the scrofulous disease of external 
 lymph-glands, and discrimination of them from other glandu- 
 lar tumours, came out still more definitely in the medical 
 writings of the sixteenth and seventeenth centuries. But 
 it was not until the close of the seventeenth century that 
 the intimate connexion between the glandular affection and 
 
 1 Celsus, lib. v, cap. xxviii, § 7, ed. Alineloveeu. Basel, 1748, 323 : " Struma 
 est tumor, in quo subter concreta quaedain ex pure et sangiaiiie quasi glaiidulae 
 oriuntur." 
 
 ^ Lib. vi, cap. xxxv, Lugd., 1551, 385. 
 
 ' Epitome, cap. cxxiv, ed. Bernard, Gotha, 1794, i, 378. 
 
 '' See Rliazes, ' Be re medica,' lib, vii, cap. viii, and ' Divisiouum,' lib. i, cap. 
 cxxix, in Opuscula, Basil., 1544, 167, 427 ; also Abulcasim, • De Chirurgia,' lib. i, 
 cap. xii, and lib. ii, cap. xlii, ed. Channing, Oxon., 1778, 51, 223, ed. Leclerc, 
 Par., 1861, 29, X18; and Avicenna, 'Canon,' lib. iv, fen. iii, Tract, ii, cap. ix, ed. 
 Venet., 1564, ii, 123. 
 
 ^ See the authors quoted in note i. 
 
 " Conf. ibid, and Actuarius, ' Melbod. med.,' lib. ii, cap. xii, in Slepliani, 
 ' Collect.,' 190.
 
 SCROFULA. 607 
 
 otlier local lesions, either coexistent or subsequout, began 
 to be kept more directly in view ; and thus tliere aldose the 
 notion of " scrofulous disease " as the outcome of constitu- 
 tional errors of nutrition depending on a morbid diathesis. 
 Next to the works of Wiseman/ CuUen,^ and other British 
 authorities, the writings that contributed most to instruct 
 the great medical public on this subject were the articles^ by 
 Faure, Borden, Charmetton, Majault and Goursaud, which 
 were sent in as prize essays to the Academic de Chirurgie 
 of Paris and were published by it ; also the writings of Hufe- 
 land^ and Weber^ connecting with these ; but most of all the 
 excellent work of Kortum." However, it was not long before 
 writers began to indulge in vague speculations on the nature 
 of the disease, resorting for an explanation of its pathogenesis 
 to the idea of a " scrofulous acrimony." At the same time 
 the scrofulous disease became the Alpha and Omega of 
 practice in children's diseases ; and for that period of life it 
 very soon came to take the place that the '^ hajmorrhoidal 
 disease,^' inaugurated by the Stahlian doctrine of the golden 
 vessel, had won for itself in the ill health of later life. As 
 Henle^ says, scrofula was a bugbear that was made, with 
 no obvious or sufficient reason, to carry everything of a 
 morbid kind that befel a child under fourteen years of age. 
 Pathological anatomy put an end to that unreal state of 
 things ; but it conducted to an opposite extreme. It taught 
 that there was nothing specific in the whole series of morbid 
 changes in scrofula, that it was a matter of chronic inflamma- 
 tory processes in various tissues, — lymph-glands, mucous 
 membranes, the skin and the bones, — such as were found in 
 many other diseases ; and it looked, to quote Henle again, as 
 if the ancient family of scrofula were about to perish through 
 their own excesses. In this movement, indeed, the good was 
 o rid of with the bad. Those who looked at things from 
 
 1 ' Eight thirurgical treatises.' Lond., 1696, Nr. iv : ' Of the King's evil.' 
 ^ ' First Lines in the Practice of Physic,' Ger. ed., Leipz., 1785, iv, 190. 
 ^ ' Recueil des pieces qui ont concouru pour Ic prix de I'Acud. roj. de Chirur- 
 gie,' Paris, 1759, iii, 21—351. 
 
 * ' Ueber die Natur . . . der Scrofelkrankheit,' Bei-l., 1785. 
 
 5 ' Von den Scrophehi u. s. w.' (einz.) Theil, Salzburg, 1793. 
 
 6 ' Coniraentarius de vitio scrofuloso,' ii tomi, Lemgo, 1789, 90. 
 
 ' ' Haudbuch der rationellen Pathologie,' Braunschweig, 1847, ii, 376,
 
 608 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 tlio gross anatomical point of view, took no account of 
 clinical facts ; tliey made tlie mistake of thinking that 
 the peculiarities of a disease were really to be sought in the 
 crroupino" of the local lesions, that the anatomical analysis of 
 all diseases whatsoever conducts us to a comparatively small 
 number of elementary pathological processes, and that it is 
 the way in which these are grouped together that determines 
 those peculiarities of each concrete disease which we judge 
 of from the clinical point of view. That was another one- 
 sided doctrine which has been overthrown in its turn, and 
 that too without any falling back into the old error ; so that 
 at the present day it is not seriously disputed that the 
 scrofulous morbid process, comprising the various local lesions 
 of which it is made up, is marked by a unity and specificity 
 such as secure for it, as scrofulosis, a place among the con- 
 stitutional disorders of nutrition. Or, if the conclusion that 
 has been drawn from Koch's discovery of so-called tubercle 
 bacilli in scrofulous glands, — that the parasite is the specific 
 excitant of the disease, — be a genuine one, its place would 
 be among the parasitic diseases. 
 
 Although this brief summary of the development of the 
 doctrine of scrofula does not, strictly speaking, belong to 
 my proper subject ; yet it seemed to me desirable to insert 
 it in order to show what difficulties are encountered in the 
 history of scrofulosis, difficulties in answering the questions 
 as to the changes in the amount of the disease in the 
 course of centuries and as to any differences noticeable 
 within the several periods, and whether scrofula, as often 
 asserted, has undergone any considerable increase of late. 
 These difficulties arise from the circumstance above men- 
 tioned that the notion of " scrofula " was until not very 
 long ago an altogether indefinite one ; that until the six- 
 teenth century, and even later, various forms of glandular 
 swellings and other sorts of tumours about the neck, even 
 goitre itself, were received in the group of yroipa^e^, 
 " scrofulas " or " struma^,'' while we are at this distance 
 of time unable to judge from the descriptions of observers 
 how much belonged to one thing and how much to another ; 
 and that, in the last century and early part of the present, 
 after the process of scrofula had become familiar in
 
 SCEOFULA. . 609 
 
 its various pathological expressions, every conceivable form 
 of children's disease wliicli men did not know what else to 
 make of was brought under scrofula, so that scrofulosis 
 dominated the whole of peediatrics. 
 
 Regarding the history of scrofula, all that one can say 
 with safety is that the malady has been prevalent at all 
 times. On the other hand, it is a question whether any con- 
 siderable increase in its amount has taken place in recent 
 times, or whether the increase is not rather an apparent one, 
 depending on an erroneous extension of the meaning of the 
 term.^ But it is a quite unproven assumption, and I am 
 convinced that it is an altogether erroneous one also, that 
 scrofula did not attain its present wide diffusion in Europe 
 until the inoculation with the small-pox and vaccination were 
 introduced, and until the potato became a general article of 
 diet. This is a clear instance of the clumsy fallacy ; two 
 events coincide in time, namely, the introduction of those 
 beneficent innovations, and the retrograde enlargement of 
 the idea of " scrofula," and these have been brought into 
 connexion ; or, in other words, there has been first of all a 
 mystification as to terms, and on the top of that the fallacy 
 of post hoc ergo jpropter hoc. At the same time it is not to 
 be denied that the malady has undergone ups and downs in 
 the course of centuries at various parts of the world, accord- 
 ing as the etiological factors favouring its production have 
 been to the fore or not ; and, as we shall see in the sequel, 
 it is only within the very latest times that the disease has 
 become at all general in some countries. 
 
 ^ On the other hand, Phillips (' Scrofula : its Nature, Causes, &c.,' Lond., 
 1846, p. 92), deduces from the mortality statistics the conclusion that the disease 
 in Loudon had declined considerably between 1700 to 1831. While the mor- 
 tality from scrofula in 1 700 was in the proportion of i to 9*80, it amounted in 
 1831 only to I in i35'89. It is clear that this statistical result possesses no 
 value; in the first place it is derived from a small number of cases (in 1700 there 
 were 73 deaths returned from scrofula in a population of 665,000, and in 1831 
 there were 9 deaths in 1,233,000) ; and in the second place the materials on 
 which the statistics are based do not deserve to be trusted in the slightest degree. 
 
 VOL. 11. 39
 
 610 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 § 213. Present Geographical Distribution. 
 
 Scrofula has very decidedly the character of an ubiquitous 
 disease ; its geographical area extends over the whole of the 
 habitable globe. In some regions and in particular tracts 
 of country it is seen more frequently than in others ; although 
 we are not warranted in saying that it is anywhere properly 
 endemic. No definite or numerically expressed measure of the 
 number of cases in the several regions is attainable ; for the 
 statistics are either wanting, oi', in the case of the statistics 
 of hospitals and the mortality returns, they are for obvious 
 reasons unsuited to such a purpose. The most useful tables 
 in this respect are the recruiting lists, giving the number of 
 recruits rejected as unfit for service on account of scrofula; 
 although even these have a limited value, as afi^ecting only a 
 somewhat mature age and only the male sex. Accordingly 
 in the account that follows of the frequency of the malady, 
 I must content myself with repeating the general terms in 
 which the authorities speak of the number of cases, such 
 terms as " very common,^^ '' common," " rare," and the 
 like. 
 
 Europe is truly classic ground for scrofula ; for there is 
 scarcely a single considerable tract of country in it that is 
 not affected more or less. In the Iberian Peninsula,^ the 
 head quarters of the malady are the large towns, both those 
 on the elevated table-land of the interior and those on the 
 plains and the sea coast ; and even places with a specially 
 good climate, such as Valencia and Cadiz, are not free from 
 it. In Lisbon scrofula is so prevalent that in 1842, accord- 
 ing to the returns of Rozas,^ the orphanage of that city 
 designed for children from four to sixteen years of age, con- 
 tained 279 among its 800 inmates (or 35 per cent.), who 
 showed the most undoubted signs of scrofula. The diffusion 
 of the disease in Italy may be gathered from the figures 
 
 ^ Faure, ' Souvenirs du midi, etc. ;' Lugol, ' Untersucbungen und Beobach- 
 tungen iiber die XJrsacben der scropbulosen Krankheiten,' From tbe French. 
 Leipz., 1845, 214; Phillips, 1. c, 87; Trogher, 'Briefe wiihreud einer Reise 
 durch Istrien u. s. w.,' Triest, 1855, 137, 157, i6i. 
 
 =* Phillips, 319.
 
 SCROPULA. 
 
 611 
 
 extracted by Sormani^ from the conscription lists of 1863- 
 1876. According to these returns, the number of persons 
 of the age of twenty who were rejected for scrofula amounted 
 to 3*5 per 1000 of those examined. According to provinces 
 and circondarias they were distributed as follows : 
 
 Yalsesia (Piedmont) 
 
 IO-8 
 
 Malfi (Basilicata) 
 
 95 
 
 Domodossola (Piedmont) 
 
 8-8 
 
 Parma (Emilia) . 
 
 8-8 
 
 Milan (Lombardy) 
 
 7-8 
 
 Paola (Calabria) . 
 
 77 
 
 Porto Maurizio (Liguria) 
 
 7-6 
 
 Pavia (Lombardy) 
 
 7-5 
 
 Mantua (Lombardy) 
 
 7-1 
 
 Monza (Lombardy) 
 
 6-7 
 
 Pisa (Tuscany) 
 
 6-7 
 
 Vergato (JGmilia) 
 
 6-6 
 
 Como (Lombardy) 
 
 6-6 
 
 Pistoja (Tuscany) 
 Massa (Tuscany) . 
 Mazzara (Sicily) 
 Udine (Venetia) 
 Civita Yeccbia (Rome) 
 Sondrio (Lombardy) 
 Perugia (Umbria) . 
 Orvieto (Umbria) . 
 E/ieti (Umbria) 
 Brescia (Lombardy) 
 Fermo (Marches) . 
 Rovigo (Yenetia) . 
 
 6'3 
 
 6-2 
 
 61 
 5-6 
 5-6 
 54 
 50 
 SO 
 50 
 4-7 
 4*1 
 2-8 
 
 From the results of this inquiry, which are borne out and 
 in part amplified by the special accounts referred to in the 
 notes, it follows that scrofula is very common all over Italy ; 
 as Parola^ says, " fra le cachessie la piii diffusa/^ But its 
 distribution throughout the country is very unequal, and 
 these inequalities are altogether independent of the geogra- 
 phical position of the several places or of their elevation 
 above the sea-level. The worst districts are some of those 
 in Piedmont, especially the circondarias of Aosta, Cuneo, 
 Vercelli and Novara ; ^ in Lombardy^ the circles of Milan, 
 Pavia, Mantua, Como, Sondrio, Bergamo, Cremona ; in 
 Yenetia,^ particularly the provinces of Venice, Vicenza and 
 Udine, while Verona enjoys a remarkable immunity i^ in 
 
 * ' Geografia nosol. dell' Italia,' Roma, 1881, 143. 
 
 ^ 'Saggio di climatologia e di geogr. nosol. dell' Italia,' Torino, 1881, 494. 
 
 ' Dubini, ' Gaz. med. di Milano,' 1847, Nr. 46; MafEoni, ' Atti dell' Acad, 
 med.-cliir. di Torino,' ii, 453. 
 
 '' See references in 'Oest. raed. Jahibb. Neueste Folge,' xi, iQ,xxi, 3 j Hilden- 
 brand, ' Annal. scbol. cliu. Ticin,' Papiffi, 1826,1, 117; Speranza, ' Annal. univ. 
 di med.,' 1856, Marzo, 449; Comolli, 'Gaz. med. di Milano,' 1848, 305; Tassani, 
 ib., 1847, 173; Balardini, ' Topogr. stat. med. della provincia di Soudrio,' 
 Milano, 1834, 55. 
 
 5 Taussig, ' Venedig und seine klimat. VerLiiltnisse,' Venedig, 1847; Parola 
 Ic. 
 
 6 Agostini, ' Annali, univ. di med./ 187.^, Dcbr., 478; Parola, 1. c.
 
 612 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Liguria, the circondarias of Genoa, and Porto Maurizio ; ^ in 
 Tuscany, the districts of Pisa, Pistoja, Massa and Siena ;^ in 
 . Eoman territory, Civita Veccliia;^ in tlie Emilia, the towns 
 of Ferrara and Bologna;* in tlie Marches, Ancona;^ in 
 Campania, the circondarias of Naples and Terra di Lavoro ;^ 
 in Apulia, Foggia;'^ and in Sicily, Palermo. It is common 
 also in Sardinia,^ but in Corsica it would appear to be sur- 
 prisingly rare.^ 
 
 For France also there are statistical returns^° of the 
 amount of scrofula in the recruiting lists from 1831 to 1853. 
 According to these the malady occurred at the rate of 10 per 
 1000 of those examined, or three times as often as in Italy .^^ 
 This average sick-rate was distributed among the several 
 departments as follows 
 
 In I Dpt. (Pas de Calais) . . . i'3 per 1000 
 
 „ 3 Dpts. (Pyren. oi'ient., Gironde, Yendee) . 4"o — 5*0 „ 
 „ 6 „ (Basses- Alpes, Gers, Indre, Charente, 
 
 Eure, Morbilian) . . 5'2 — &o „ 
 
 „ 1 1 „ (Hcrault, Indre-Loire, Haute-Garonne, 
 Hautes-Pyrcn., Somme, Haute- 
 Yienne, Yaucluse, Tarn-Garonne, 
 Seine-Mai'ne, Meurthe, Doubs) . 62 — 70 „ 
 ,,12 „ (Ille-Yillaine, Gard, Lot-Garonne, 
 Seine-Oise, Aude, Haute-Marne, 
 Ardennes, Correze, Seine infer., 
 Calvados, Haute-Saone", Bouches- 
 du-Rhone) . . • 7"i— 8*0 „ 
 
 ^ Speranza, L c; ' Descrizione di Geneva,' &c., 1846. 
 
 * Speranza, 1. c.j Dauesi, 'Relaz. topogr. . . . della citta di Siena,' &c., Siena, 
 1842. 
 ^ Jacqnot, ' Gaz. med. de Paris,' 1853, 532. 
 ^ Parola, 1. c. 
 
 '" Briard, ' Travaux de la Soc. de med. de Dijon,' Ann., 1834 — 37, 122. 
 ® de Renzi, ' Topogr. statistica-medica della citta di Napoli,' &c.. Nap., 1845 t 
 Parola, 1. c. 
 7 lb. 
 
 ^ Moris in de la Marmora, ' Voyage en Sardaigne.' 
 9 Vanucci, ' Bull, de I'Acad. de med.,' 1838, Mai. 
 
 10 According to Boudin, 'Traite de geographie et statist, med.,' Par., 1857, ii, 
 " According to Chervier's figures (' Annal. de demograpliie,' 1880), taken from 
 the conscription lists of the French army for the years 1850-69, the mean rate of 
 sickness from scrofula was 17-04 per 1000. The enormous difference in the 
 amount of the disease hetween the male populations of Italy and of France is no 
 doubt explicable in great part by the fact that the French military surgeons took 
 a much wider view of the term " scrofula " than the Italian ; but it may be 
 explamcd in part also by the greater prevalence of the disease in France.
 
 SCROFULA. G13 
 
 I 
 In i5Dpts. (Sartlie, Jura, Clier, Loire iufer., Cotes- 
 
 du-Nord, Mayenne, Meuse, Ardeche, 
 
 Charente infer., Marne, Cote-d'Or, 
 
 Tarn, Maine-Loire, Ain, Finistere) . 8'i — 9*0 per 1000 
 „ 16 ,, (Tonne, Eure-Loir, Lot, Yienne, 
 
 Drome, Var, Loire-Cher, Basses- 
 
 Pyren., Manclie, Arriege, Allier, 
 
 Isere, Creuse, Bas-Rhin, Dordogne, 
 
 Saone-Loire) . . . 9'i — lo'o „ 
 
 „ 8 „ (Moselle, Seine, Puy-de-Dome, Aisne, 
 
 Orne,Aube, Aveyron, Hautes-Alpes) no — i2'o „ 
 „ 8 „ (Loiret, Yosges, Haiit-Rliin, Rlione, 
 
 Landes, Deux-Sevres, Loire, Oise) . i3"o — iS'o „ 
 „ 5 „ (Haute-Loire, Lozere, Cantal, Nord, 
 
 Nievre) . . . 20'o— 30*0 „ 
 
 These facts^ taken along with more special inform ation^ 
 teach us that in France there are a few great centres of 
 scrofula which do not owe their pre-eminence, we may 
 remark at the outset, to its prevalence in large towns such as 
 Havi'e, Lille, Nantes, Paris, E-heims, Strasburg, Toulouse, 
 and Marseilles, or at all events not to the urban element 
 alone. One of the greatest of these centres includes the 
 south-eastern departments of Haufces-Alpes, Isere, Rhone, 
 Loire, Haute-Loire, Lozere, Cantal and Aveyron (comprising 
 a large part of Dauphine,^ Lyonnais^ and Languedoc) ; and 
 in that region the average sick-rate from scrofula is 15 to 20 
 per 1000. Joining on to that is another area, including the 
 departments of Saone-Loire, Allier, Puy-de-Dome, Creuze, 
 Nievre and Loiret, and extending from Auvergne through 
 Bourbonnais and Nivernais ; ^ also a focus in the Jura 
 (Franche Corate),* another in Alsace (Haut-Rhin, Bas-Rhin 
 and Vosges)/' and a third in the north of the country, par- 
 
 * See Grange, 'Anual. tie Cliimie et de I'hys.,' xxiv, 364; Lepelletier, 'Traite 
 ■eomplet sur la maladie scrofuleuse,' Paris, 18.^0. 
 
 ^ Maviiig et Quesnois (' Topogr. et stat. mod. dii Dpt. du Ilh&iie,' Lyon, 1866), 
 ■estimate from the conscription lists from 1854 to 1863 that the number of 
 persons rejected as unfit for militai-y service on account of scrofula in the Depart- 
 ment of the Rhone was i3"8 per 1000, and tliat in some cantons the figures rose 
 to 2 2'S, and even to 30 per 1000. 
 
 ■* See Brieude, ' Hist, et mem. de la soc. roy. do mud.,' v, Mem., 306 (referring 
 l/j Upper Auvergne). 
 
 * Germain, ' Annal. d'hyg.,' 1850, Juli, 123. 
 
 * Didelot, 'Hist, et mem. de la soc. roy. de mod.,' ii. Hist. 135; Cuynat, 
 Travaux de la soc. de med. de Dijon,' 1832, 22; Georgeou, ' Consider, gen. sur
 
 614 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 ticularly in the Department du Nord,, where the colliery 
 districts, as well as the city of Lille^ furnish a very consider- 
 able contingent of the cases. 
 
 In Switzerland scrofula is prevalent in the large towns, 
 and, after them, more especially in the deep-cleft valleys on 
 the slopes of the Jura and the Alps ; most of all in the 
 Ehone valley from Vallais to St. Maurice, next in the 
 Canton of Bern and in the valleys running towards Lake 
 Lucerne, and to a less extent among the High Alps and on 
 the plains.^ 
 
 In Belgium, as all the authorities agree, it is only since 
 the first quarter of this century that scrofula has come to be 
 so generally diffused ^ as we now find it, particularly in East* 
 and West^ Flanders and in Antwerp.^ Holland, on the 
 other hand, has been from the first and is still one of the 
 chief seats of scrofula.^ 
 
 Next we come upon a very extensive region of scrofula 
 in Germany and Austria. Besides the large towns such as 
 Munich,^ Vienna, Stuttgart,^ Dresden,-^° Leipzig,^^ Berlin,^" 
 Stettin,^^ Hamburg, Danzig and Breslau,^* there are many 
 
 I'hygiene dans les campagnes de la partie montagneuse des Vosges,' Strasb., 1863, 
 27. 
 
 * Bouisson, '^^tude med. sur I'ouvrier houillier,' Par., 1866. 
 
 ^ See Lebert, ' Lehrbuch der Scrophel- und Tuberkelkranklieiten.' From the 
 French. Stuttg., 1851, 46; and Lombard, ' Traite de cliinatol. med.' 
 3 Meynnc, ' Topogr, med. de la Belgique,' Brux., 1865, 116. 
 
 * Overloop, * Annal. de la Soc. de med. de Gand,' 1842, Oct.; Waldack, ib., 
 184s, Jan., 69. 
 
 ^ Woets, ' Annal de la Soc. de med. de Bi'uges,' i, 1 7. 
 
 ' Thys, -'Annal. de la Soc. de med. d'Anvers,' 1845, 37; Luyks, 'Arch de la 
 med. beige,' 1845, Juin, 78 ; Peutermans, ib., Aug., 181. 
 
 7 Thyssen, ' Geschiedk. beschouw der ziekten in de Nederlanden,' Amsterd., 
 1824; Dolleman, 'Disquis. hist, de plerisque apud Belgas septentr. endemiis 
 morbis,' Amstel., 1824, 65 j Guislain, 'Annal. de la Soc. de med. de Gand,' 1842, 
 Jan. 
 
 8 According to information obtained by Phillips, two thirds of all the children 
 received into the Munich orphanage suffer from scrofula. 
 
 3 Plieninger, ' Beschreibung von Stuttgart u. s. w.,' Stuttg, 1834. 
 
 ^° Meyer, ' Versuch einer med. Topographic . . . vou Dresden,' Stolberg, 1 840, 
 253- 
 
 " Krug, 'Acta policlinica,' Lips., 1841, 60. 
 
 " The scrofulous children among the inmates of the Fricdrich Orphanage at 
 Berlin are 53 per cent, of the whole. 
 
 >3 Miiller in ' Hufeland's Journ. der Arzeneikde,' 1843, ^^^h 9°- 
 
 " Graetzer, ' Beitr. zur med. Statistik der Stadt Breslau,' Bresl., 1834.
 
 SCEOFULA. 615 
 
 otlier foci of it of greater or less extent, sucli as tlie Ditt- 
 marschen/ the Harz^ country, the Saxon Metal Mountains/ 
 Upper Silesia/ the valleys of the Giant Mountains/ many 
 parts of Westphalia/ Thuringia/ Odenwald/ certain moun- 
 tainous circles of Bohemia/ several parts of Upper Austria/^ 
 Salzburg/^ Styria/^ and the Austrian Military Frontier .^^ 
 
 In Great Britain the populous centres of trade and manu- 
 facture have always been the principal seats of scrofula.^* 
 Phillips estimates from an enumeration of sick persons (which 
 is, however, a very untrustworthy one) that an average of 
 24' 5 per cent of the population in England are affected with 
 scrofula, the rate falling in some parts of the country to 1 1 
 per cent, and in others rising to the (extremely questionable) 
 figure of 72 per cent. In Ireland also, according to Wylde's^^ 
 researches, the malady has been prevalent in widest diffusion 
 from the earliest times. In the Shetland Islands scrofula 
 is said to be indigenous in almost every family .^^ 
 
 1 Dohrn in ' PfafE's Mittheilungen,' Neue Folge i. Heft 6, 32. 
 
 2 Klinge in ' Hufeland's Journ. der Arzeneikde.,' 1 798, vi, 902 ; Wendelstadt, 
 ib., 1801 ; lii, Heft 2, 125 ; Fuchs, ' Hannov. Aiinal. der Heilkde,' 1840, v, 73. 
 
 3 Petrenz, ' Wochentl. Beitr. zur Klinik, 1833, i, 245 ; Ettmiiller, ib., 1834, i, 
 611. 
 
 4 Loriuser, • Pr. med. Vereins-Ztg., 1833, No. 12. 
 
 * Preiss, * Die klimatischen Verhaltnisse des Warmbrunner Thales u. s. w.,' 
 Bresl., 1843. 
 
 * Nicolai in ' Rust's Magazin,' xxxix, 97 ; * Sauitatsberichte aus Westfalen/ 
 
 i845» 45- 
 7 Fuchs, ' Topogr. des Kreises Schmalkaldcn,' Marb., 1848; Liibbeu, 'Corre- 
 
 spondenzbl. des arztl. Vereins von Tliiiringen,' 1880, Nr. 4, 112. According to 
 the reports of Thuringian practitioners for 1874 and 1875, scrofula (and rickets) 
 were found most seldom in the valley of the Werra, next to that in the moun- 
 tainous districts, and most commonly in the Thuringian basin at elevations of 
 150 to 300 metres (500 to 1000 feet). 
 
 * Ebel in ' Hufeland's Journ. der Arzeneikde.,' 1840, Juni, 106. 
 
 3 'Oest. med. Jahrbb.,' 1840, Nste. Folge, xxiv, 608, 1843, ii, 354, 1845, iv, 
 
 334- 
 " lb., 1831, Nste. Folge, i. Heft 4, 46, 1834, vii, 359, 1840, xxiv, 265. 
 
 " lb., 1836, xi, 391, 1844, iv, 360; Maffei, ' Der Cretinismus u. s. w.,' 175. 
 
 12 Pilz, ' Oest. med. Jahrbb., 1848, i, 357, iii, 80; Macher, ' Med.-statist. Topo- 
 graphic des Herzogthums Steyermark,' Graz, i860. 
 
 13 Miiller, 'Oest. med. Jahrbb,' 1842, i, 227, 340, 1843, iv, 343. 
 
 ^* See Autenrieth, ' Uebersicht der Volkskrankheiten in Grossbritanien, 
 Tubing, 1823, 93 i Forbes, ' Transact of the Prov. Med. Assoc.,' iv, 189 ; Alison, 
 ♦Lancet,' 1841-42, i, 800. 
 
 " ' Edinb. Med. and Surg. Journ.,' 1845, J^^y "» 12, 16. 
 
 16 Sexby, in 'Dobell's Eeports,' 187 1, 522.
 
 616 GEOGKAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Accounts tlie same as these of the common, or, as it is 
 called, endemic occurrence of scrofula, come to us from 
 Denmarh,^ Norway and Sweden. In Sweden (as in Belgium) 
 it is only since tlie beginning of the century, according to 
 Huss/ that the malady has appeared in some districts, such 
 as Angermanland, and in others attained its present general 
 diffusion. The worst districts are Malmohus, Halland, 
 Calmar, Jonkoping, Skaraborg, Bohus, Nykoping, Upsala, 
 Stockholm and Fahlu.^ The assertion of Schleisner* that 
 scrofula is rare in Iceland is contradicted by Finsen.' But 
 Manicus*" and Panum^ agree that it is rare in the Faroe 
 Islands, being seen, according to the latter authority, only 
 in the children of Danish families. 
 
 There are many accounts of the occurrence of scrofula 
 throughout the enormous extent of the Russian Emjpire ; and 
 these, casual though they be, enable us to conclude that the 
 cases are numerous and widely distributed. This applies 
 most to Poland,^ St. Petersburg,^ and the Baltic Provinces j^° 
 but there are corresponding accounts from Kovno,^^ Mohilev,^^ 
 Jaroslav,^^ Novgorod,^* Kursk,^^ Kasan,^'' Viatka,^^ Kishniev,^** 
 
 ^ Otto, in ' Eust's Magaz. fiir Heilkde,' liv, 203. 
 ^ ' Om Sverges endemiska Sjukdomar,' Stockh., 1852, 9. 
 
 3 Huss, 1. c, 18, 20, 54, 67, 87 ; and Berg, ' Bidrag till Sveriges med. Topografi 
 och Statistik,' Stockb., 1853, a. v. 0. 
 
 * ' Island undersogt, &c.,' 3. 
 
 5 ' Jagttagelser angaaende Sygdomsforboldene i Island,' Kjobenh., 1874, 57. 
 
 * 'Bibl. for Laeger,' 1824, i, 15. 
 ' lb., 1847, i, 277.310. 
 
 8 Tbeiner, * Magazin fiir Heilkde. iu Polen,' 1828, 224. 
 
 9 Attenbofer, ' Med. Topogr. der Hauptstadt St. Petersburg,' Ziirieb, 181 7, 230; 
 Heine, in ' Scbmidt's Jabrbb.,' 1838, xvii, 224; Licbtenstadt, in 'Becker's 
 wissenscb. Annal. der Heilkde.,' 1834, xxx, 76 ; Doepp, ' Verm. Abbandl. deutscber 
 Aerzte in Petersburg,' 1835, v, 310. According to Phillips (1. c, 88) tbere were 
 343 cbildrea witb scrofula among the 840 inmates of tbe Foundling Hospital. 
 
 ^° Moritz, 'Specimen topogr. med. Dorpatensis,' Dorp., 1823. 
 " Weljamowitscb, ' Med. Ztg. Russl.,' 1848, 134. 
 1* Kleinenberg, ib., 1847, 410. 
 '^ Scbolvin, ib., 1848, 331. 
 " Bavdowski, ib., 1850, 171. 
 ^ Guttceit, ib., 1851, 244. 
 
 J® Erdmanu, ' Med. Topogr. des Gouvernem. Kasau,' &c., Riga, 1822, 159, 252; ' 
 Blosfeld, ' Petersb. Journ. fur Natur- und Heilkde.,' Nr. 4, 1 5 1. 
 17 Jonin, ' Med. Ztg. Russl.,' 1849, 45- 
 ^8 Heine, ib., 1845, 80.
 
 SCROFULA. CI 7 
 
 Odessa,^ Astrakhan/ and Orenburg.^ In the Crimea (Se- 
 bastopol) it would seem to be rare/ and to be altogether 
 unknown among* the Kirghiz hordes.^ In the mountainous 
 parts of Transcaucasia, such as Grusia, scrofula appears to 
 be rare/ but in other parts of that country it is often met 
 with.'^ From various parts of Siberia also, such as Tomsk/ 
 the region of Lake Baikal (among the Buriats)/ and 
 Vladivostock/^ we have accounts of the frequent occurrence 
 of scrofula. In Hungary^^ it would appear to be not less 
 widely spread than in Russia. In Roumariia}'^ and Monte- 
 negro^^ it takes a foremost place among the chronic diseases ; 
 and the same is true of Ttio-key,^* where it is met with, in the 
 larger communities not less frequently than in Paris and 
 other European cities. ^^ The opinion of Wibmer^^ that 
 scrofula is rarer in Greece than in Western Europe is opposed 
 by the statements of Kay^^ and Pallas/^ who are agreed as 
 to its great frequency ; and to the same effect are the 
 accounts of Hennen,^^ Horner,^" Ferrara/^ and others for the 
 Ionian Islands. 
 
 In Asiatic territory scrofula is prevalent to the same 
 
 ' Audrejewsky, ia ' Graefc uiid Walther's Journal/ xx, 277. 
 
 ^ Herrmann, ' Med. Ztg. Russl.,' 1845, 187. 
 
 ^ Maydcll, ' Nonuulla topogr. med. Orenburg, spect. Dorpafc/ 1S49, 
 
 * Heinrich, 'Med. Ztg. Russl.,' 1845, 380. 
 
 * Maydell, 1. c. 
 
 ^ Ref. in ' Hecker's wissenschaftl. Aunal.,' 1835, xxxi, 331. 
 
 <^ Hirtzius, ' Russ. Samml. fiir Natur- und Ileilkde./ i, 561. 
 
 8 Rex, ' Med. Ztg. Russl.,' 1859, 40S. 
 
 ^ Haupt, ib., 1845, .S76. 
 
 ^o SoUaud, 'Arch, de med. nav., 1882, Sptbr., 196. 
 
 ^' See Jankovich, ' Pestli und Ofen mit ibren Bewohnern u. s. w.,' Ofen, 1838, 
 304 ; Bartscb, ' Ungar. Zeitscbr. fiir Natur- und Heilkde.,' iii, No. 30. 
 
 1^ Cbampouillon, 'Mem. de med. milit.,' 1868, Mars, 191 j Leconte, ' Consider, 
 sur la patbol. des provinces du Bas-Danubc,' Montp,, 1869, 42. 
 '^ Boulogne, 'Mem. de med. milit.,' 1868, Dcbr., 486. 
 
 " Oppcnbeim, ' Ueber den Zustand der Heilkde. ... in der Tiirkei,' Hamburg, 
 ^^?>h 63 ; Rigler, ' Die Tiirkei u. s. w.,' ii, 416; Tbirk, ' Oest. med. Woebenschr., 
 1846 781. 
 '^ Beyran, ' Gaz. med. de Paris,' 1854, 342. 
 16 In Seboepff, ' Jabresber. zur pract. Med.,' 1841. 
 1^ In Pbillips, 90. 
 
 's ' Annali univ. di med.,' 1842, Aprile. 
 13 ' Sketches,' &c. 
 
 ^^ 'Med. and topogr. observations upon tbe Mediterranean,' Pbilad., 1839. 
 '-'I ' Topogr. med. de I'ile de Leucade,' &c., 1827.
 
 618 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 extent as in the countries of Europe just mentioned. It 
 occurs on tlio coasts and in inland districts of Syria^ Meso- 
 potamia^ and Arabia^ (particularly in tlie southern highlands 
 of Nejd). For other parts of Nearer Asia, such as Persia 
 and Turkestan, I do not know of any accounts relating to 
 scrofula. From India, on the other hand, we have numerous 
 reports which go entirely against the assertions of Scott/ 
 Morehead/ and others that scrofula is rare in that country, 
 or of Ewart,^ that it is a good deal less common than in 
 Europe. Gordon's observations in Bengal lead him to say 
 that " scrofulous affections of the cervical as well as the 
 mesenteric glands were the most fi'equent ailments among 
 children of both sexes, and the mortality from the latter cause 
 exceedingly great ;"'' and the considerable frequency of the 
 malady is in like manner asserted by Shortt,^ Huillet,^ Eyre,^^ 
 and Day,^^ for various parts of the Madras Presidency ; by 
 Annesley^^ for Mysore, Kinnis^^ for the Bombay Presidency, 
 Gibson^* for Gujerat, Hinder^^ for Umritsur (Lahore), and 
 McClelland^^ for Kumaon. 
 
 An illustration of tlie commonness of the malady in India is afforded 
 by tte results of an enumeration of scrofulous children in the schools 
 of Calcutta and other cities, which was made at the instigation of 
 
 ^ Pruner, 'Die Krank. des Orients,' Erlang., 1846, 321; ToLler, ' Beitr. zur 
 med. Topogr. von Jerusalem,' Berl., 1855, 5^; Barret, 'Arch, de med. nav.,' 
 1878, Ao<it, 87; Robertson (' Edinb. Med. and Surg. Journ.,' 1843, April, 247), 
 observes that scrofula is rare in the mountainous districts of Syria. 
 
 ^ Floyd, 'Lancet,' 1843, Nr. 4. 
 
 3 Pruner, 1. c. j Palgrave, ' I'Union med.,' 1866, 308. 
 
 ^ ' Journ. of Sc. and Arts.,' i, Nr. 2. 
 
 * * Clinical llesearches,' &c. 
 
 « 'Lancet,' 1881, May, 784. 
 
 ' 'Med. Times and Gaz.,' 1855, Dcbr., 538. 
 
 8 'Madras Quart. Journ. of Med. Sc.,' 1866, July. 
 
 '■> ' Arch, de med. nav.,' 1868, Fevr., 82. 
 
 1" • Madras Quart. Journ. of Med. Sc.,' i860, Octbr., 340. In Bellary, 1851-55, 
 564 cases of scrofula were admitted, or 7 per cent, of the whole number of 
 patients. 
 
 ^' lb., 1862, Jan., S3' 
 
 ^* 'Researches into the More Prevalent Diseases of India,' Lond., 1841, 109. 
 
 1^ 'Edinb. Med. and Surg. Journ.,' 1851, April, 310, 316. 
 
 " ' Transact, of the Bombay Med. Soc.,' 1837, h 69. ' 
 
 " • Med. Times and Gaz.,' 1855, Dcbr., 538. 
 
 16 ' Dublin Journ. of Med. Sc.,' xi, 338.
 
 SCROFULA. 6] 9 
 
 Phillips. Of loo children born in India and under ten years of age, 
 who were examined by Jackson, the most indubitable signs of scrofula 
 could be detected in the larger number ; among 715 children examined 
 by Spry there were 75 of mixed blood who were all scrofulous, 136 of 
 English parentage who were all healthy, and 504 Hindu children of 
 whom 300 were scrofulous. 
 
 In tlie absence of fuller information from Further India, 
 I am nnable to say how far Breton's^ statement that scrofula 
 is rare among the Anamese, may apply generally. But for 
 the Malay Ardii'pelago Heymann^ says : " Of all the dyscra- 
 sias the scrofulous comes to the front most. It is a malady 
 of childhood particularly, so much so that the well-known 
 torpid habit of scrofula may be seen in the Javanese youth 
 wherever we go ;" and this account is entirely confirmed in 
 the writings of v. Leent.^ As to the enormous frequency of 
 scrofula in China (Tientsin, Fukiang, Ohee-foo, Canton, 
 Shanghai, Pekin) there is complete unanimity among obser- 
 vers ;* and the authorities for JajJan^ give the same account 
 of it there. 
 
 On the continent of Atistralia and in the islands of the 
 Pacific scrofula would appear not to have been general until 
 recent times,° or since the natives came in contact with 
 Europeans and in consequence underwent a radical change in 
 their manner of life. In some localities the malady is 
 prevalent to a very great extent, and it has exerted a most 
 injurious influence on the working power of the native popu- 
 lation. The regions most affected are the Havmiian Islands^ 
 
 1 ' Quelques consider, sur la guerison des plaies chirurgicales . . . chez les 
 Annamites,' Par., 1876. 
 
 * ' Darstellung dor Kraulilieiteu in den Tropenliindern,' i 77. 
 
 ^ 'Arch, de med. nav.,' 1867, Octbr., 246, 1870, Janv., 14, 1877, Fevr., 100. 
 
 •* Rose, 'Pacific Med. Journ.,' 1862, Octbr.; Wilson, ' Med. Notes on China,' 
 Lond., 1846, 19; Friedel, 'Beitiiige,' 62, 69, 126; Moraebe, ' Annal. d'liyg.,' 
 1870, Janv., 54; Henderson, ' Edinb. Med. Journ.,' 1876, Novbr., 405 ; Dudgeon, 
 'Glasgow Med. Journ.,' 1877, July, 330; Weruich, ' Geogr.-med. Studien,' 
 Berl., 1878, 293. 
 
 * Friedell, 1. c, 32 ; Pompc van Meerdervort ; Wernicli, 1. c, i6i. 
 
 * Scott ('Transact, of the Prov. Mod. Assoc.,' 1835, i"> -A^PP- xii) met with 
 only occasional cases of scrofula iu Hobart Town from 182 1 to 1831. Down 
 to a later date Tasmania continued to enjoy a comparative immunity from tlie 
 malady (Hall, ' Transact, of the Epidemiol. Soc.,' 1865, ii, 85). 
 
 ^ Chapin, ' Amer. Journ. of Med. Sc.,' 1837, ^^1 '> Oulick, ' New York Journ. 
 of Med.,' 1855, March; Ref. in 'Arch. nav. de med.,' 1864, Dcbr., 486.
 
 <>20 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 Tahiti^ and New Zealand," in whicli last scrofula has wrought 
 frightful devastation among the Maoris. The disease is also 
 met with very frequently in the Navigator's Islands,^ the 
 Tonga^ and Figi^ groups, the Gamhier Islands,^ New Cale- 
 donia'^ and the Neiv Hebrides.^ 
 
 The existence of scrofula on African soil is attested by 
 definite information for only a few localities. McRitchie^ 
 has seen it often among the inhabitants of 8t. Helena ; and 
 GuioP° has observed it among the Malagasys in Nossi-Be 
 (north of Madagascar). According to Livingstone's state- 
 ment (which is to bo taken with i-eserve), scrofula is unknown 
 in those parts of Central Africa that lie between the i5tli. 
 and 25th parallels of southern latitude. Among the Hotten- 
 tots and Kaffirs of Ga2)G Colony it is widely prevalent/^ and it 
 is of common occurrence also among the Dutch colonists.^^ 
 Other principal seats of it are in Abyssinia, particularly the 
 Red Sea coast around Massowah and the less elevated plains ;'^ 
 and in Egy])t^^ where the Georgian and Circassian slaves, the 
 children of the fellahs, and the Turkish children living in the 
 harems, are the greatest sufferers. Also in the adjoining 
 
 1 Wilson, ' Ediub. Med. and Surg. Jouru.,' 1806, July, 285 ; Rcf. iu ' Arch, de 
 med. nav.,' 1865, Oetbr., 290. 
 
 * Swainsou, ' On the Climate of New Zealand,' Loud., 1840, 58 ; Dieffenbach, 
 'Travels iu New Zealand,' Loud., 1843, i, 14, ii, 21 ; Thomson, ' Erit. and For. 
 Med.-Chir. Rev.,' 1855, April; Tuke, ' Edinb. Med. Journ.,' 1863, Oetbr., 
 221. 
 
 ^ Turner, 'Nineteen Years iu Polynesia,' Loud., 186 1 ; Ref. iu 'Arch, de med. 
 iiav.,' 1866, Jauv., 32. 
 Ref., ib., 28. 
 lb., 32, 
 Le Borgue, ' Geogr. med. de I'archipel des lies Gauibier,' Par., 1872. 
 
 ' Vinson, ' Topogr. med. de la Nouvelle-Caledouie,' &c., Par., 1858 ; de Rochas, 
 ■^Topogr. med. de la N.-C.,' Par., i860, 31 ; Charlopin, ' Notes rec. eu Caledonie,' 
 Montp., 1868, 21 ; Boyet, 'Arch, de med. nav.,' 1878, Sptbr., 228. 
 
 « Boyet, 1. e. 
 
 " ' Transact, of the Calcutta Med. Soc.,' 1836, viii, App. xxix. 
 
 1" ' Arch, de med. nav.,' 1882, Novbr., 330. 
 
 " Bhick, ' Ediub. Med. aud Surg. Jouin.,' 1853, Apr., 256 ; Scherzer, ' Zeitschr, 
 ^er Wiener Aerzte,' 1858, 152 ; Schvvarz, ib., 659. 
 
 '' Schwarz, ib., 630; Kretzschmar, ' Siidafrikanische Skizzen,' Lcipz., 1853. 
 ^ '^ Bruce, 'Travels,' Ger. ed., iii, 32 ; Petit, iu Lefebure's 'Voyage;' Pruuer, 
 'Kraukheiteu des Orients,' 321; Courbou, ' Observ. topogr. et med.,' &c.. Par., 
 J 861, 37 ; Blanc, ' Gaz. hebdom. de med.,' 1874, 349, FeuiU. 
 
 " Pruuer, 1. c. ; Ref. iu < Arch, de med. uav., 1869, Mai, 326.
 
 SCROFULA. 621 
 
 negro countries, as well as in Tunis^ and Algiei^s^ scrofula 
 takes one of tlie first places among the chronic disorders of 
 nutrition. I am not acquainted with any trustworthy inform- 
 ation as to its occurrence in Senegamhia j^ but it is said by 
 Ballay* to be a very general malady in the Ogowai country 
 (region of the Gaboon, on the western side of the continent 
 one degree south of the equator) ; and it would appear from 
 darkens" way of speaking to be anything but rare on the 
 Gold Coast. 
 
 The information before us from the Western IlemispJiere is 
 also insufficient to furnish a tolerably complete outline of the 
 distribution of scrofula there. From the most northern 
 latitudes we have Blaschke's^ account of its great frequency 
 among the native children in New Archangel (Alaska) ; and 
 Gras'^ tells us that in Miquelon {Newfoundland) , the home of 
 cod-liver oil, scrofula contributes not a little to the mortality 
 among children. In Greenland, on the other hand, we have 
 it on the authority not only of Lange^s^ own experience but 
 also of the observations of several of his predecessors in office, 
 that scrofula is extremely rare or even unknown. In the United 
 States it must now be as prevalent as in Europe. There is a 
 noteworthy remark of Hildreth's/ dating from the year 1 830, 
 to the effect that the diffusion of the malady had kept pace 
 with advancing civilisation, proceeding from east to west; 
 
 ^ Ferrini, ' Saggio sul clima . . . di Tunisi,' &c., Milano, i860, 216; Rebatel 
 and Tirand, 'Lyon medical,' 1874, Nr. 1.3, 249. 
 
 ^ Cambay, 'Mem. de med. milit.,' 1842, Ivii, i; Bertherand, ' Med. et hyg. 
 des Arabes,' Par., 1855; Armand, 'Med. et hyg, des pays cliauds,' &c., 417; 
 Challan, ' Gaz. med. de I'Algerie,' 1868, 116; Creissel, 'Mom. de med. milit./ 
 1873, 369; Claudot, ib., 1877, 194. The statements of Bertvund (ib., 1867, 
 Mars., 199) and Bazille (' Gaz. med. de I'Algerie,' 1868, 30) as to the rarity of 
 scrofula among the Arab children, particidarly as regards Kabylia, have been 
 entirely overthrown by the observers above quoted (see the chapter, in the next 
 volume, on " Maladie du sommeil "). 
 
 ^ Chassaniol ('Arch, de med. nav.,' 1865, Mai, 507) says that he did not see it 
 often ; but Corre (ib., 1S77, Mai, 330) says that scrofula is exceedingly common 
 among the natives on the coast of Senegambia. 
 
 * "L'Ogooue" (' Afrique equatoriale occidentale '), Par., 1880, 39. 
 
 5 'Transact, of the Epidemiol. See.,' i860, i, 104. 
 ! ^ 'Topogr. med. portus Novi-Archangelcensis,' Petrop., 1842, 62. 
 
 7 ' Quelques mots sur Miquelon,' Montpell., 1867. 
 
 8 ' Bemaerkninger om Gronlands Sygdomsforhold,' Kjobenh, 1864, 27. 
 3 • Amer. Jouru. of Med. Sc./ 1830, Febr., 329.
 
 622 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 " scrofulous affections are more frequent/' lie says, referring 
 to Ohio, " than they were formerly ; and will probably 
 continue to increase as the country becomes more highly 
 cultivated and people more luxurious in their habits." 
 Along with this we may take the fact which is vouched for 
 equally by Moses^ and by Glisan," that scrofula did not exist 
 among the Indians of Oregon Territory until they began to 
 be more and more confined in their hunting grounds, to settle 
 at particular spots, to adopt the customs and vices of the 
 white man, and to degenerate under the influence of an 
 entirely altered manner of living. In California also, where 
 Praslow^ met with little of it at the time of the first outflush 
 of prosperity in the State, it is now very prevalent (according 
 to Lantoin'*), so far at least as relates to San Francisco. At 
 Monterey, which is a long way from the gold fields and 
 escaped the rush of adventurers, the disease was but little 
 prevalent even in 1853 ; but there is no later intelligence of 
 it from that part of California. 
 
 In Vera Cruz, on the Mexican coast, Heinemann^ has often 
 seen scrofula among the children of mixed parentage and of 
 the white race ; but on the table-land of Mexico (Anahuac) 
 it is rare.'' From Central America I know of only one 
 notice''^ of scrofula, to the effect that it is often observed in 
 Guatemala. For the West Indies we have the older accounts 
 of scrofula in Jamaica by Armstrong^ and Lempriere,^ the 
 former testifying to its common occurrence among negro 
 children, and the latter stating that it was much rarer than 
 in England and of a very mild type. Among recent autho- 
 rities, Rufz^" says for Martinique what Lempriere had said 
 for Jamaica ; whereas Goes^^ for St. Bartholomew, Hamon- 
 » lb., 185s, Jan., 32. 
 
 * lb., 1865, Jan., 79. 
 3 L. c, p. 56. 
 
 * 'Arch, de med. nav.,' 1872, Mars. 
 
 5 In ' Virchow's Archiv,' 1873, Iviii, 178. 
 
 « Jourdanet, 'La Mexique,' &c., Par., 1864, 412; Colndet, 'Mem. de med. 
 milit.,' 1869, Avril, 273. 
 
 ' Durant, 'Arch, de la mod. beige,' 1846, Mai. 
 
 * In Duncan, ' Annals of Med.,' 1802, vi, 370. 
 
 » ' Observations on the Diseases ... in Jamaica,' Lond., 1799, i, 45. 
 '« ' Arch, de med. nav.,' 1869, Novbr., 349. 
 " ' Hygiea,' 1868, Octbr., 460.
 
 SCROFULA. 623 
 
 Dufougeray^ for St. Martin, and Jackson^ for Barbadoes 
 are of one opinion tliat the malady is prevalent generally 
 tliroughout these islands. It is not to be denied that these 
 discrepancies in the statements of authorities in the West 
 Indies may perhaps depend on the scantiness of the observa- 
 tions ; but it is possible, also, that they may be due to real 
 differences in the several localities. It may be the same with 
 the discrepant accounts of the prevalence of scrofula in 
 Brazil. Sigaud's^ opinion is that " les scrophules sent 
 remarquables par leur rarete;" while Eendu* assures us that 
 '' les scrofulos .... sent des affections tres frequentes au 
 Bresil;" and Tschudi^ speaks of its endemic prevalence in 
 the northern provinces, while Plagge^ asserts the same for 
 the province of Maranhao, and Rey^ mentions the frequent 
 occurrence of the disease in Santa Catharina, particularly 
 in the up-country districts. In the River Plate's States 
 (Argentine Republic), particularly in the large towns (Monte 
 Video, Buenos Ayres), scrofula is rarely seen among the 
 whites but more commonly among negroes and mestizzos, 
 according to Mantegazza^ and Rey, who are corroborated by 
 Saurel. In Paraguay also it is rare.^ But in Chili^° and 
 Peru^^ it has attained to a very considerable diffusion, and, as 
 Tschudi tells us, not only along the coast, but also in the 
 highest mountain towns ; even in Oerro de Pasco, at a height 
 of 13,500 feet, he found many scrofulous persons. In 
 Ecuador (Guayaquil) scrofula holds a prominent place among 
 chronic diseases.^^ 
 
 1 ' Arch, de med. nav.,' 1883, Jan., 57. 
 
 • ' Boston Med. and Surg. Journ.,' 1867, Julj^, 448. 
 
 3 ' Du climat et des maladies du Bresil,' Par., 1844, 424. 
 
 * ' Etudes topogr. et med. sur les Bresil,' Par., 1848, 81. 
 ^ 'Oest. med. Woehenschr., 1846, 472. 
 
 « 'Monatsbl. fiir med. Statist.,' 1857, N'r. 10. 
 
 ' 'Arch, de med. nav.,' 1877, Jauv., 27. 
 
 ^ ' Lettere mediche sulla America meridionale,' Milano, i860, i, 14, 19, 
 
 3 Mantegazza, ib., i, 285. 
 
 '" Brandiu, ' De la influencia de los diferentes climas del universe sobre el 
 hombre,' &c., Lima, 1826; Gillis, in 'Deutsche Klinik,' 1856, Nr. 24; Fischer, 
 'Arch, de med. nav.,' 1864, Juill, 21 ; Duplouy, ib., Aout, 108; Ullersperger, in 
 'Virchow's Archiv,' 1869, xlviii, 501. 
 
 '^ Tschudi, 1. c. ; Duplouy, 1. c, Sptbr., 189. 
 
 '2 Duplouy, ib.,_Octbr., 282.
 
 624 GEOGRAPHICAL AND HISTORICAL TATHOLOGT. 
 
 § 214. Influence op Climate and Change of Eesidence. 
 
 Altliongh our knowledge of tlie geograpliical distribution 
 of scrofula remains incomi^lete, and altliougli for the present 
 we are not in a position to find a numerical expression for 
 the frequency of the disease in the various parts of the world,^ 
 which would give us the only safe means of making a com- 
 parison ; yet there can be no doubt at all that the malady is, 
 as we said at the outset, a decidedly ubiquitous one, and 
 that the conditions of climate proper to the various latitudes 
 of the globe exert no decisive influence either on its existence 
 or on its amount. The prominent place that scrofula takes 
 among the national maladies of India, the East Indies, the 
 southern coasts of China, and the tropical provinces of Brazil 
 and Peru affords evidence that the disease spares the equa- 
 torial regions just as little as the temperate and high lati- 
 tudes ; while its comparatively rare occurrence in the States 
 of the River Plate, in Greenland, in the Faroe Islands and 
 elsewhere, teaches us that its prevalence stands in no 
 necessary association with a temperate or cold climate. The 
 slight influence of the climate of a locality upon the amount 
 of scrofula is further shown by the very unequal distribution 
 of the disease at the several points within large districts 
 which present no material differences in regard to their 
 climate ; as well as by the fact that at other points, where 
 there are such climatic differences, as on the central plateau 
 of Spain compared with the Mediterranean coast, scrofula is 
 uniformly common j and lastly by the observations above 
 mentioned, that in some considerable territories the malady 
 did not appear, or did not spread much until modern or quite 
 recent times, such territories having previously enjoyed a 
 marked exemption from it. 
 
 There is one respect in which the influence of climate does 
 
 ' The tables of inortality do not afford materials suited to that purpose. Not 
 to mention the unavoidable errors of diagnosis, doubtless even of a gross kind, 
 which run through them, there is, in regard to scrofula in particular, the fact 
 that in many of these lists rickets is mixed up with it, while cases ending 
 fatally in scrofulous affections of the bones are placed under diseases of the 
 osseous system.
 
 SCROFULA. 625 
 
 appear to have an important significance for the development 
 of the disease. It is shown in the fact that an unusually 
 large number of persons who had come from lower latitudes, 
 the tropics especially, into colder regions, are attacked by 
 scrofula, all the more speedily and the more severely the 
 greater the difference between the climate of their new and 
 their old home. 
 
 " I have observed," says Lugol,' " that the residents from countries 
 ■within the tropics exhibit the saddest traces of the effect of our tempe- 
 rate climate upon them ; scrofulous disease develops in them with 
 unusual rapidity." Prichard^ met with many facts confirming that 
 observation among persons born in Brazil or the Southern States of the 
 Union, who came to Paris. 
 
 Cooper, writing of England, says :' " People from the East or West 
 Indies, who come over to this country, not unfrequently fall a prey to 
 scrofulous disease. Many childi-en bom in the East and West Indies 
 are sent to this country to be educated, and therefore we have an oppor- 
 tunity of seeing the effect of climate on their constitutions ; and I can 
 assure you, that it frequently requires the greatest possible care to save 
 them from the danger of scrofulous disease of the joints and absorbent 
 glands, and very often, with all your care and attention, they will die of 
 scrofulous disease. Those of the West Indies less frequently die of 
 scrofula than persons from the East Indies ; but I have seen some from 
 the South-Sea Islands, and most of them have died from scrofulous 
 <;omplaints." 
 
 Peai'son,* who had medical charge of an institution for persons 
 brought from the West Coast of Africa to England, says : " It is 
 remarkable that boys bi'ought from tropical climates, from the age of 
 eight to twelve, almost uniformly become scrofulous. They bear the 
 first winter tolerably well, but droop during the second, and the third 
 generally proves fatal to them." 
 
 It cannot well be denied, as a general truth, that weather 
 influences which are absolutely bad, or (as in these cases) 
 relatively so, and which make themselves felt most at the age 
 of childhood, may lower the body^s power of resisting noxious 
 influences in general, and so create a predisposition for the 
 development of scrofula. But in considering the frequency 
 of attacks among persons arrived from foreign parts, we 
 have to keep iu mind also, that in changing their climate 
 
 * L. c, p. 231. 
 
 2 Art. " Scrophule," in the ' Dictionnaire de Medecine.' 
 
 3 • Lancet,' 1824, iv, 65. 
 
 ■• •Annual Med. Rev.,' ii, 130. 
 
 VOL. II. 40
 
 626 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 they at the same time make material changes in their mode 
 of living ; and these changes must not only weigh in the 
 scale in our estimate of the pathogenesis, but they are doubt- 
 less a factor of especial importance therein. 
 
 § 215. Question of the influence of a Wet Soil. 
 
 In support of the idea that the altitude has a direct 
 influence on the occurrence and diffusion of scrofula^ there 
 is not a single piece of evidence from any side. The rarity 
 of the disease on the Anahuac (table-land of Mexico), and at 
 some elevated points in the Swiss and Italian Alps and in the 
 Vosges, is accounted for not by their altitude itself, but by 
 other causes ; for at many other equally elevated and even 
 more elevated points scrofula is met with in as general dif- 
 fusion as on the plains and in not less numerous cases. 
 
 We find examples of tliis in tlie prevalence of the malady at some 
 places in the Saxon and Bohemian Metal-mountains, in Upper Austria, 
 and in the Alps and the Jura of Canton Vaud, where, as Lebert tells us,i 
 the number of the scrofulous never failed to strike him in his numerous 
 excursions to the mountains. Other instances are the prevalence of the 
 disease on the elevated table-land of Mysore, in the highest passes of the 
 Himalaya in Kumaon (Mc Clelland), and in the Peruvian Andes at 
 elevations of 3000 to 4000 metres (10,000 to 13,000 feet). 
 
 There is just as faint a connexion to be discovered 
 between the existence or amount of scrofula and particular 
 geological conditions. Escherich/ who reasons on the basi& 
 of a few facts and whose premises [e. g. the genetic con- 
 nexion of scrofula with goitre and cretinism) are erroneous, 
 has adopted the opinion that the disease occurs as one proper 
 to the locality, and not as an acquired habit, on the older rocks 
 only (including the primary, the transition, and the mesozoic 
 formations up to the chalk), while it exists in mere sporadic 
 cases on the tertiai-y and recent deposits. This idea is over- 
 thrown by the wide diffusion of scrofula on the alluvial and 
 diluvial soils of Holland, Belgium, North Germany t"yid other 
 countries. A geological map which I have used to elucidate 
 
 ^ L. c, p. 48. 
 
 =" ' Allgem. Zeitschr. fiir Chirurgie und Heilkde.,' 1843, No. 30.
 
 SCROFULA. 627 
 
 the question at issue, serves to show that more or less con- 
 siderable centres of scrofula can be made out on almost every 
 geological formation, and that no formation has a preference 
 either way over any other. 
 
 The views of observers diverge as to the influence of a 
 ivet or sivampy soil on the production of scrofula -, and it is 
 this very difference of opinion, with the arguments adduced on 
 either side, that provide us, to my thinking, with the correct 
 means of estimating the etiological importance of the factor 
 in question. The accounts of the general diffusion of scrofula 
 in some districts of Sweden,^ in the damp low-grounds of 
 Oldenburg" and Holland,^ in the wet or swampy valleys of 
 Upper Austria* and Styria, and in the plain of Lombardy,^ 
 lay quite special stress upon that factor in the pathogenesis ; 
 whereas other observers tell us that the disease within the 
 limits of their own practice is actually more common on dry 
 soil than in damp localities in the vicinity.^ Some Belgian 
 authorities, such as Waldeck, would assign the draining of the 
 ground as one of the determining causes of the occurrence of 
 scrofula, and would discover a causal connexion between such 
 changes in the soil and the notable increase of the malady 
 which was observed in many parts of Belgium about the 
 period from 1830 to 1840. The fallacy of this conclusion has 
 been aptly exposed by Meynne,'^ in adducing proof that the 
 increasing misery of living among the poor of the country iu 
 that very period was the real cause of the phenomenon ; 
 " depuis cette epoque les salaires ont diminue, une grande 
 misere est survenue parmi les tisserands, fort nombreux dans 
 ce canton (Ecloo) ; I'alimentation s'en est ressentie, elle est 
 
 * Huss, 1. c, p. 69. 
 
 ^ Goldschmidt, in ' Hiiser's Arch, fiir die ges. Med.,' 1845, ^ii, 308. 
 
 3 See Biichner, ' Bijdrag tot de geneesk. Topogr. van Gouda,' Gouda, 1842. 
 
 ^ Streinz, • Oest. med. Jahrb./ 1831, Neueste Folge, i, 4, Heft 46. 
 
 5 lb., 1. c. 
 
 ^ In some wet and (liere or tliere) swampy districts of the western and southern 
 coasts of France, and in some swampy localities in the department of the Somme, 
 scrofula is rarer than in Rheims and Orleans, which are built upon a dry bottom, or 
 in Montpellier, which is situated on hilly ground. Beacoiisfield (Bucks), according 
 to Rumsey (' Transact, of the Prov. Med. and Surg. Assoc./ 1844, June), although 
 it lies low and is damp, has not nearly so much scrofula as some adjoining dis- 
 tricts where the soil is dry. 
 
 7 L. c, p. 157.
 
 628 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 devenue insuffisante pour beaucoup d'ouvriers, suffisante mais 
 grossiere et exclusivement vegetale pour la generalite." 
 Lugol, guided by ample observations made in France^ pro- 
 nounces very decidedly, and it appears to me witb perfect 
 justice, against the doctrine that the amount of scrofula 
 stands in any definite relation to the wetness or dryness of 
 the soil. 
 
 " Brittany," he says,' " is a damp region, but sci-ofula is not endemic 
 in it ; and if it does present itself in that character at a few places within 
 the province, these are not the dampest localities. In no locality is the 
 disease so common and of so severe a type as in the dry country 
 
 of Champagne In the Pyrenees, we find particularly striking 
 
 contrasts in the nature of localities where scrofula is endemic. Let us 
 take as an example a village on the banks of the Adour. The water in 
 that stream runs at a level with the huts built on the bank ; consider- 
 able quantities of it flow around the dwellings and into the gardens, in 
 which the prevailing colour is the green of a landscape. The dwellers 
 
 in this spot are scrofulous a fact which may seem at the first 
 
 glance to confirm the notion that dampness is the cause of endemic 
 scrofula, all the more so that the huts which stand a little way back 
 from the bank and are a few metres above the water-level are occupied 
 hy a far finer set of people in every respect. The higher we go, the 
 )jetter the type of inhabitants. But at a point still higher above the 
 stream, in a dry and pure region, we come suddenly upon an unexpected 
 thing — the residents at the top of the mountain are scrofulous. Thus 
 we find scrofula to be endemic at places which are entirely different 
 fi'om those on the river or situated at corresponding elevations. These 
 contrasts, which may be often seen in the Pyrenees within a short radius 
 as well as in other countries where scrofula is endemic, ai-e against the 
 idea that dampness or any other condition of locality is the cause that 
 produces an endemic of scrofula." 
 
 However, in discussing this question, we ought not to 
 overlook the consideration that dampness of the ground has 
 a definite effect on the social condition of the people as well 
 as on the conditions of climate, and may accordingly exert 
 m the last resort an influence, if only a remote one, on the 
 occurrence of scrofula. 
 
 ' L. c, p. 216.
 
 SCROFULA. • 62^ 
 
 § 2 1 6. Evidence that it is due to Dietetic and Hygienic 
 
 Errors. 
 
 Tn tlie opinion of nearly all observers, tlie real cause of the 
 scrofulous disease is to be looked for in some error of nutri- 
 tion and manner of living ; although as yet no agreement has 
 been arrived at among them whether it is a matter of some 
 noxious influence of a definite kind, or whether various 
 injurious things, rooted in a defective hygiene and acting 
 singly or in combination, may not furnish the pathogenetic 
 factor. Another open question is how far the attack of 
 illness depends upon individual predisposition or congenital 
 morbid diathesis. 
 
 The social positions of various classes of the population as 
 fixed by a certain measure of comfort or by the possession of 
 the bare necessaries of life, do not reveal on the large scale 
 any real differences in the amount of scrofula. Even if the 
 disease is, under certain conditions to be given in the sequel, 
 rather more common in towns than among the country 
 population, yet it is no stranger to the latter ; and whoever 
 has had occasion, like the writer of these lines, to study the 
 state of health among the inhabitants of country districts, 
 cannot but confirm the opinion of Lebert, Phillips and others, 
 that scrofula takes, under those conditions as well as under 
 their opposite, one of the foremost places among the prevalent 
 maladies of childhood and youth. Unfortunately the sta- 
 tistics do not afford the means of proving this mathematically, 
 for reasons that have been several times stated. Still less 
 do they help us to estimate the number of cases among 
 the well-to-do and the indigent respectively. But in that 
 matter also the daily experience of practitioners discovers 
 no important differences ; and it is only when there is a con- 
 centration of the influences favorable to the origin of the 
 disease pressing uniformly upon one considerable section 
 of the population that the predominance of scrofula is seen 
 to be dependent on circumstances of living, as will appear in 
 the sequel. 
 
 The cause of the disease must be sought, accordingly, in 
 such influences as are universal in their nature, are generally
 
 630 GEOGEAPniCAL AND HISTORICAL PATHOLOGY. 
 
 diffused over the globe, and make themselves felt equally 
 among all classes. Among these a principal factor, according 
 to experience, is the more or less unsatisfactory ivay of feeding 
 infants and very young children. This doctrine, which has 
 been firmly held by the practitioners of all times, finds very 
 decided expression in all the accounts before me from the 
 most various parts of the world. From no quarter has it 
 met with opposition ; neither is it weakened by the consider- 
 ation that scrofula, as we have seen, is a disease not of the 
 proletariat only, but just as much of the children of the better 
 situated and well-to-do classes. 
 
 " The frequency of scrofula amongst the classes of society 
 who live in wealth or comfort/' says Phillips^ " has been 
 supposed to militate against any view of the disease which 
 assigned to insufficient food or improper feeding a large share 
 in the production of the disease. But diseased nutrition may 
 co-exist with sufficiency of food and even with seemingly 
 judicious feeding, and is, perhaps, as frequently found in 
 the pampered child of luxury as in the cottage of the 
 peasant." 
 
 A second factor in the pathogenesis, which many observers 
 would rate as of specially high importance, is the rvant of 
 exercise for children in the open air, or the constant keeping 
 of them indoors, especially where the ventilation is had and the 
 atmosphere charged with organic e^uvia. In some quarters 
 this noxious influence is even made out to be the true cause 
 of the disease. Thus Alison," from his experience of the 
 Edinburgh Dispensary, says : " I am thoroughly convinced, 
 from the amount of it (scrofula) that I have seen in families 
 not suffering under any material privations, that it depends 
 much more on want of pure air and exercise, than on deficient 
 nourishment." 
 
 To the same effect are the opinions of Cooper,^ Eager,* 
 Byford^ and others ; while Baudelocque,^ from his experience 
 
 ' L. c, p. 242. 
 
 * ' Transact, of the Edin. Med.-Chir. Soc.,' 1824, i. 397. ^ l, c., 72. 
 
 * ' Dublin Journ. of Med. Sc.,' 1834, July, 347 : "I have abundant reasons to 
 think that the absence of direct solar rays and a long sojourn in a confined atmo- 
 sphere contribute more than any other towards the development of scrofula." 
 
 * 'Transact of the Amer. Med. Assoc.,' 1855, viii. 
 
 Revue med.,' 1832, Jan., p. 10; and ' Etudes sur les causes . . . de la 
 maladie scrophuleuse,' Par., 1834.
 
 SCROFULA. 631 
 
 of the Hopital des Eufants in Paris, lays particular stress on 
 this factor as '^'' cause principale de la maladie scrofuleuse, 
 una cause qui domine toutes les autres, et sans laquelle peut- 
 etre la maladie ne se developperait jamais, ou au moins serait 
 tres-rare." 
 
 Even Lugol/ who refers the spread of scrofula exclusively 
 to heredity, assigns to the injurious influence in question a 
 prominent place among the contributory causes. 
 
 But against the somewhat exclusive pre-eminence that 
 Baudelocque has given to this etiological factor, we have to 
 place the circumstance that scrofula is far from rare, as we 
 have seen, among the population of many country districts, 
 notwithstanding that the children pass the time in running 
 about in the open air. In many such localities, indeed, it is 
 very widely spread, as in the mountainous parts of the 
 Canton Vaud, accordiug to Lebert's observations. On the 
 other hand there is a large number of facts which put it 
 beyond doubt that want of fresh air and exercise has an 
 importance for the development of the malady that is not to 
 be underrated. We have first of all the predominance of 
 scrofula among the children of the poor and of the working 
 class in the great centres of industry and trade, especially in 
 the large manufacturing towns ; on which point there is but 
 one opinion among the authorities." 
 
 Next there is its prevalence in the mountain villages of 
 Bohemia, Saxony and the Harz, inhabited by spinners, weavers 
 and stocking-workers, who are put to these occupations at a 
 very eai"ly age and who ply their industiy in small and dull 
 rooms.'^ Again we find the malady extremely common in 
 
 ' ' Gaz. des li6pit.,' No, 71 ; and ' Recliercbes, &c.,' p. 240 (Germ. ed.). 
 
 2 See the ' Sanitatsbericbt des Mediciual-CoUegiums von Westfalen,' 1845, p. 
 45, with reference to the diffusion of the disease in the manufacturing towns of 
 "Westphalia; and the account given by Meynne (1. c., p. 487). for Belgium. 
 
 3 See Cartellieri's statements ('Oest. med. Jabrb.,' 1843,11,354) with reference to 
 the Circle of Leitmeritz, in Bohemia ; and Klinge's for Andreasberg, in the Harz, 
 where even the little girls are employed in making bone-lace. Black (' Transact. 
 of the Prov. Med. and Surg. Assoc.,' 1832, v, 179) remarks of the state of health 
 among the young persons employed in the spinning-mills of Bolton : " They are 
 more peculiarly liable than other classes of the operatives to the different kinds 
 of scrofula affecting girls and boys in the joints and glands." The same view 
 is taken by Hinder (' Med. Times and Gaz./ 1854, Feb., p, 54) of the causes of 
 the enormous amount of scrofula among the children of the shawl-weaving popu-
 
 632 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 the coal districts of England, Scotland/ and the North of 
 France. Under all these circumstances there is an ensemble 
 of harmful influences to be allowed for ; and it remains a 
 question, accordingly, how much importance is to be assigned 
 to anyone of them. But apart from such cases, the import- 
 ance of the particular factor that now concerns us can be 
 shown in a very convincing manner in cases where the 
 disease either breaks out generally among all groups of the 
 population, other noxious influences, such as of diet, being 
 excluded ; or, where the conditions are in other respects the 
 same, but the malady falls mostly on that one section which 
 is principally or exclusively subject to the injurious influence 
 in question. Of that sort is the evidence furnished by the 
 state of health among children or young persons in foundling 
 hospitals and orphanages, in workhouses, homes of industry 
 and such like institutions. Out of a large number of observa- 
 tions of that kind I give here a few of the most interesting 
 and most convincing. 
 
 In the Educational Institute of St. Petersburg, according to Doepp, 
 there were, from 1830 to 1833, among pupils of ten to twenty-three years 
 of age, four times as many cases of scrofula in girls as in youths. The 
 reason of this could not be either the food, wbicb was the same for aih 
 or the lodging, which was even better for the girls than for the boys and 
 young men ; it could only be that the female pupils, yielding to their 
 incorrigible propensity for a sedentary life, would stay constantly 
 in their small rooms in the Institute, and could not be induced, whether 
 by exhortation or by discipline, to resort to the large recreation-rooms 
 or to spend part of their time in the garden of the institution. Blatin 
 states that, in the Training College of Billodes near Locle (Neuchatel)^ 
 where the pupils are kept shut up in rooms almost constantly, they are, 
 without exception, scrofulous. Glover" adduces the fact published by- 
 Tyler Smith ,3 that in a workhouse in Kent the whole of the seventy- 
 eight boys and all but three of the ninety-four girls, were found to be 
 suffering from scrofula, although only a few of them had shown signs 
 
 lation of Umritsur, in Cashmere. He points out that while the adults are 
 employed in sorting and spinning the wool, children of eight years and upwards- 
 are busy the whole day over the loom in buildings that are overcrowded although 
 open, and that when work is over they spend their time in dull, filthy and 
 unventilated rooms. 
 
 ^ Alison, 'Lancet,' 1842, i, 800. 
 
 ' 'On the Pathology and Treatment of Scrofula,' Lond., 1846, Germ. Transl.» 
 Berlin, 1847, P- 134. 
 
 3 ' Scrofula, its nature, &c.,' Lond., 1844.
 
 SCKOPULA. 63 
 
 o 
 
 of the disease before they were admitted into the institution. Glover 
 inquired also into the number of cases of scrofula in three workhouses, 
 among whose inmates there were altogether 164 persons below the age 
 of fifteen : the first, in a large manufacturing town, had 53 children 
 with scrofula out of 112, or 47 per cent.; the second, in a seaport, had 
 9 cases of scrofula out of 35, or 26 per cent., this being the proportion 
 for those who lived continuously in the house, whereas among 20 who 
 only came to school there was not a single case ; in the third, a country 
 workhouse, there were 7 children out of 18, or 39 per cent., who were 
 more or less scrofulous. Fourcault' mentions the following fact with 
 reference to children in the workhouse attached to the General Hospital 
 of Lille, of whom a large number of both sexes, foundlings and 
 orphans, had been brought up previously in the country, and were taken 
 in as soon as they were able to work : the girls occupy large and well- 
 ventilated rooms, where they busy themselves with female handiwork ; 
 the boys take service with artificers in the town. The latter keep in good 
 health, but large numbers of the girls develop a general feebleness of 
 habit, chlorosis, and the like, and many of them die of scrofula. Hall, 
 observes that scrofula is, generally speaking, rare in Tasmania, but that 
 it is seen very often in the children who are inmates of the overcrowded 
 and badly-maintained orphanages in the colony. " In the Department 
 of Lozere," says Alibert," " a third part of the population is occupied in 
 the manufacture of a woollen stuff known as ' serge de Mende.' That 
 is the one industry of the country, and the chief source of livelihood of 
 the inhabitants. The wool is worked without oil ; and to facilitate the 
 working of it, the industry is carried on in low, vaulted rooms, very 
 damp and hot. It is this class of work-people that supplies the largest 
 contingent of scrofulous persons in the Department." Bredow^ gives 
 the following observations on the development of scrofula among the 
 juvenile hands (eleven to twenty-two years old) in the woollen-spinning 
 division of the Imperial Alexandrowski Factory, and in a private silk- 
 mill. In the Imperial Factory there were 666 hands between the ages 
 mentioned; of these 360 lived at the works, and 32 of them, or 9 per- 
 cent., acquired scrofula after entering ; 21 7 lived outside the factory, and 
 29 of them, or 13 per cent., became scrofulous subsequent to joining; 
 and of the remaining 89, who lived in villages several versts distant 
 from the factory, only 2 had the disease, or less than 2 per cent. Of 
 162 persons of the same ages in the private silk factory, 6^, or 40 per 
 cent., became scrofulous dui-ing the time they wei'e employed in it. 
 We have to bear in mind here that in both factories there was nothing 
 wanting in cleanliness, good clothing, and proper food ; but that (i) the 
 young hands in the Imperial Factory spent the leisure time allowed 
 them in running about and playing in the open air, while the boys in. 
 
 ' 'Causes generales des maladies chroniques,' Paris, 1844. 
 
 •^ 'Precis theorique et pratique sur les maladies de la peau,' Paris, 1818, ii^ 
 
 364- 
 
 ^ 'Preuss. med. Vereins-Ztg.,' 1845, ^o- 45-
 
 634 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 the private factory spent most of tlie corresponding intervals in their 
 dull sleeping places or in lolling lazily upon their beds ; (2) those of the 
 hands who had to go several versts every day to and from the factory 
 enjoyed the best health ; and (3) the worst cases were those who, after 
 being used to the open air, hardly ever left the gloomy purlieus of the 
 factory, except to go to their dormitories. 
 
 Lastly, I shall refer to Dr. Baly's report (as given by PhillipsV on 
 the occurrence of scrofula among the prisoners confined in Millbank 
 Penitentiary ; although, as Baly himself regrets, it affords no perfectly 
 clear view of the circumstances in question, for the reason that 
 scrofula, in the table of sickness, is entered under the same heading 
 with pulmonary consumption, and it is possible only within limits to 
 sepai-ate out the cases belonging to the latter disease. A.ccording to 
 the figures there were, in 1840, 14 per 1000 attacked with scrofula 
 among 1052 prisoners, and, in 1S44, 135 per 1000 among 3249 prisonei's. 
 (It has to be observed that for those who were received into the 
 prison with the first signs of scrofula upon them, the origin of the 
 malady might be referred to former imprisonments.) Among the 
 prisoners received in 1840 were 510 female convicts under sentence of 
 ti'ansportation who remained on an average three months at Millbank, 
 and only two cases of scrofula developed among these ; whereas among 
 520 others admitted the ?ame year, who remained in the prison from 
 two to three years, no fewer than 78 were aff'ected with scrofula and 
 pulmonary consumption before the end of their term of imprisonment. 
 It is noteworthy that the number of cases rises in proportion to the 
 duration of the imprisonment ; so that in 1000 prisoners, 6'g either died 
 or were released on account of the disease in their first year, 31 '32 in 
 their second, 49*9 in their third, 52-38 in their fourth, and 63-83 in their 
 fifth. Baly expressly says that there was no reason to look for the 
 cause of these attacks in the kind of diet, inasmuch as the diet of 
 Millbank Penitentiary, since the unfortunate experience of 1824 (see 
 P- 550), left nothing, to desii-e ; and that the cause was more probably to 
 be assigned exclusively to the want of exercise in the open air, or, in 
 other words, to living in an atmosphere rendered impure by organic 
 effluvia. 
 
 An impartial survey of all tlie facts liere given, wliicli are 
 corroborated by the observations above referred to on the 
 causes of the outbreak and spread of scrofula among the 
 natives of New Zealand, Oregon and other countries, should 
 lead us, in my view, to the conviction that both etiological 
 factors (diet and close confinement) play a prominent part in 
 the pathogenesis. It is all the more difficult to say which of 
 them is the more important, for the reason that they often 
 act side by side as causes of disease. 
 
 ' L. c, p. 362.
 
 SCROFULA. G35 
 
 The history aud geogi-aphical distribution of sci-of ula teach 
 uSj further, that no race or nationality enjoys an absolute or 
 even relative immunity from it, that the malady becomes pre- 
 valent among all communities and families whenever the etio- 
 logical factors favorable to its development make themselves 
 felt. Some observers, such as Marpurgo, Vauvray and others, 
 assure us that the disease is rare among the nomade Arabs ; 
 but the explanation of that is not their nationality, inasmuch 
 as their own stock are by no means exempt from scrofula in 
 towns and settlements in Algiers, Again, if the malady is 
 not often seen among the nomade Kirghiz,^ the reason of that 
 is that weakly children are regarded by them as a punishment 
 from heaven, and perish from want of tending before scrofula 
 has time to develop. 
 
 § 217. To A GREAT EXTENT INHERITED, BUT NOT NECESSARILY 
 
 PROM Scrofula in the Parents. 
 
 One of the most intricate points in the etiology of scrofula 
 is the question of the hereditary transmission of the disease. 
 It is altogether denied or very much doubted by some 
 (Phillips, Rilliet and Barthez, and others), who are supported 
 by few observations, or by very faulty statistics, or by 
 erroneous assumptions ; but by far the larger number of 
 observers at all times have pronounced decidedly for hereditary 
 transmission. Among others Cooper says : " That scrofula 
 is a hereditary disease appears as clear to me as can be ; and 
 they who deny it, deny the evidence of their senses.'^ A 
 few, such as Lugol and Guiet, have even gone so far as to 
 make the inherited disposition a conditio sine qua non for the 
 development of the malady. '' Pour nous,'' says Guiet," 
 '' un enfant nait scrofuleux, mais les circonstances qui viennent 
 se grouper autour de lui apres sa naissance peuvent hater ou 
 retarder ou me me quelquefois arreter le principe qui lui a ete 
 
 *■ This statement of Maydell for the Kirghiz Steppe is one that I cannot con- 
 firm from my own observations made (to a very limited extent however) in the 
 Government of Astrakhan. In the kibitkas of the Kirghiz, loaded with filth, 
 I have seen several children with typical scrofula. 
 
 » * Revue med.,' 1884, April, p. 533.
 
 636 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 transmis par I'heredite : ce n'est done que d'une maniere 
 secondaire que nous comprenons le mode d'action des causes 
 enoncees plus haut." 
 
 At the present day there is really no doubt that scrofula 
 may develop quite independently of hereditary conditions, 
 and under the noxious influences above mentioned ; but 
 heredity forms an especially prominent factor in its evolution. 
 The only differences of opinion are whether the inherited 
 diathesis of the children is always to be referred to scrofula 
 of the parents, or whether it may not be sometimes the con- 
 sequence either of other diseases in the progenitors, such as 
 syphilis/ or cancerous disease, or of conditions of ill-health 
 due to immaturity or advanced age, or of drunkenness, or of 
 the marriage of near kin. As to the nature of the diathesis, 
 also, there is for the present much obscurity, some discovering 
 it in irregularities of the blood and lymph, from the humoral 
 point of view, while others, from the side of solidism, find it 
 in an abnormal state of the lymphatic glandular system, and 
 still others in the transmission of an organic (parasitic) germ. 
 When the disposition is highly developed, opportunities which 
 are slight in themselves may serve to bring out the disease ; 
 and this is how we explain the frequent occurrence of scrofula 
 in well-to-do families, in which there seem to be present all 
 the conditions necessary for the healthy development of the 
 young, but in which the disease passes by inheritance from 
 generation to generation. 
 
 § 218. No Evidence that it is Inocdlable along with 
 Vaccinia or otherwise. 
 
 Against the interpretation of scrofula that we have given 
 up to this point, as a disease, namely, that depends upon 
 
 ' An opinion specially held by Otto for Denmark, Briard for Ancona, Moris 
 for Sardinia, King ('Med. Gaz.,' v, 805) for England, Courbon for Abyssinia, 
 and a number of authorities for the southern United States and for the islands 
 of the Pacific that have had particularly severe visitations of late. There 
 are fallacies or errors of diagnosis underlying the doctrine formerly held by 
 Astruc, Hufeland, Alibert and others, and lately revived by Rabatel for Tunis 
 (although long ago overthrown by Kortum), that congenital syphilis under some 
 circumstances takes the form of scrofula, or that, as Rabatel says, there is 
 •' transformation par I'heredite d'une autre diathese, de la syphilis."
 
 SCROFULA. 637 
 
 chronic errors of nutrition, there was a theory developed in 
 the first scientific treatises on the malady to the effect that 
 it owed its origin to a miasma, or that it was to be counted 
 among the infective diseases, spreading by way of contagion. 
 Bordeu^ was the first to formulate definitely the doctrine of 
 the miasmatic-contagious character of scrofula : " II existe 
 done dans la nature une sorte de mias^ne scrofuleux,'' he says, 
 " qui est sans doute forme quelquefois par les revolutions qui 
 arrivent aux differentes humours, et qui peut fort bien, en 
 passant d'un sujet a I'autre, aller, comme le levain dans la 
 pate, gater des humeurs saines ; mais il faut qu'il trouve une 
 disposition particuliere dans le sujet pour y agir ; il a besoin 
 d'y etre mis en action par un certain jeu des oi'ganes, et par 
 I'etat particulier des liqueurs/^ 
 
 Contemporary and later writers, such as Charmetton, 
 Pujol,^ Baumes^ and others, held fast to the belief in a con- 
 tagious transmission of the malady, tacitly accepting the 
 assumption of a " scrofulous virus ;" and latterly there has 
 been no lack of hypotheses of transmission by the milk of 
 scrofulous nurses, by the milk and flesh of tuberculous cows, 
 by vaccination, and so forth ; nor of speculative attempts 
 to prove the 'parasitic nature of the hypothetical virus, which 
 latter may appear to have found positive support in the dis- 
 covery by Koch of the so-called bacillus of tubercle. From 
 the clinical point of view, or following the statistics of 
 practical experience, the notion of a specific morbid poison 
 of scrofula, communicable by contact or per distans, has no 
 warrant whatsoever. The number of cases where the disease 
 has developed in persons who had, before their illness, been 
 brought into more or less intimate and prolonged contact 
 with scrofulous subjects (assuming that the facts may be 
 taken to justify the conclusion post hoc ergo propter hoc), is 
 so insignificant in proportion to the enormous number of the 
 scrofulous who are continually in the closest intercourse with 
 their whole circle, and that sometimes a very large circle — I 
 am thinking of scrofulous children at school — without in the 
 
 ' L. c, 74. In ' Oeuvres completes,' Par., 1818, i, 442. 
 ^ 'Oeuvres diverses de med. prat.,' Castres, 1802, iii, i. 
 ^ ' Traite sur le vice acrophuleu-x, &c.,' Par., 1805.
 
 638 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 least imperilling their associates/ that no impartial observer- 
 can seriously entertain the idea of concluding for the spread 
 of the disease by contagion. But even these isolated cases, 
 when closely looked into, lose all the value assigned to them 
 as evidence of that doctrine. They are mostly cases of ill- 
 ness among children of the same family, who do not fall ill all 
 too-ether, but one after the other as they reach a certain age ; 
 and they are not by any means all the children of the family, 
 but only some of them, the other brothers and sisters remain- 
 ing in good health. Foundling hospitals, orphanages, training 
 institutions and the like, where there is ample means of 
 observing how the disease spreads, do not furnish a single 
 report in which it is even hinted at that the disease had been 
 propagated among the juvenile inmates by way of contagion. 
 On the other hand some of the authorities, such as Baude- 
 locque for the Hopital des Enfants, and Pinel and Richerand 
 for the Hopital St. Louis, explicitly deny this mode of diffu- 
 sion. Baumes says that scrofulous nurses may give the 
 disease to their sucklings, but he is in our debt for a proof 
 that they have ever done so. The assertion that the milk 
 of tuberculous cows induces scrofula rests upon mere hypo- 
 thesis ; ^ not a single well-authenticated case of that kind has 
 occurred, whereas it can be shown that the whole population 
 of villages have eaten the meat of tuberculous cattle for 
 years together (and doubtless drunk the milk of tuberculous 
 cows) without any increase in the amount of scrofula having 
 been remarked among them.* 
 
 It cannot be denied that children fall into scrofula from 
 time to time after vaccination ; but there is no evidence 
 
 1 "Quotidie occurrunt exempla," says Kortum (1. c, 216), " ubi sani infantes 
 cum scrofulosis arcto et ipsius lecti consortio fruuntur, nee tamen ipsis morbus 
 commnnicatur." 
 
 ^ I do not express my own conviction merely, but the conclusion deduced from 
 the experience of many busy and observant practitioners with whom I have con- 
 versed on the question. 
 
 2 It is well known that the pearl-disease of cattle has been identified with 
 tubercle (aud scrofula) of the human subject [but only in the ultimate micro- 
 scopic analysis], 
 
 ■• See the interesting paper by Schottelius, in ' Virchow's Archlv,' 1883, xci, 
 136. The fact stated in the text I have on the authority of a thoroughly trust- 
 worthy medical officer ; and other observations of the same kind have been made 
 on an extensive scale.
 
 SCROFULA. 639 
 
 that sucli illnesses are the consequence of inoculation of a 
 scrofulous virus. ^ Moreover^ a transmission of scrofula by- 
 vaccination from arm to arm is so much the less likely, that 
 the vaccinifers are mostly in their first year, or at a time 
 of life when the disease is not yet developed, or, if the phrase 
 be preferred, is still latent.^ I have already mentioned (p. 609) 
 how this doctrine of inoculating" with scrofula arose; in recent 
 times it has been inflated to the most absurd extent by the 
 anti-vaccinationists and turned to very good account for their 
 purposes. 
 
 As regards clinical experience, then, there is nothing to 
 warrant the opinion that scrofula is a contagious disease; and 
 in that sense Begin^ long ago Avrote, in somewhat incisive 
 words : " Une ignorance et une credulite stupides inventent 
 la doctrine de la contagion des ecrouelles ; une faculte 
 de medecine* donne sa sanction a cette opinion ; trois ou 
 quatre observateurs inhabiles croient avoir, dans les faits 
 qu'ils ont recueillis, la confirmation de son exactitude ; et 
 bientot la foule, copiste servile des opinions des autres, com- 
 meute, amplifie et proclame enfin comme loi de la nature, ce 
 que la plus simple observation infirme chaque jour." 
 • Even if we take the other line of research, namely, the 
 experimental, there has been, in my opinion, no evidence 
 obtained in favour of the contagious character of scrofula. 
 Kortum's indefensible experiments to infect children with 
 the matter from scrofulous abscesses had no effect f nor had 
 
 ^ Lepelletier tells us that one of his colleagues had the hardihood to introduce 
 a quantity of scrofulous pus into punctures made upon children on account of 
 vaccination ; the vaccine developed excellently, but of scrofulous illness there 
 was not a trace (the incident is quoted by Phillips, 1. c, p. 146). 
 
 * The prohibition in the vaccination law of Germany against taking vaccine 
 lymph from the arm of a scrofulous child is in any case right ; for, apart from 
 the question here at issue, ailing persons in general are not suited to take vaccine 
 matter from. 
 
 ^ 'Diet, des Sc. med.,' Paris, 1820, vol. 1, p. 293. 
 
 * The reference is here to the declaration of the Paris faculty in 1758. 
 
 ^ " Quippe materiem ex talibus (scrofulosis) ulceribus desumtam," saj's Kor- 
 tum (p. 2i8), " puello sano ad latus colli Integra cute infricavi, alio vero puero 
 cuticula exiguo vulnusculo, velut in variolarum insitione fieri solet, disrupta, 
 itidem in superior! colli regione, nempe infra et pone processum mastoideum 
 applicavi, — et ne ullam quidem inde observare potui niorbi commuuicationem." 
 In justification of his experiment he adds : " Nemo dicat audacula haecce tenta- 
 mina, cum firmissimis iudubitatisque rationibus essem persuasus, nullum inde
 
 '640 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 those of Lepelletier, first upon guinea-pigs,^ and afterwards 
 upon himself. Scarcely had the parasitic doctrine raised 
 its head, when Moretto^ hazarded the conjecture that scrofula 
 might be due to a vegetable or animal parasite, the grounds 
 of his surmise being that " tuberculous growths '' on animals 
 and plants were caused by parasites, and that the heredity 
 of scrofula presupposed a definite germ of disease. Subse- 
 quently Hiiter^ developed the theory that the plasmatic 
 vessels in childhood undergo dilatation owing to the large 
 amount of the nutritive juices ; and inasmuch as they extend 
 to the surface layers of skin and mucous membrane, these 
 latter lose that firmness which protects them from the 
 invasion of inflammation-breeding organisms suspended in 
 the air, so that the parasites enter and set up scrofulous 
 inflammation, first in the skin and mucous membrane, and 
 afterwards in the lymph-glands, which they reach by the 
 lymphatic vessels. More recently Koch has adduced evi- 
 dence that the tubercle-bacilli discovered by him are found 
 also in scrofulous glands, and that the inoculation of the 
 parasite (bred pure by cultivation) upon animals is followed 
 by tuberculosis in them. I refrain for the present from 
 going more particularly into the question of the causal rela- 
 tion of this parasite to the scrofulous process. When I 
 •come to speak of the connexion which subsists from the 
 historical and etiological point of view betiveen 'pulmonary 
 consumption and scrofula, I shall have an opportunity of 
 -discussing that question. In the meantime I give it as my 
 
 damnum pueris subnasci posse. Imitentur Lectores, si placet, experimentula, 
 euudemque eventum fore polliceor." 
 
 • He first shut up the animals in a small dark place, such as seemed to be 
 ^)articularly coudueive to the development of scrofula; next he mixed their food 
 with pus from typical cases of scrofula, in such quantities that each of them 
 consumed half a teaspoonful daily. Also he injected eight to ten drops of the 
 pus into the crural vein, and rubbed the matter into a wound made in the region 
 of the inguinal lymphatic glands and into a smooth-clipped spot on the neck. 
 The animals were killed a few months after, but in none of them was there any 
 trace of scrofula. Lepelletier and his colleague Goodlad several times inoculated 
 themselves with scrofulous pus, but no signs of scrofula ever followed (quoted in 
 Phillips, p. 146). 
 
 ^ ' Annali univ. di mediciiia,' 1859, Settembre, p. 520. 
 
 5 'Die scrophulose und ihre lokale Kehindlune,' Leipz., 1872 (' Volkmann's 
 •Saramlung klin. Vortr.,' No. ^9).
 
 SCROFULA. 641 
 
 opinion that the results arrived at hitherto by means of 
 experimental research upon animals have not shaken the 
 conviction of clinical experience that scrofula is non-con- 
 
 tagious. 
 
 VOL. II. 41
 
 CHAPTER XVIII. 
 DIABETES. 
 
 § 219. Defective Historical Record. 
 
 The proved importance of the historical and geographical 
 
 lines of pathological inquiry for the working out of the 
 
 etiology of disease, or for elucidating the causal connexion 
 
 of climatic, seasonal, telluric and social influences with 
 
 the existence or spreading of maladies, is brought home 
 
 to us with double force by the omissions and imperfections 
 
 in our historial and topographical information about those 
 
 diseases which stand most in need of some such etiological 
 
 elucidation. For diabetes this holds good to the fullest 
 
 extent as regards both the historical evidence and the topo- 
 
 gi-aphical. The very manifest want of tolerably safe and 
 
 exhaustive topographical details about that disease is explained 
 
 by the fact that it is seldom seen at all ; it has accordingly 
 
 escaped the notice of all observers who were not specially 
 
 on the outlook for it, most of all in those parts of the world 
 
 where practitioners have had no opportunities of ascertaining 
 
 the state of health of the population except within a very 
 
 narrow circle ; and in other countries the desideratum has 
 
 been very inadequately supplied by the statistics of mortality, 
 
 which are not only wanting in absolute trustworthiness so far 
 
 as they go, but have assigned in only a trifling proportion of 
 
 instances a special place to diabetes among the causes of 
 
 death, ranging it in most cases under the general head of 
 
 " chronic disorders of nutrition " or " diseases of the uro- 
 
 poietic system," and mixing it up with Bright's disease, 
 
 gout, gravel and the like. It is obvious that hospital 
 
 statistics cannot be depended upon in such an inqury ; for
 
 DIABETES. 643 
 
 diabetes is well known to be commonest among tbose classes 
 who least resort to hospitals in their sickness. I have thought 
 it well to premise this much as an apology for the sketchy- 
 character of what follows. It gives me the opportunity also 
 of expressing the wish that subsequent investigators and 
 statisticians may endeavour as far as possible to fill up this 
 very perceptible lacuna. 
 
 § 220. Earliest References to Diabetes. 
 
 The history of diabetes goes back to the most remote 
 antiquity. The earliest accounts come from India ; in the 
 Ayur Veda of Susruta^ we read : " Mellita urina laborantem 
 quem medicus indicate ille etiam incurabilis dictus est 
 
 . . Omnes urinales affectiones tempore incurabiles fiunt ; 
 ad mellitum urinae statum perveniunt et tunc insanabiles 
 fiunt." 
 
 In another passage^ of that work, where the same disease 
 is treated of circumstantially, the phrase occurs, " dulcis fit 
 urina, sudor et phlegma;" and there can be no doubt that 
 diabetes is the malady referred to.^ The occurrence of the 
 disease in various parts of Europe and Asia during the later 
 period of antiquity, and throughout the middle ages, is indi- 
 cated in various ways in the writings of the Graeco-Roman,* 
 Arabian and Arabistic schools; but from none of these does 
 
 ' ' Nidanasthana,' cap. vi, in Hessler's Latin translation, Erlangen, 1844, '> '84. 
 
 * 'Chikitsitasthana,' cap. xii, xiii, in the Latin transl., ii, 103. 
 
 3 Christie (' Edin. Med. and Surg. Journ.,' 181 1, July, p. 285) gives an account 
 of a Cingalese medical treatise of the fifteenth century of our era, translated from 
 the Sanscrit, in which the disease is also referred to under the name of " madu 
 mehe," or " honey-urine." It is a probable guess that the work in question may 
 have been a translation of the treatise of Susruta. 
 
 •• There is nothing in the Hippocratic Collection which points to diabetes. The 
 first mention of the disease is in Celsus (" Urina super potionum modum etiam 
 sine dolore profluens, maciem et periculum facit," lib. iv, cap. xx, § 2). The first 
 to use the name of SiajSijTrjg was Aretaeus (' De causis diuturn. morb.,' lib. ii, 
 cap. ii, and ' De morbor. diuturn curatione,' lib. ii, cap. ii) ; he speaks of the 
 malady as a mysterious one {Qdivfia TrdHoQ) and of rare occurrence {ov Kapra 
 ^vvT)9eg dvOpuiiroKTi), wherein the flesh and frame melt into urine (aapKdv Kai 
 fiiXtwv ig ovpov ^vvrrj^ig). Galen also mentions the disease in several passages 
 of his writings ('De symptom. difEerentiis,' lib. i, cap. vi, Kiihn's ed., vii, 81 ; 
 De crisibus,' lib. i, cap. xii, Kiihn's ed., ix, 597); but he states in another
 
 644 GEOGEAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 it appear that their authors had been acquainted with the 
 sweet taste of the urine, and the same is true of the medical 
 observers of the sixteenth century. Willis in his ' Pharma- 
 ceutice rationalis/^ published in 1674, calls attention to that 
 property of the urine in diabetes ; but it was not until a 
 hundred years after that Dobson^ showed that the taste of the 
 urine depended on a sugary substance contained in it, which 
 he detected by means of a fermentation experiment, and that 
 the serum of the blood also in cases of diabetes had a sweet 
 taste. Twenty years later, there was published the well-known 
 essay on diabetes by Rollo,^ who was the first to discuss the 
 subject thoroughly and who laid the foundation of all subse- 
 quent writings upon it. 
 
 § 221. Area op Prevalence mostly within the Temperate 
 
 Zone. 
 
 From the references of Indian, Graeco-Roman and Arabian 
 writers we obtain evidence that the geographical area of 
 diabetes even in those remote times extended over a large 
 part of Southern Europe, Nearer Asia and India. These data 
 were afterwards supplemented by notices of the malady from 
 almost every country of Central and Northern Europe ; and 
 towards the end of last century there came information of 
 cases of diabetes among the European population of North 
 America. In all those countries within recent times the 
 
 passage (' De locis affectis,' lib. vi, cap. iii, Kiihn's ed., viii, 394) that he had seen 
 only two cases of it. Short notices of it occur subsequently in the compendiums 
 of all the later Greek physicians, as well as in Rhazes (' De re medica ad Alman- 
 sorem,' lib. ix, cap. 78), and in Avicenna (' Canon,' lib. iii. Fen. 19, Tract, ii, cap. 
 1 7), and Avenzoar (' Alteisir.,' lib. ii, Tract, ii, cap. vi, Venet., 1490, fol. 25) ; also in 
 the Salernians, particularly Constantinus Africanus (' De morbis cognosc. et 
 curand.,' lib. v, cap. 18, and 'Liber aureus,' cap. 39, § 2, Basil., 1536, 118, 182), 
 and Platearius ('Practica,' "De aegritud. renum," cap. i, Lugd., 1525, fol. 219 b, 
 or in de Renzi's ' Collectio Salernitana,' " De egritudinum curatione," Napolii 
 1853, ii, 310), and in nearly all the writers of medical handbooks in the latter 
 part of the middle ages. 
 
 J^ Sect, iv, cap. iii, 0pp. Amstelod., 1682, p. 64. 
 
 = 'Med. Observ. and Inquiries by a Soc. of Phys.,' Lond., 1776, v, 298. 
 
 2 'Account of two Cases of the Diabetes mellitus, &c.,' Lond., 1797 ('Notes of 
 
 Diabetic Case,' Deptford, 1796).
 
 DIABETES. 
 
 645 
 
 disease has been seen in greater or less frequency; but 
 whether it is more common in some of them than in others, 
 it is impossible for the present to settle with any degree of 
 probability except for a few places. In the following table 
 I have put together the results of statistical returns for 
 certain countries or cities ; but I would attach no further 
 importance to them than as proving that the disease, esti- 
 mated by the mortality that it causes, is one of the rarest. 
 It remains doubtful on what the considerable differences in 
 the frequency of diabetes at various places depend ; and 
 whether such difference really exist, or are merely so brought 
 <3ut by the defectiveness of the returns. 
 
 Table of the death-rate from diabetes in various countries. 
 
 Locality. 
 
 England^ 
 
 Ireland ^ 
 
 Schleswig-Holstein ^ . 
 
 Berlin* 
 
 Chemnitz* 
 
 Frankfoi't-on-Main ^ 
 
 Wiii'zburg ' 
 
 Brussels^ 
 
 Philadelphia' 
 
 Period. 
 
 1852-69 
 
 1841 
 1S71-79 
 1877-79 
 1871-74 
 1865-80 
 
 1852-55 
 1864-80 
 
 1872-77 
 
 Mean 
 
 annual 
 
 deatli-rate 
 
 from 
 diabetes. 
 
 Mortality from 
 diabetes 
 
 550-0 
 ir8-o 
 
 i4"3 
 300 
 
 2-5 
 
 3'4 
 
 10 
 
 33 
 15-7 
 
 per Tooo 
 
 in- 
 habitants. 
 
 per 1000 
 deaths. 
 
 0*027 
 0'oi4 
 0014 
 0029 
 0035 
 0035 
 0*040 
 
 0'02I 
 
 125 
 074 
 065 
 0-94 
 I'OO 
 
 i'6o 
 
 I'20 
 
 o'6o 
 0-88 
 
 In St. Petersburg diabetes would appear to be very rare 
 
 ' 'Thirty-second Annual Report of the Registrar- General, &c.,' Lond., 187 1, 
 
 230. 
 
 ' Wylde, 'Ediub. Med. and Surg. Journ.,' 1845, July 8. 
 
 ^ Bockendahl, ' Jahresbericht der offentl. Gesundheitsverh. der Provinz 
 •Schleswig-Holstein.' 
 
 * ' Statistisches Jahrb. der Stadt Berlin.' 
 
 ^ Flinzer, ' Mittheil. des statist. Bureaus der Stadt Chemnitz.' 
 
 ^ ' Jahresberichte iiber die Verwaltung des Medicinalwesens der Stadt Frank- 
 furt a. M.' 
 
 7 Virchow, in ' Verhandl. der Wiirzb. phys.-med. Gesellschaft,' x. 
 
 8 Janssens, 'Bull, de I'Acad. de med. de Belgique,' Ann. 1865 — 1881. 
 
 9 'Transact, of the Pennsylvania State Med. Soc.,' 1873 — 1878.
 
 646 GEOGEAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 according to the corroborative statements of Attenhofer^ and 
 Lefevre/ tlie former remarking that not a single case had 
 occurred in his own practice or in that of a number of his 
 colleagues during a period of six years. Otto^ gives the 
 same account for Co'penhagen, where there was no case of 
 diabetes entered in the table of deaths from 1835 to 1838. 
 There are references to diabetes in Turhey by Rigler^* and 
 in Egypt by Pruner^ and Griesinger/ in Morocco also the 
 malady is seen from time to timeJ Among the natives of 
 Senegambia, on the other hand, Chassaniol^ tells us that he 
 had not seen a single case ; neither is there any mention 
 of it in the records of English and French practitioners on 
 the Guinea Ooast. It is strikingly common in Ceylon^ and 
 at some points of India, particularly, as would seem, on the 
 Coromandel Coast^° and in Bengal,^^ being much rarer in the 
 Bombay Presidency .^^ From China, Japan, Australia and 
 the islands of the Pacific there are no accounts of diabetes ; 
 neither is it mentioned at all by the authorities for Central 
 America and the West Indies, while Blair^^ explicitly says 
 that in Guiana it is absolutely unknown. In Vera Cruz 
 {Mexico), Heinemann has seen it comparatively of ten. ^* 
 Jordao's statement^^ that it is not unfrequently met with in 
 Brazil is directly contradicted by Jobim, who says that he 
 
 1 c 
 
 2 < 
 
 'Med. Topogr. rler Hauptstadt St. Petersburg,' Zurich, 181 7, 235. 
 'Lond. Med. Gaz.,' 1834, Novbr. » 
 
 ' 'Transact, of the Prov, Med. and Surg. Assoc.,' 1839, vii, 237. 
 
 * 'Die Tiirkei und deren Bewohner,' ii, 323. 
 
 * • Die Krankheiten des Orients,' 367. 
 
 « ' Archiv fiir physiol. Heilkde.,' 1859, 5. 
 
 7 Ref. in 'Med. Times and Gaz.,' 1875, July, 96. 
 
 8 'Arch, de med. nav.,' 1865, Mai, 508. 
 
 s Christie, 1. c; Davy, 'Account of the Interior of Ceylon,' Lond., 182 1. 
 ^ " Sec Eyre, 'Madras Quart. Journ. of Med. Sc.,' i860, Octbr., 341; Cornish, 
 ib., 1861, July, 8q; Ref. in ' Madras Monthl. Journ.,' 1870, May, 373; also the 
 accounts by von Ruhde ('Bibl. for Laeger,' 1831,1, 281) for Tranquebar; HuiUet 
 ('Arch, de med. nav.,' 1S69, Fevr., 83) for Pondicherry; and Auboeuf ('Contri- 
 butions a I'etude de I'hyg. et des malad. dans I'lnde,' Par., 1882. «^) for KarikaL 
 
 " Eyre, 1. c. *"" 
 
 ^' Morehead, 'Clinical Researches on Disease in India,' Loud., 1856,11,297; 
 Eyre, 1. c. 
 
 »' 'Account of the last Yellow Fever Epidemic,' Lond., 1852, 20. 
 ' In ' Virchow's Archiv,' 1873, Iviii, 178. 
 " 'Consider, sur un cas de diabete,' Par., 1857.
 
 DIABETES. 647 
 
 did not observe a single case of it during a practice of many 
 years at Eio ; and we may find a confirmation of this in the 
 silence about tbe malady maintained by Sigaud, Rendu and 
 otber authorities on the diseases of that country. In Peru 
 also, it would appear from Smith^ and Tschudi,^ to be 
 extremely rare ; the latter, indeed, tells us that the Peruvian 
 practitioners are quite unacquainted with it. 
 
 § 222. Etiological Questions. 
 
 It is obvious that, from these scanty details of diabetes 
 throughout the world, we can draw no just conclusion as to 
 the influence of climate and the like on its geographical dis- 
 tribution. But the assertion often made, that a damp and 
 cold climate disposes especially, to the disease, is entirely 
 upset by the facts adduced. The prevalence of the disease 
 in Ceylon and some parts of India, particularly among high- 
 caste Hindus whose diet is exclusively vegetable (Cornish), 
 appears to favour the doctrine of Rhude, Davy and others, 
 that its commonness has something to do with a diet that is 
 mostly if not altogether non-nitrogenous. But the question 
 would remain, why it is that diabetes is seldom or perhaps 
 never seen in many other tropical countries of the Eastern 
 and Western Hemispheres, in which the diet of the native 
 population is the same. 
 
 1 'Edinb. Med. aud Surg. Journ.,' 1841, Octbr., 400. 
 ' ' Oest. med. Wochenschr.,' 1846, 473.
 
 CHAPTER XIX. 
 
 GOUT. 
 
 § 223. Copious references to Gout in Ancient Literature. 
 
 If our inquiry into the position of diabetes in place and 
 time leads to no very satisfactory result, in consequence 
 of the want of information about it in medico-topographical 
 writings ; the study of gout from the geographical and his- 
 torical points of view meets with hardly less serious obstacles 
 in the documents relating thereto, from the fact that the 
 gouty process has often been confused with chronic rheu- 
 matism and with arthritis nodosa {" rheumatic gout ") not 
 only by the observers and authorities of former times but 
 also by those of the modern period and of the latest date. 
 The available writings upon gout possess, therefore, only a 
 Hmited utility for the scientific handling of the malady in 
 the particular directions of this work ; more especially they 
 are unserviceable in that much ventilated question whether 
 the fluctuations in the number of cases, which would seem 
 to have occurred fi'om time to time according to contemporary 
 data, had occurred really, and in particular whether the 
 disease has undergone a considerable diminution of recent 
 years as compared with last century ; or whether such fluctu- 
 ations are to be explained rather by the changing ideas of 
 the day as to what was " gout " — by the varying connotation 
 and scope of the term at various periods. 
 
 We are able with certainty to follow gout back as far as 
 the time of Hippocrates, that is to say, the fifth century 
 B.C. ; there are many unambiguous references to iroBaypa in 
 the Hippocratic Collection, which show that the malady was
 
 GOUT. 649 
 
 well known to the practitioners of that age.^ It follows, 
 moreover, from the quotations in the chapter on gout^ in 
 Caelius Aurelianus (that is to say, Soranus),^ that special 
 attention had been given to gout by the post-Hippocratic 
 Stoics (Diodes and Praxagoras) and by the Alexandrians 
 (Herophilus and Erasistratus), whose writings have not come 
 down to us, and that Erasistratus even wrote a monograph 
 on the subject.* In the Koman Empire of the West, gout 
 appears to have been of frequent occurrence as early as the 
 last years of the Republic ; ^ but all the writers on medicine 
 of the time, as well as the poets and philosophers, are agreed 
 in saying that it grew to be remarkably prevalent amidst 
 the increasing luxury and sensuality under the early emperors. 
 Neither does that prevalence of the disease appear to have 
 been limited to Italy ; for, according to the statement of 
 Caelius Aurelianus,® gout was reckoned among the maladies 
 of common occui'rence in Caria (south-western division of 
 Asia Minor) and in Alexandria. 
 
 As early as the time of Pliny (first century of our era), a 
 considerable increase in the number of cases had been 
 remarked : '' Podagrae morbus," says that writer/ " rarior 
 solebat esse non modo patrum avorumque memoria, verum 
 etiam nostra, peregrinus et ipse. Nam si Italiae fuisset 
 antiquitus, latinum nomen invenisset." Seneca, the con- 
 temporary of Pliny, who, as a Stoic, missed no opportunity 
 
 ^ See ' Praenot. Coacae,' Sect, v, § 502, ed. Littre, v, 700; 'Aphorism.,' lib. v, 
 § 25, and vi, § 28 — 30, 55; 'Epidem.,' lib. ii, sect, iii, § 12, e. c. v, 114; ' De 
 affectionibus,' § 31, e. c. vi, 242 ; ' Prorrhet.,' lib. ii, § 8, e. c. ix, 26. In the last 
 mentioned treatise, which is probably later than Aristotle, the subject is treated 
 with particular fulness. 
 
 ^ " De morbis acutis et chronicis," * Morb. Chron.,' lib. v, cap. ii, Amstelod., 
 
 I7S5. P- 566. 
 
 3 It is well known that the treatise of Caelius Aurelianus is a translation, and 
 in all probability a literal translation, of the work on medicine by the great 
 methodist Soranus, who lived in Rome in the second century of our era. 
 
 * It appears from a reference in Caelius Aurelianus that the King Ptolemy 
 (probably Soter) was a sufferer from gout, and that Erasistratus treated him for it. 
 
 ^ In evidence of this there are the exhaustive memoirs on the disease by 
 Asclepiades and Themison, mentioned by Caelius Aurelianus. Cicero also 
 mentions patients with the gout in many passages of his writings (e.^.'Epistol.,' 
 vii, 4, ad M. Mar., and ' De finibus,' v, 3). 
 
 « L. c, p. 558. 
 
 7 ' Hist, nat.,' lib. xxvi, cap. Ixlv, ed. Franzius, Lips., i^SSi vii, 851.
 
 650 GEOGEAPHICAL AND HISTOEICAL PATHOLOGY. 
 
 in his writings of animadverting on the dissolute and riotous 
 life of Rome and on the after-consequences to the health of 
 the community, dwells upon the fact that podagra was com- 
 mon even among the women ; and he adds the remark that 
 it was not surprising, for their sex emulated the excesses 
 of the men in every respect.^ " In the time of Hippocrates/' 
 says Galen/ "there were only a few who suffered from 
 podagra, such was the moderation in living {^la to tov 
 (5iov Koafxiov) ', but in our own times, when sensuality has 
 touched the highest conceivable point, the number of patients 
 with the gout has grown to an extent that cannot be esti- 
 mated (ctTTEjooV Ti TO ttX^Ooc twv 7roSa'yf)i(t»vra)i').' The same 
 enormous prevalence of the malady afforded a subject to the 
 satirist Lucian for his little comedy of " Tpa-yaTroSa-ypa,' in 
 which he introduces Podagra as a goddess and represents 
 her in a witty fashion as exercising absolute sway over 
 mankind.^ The most prominent physicians of the time took 
 occasion also to write on the subject at great length, the 
 chief treatises that have come down to us being those of 
 Aretaeus * and Caelius Aurelianus (that is to say, Soranus) . 
 
 The word dpOping, used by Galen, is applied by liim and the later 
 Greek and Roman writers on medicine to express "inflammation of the 
 joints " in general ; while of special forms of it, good descriptions are 
 given of la-xiue or inflammation of the hip-joint, of ■iToddypa and x£«pa'yp« 
 (distinguished as voaiiiiara Qfpfxa kuI 4^vxpd according to a humoral 
 principle founded on the morbid phenomena), and lastly of gouty 
 
 ' ' Epistol.,' 95, 0pp., ed. Haase Lips., 1853, iii, 302 : " Non mutata feminarum 
 natura, sed vita est ; nam cum virorum licentiam aequaverint, corporum quoque 
 virilium iucommoda aequarunt. Non minus pervigilant, non minus potant, et 
 oleo et mero viros provocant ; aeque invitis ingesta viscerlbus per os reddunt et 
 viuum omne vomitu remetiuntur." Seneca mentions and treats of gout in 
 many other passages of his writings (e. g. ' Epist.,' 53, 67, 78, ed. cit., iii, pp. 1 1 », 
 ^S2> 197) ; and in his ' Lud. de morte Claudii Caesaris' (§ 13, ed. cit., i, 273), he 
 remarks that the Emperor Claudius was a sufferer from it. 
 
 * 'Comment, in Hipp, aphorism.,' cap. xxviii, ed. Kiihn, xviii, A. 42, Other 
 references to gout in the writings of Galen will be found in the following : ' De 
 sanitate tuenda,' lib. vi, cap. vii, e. c. vi, 415; 'Method, med.,' lib. vii, cap. xi 
 e. c. X, 513 J ' De compositione medic, secund. locos,' lib. x, cap. ii, e. c. xiii, 331 ; 
 ' De remed. parabll.,' lib. i, cap. xvi, e. c. xiv, 383 ; ' De theriaca lib. ad Pisonem, 
 cap. XV, e. c. xiv, 274. 
 
 ' The little comedy of Qkvitovq appended to this drama, and dealing with the 
 same subject, is apochryphal. 
 
 ■ De causis et signis diuturnor. morbor,,' lib. ii, cap. xii. 
 
 4 « ■
 
 GOUT. 651 
 
 nodules under the name of Trwpoi, or swellings of stony hardness.^ We 
 find mention already of tlie metastases of gout also, Galen speaking 
 of gout flying to the stomach (/xsrscrr/; elg rijv yaorspa),^ and to the lungs,^ 
 and Aretaeus of gouty asthma.'* It can hardly be doubted that chronic 
 articular rheumatism, and particularly arthritis nodosa, had entered 
 into their conception of " podagra." 
 
 Whether any diminution of the number of cases occurred 
 in the time of the later Empire and in the middle ages is not 
 ascertainable from the medical writings of those periods ; the 
 less so that "arthritis'^ (or as the mediaeval writers, and, so far 
 as I know, Constantinus Africanus first, name it " arthetis ") 
 would appear to have been more widely prevalent than for- 
 merly, while the term " podagra " occurs less often (the 
 disease being now and then called " gutta " or •' drop ''^), and 
 in the end becomes merged almost entirely with other dis- 
 eases of the joints under the general name of " arthritis/' 
 The very prolix dissertations on gout in the compendiums 
 of Aetius,^ Paulus ^gineta,'^ aud Alexander of Tralles^ (who 
 occupies himself almost entirely, and at enormous length, with 
 directions for treatment), as well as in the writings of the 
 Arabians, particularly Serapion the elder,'"^ Ehazes,^^ Abul- 
 casim,-^^ Avicenna,^^ and Avenzoar^'^ (whose work is one of the 
 best), merely reproduce the data of the earlier Greek prac- 
 titioners, and give us no means of forming a conclusion as to 
 the frequency of the disease. The same is true of the works 
 of mediaeval physicians of the West, of Constantinus Africa- 
 
 I The word irtipoi is also used to designate bony callus. 
 - ' Method, med.,' 1. c. 
 
 3 ' De theriaca lib. ad Pisonem,' 1. c. 
 
 "• L. c, ed. Kiibn, p. 174. 
 
 5 The first use of the term " gutta " that I can find is in Valescus de Tharanta, 
 who defined it : " Est passio in ligamentis et nervis junctuarum ex humore vel 
 ventositate ad eos decurrentibus a membris superioribus vel circumvicinis." It 
 is here used, therefore, in the same sense as "gutta in oculis" applied to cataract. 
 It is clear that the French "goutte" and the English "gout" are derived from 
 "gutta." 
 
 fi ' Sermo,' xii, cap. vi — xlviii. 
 
 ' Lib. iii, cap. 78. 
 
 ^ Lib. xii. 
 
 * 'Practica Tract.,' iv, cap. 23 — 30, Lugd., 1525, fol. 44, seq. 
 
 10 ' De re medica,' lib. ix, cap. 90, and ' Lib. de affect, juncturarum.' 
 
 II ' Method, med.,' lib. i, cap. 45. 
 
 1* 'Canon,' lib. iii. Fen. 22, tract. 2, cap. 55, seq. 
 
 ^ ' Theisir.,' lib. ii, tract, vii, cap. 30, Venet., 1490, fol. 32.
 
 «52 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 nus,^ and of the Salernians Platearius/ Valescus de Tharanta/ 
 Arnaldus Villanovanus/ Savonarola/ and Guainerio ;" as 
 well as of the monograph on the disease by Demetrius 
 Pepagomenos/ a physician of the thirteenth century practising 
 at the Byzantine court, which is for the most part based 
 upon the woi'ks of Paulus and Alexander. 
 
 The literature of gout in the sixteenth century opens with 
 the writings of Paracelsus" on podagra (of very doubtful 
 genuineness, however), which have no historical interest 
 except that they are the first to introduce the German name 
 of " Zipperley,^' applied to the disease, and that the discus- 
 sion of the subject in them is elaboi'ate enough to prove to 
 us that gout must have played a very prominent part among 
 the diseases of the time. The same conclusion is justified 
 also by the numerous treatises on podagra in the medical 
 literature of the sixteenth, seventeenth, and eighteenth cen- 
 turies ; although we are still prevented, by the confounding 
 of true gout with chronic rheumatism and arthritis nodosa, 
 from coming to any definite opinion as to the amount of the 
 disease. According to these writings, however, it w^s spread 
 over the whole of Europe. 
 
 A new source of error arose after Sydenham's classical des- 
 cription^ of the malady as he observed it in his own person, 
 and after Hoifmann's^° and van Swieten's^^ excellent works on 
 
 ^ 'De morb. cognosc. et curaud./ lib. vi, cap. xix, Basil., 1536, 137; and 'Lib. 
 aureus,' cap. xlv, e. c. 185. 
 
 ■■' ' Practica,' 184 b, and in de Eenzi, ' Collect. Salernit.,' ii, 349—356. 
 
 •■' ' Philonium,' lib. vi, cap. 23, Lugil., 1490, fol. 295 b. 
 
 •• 'Parabolae medicationis,' 0pp., Basil., 1585, 985, and 'Breviar.,' Lib. ii, 
 cap. 45, e. c. 129 h. 
 
 ' ' Practica tract.,' vi, cap. xxli, Ruhr, x, Venet., 1497, fol. 272 ^• 
 
 * ' Commentar. de aegritud. juuctur.,' cap. i, seq., in ' Practica,' Lugd., 1534, 
 fol. 171b (contains a few observations by the author himself). 
 
 ' • De podagra libellus,' Romae, 15 17 (reprint in Stephan's collection, Paris, 
 ^567. p. 837). 
 
 ^ ' Buch von den tartarischen Krankheiten,' cap. 19, 0pp. Strassb., 1603, 313 ; 
 ' Vom Podagra,' e c. 539 ; ' Liber de podagricis ' (in German), e. c. 563. 
 
 ' ' Tract, de podagra,' 0pp., Genev., 1736, i, 300. 
 
 '" ' Med. ration, system.,' Tom. iv, Sect, ii, cap. xi, 0pp., Genev., 1753, ii, 399; 
 ' Diss, de genuino dolor, podagr. remed.,' Hal., 1697, OPP- Supp., ii, Pars.ii, 173; 
 ' Diss, de podagra retrocedente in corpus,' Hal., 1700, 0pp., ib., 187 ; ' Diss, de 
 cura doloris podagr.,' Hal., j 738, 0pp., ib., 180. 
 
 " 'Comment, in Boerhaave aphorismos,' § 1254—1282, Lugd. Batav., 1764, 
 iv, 287—393.
 
 GOUT. 655 
 
 the subject, which, drew the line sharply between gout and 
 rheumatism. Coincidently with the more precise determina- 
 tion of the existence of a gouty diathesis, or, in other words, 
 with the proof of a constitutional character for the disease, 
 the province of " gouty ailments " underwent an extension 
 beyond all bounds ; so that all the advantage on the one side 
 by the sharper separation of gouty affection of the joints from 
 other degenerative articular changes (rheumatism in particu- 
 lar), was lost on the other side by overstraining the doctrine 
 of " internal gout," which was resorted to, along with the 
 " haemorrhoidal disease," whenever there was a difficulty 
 about the diagnosis. It is only within recent times, and 
 mostly since morbid anatomy began to be cultivated, that 
 sobriety of view has entered into the doctrine of gout ; and 
 accordingly the large place that the disease held in former 
 centuries has been a good deal restricted, although it may 
 still happen to us at the present day to hear and read of 
 rheumatic arthritis and arthritic rheumatism. 
 
 Care is needed, therefore, in estimating and weighing the 
 data as to gout, so as to arrive at its history in the past and 
 its prevalence in the present ; and we may take it as certain 
 that its comparative rarity in recent times beside former 
 centuries depends not a little upon the more precise diagnosis 
 of the malady, or upon the disentanglement of what is included 
 under " gout " from among other forms of disease resembling 
 it. At the same time it cannot be doubted, after the trust- 
 worthy observations^ that have been made in Spain, Italy, 
 Belgium, Holland, Switzerland, and even on the classical 
 soil of England, that gout in recent times has undergone a 
 real and very considerable abatement compared with previous 
 centuries, just as in the early period of the Roman Empire 
 it underwent a considerable increase as compared with the 
 earlier age of antiquity. So far as we may conclude from 
 the medico-topographical records before us, there are very 
 few parts of the world where it counts at the present day 
 among the more common constitutional disorders of nutrition, 
 and there are none where it has the character of a truly 
 endemic malady. 
 
 ' See in particular the admirable research of Corradi, ' Delia odierna diminuzione 
 della podagra e delle sue cause,' Bologna, i860; also the writings of Dolleman
 
 454 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 § 224. Present G-eographical Distribution : Eare 
 
 IN THE Tropics. 
 
 The geographical area of gout at the present time includes 
 a very large part of the temperate zone ; but within that 
 area there are very considerable differences obtaining in the . 
 amount of the disease at the various points of observation, 
 for which there is no arithmetical expression to be had. In 
 Spain, according to somewhat antiquated information/ it 
 would appear to be particularly common in Asturias. In 
 Italy the regions most affected were the Alpine valleys of 
 Piedmont/ Naples^ (among the well-to-do) and Sardinia.* 
 For France, Lorraine and Normandy^ are given as the chief 
 seats; in the large towns of the Department of the Rhone, also^ 
 it is far from rare even among the less comfortable classes of 
 the populace, one of the authorities^ remarking that '^ il suffit 
 d' avoir exerce dans une grande ville, pour savoir que dans 
 les classes inferieures on rencontre un assez grand nombre de 
 goutteux." 
 
 For Siuitzerland we hear from Lebert^ that gout has grown 
 rarer among the upper classes " since manufactures and 
 railways have begun to claim many of their energies formerly 
 unused.^^ In Belgium, where the disease has become a good 
 deal less common/ it is now met with mostly in Flanders 
 and in the Walloon provinces.^ In Holland also it is now 
 seen on the whole rarely .^° For Germany Ave have accounts 
 
 for Holland, Coley for Belgium, Lebert for Switzerland, and Owen, Fuller, Budd, 
 and others (see p. 655) for England. 
 
 ' Tliiery, ' Observ, de physique et de medecine faites en . . Espagne,' Par., 
 1791, ii, 108. 
 
 * 'Brunner, 'Verhandl. der Schweiz. ilrztl. Gesellsch.,' 1829, i, 151. 
 
 =• de Renzi, ' Topogr. e statist, med. della citt^ di Napoli, &c.,' Nap., 1845, 326. 
 
 * Moris in de la Marmora's 'Voyage.' 
 
 5 Simonin, ' Rech. topogr. et med. sur Nancy,' Nancy, 1854, 250; Charcot, 
 'Med. Times and Gaz.,' 1867, March, 245. 
 
 * Marmy et Quesnois, ' Topogr. stat. et med. du Depart, du Rhone, &c.,' Lyon, 
 1866, 548. > ' 3 ' 
 
 ' ' Handbuch der pract. Med.,' 1859, ii, 898. 
 
 * Coley, ' Remarks on the Climate and the Diseases occurring in Belgium,' 
 Bruss., 1852, 163. 
 
 ^^ Meynne, ' Topogr. med. de la Belgique,' Brux., 1863, 211. 
 
 Dolleman, 'Disquis. de plerisque apud Belgas septentrionales endemiis 
 morbis,' Amstelod., 1824, 55.
 
 GOUT. 655 
 
 of its comparatively frequent occurrence in Hamburg/ Meck- 
 lenburg,^ tbe Harz/ Bremen/ Gottingen/ Dresden/ Wies- 
 baden/ Ludwigsburg/ Passau/ and Upper Austria /° in 
 Berlin it came under Traube's notice extremely seldom/^ 
 England still remains one of its principal seats, altbough 
 there too, as we learn from Fuller, Budd,^^ Watson,^^ Forbes,^* 
 and others, there has been a considerable decrease noticeable. 
 Forbes writes : " Two of the oldest practitioners in the dis- 
 trict (the Land's End), each resident in a small country 
 town, assured me that in their earlier practice, that is, forty 
 or fifty years before, gout was much more frequent than at 
 present — in the proportion, they said, as a hundred to one.'' 
 It is very remarkable, on the other hand, that Scotland and 
 Ireland have always enjoyed a notable immunity from gout. 
 From Denmarh I know of only one account, by Otto,^^ who 
 says that the malady is relatively common, especially in 
 Copenhagen. For Sweden and Norway there is no recent 
 information about it. In Lapland (according to Linnaeus), 
 and in Iceland and the Faroe Islands^'^ it is quite unknown. 
 In Russia, if we may still depend upon accounts dating from 
 the earlier years of the century, gout is of frequent occur- 
 rence in the Baltic provinces^^ and in St. Petersburg ; ^^ it is 
 
 * 'Hamburg in naturhistor. und med. Beziehung.,' Hamb., 1830, 89. 
 
 2 Ebstein, 'Die Natur und Bebandl. der Gicht,' Wiesbad., 1882, 138. 
 
 3 Id. 
 
 * Heineken, 'Die freie Hansestadfc Bremen, &c./ Brem., 1837, ii. 
 5 Ebstein, 1. c. 
 
 fi Mayer, ' Versuch einer med. Topogr. von Dresden', StoUberg, 1840, 288. 
 7 Miiller, 'Med. Topogr. der Stadt Wiesbaden', Wiesb., 1846. 
 « Horing, 'Wurttemb. med. Correspondenzbl.,' 1839, '^' 275- 
 
 9 Friedrich, 'Bayr. arztl. Intelligenzbl.,' 1855, 353. 
 
 10 Gugger, ' Oest. med. Woehenschr.,' 1843, 785. 
 
 11 'Berl. klin. Woehenscbr.,' 1865, 474. 
 
 1* In Tweedie's ' Library of Medicine,' v, 208. 
 
 '* 'Lancet,' 1842, Nov. 
 
 " 'Transact, of the Provincial Med. and Surg. Assoc.,' 1839, iv« 203. 
 
 '5 Scudamore, ' Treatise on the Gout,' Germ, ed., Halle, 1819, 54. In Glasgow 
 gout is very rare, even among the rich classes. 
 
 '« ' Transact, of the Prov. Med. and Surg. Assoc.,' 1. c. 
 
 '7 Manicus, 'Bibl. for Laeger,' 1824, i, 15. 
 
 IS Bluhm, ' Beschreibung der in Reval herrschenden Krankheiten,' Marb., 1790, 
 141 ; Moritz, ' Spec, topogr.-med. Dorpat.,' Dorp., 1823. 
 
 J9 Attenhofer, 1. c, 231.
 
 656 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 also reported from Odessa.^ On the other hand it is exceed- 
 ingly rare to meet with it in the governments of Samara^ and 
 Kasan/ and in Transcaucasia it would appear to be quite 
 unknown.* In Turkey, also, cases of gout are rarely seen.^ 
 
 In the tropical and subtropical regions of Asia gout either 
 does not occur at all or only in exceptional cases. This holds 
 good for Syria, Persia, and Arabia,^ although in those coun- 
 tries, to judge by the writings of Arabian and Syrian physi- 
 cians of the middle ages, gout was by no means a rarity 
 formerly. With reference to gout in India, Ainslie, who 
 had thirty years' experience, says : " I do not think that I 
 ever knew but one Hindoo who had a well-marked gout ; 
 the Mahometans are not so fortunate in this respect. Those 
 Europeans who are subject to the attacks of it have, for the 
 most part, long intervals betwixt the fits, and when they do 
 come they are generally slight.'' 
 
 On the Himalayan slope it would appear that the disease 
 is not altogether rare^ (whether among natives or Europeans 
 is not mentioned) ; and in the East Indies it is given as a 
 not uncommon malady even among the natives.^ On the 
 other hand it is quite unknown in Ceylon,^ or among the 
 natives of Assam}^ For China there is only one notice before 
 me, relating to Amoy,^^ where the disease has been seen rather 
 often among the indigenous population. In the medico- 
 topographical records of the Australian continent and the 
 islands of the Pacific there is not a word said of the occurrence 
 of gout. According to the account of Thomson,^^ dating from 
 
 ' Andrejewsky in ' Griife and Waltber's Journal,' 1833, xx, 277. 
 ' Ucke, ' Das Klima und die Krankheiten der Stadt Samara,' Berl., 1863, 211. 
 ^ Erdmann, 'Med. Topogr. des Gouv. Kasan,' Riga, 1822, 154. 
 * Ref. in Keeker's ' Annal fiir wissensch. Heilkde.,' 1833, xxxi, 331. 
 ^ Oppenheim, ' Ueber den Zustand der Heilkunde . . in der Tiirkei/|Hamb., 
 18.^3. 76; Rigler, ' Die Turkei und deren Bewohner, &c.,' ii, 365. 
 
 6 Marshall, ' Edinb. Med, and Surg. Journ.,' 1832, Oct., 347; Tobler, ♦ Beitr. 
 zur med. Topogr. von Jerusalem,' Berl., 1855, 41, 
 
 7 Farquhar, 'Indian Annals of Med. So.,* 1863, April, 464, 
 
 8 Heymann, ' Krankb. der Tropeulander,' 181; van Leent, 'Arcb. de med. 
 nav.,' 1867, Oct., 246. 
 
 ' Davy, ' Account of the Interior of Ceylon.' 
 >" Beaufils, 'Arch, de med. nav.,' 1882, April, 266. 
 
 " Friedel, ' Beitrage, &c.,' 109; Ref. in 'Arch, de med. nav.,' 1866, Sptbr., 166 
 'Brit, and For. Med.-Chir. Rev.,' 1855, April.
 
 GOUT. 657 
 
 1837, *^® disease had never been seen in New Zealand ; nor in 
 the Hawaiian Islands according to Chapin^ (1855). 
 
 The African continent, alsO;, with the islands adjoining it, 
 enjoys an almost complete immunity from gout. That is 
 the expressed opinion o£ all the authorities for EgijptJ^ the 
 countries of the Niger, ^ Algiers,^ 8enegamhia,^ the West 
 Goast,^ and Madeira? The only exceptions to this are 
 found in Vinson's notice^ (somewhat untrustworthy) of its 
 common occurrence among the Hovas occupying the plateau 
 of Madagascar, and in the statement of Ferrini^ (also question- 
 able) that it is not unfrequently seen in Tunis. 
 
 In the Western Hemisphere, so far as one may judge from 
 the information about gout that comes to us thence, the malady 
 is for the most part confined to countries within the temperate 
 latitudes. In Greenland it is extremely rare,^'' and there is 
 no mention of it at all for Canada and other teri-itories in the 
 far north. In the large and populous towns of the United 
 States, supplied with the luxuries of Europe, gout would 
 appear to be as common as it is under the same circum- 
 stances in the Old World/^ although our information on the 
 subject is scanty. According to a notice of the year 1830 
 by Hildreth,^^ for Washington, gout was quite unknown 
 among the indigenous inhabitants of that region. In Vera 
 Cruz, Heinemann^^ saw only two cases of it during six years. 
 There is no mention of it in the medical accounts from Central 
 America. In the West Indies, as we learn from both early 
 and recent authorities," it is seen in rare cases only. The 
 
 1 ' Amer. Journ. of Med. Sc.,' 1837, May, 93. 
 
 ^ Eoser, ' Ueber einigc Krankheiteu des Orients,' Augsb., 1837, 73; Clot-Bey, 
 ' Apercju gen. sur I'Egypte,' ii, 319, u. a. 
 
 •* Broccbi, ' Giornale,' v, 559. 
 
 •* Bertherand, ' Med. ct byg. des Arabes,' Par., 1855. 
 
 ^ Chassaniol, 'Arch, de med. nav.,' 1865, Mai, 507. 
 
 ^ Copland, ' Dictionary,' iv. 
 
 ' Kampfer, ' Haitib. Zeitscbr. fiir Med.,' 1847, xxxiv, 159. 
 
 8 'Gaz. hebd. de med.,' 1866, Nr. 49, Feuill. 
 
 3 ' Saggio sul clima e suUe precipue malattie della citta di Tunis!, &c.,' Milano, 
 i860, 238. 
 '" ' Bemaerkn. oni Gronlands Sygdomsforliold,' Kjobenh., 1864, 30. 
 ^' See Hosack, 'Essays,' New York, 1824, ii, 233. 
 1- ' Amer. Journ. of Med. So.,' 1830, Febr., 330. 
 " In ' Virchow's Arcb.,' 1873, Iviii, 161. 
 '* Dancer, 'History of the late Expedition against Fort St. Juan, &c.,' Lond., 
 
 VOL. II. 42
 
 658 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 same is true for Guiana -^ and still more so for Brazil where 
 gout is almost unknown, according to the unanimous opinion.^ 
 It applies also to Peru, where Smith'' saw only one case during 
 a residence of more than ten years ; but it would appear 
 to be more common among the Creoles of the Sierra, and in 
 Chili also it occurs not unfrequently.^ 
 
 § 225. High Degree of Heredity. 
 
 It may be said to be a doctrine generally admitted at the 
 present day, and beyond all questioning, that the process of 
 gout depends upon a constitutional disorder of nutrition, 
 that a morbid diathesis — the uric-acid diathesis — underlies 
 it, and that the diathesis is sometimes inherited and some- 
 times acquired. The task of historical and geographical 
 research, accordingly, is to inquire what are those factors, 
 involved in circumstances of climate, manner of life, and of 
 nationality, and associated with the distribution and degree 
 of prevalence of the malady in place and time, which may be 
 brought into causal connexion with the pathogenesis ; or, 
 otherwise expressed, it is to explain the influences upon 
 which the development of the gouty diathesis depends, or 
 which seem calculated to further the evolution of the disease 
 itself where the diathesis had been either inherited or acquired. 
 
 The heredity of gout (or of the gouty diathesis) was a 
 subject about which the physicians of antiquity and the 
 middle ages were perfectly agreed. Galen lays special 
 
 1781; Lempri^re, 'Pract. Observ. on Diseases . . in Jamaica,' Loud., 1799,1, 
 so; Forstrom, ' Svensk. Lak. Sallsk. Handl.,' 1817, iv, 231; Chassaniol, ' Arch, 
 de nied. nav.,' 1865, Mai, 507; Rufz (ib., 1869, Novbr., 350) saw twenty-cigiit 
 cases of gout in Martinique during a long series of years. 
 
 ' Rodschied, ' Bemerkungen u. s. \v.,' 172. The statement of Blair (' Account 
 o£ the last Yellow Fever Epidemic, &c.), that gout is of couimon occurrence in 
 British Guiana, along with rheumatism, is most probably based on a laxity of 
 diagnosis. 
 
 ^ Martius, 'Das Naturell und die Krankheiten der Urbewohncr Brasiliens,' 
 Munch., 89; Dundas, 'Sketches of Brasil,' Lond., 1852, 37; Sigaud does not 
 mention it at all. 
 
 •'' ' Edinb. Med. and Surg. Journ.,' 1841, Oct., 399. 
 
 * Tsehudi, ' Oest. med. Wochenschr.,' J846, p. 731. 
 
 * Rcf. in 'Arch, de med. nav.,' 1864, Aout, p. 107.
 
 GOUT. 659 
 
 stress on that factor in his explanation of the steadily 
 increasing spread of the disease in the Roman Empire ;^ 
 Aetius says^ in fact, that the development of the malady is 
 in most cases to be referred to hereditary transmission -^ 
 while, in modern times, Cullen/ Hamilton/ and others, go 
 so far as to take the inheritance of the diathesis as the sole 
 determining cause of the disease. Although the last of 
 these opinions is decidedly an exaggeration, yet heredity is 
 a factor in the etiology that is to be rated very highly. 
 Scudamore^ was able to trace heredity in 34 cases out of 
 77, Patissier^ in 34 cases out of 80, Gairdner^ in 140 cases 
 out of 156. Of 65 cases of gout that came under his treat- 
 ment at a mineral spa, Braun^ could not find one in which 
 there was not some evidence of a disposition inherited from 
 the parents or grandparents. Garrod^ found that the half of 
 all his hospital cases of gout could be referred to heredity ; 
 while his experience in private practice leads him to estimate 
 the cases of inherited gout at 75 per cent, of the whole. 
 An interesting case given by him is that of a gouty patient, 
 fifty years of age, who stated that the disease had been 
 handed down in his family from father to son for 400 years. 
 But, however highly we may rate this factor in the etiology, 
 we learn from the history of the disease, from the fluctua- 
 tions in its amount from period to period, and above all from 
 the very considerable abatement of the malady in recent 
 times (a fact which cannot be doubted), that even the here- 
 
 ^ In ' Comment, in Hipp. Aphor.,' 1. c, where his words are : " -KpodiKiikvQi. Se 
 TCUQ tlprifiivaiQ aiTiaiQySi ut vvv TroSaypi-uiai iroXXoi,Kal rb nartpuv tovq TzXi'iarovQ 
 yeyov'tvai Kai Trdinr(i>v -ijSr] TroSaypiKuJV, tip' ujv StjXovoti to ffnepfia jjiOxQripoTipov 
 
 ^ L. c, cap. vii, e. c. 309 : " Ut plurimnm vero aptitudines a parentibus in 
 filios ac posteros transferuntur." 
 
 ' ' First Lines in the Practice of Physic,' Germ, ed., i, 12, Leipz., 1778, i, 289. 
 
 4 ' Letters on the Cause and Treatment of the Gout, &c.,' Lynn (Norfolk), 
 
 1809. 
 
 5 L. c, 40. This is the statement in the translation which I have used. 
 Garrod quotes Scudamore as giving 523 cases, of which 309 were proved to he 
 hereditary. I suppose these are the figures in the 4th edition of Scudamore's 
 treatise (1822), which I have not the means of referring to. 
 
 ^ 'Report of the Paris Academy.' 
 
 7 * On Gout,' Germ, transl. by Braun, Wiesb., 1858. 
 
 8 ' Beitrage zu einer Monogr. der Gicht.,' Wiesb., i860, 53. 
 
 3 ' Treatise on Gout and Rheumatic Gout,' Lond., 1876, 2oq.
 
 660 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 ditary diathesis stands in a certain dependence on exterior 
 influences, tliat it becomes aggravated or weakened under 
 those influences, and that in some circumstances it may even 
 be altogether abrogated. 
 
 § 226. Connexion with Luxurious Living ; exceptions both 
 
 Positive and Negative. 
 
 Among such exterior influences, apparently capable not 
 ouly of heightening the disposition towards the disease and 
 of furthering its actual development, but even of evoking 
 the gouty diathesis itself and so of inducing gout apart from 
 heredity, the individual's manner of dieting and of living 
 takes the first place. All medical observers, who have gone 
 at all closely into the causes of gout, are agreed that the 
 malady is commonest by far among the rich or better-off 
 classes of society, being met with to a much smaller extent 
 among the working classes and the poor; and that a volup- 
 tuous or luxurious table, implying the unstinted use of 
 spirituous liquors and animal food, especially when asso- 
 ciated with want of exercise, if perhaps not absolutely a 
 conditio sine qua non in the pathogenesis, is at any rate the 
 chief occasion of the gouty diathesis being established, or, 
 where it had existed previously, of its being aggravated to 
 the point of the evolution of the actual disease. 
 
 As early a writer as Galen, who agrees in this with his non-profes- 
 sional contemporaries, liacl said: " Kara filv roix 'iTriroKpc'tTovQ xp°^"^^ 
 oXtyot navTairaa-iv tn o^ ay pi u>i', Sid to tov jSi'ov k6(T[iiov, I'jv^yjfi'ivrjg Si Trjg Tpofijg 
 ti'c roiToiiroi' iv toTq KaO' ^'jfiag yppvoig, wg av fH]S' itrivoHV tarri TrpoaBjixriv avnj, 
 dniipov Ti Tu n\i'}!^og twv TToSaypiibvTwv fcrru'." 
 
 Among the principal causes of gout Aetius reckons " ebrietates," and 
 " consuetorum exercitiorum intermissiones ;" and the opinions of all 
 subsequent Greek and Arabian writers on medicine are to the same 
 effect. " Plurimum innascitur haec passio," says Constantinus, •" sua- 
 viter et quiete viventibus, et exercitia negligentibus et purgationes at 
 corporis mundificationes nolentibus, maxime cum multum comodant 
 atque bibant." Arnaldus has a similar explanation, and he adds these 
 W(jrds : " Fiunt autem in praelatis et in his qui fuerunt pauperes et 
 posted ad divitias et prosperitates ascenderunt." 
 
 1 ( 
 
 Commeut. in Hipp. Aplior.,' 1, c.
 
 GOUT. 661 
 
 We sliall hardly err if, following the unanimous testimony 
 of contemporary writers, we connect the increase in the 
 number of cases of gout and the enormous diffusion that it 
 reached in the early period of the Roman Empire with the 
 luxuriousness of the Roman life, which rose at that time to the 
 most riotous excesses ; and pointing in the same direction is 
 the decline in the number of cases in modern and recent 
 times under the influence of rational dieting. It is also 
 worthy of all attention in our inquiry into the importance of 
 that factor, that in the tropics, where gout is rai^e in general, 
 only those circles of society are affected by it who cultivate 
 the pleasures of the table in contrast to the sober-living 
 natives. Thus we learn from Rufz that the few cases of 
 gout which he had in Martinique were exclusively among 
 rich people. It is observed by Chassaniol that cases of gout 
 occur from time to time in negroes in the West Indies, but 
 only among the moneyed class of them. In India, as we 
 have seen, it is met with only among Europeans and Moham- 
 medans, and never among the temperate-living Hindus. In 
 Egypt also it is not found except in Europeans and Turks 
 who give themselves up to a life of luxury. 
 
 This factor, we repeat, is a most important one in the pro- 
 duction of the gouty diathesis or of an actual attack of gout ; 
 but we cannot forget, on the other hand, that there are not 
 unfrequently attacks of gout quite independently of inherited 
 diathesis, in persons who had been in no wise subject to 
 those harmful influences, but, on the conti'ary, had kept 
 a very simple and even meagre table. Thus Friedrich, in 
 Passau and its vicinity, found cases of gout among people 
 living in a very moderate way ; Dickson tells us that gout 
 is unusually common among the Custom-House officers in 
 London, but that it occurs in thena altogether irrespective 
 of their manner of life ; and Marmy speaks of the compara- 
 tively numerous cases of gout among the poorer classes in 
 Lyons. On the other hand, daily experience teaches us that 
 large numbers of people who are given to the immoderate use 
 of alcohol (wine or beer), whose diet is mostly animal food, 
 and who lead the most luxurious kind of life, continue quite 
 free from gout. This fact confronts us on the greatest scale 
 in the tropics, where the well-to-do classes are extremely
 
 662 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 seldom affected Avitli gout, notwitlistanding errors in their 
 diet of every kind. On this point Dundas is very decided, 
 on the strength of his observations in Brazil.' Curiously 
 enough his observations have received little attention in the 
 writings upon gout, even in the works by his own countrymen. 
 
 The exemption, he says, which the natives of Brazil, and almost 
 equally the foreign residents, enjoy from gout is all the more remark- 
 able that the prevailing usages and practices in the higher classes 
 of native society, as well as among the well-to-do foreigners, would 
 rather lead us to expect gout to be of necessity a very fi-equent 
 occurrence. The life led by the rich classes of society is almost without 
 exception an inactive and indolent one. There is no exercise for their 
 mental and bodily powers, and for that reason gross sensuality is all 
 the more indulged in; and although the Brazilians are not exactly given 
 to excesses in wine-drinking, they are fond of frequent and plentiful 
 meals of animal food and of having their dishes highly flavoured. Here, 
 accordingly, we have in unusual perfection all those conditions which 
 are looked upon in Europe as the most material causal factors in the 
 development of the gouty diathesis. But gout does not occur in 
 Brazil; or, if it do occur at all, it is extremely rare. . . . The 
 immunity from gout enjoyed by the residents in this hot climate is a 
 thoroughly well-established fact ; but it will follow conclusively from 
 the sketch just given of the manner of life of the Brazilians that there 
 is no ground whatsoever for explaining that exemption by any sober 
 mode of living which they practise, or by a diet that is poor in nitrogenous 
 elements in comparison with the diet of higher latitudes. And the same 
 may be proved for the inhabitants of other tropical regions, and par- 
 ticularly for those of other countries in South America. We should 
 thus have to seek an explanation of the phenomenon among circum- 
 stances of a different kind. 
 
 I shall not go farther into the theory which Dundas works 
 out in connexion with the above. I merely draw from his 
 observations, taken along with facts already adduced, the 
 following conclusions : that the development of the gouty 
 diathesis (irrespective of heredity) is undoubtedly under the 
 mfluence of an erroneous manner of living and feeding; 
 that it is not an effect, however, due to the sum of all those 
 harmful things previously enumerated,— to excesses, or to an 
 intemperate and luxurious manner of life in general ; but 
 that m the manner of life, there must be some definite, and 
 m a measure specifically active factor to constitute the true 
 
 Lond?,t-2^' ""^ ^'^^'^' '"'^^"'^^"^ ^'^^ V^^^^s °f Tropical and European Fever,
 
 GOUT. 663 
 
 cause of the malady, a factor whicli may make itself felt 
 irrespective of gross errors of diet, or in those who lead a 
 temperate life ; and that this factor is one which may be 
 overpowered and rendered harmless to the organism when 
 other influences are brought into play or some particular 
 state of body is induced. Of the nature of that specific 
 cause of the gout, neither anatomy, nor clinical observation, 
 nor etiology has told us anything as yet. 
 
 § 227. Influence op Season and Climate. 
 
 In the course of this chapter it has been several times 
 mentioned, and it will be apparent also from the sketch of the 
 geographical distribution, that gout is of rare occurrence in 
 low latitudes. Hereupon arises the question whether this 
 relative immunity of the tropics depends on the climate ; or, 
 in other words, what influence upon the occurrence and dif- 
 fusion of the disease the hind of weather can be shown to 
 exert. 
 
 In the very earliest writings on gout, such as those of 
 Hippocrates, Galen, and Caelius Aurelianus, as well as in 
 those of nearly all the later observers, such as Sydenham, 
 van Swieten, Scudamore, Dickson, Garrod and others, spring 
 and autumn are given as the proper seasons of gout. The 
 general view is that damp and cold weather are specially 
 apt to bring on paroxysms of the malady ; and Garrod in 
 particular says that even in chronic cases of gout the patients 
 are usually much better during the summer than in other 
 seasons of the year. The temperature and moisture of the 
 air accordingly exert an undoubted influence on the course 
 of the malady ; and it is reasonable to suppose that weather- 
 conditions of a favorable kind, such as the rather high and 
 steady temperature peculiar to the tropics, would not be 
 without significance even for the existence or non-existence 
 of the disease in itself, and that the rare occurrence of gout 
 in low latitudes is partly at least due to the influence of the 
 climate. The opinion that has been several times put for- 
 ward, to the effect that the immunity from gout enjoyed by 
 residents in the tropics is referable solely to their temperate
 
 664 GEOGRAPHICAL AND HISTORICAL PATHOLOGY. 
 
 and abstemious manner of life, can really apply to only a 
 part of the native population ; for the Europeans and the 
 well-to-do classes of the other nationalities, it is by no 
 means relevant, as Dundas has shown for Brazil, and as one 
 might prove in like manner for India. We shall have to 
 withhold our explanation of why the tropical climate is 
 adverse to the development of the disease or conducive to a 
 mild type, until such time as we have obtained a better insight 
 into the real nature of the gouty diathesis, and the etiologi- 
 cal factor underlying it.^ 
 
 § 228. DouBTFDL Influence op Race. 
 
 Whether circumstances of race and nationality may deter- 
 mine'the occurrence of gout, cannot be decided with certainty, 
 for the reason that, in a mixed population such as we always 
 have to consider in the question before us, there are at the 
 same time material diiferences in the manner of life of the 
 several racial groups ; so that it is impossible to be sure what 
 factor has to be credited with the disposition of one race to 
 take the disease, or to what the immunity of another race is 
 to be ascribed. It appears from the statements of Quarrier 
 and Chassaniol,^ that gout has been seen among the negroes ; 
 and if the authorities are not in error it occurs also among 
 Malays in the East Indies, and in China, and among the 
 Hovas in Madagascar. On the other hand we find no refer- 
 ences to cases of gout among the Hindus or among the 
 native Indians of North and South America ;* but the ques- 
 
 ' I may mention, as a curiosity, that even gout has not escaped the fate of 
 being ckssed among the communicable (contagious) diseases. Boerhaave was the 
 first to express an opinion to that effect ; and such was the great influence of 
 that excellent physician on his contemporaries, that he found many to believe 
 him. Van Swieten, in his commentaries on the 'Aphorisms' (§ 1255, iv, 299), 
 does not altogether deny the contagiousness of the malady, and he adduces in 
 evidence of it the fact that wives who had tended their gouty husbands day and 
 night were ultimately attacked by the disease. But he does not appear to take 
 the matter altogether seriously ; at all events he is careful to add : " Licet et 
 multa; alia, qua; eodem officio strenue perfungebautur, immunes manserint." 
 
 ' 'Edin. Med. and Surg. Journ.,' 1808, Oct., p. 459. 
 
 ^ ' Arch, de med. nav.,' 1. c. 
 
 * Schwarz (' Zeitschr. der Wiener Aerzte,' 1858, p. 579) mentions his having
 
 GOUT. 666^ 
 
 tion tliat arises here is wlietlter tlie reason of that exemp- 
 tion is not to be looked for in the mode of life much rather 
 than in the physiological type of the race. 
 
 I shall have an opportunity of discussing the relations 
 hetiveen gout and gravel as regards local distribution, when I 
 come to speak of the latter morbid condition. 
 
 been assured ty Dr. Candido, who had travelled through Brazil, that he had not 
 met with a single case of gout among the Indians of the country.
 
 INDEX. 
 
 United States, ^c. 
 
 The foil oiving Lists and Tables occur throughout the volume . 
 Anchylostoma duodenale, list of writers on . 
 Seriberi, list of writers on 
 Ergotism, chronological table of epidemics of 
 Erysipelas, chronological table of epidemics of, in the 
 Filaria sanguinis hominis, list of writers on . 
 Guinea-worm, list of writers on 
 Pellagra, list of loriters on 
 Puerperal fever, chronological table of epidemics of 
 
 ,, „ list of writers on . 
 
 Scurvy, chronological table of epidemics of . 
 
 „ list of writers on 
 Yaws, list of writers on . . . 
 
 321 
 60 [ 
 204 
 401 
 335 
 357 
 245 
 422 
 
 471 
 
 S2I 
 
 565 
 
 no 
 
 Aberdeen, puerperal fever 450 
 
 Abyssinia, leprosy 11, syphilis 78, 
 goitre 148, tap)eworm 281, ringworm 
 374, scurvy 529, scrofula 620 
 
 Acclimatisation stops mountain sick- 
 ness 506, creates liability to beriberi 
 585 
 
 ACEODTNIA, symptoms of 248; history 
 iu France of 249 ; instances out of 
 France 250; resemble s erorotism and 
 pellagra 251 ; the food suspected 
 252; has been mostly iu garrisons, 
 prisons, &c. 252 
 
 Aden, hosjntal gangrene 480, scurvy 
 528 
 
 ^gean Islands, leprosy 23, " ponos " 
 561 
 
 iEmilia, leprosy 2\, pellagra 222 
 
 Affinities between leprosy, pellagra 
 and beriberi as toxic effects of the 
 staple diet 36, 230, 589, and in their 
 nervous phenomena 58, 218-220, 
 570 ; between ergotism, pellagra and 
 acrodynia as vegetable intoxications 
 241, 251 ; between syphilis, yaws und 
 button scurvy in their contagiousness 
 108, 113 ; of hospital gangrene to 
 diphtheria and erysipelas 490 
 
 Africa, East Coast of, syphilis 76, 
 anchylostoma HZ, filaria 334, rarity 
 of erysipelas 393 
 
 Africa, South, leprosy 13, syphilis 77, 
 89, distoma 296 
 
 Africa, West Coast of, leprosy 12, 
 syphilis l^,yaws 105, tapeworm 282, 
 anchylostoma 315, filaria 328, 
 guinea-tvorm 339, itch 362, sand- 
 flea 364, scurvy 529, scrofula 621 
 
 Agra, epidemics of hospital gangrene, 
 484 
 
 .Aisne (Dpt.), goitre 129 
 
 Alaska, syphilis 80, erysipelas 393, 
 scurvy 529, scrofula 621 
 
 Algiers, leprosy 12, syphilis 78, tape- 
 worm 282, itch 362, chlorosis 498, 
 501 
 
 Alicante, leprosy 30 
 
 Altai Mountains, goitre 145 
 
 Altitude, alleged influence of, iu 
 syphilis 87 ; so-called limits of, in 
 goitre 164; limit of, in pinta 383; 
 in mountain sickness 504 
 
 Amboina, syphilis 74:,beriberi now rare 
 575, 584 
 
 America, leprosy introduced 10, 27 ; 
 syphilis introduced 67, 80 ; yaws 
 said to have been introduced 106 ; 
 guinea-worm introduced 343 ; beri-
 
 668 
 
 INDEX. 
 
 leri has lately become endemic in 
 57G 
 
 Amoor, stfphiUs 73, scurvy 526, 560 
 
 Amoy,filari(i 329, ffout 656 
 
 An.'FMIA, due to anchylostoma dnode- 
 nale 317, 319 ; vague statements as 
 to increase of 492 ; general, of the 
 tropics 502 ; tlie same inherited by 
 the children 502 
 
 ANJCMIA MONTANA, SCe MOUNTAIN 
 
 Sickness 
 
 Anesthesia in leprosy 58, in pellagra 
 218, in acrodynia 248, in beriberi 571 
 
 Anchylostoma duodenale the cause 
 of " cachexie aqueuse " of negroes 
 in West Indies, &c. 313 ; its geo- 
 graphical distribution mostly tropical 
 314 ; cases in Lombardy and else- 
 where in Europe 316; discovery of, 
 as cause of "cachexie aqueuse" 
 318 J how introduced into man's 
 body 319 ; list of writers on 321 ; 
 found in cases of beriberi 599 
 
 Andaman Islands, syphilis 74 
 
 Anquillula steecoealis, association 
 of, with the endemic diarrhoea of 
 Coctiin China 323 j view that it is 
 not the cause but the consequence 
 324 
 
 Animals subject to goitre 163, to 
 mountain sickness 504 
 
 Antiquity of leprosy 2, syphilis 59, 
 goitre 121, ergotism 203, guinea- 
 worm 337, erysipelas 390, pnerperal 
 fever 417, hospital gangrejie 476, 
 chlorosis 493, scurvy 511, beriberi 
 572, scrofula 604, diabetes 643, 
 gout 648 
 
 AoaUi, goitre 123, 126 
 
 Arabia, leprosy 14, guinea-ivorm 341, 
 itch 361, ''foul sloughing ulcer" 
 481, scurvy 528, scrofula 618 
 
 Argentine Republic, leprosy 30, syphi-^ 
 lis 83, goitre 152, tapeworm 285* 
 " myiasis " 369 
 
 Armies, see Teoops 
 
 AscABis LUMBEicoiDES, enoi'mously 
 common in the tropics 299 ; question 
 of its mode of access to the body 
 301 ; favoured by heat and mois- 
 ture 302 
 
 Asia Minor, leprosy 14, goitre 145, 
 erysipelas 393 
 
 Asturias, pellagra 220, gout 654 
 
 Atlas Mountains, goitre 148 
 
 Australia, leprosy (among Chinese) 19, 
 hydatids 293, 295, scurvy 528, 544, 
 ij49 (and note 550) 
 
 Austria, goitre 133, scrofula 615 
 
 Azores, leprosy 12, goitre 148 
 
 B 
 
 Baden, goitre 137 
 
 Bahia, leprosy 10, filaria 327, 329, 
 guinea-ioorm 344, beriberi 577 
 
 Balti, goitre 145 
 
 Baltic (shores of), endemics of syphilis 
 93 ; scurvy 513, 559 
 
 Banka, beriberi 574, 590 
 
 Batavia, leprosy 48, beriberi, 575, 586 
 
 Bavaria, goitre 135 
 
 Beerbhoom, leprosy 16 (table) 
 
 Belgium, goitre 142, ergotism 213, 
 acrodynia 250, scrofula 614, 627 
 
 Bellary, beriberi 592 
 
 Belluno, syphilis 95, pellagra 231 
 
 Bengal, leprosy 15, syphilis 72, goitre 
 146, (free from) guinea-worm 342, 
 spotted skin 388, hospital gangrene 
 482, 484, scitrcj/ 525 (table), beriberi 
 575, scrofula 618 
 
 Bergamo, pellagra 231 
 
 Bergen, leprosy 26, 50 ; puerperal fever 
 433 
 
 Beeibeei, etymology of name 569(«o^c); 
 clinical history of the two forms 
 (dropsical and paralytic) 570 ; acute 
 and chronic 571 ; moi-bid anatomy 
 571 ; an ancient disease in China and 
 Japan 572 ; earliest references to, in 
 the East Indies 573 ; recent appear- 
 ance in Brazil 573; chief seats- - 
 Japan 573, China 574, East Indies 
 574, Madras Circars 575, Mauritius, 
 &c. 576, West Indies 576, Brazil 577; 
 outbreaks on board ship in the tropics 
 577; mostly tropical 579; endemic 
 at circumscribed spots 579; heat, 
 moisture, and sudden changes favor- 
 able to it 579 ; tables of admissions 
 according to season (Madras Pres. 
 and Tokio) 580; connexion with the 
 coast — statistics for Madras 581 ; 
 does not go with malarious soil 582; 
 children little liable 583, except in 
 schools 583 ; women much less liable 
 than men 583 ; Europeans almost 
 exempt 584; new arrivals protected 
 until acclimatised 585 ; strong men 
 in the prime of life most liable 586 ; 
 sedentary occupations (professions) 
 are most favorable to it 587 ; close 
 confinement on shore or on board 
 ship helps it 588; suspected influence 
 of rice diet — evidence from the East 
 Indies 590, Japan 591 ; objections to 
 the diet-theory 591 ; theory of its 
 rheumatic nature 594 ; alleged affinity 
 to scurvy 595, to pernicious anamia 
 595, to malarial disease 596 ; due to
 
 INDEX. 
 
 669 
 
 a specific cause 597, of a toxic nature 
 598; alleged jjarasitic origin 598; 
 anchjlostoma often present in intes- 
 tine 599 ; summary of its peculiari- 
 ties 600; not a communicable disease 
 600; list of writers on 601 
 
 Berlin, puerperal fever 457 
 
 Bhootan, goitre 145 
 
 Bidschow, syphilis 97 
 
 'B'n'\a\ng\ia,\x\, puerperal fever 452, 454 
 
 Black tongue, syn. for malignant ery- 
 sipelas in the United States, 399, 404 
 
 Bokhara, guinea-tvorm 341 
 
 Bolivia, goitre 152 
 
 Bombay Pres., leprosy 16, 33, guinea- 
 worm 345 ; free from beriberi 575 
 
 Borneo, leprosy 18, beriberi 574: 
 
 Bornou, yaius 105, goitre 148 
 
 BoTHRiocEPHALUS LATUS, limited area 
 of 288 ; in Sweden, Finland, &c. 289 ; 
 in Switzerland 289, 290; in other 
 countries 289 ; goes with a fish-diet 
 291 ; has an intermediate host 291 
 
 BOTS in the human subject, in South 
 America 370 ; in Shetland and Nor- 
 way 371 
 
 Brazil, leprosy 29, 46, syphilis 82, yaws 
 106, goitre 152, anchylostoma 314, 
 Jilaria 327, 333, guinea-toorm 343, 
 sandftea 365, hots 370, spotted skin 
 387, berberi 577, 593, scrofula 623, 
 free from gout 662 
 
 Breno, syphilis 96 
 
 Brescia, pellagra 231 
 
 Brest, anguillula 325 
 
 British Columbia, syphilis 80 
 
 Brussels, acrodynia 251, 252 
 
 BuBAS, Spanish name for yaws 104 
 
 Burdwan, leprosy 16 (table) 
 
 Burmah, leprosy 17, goitre 147, beri- 
 beri 574 
 
 " Burning of the Feet " in pellagra 
 217, in acrodynia 248, a symptom 
 of beriberi 570 
 
 Button Scuevy, an Irish disease re- 
 sembling yaws, written about from 
 1823 to 1851,112; clinical characters 
 112 ; used to be endemic at a few 
 spots in the South of Ireland 113 ; a 
 contagious malady 113 
 
 Cachexia Afeicana 1 See Anchy- 
 
 CACHEXIE AQUEUSE J L03T0MA 
 
 Calabash Islands, beriberi 574 
 Calcutta, Jilaria 327, beriberi 575, 
 scrofula 618 
 
 California, syphilis 81, goitre 150, 
 scurvy 537 
 
 Canada, syphilis 81, goitre 149, scurvy 
 529 
 
 Canary Islands, leprosy 12, itch 362 
 
 Cape Colony, leprosy 13, syphilis 77, 
 distoma 295, scurvy bb6, scrofula 620 
 
 Capistrello, syphilis 97 
 
 Carinthia, goitre 133 
 
 Carnatic, guinea-worm 342, 346 
 
 Carpathians, ^oiY/e 134, 135 
 
 Cascadoe, form of ringworm in the 
 East Indies 377 
 
 Caucasus, leprosy 24 
 
 Cayenne, leprosy 29, lead colic 270, 
 sandflea 367, bots 370, beriberi 576 
 
 Celebes, beriberi 574 
 
 Cerro de Pasco, verruga 117, goitre 
 152 
 
 Ceylon, leprosy 17, 33, yaws 105, goitre 
 147, beriberi 575, 585, diabetes 646, 
 647 
 
 Chavanne, syphilis 97 
 
 Children most liable to yaivs 104, to 
 ergotism 215 ; peculiar form of 
 scurvy in 561 ; not much liable to 
 beriberi 583 
 
 Chili, syphilis 83, goitre 152, sandflea 
 365, gout 658 
 
 China, leprosy 4, 18, syphilis 66, goitre 
 147, Jilaria 328, itch 361, beriberi 
 (antiquity of) 572, now rare in 574, 
 597, scrofula 619 
 
 Chiselborough, cretinism 143 
 
 Chlorosis, ancient and medieval 
 references to 493 ; general sketch of 
 its distribution 494 ; common in 
 Norway 495 ; great increase of, in 
 Sweden 496; in Mexico and the 
 West Indies 497 ; in Algiers, India 
 and China 498 ; affects all races 
 498; congenital, inherited and ac- 
 quired 499 ; chiefly in young women 
 leading an indoor life 500 ; evidence 
 of this from Sweden 500, from Mi- 
 quelon and other places 501 
 
 Chota Nagpore, goitre 146 
 
 Circars, beriberi 575, 580, 581 
 
 Climate, see Heat, Rainfall, Sea- 
 son, Tropics 
 
 Coblenz, goitre 139 
 
 Cochin, anchylostoma 315 
 
 Cochin China, leprosy 17, syphilis 73, 
 goitre 147, anguillula 323, ring- 
 worm 374, chlorosis 498, scurvy 528 
 
 Cocos Island, epidemic of beriberi 574 
 
 Colombia, leprosy 29, pelade 253 
 
 Comacchio, leprosy 21 
 
 Comoro Islands, yaios 105, anchylos- 
 toma 315
 
 C70 
 
 INDEX. 
 
 Confinement indoors as factor in 
 chlorosis 499, in scurvy 541, in beri- 
 beri 587, 588, in scrofula 630 
 
 Congo, sand-flea 364 
 
 Contagiousness of leprosy (ques- 
 tioned) 44, of yaws 108, of hutton 
 scurvy 113, of verruga (doubtful) 
 119, of pinta 386, of erysipelas 414, 
 of hospilal gangrene 489 ; theory of, 
 in scurvy 559; absent in beriberi 
 600, and in scrofula 637 ; alleged 
 by Boerhaave in gout G64 (note) 
 
 Corfu, leprosy 23, pellagra 226, 236 
 
 Corsica, scrofula rare in 612 
 
 Costa Rica, leprosy 28, yaws 106, goitre 
 150, sand-flea 365 
 
 Courland, syphilis 95 
 
 Crete, leprosy 23, 33 
 
 Cretinism, relation of to goitre first 
 shown by Paracelsus 122; in Italy 
 126, in France 129, especially in 
 Savoy 129, in Switzerland 130, 
 Tvrol, &c. 132, Hungary, Galizia, 
 &c. 135, Franconia 136, Baden 137, 
 Siberia 144, India 146, Madagascar 
 148, United States 150, New Gran- 
 ada 151, Salta (Argentine Republic) 
 152; general immunity of South 
 America from 150 — 153 ; geological 
 table showing where it is and is not 
 associated with goitre 168 ; both 
 sexes equally liable 185 ; traced to a 
 virus 197 ; its connexion with goitre 
 199; tables showing the goitrous 
 parentage of cretins 200, 201 ; al- 
 ways congenital 201 ; a non-goitrous 
 mother migrating to a goitrous 
 locality may bear a cretinous child 
 202; runs in families 202 
 
 Crimean War, acrodynia 250, hos- 
 pital gangrene 479, scurvy 536, 547 
 
 Croatia, syphilis 95 
 
 Crusades, alleged diffusion of leprosy 
 by 7 
 
 Cuba, beriberi 576 
 
 Curasao, guinea-tvorm 343 
 
 Cyprus, leprosy 14 
 
 D 
 
 Dalmatia, syphilis 95 
 
 Deccan, gtunea-worm 342 
 
 Decrease of leprosy 8, goitre 153, 
 ergotism 213, lead colic 277, puer- 
 peral fever 463, scurvy 520, 553, 
 beriberi in Amboina 575, gout 653 
 
 Demerara, leprosy 20,filaria 329 
 
 Denmark, endemic syphilis 94, puer- 
 peral fever 459 
 
 Detroit, goitre 149 
 Devonshire, lead colic 266 
 Diabetes, few statistical data of 642 ; 
 references to, in Sanscrit and other 
 ancient writings 643 ; observations 
 of Willis, Dobson and Rollo 644; 
 mostly found in the temperate zone 
 644; table of death-rate from, in 
 various countries 645 ; common in 
 Ceylon and in some parts of India 
 646, and probably due there to the 
 exclusively vegetable diet 647 
 Diarrhcea, endemic, of Cochin China 
 
 323 
 Diet (putrid fish) as cause of leprosy 
 36, (damaged maize) of pellagra 
 230, (rice) of beriberi 589, (wanting 
 vegetables) of scurvy 545, (purely 
 vegetable) as cause of diabetes in the 
 East 647 ; a factor in gout 660. 
 Diphtheria, relation of, to erysipela- 
 tous sorethroat 397, 398 (note) ; to 
 hospital gangrene 490 
 Disappeaeance of button scurvy 113 
 Distoma haematobium indigenous to 
 Egypt and the Cape 296 ; its fre- 
 quency in these countries 296; 
 causes hajmaturia and calculus 297 ; 
 question bow it invades the body 
 297 ; affects the young mostly, and 
 boys much more than girls 296 ; 
 summer searson favorable to it 299 
 Dittmarschen, endemic syphilis 94 
 Dominica, yaivs 106 
 Doncaster, puerperal fever 453 
 Dorpat, syphilis 95 
 Dracontiasis, see Guinea-worm 
 Dropsy in anchylosfoma disease 313, 
 in beriberi 571 
 
 E 
 
 East Indies, leprosy 18, 47, syphilis 
 74, 87, yatos 105, guinea-ioorm 343, 
 ■itch 361, ringworm 374, beriberi 
 574, 584, 588, 590, scrofula 619, gout 
 656 
 EcHiNOcoccus, see Hydatids 
 Ecuador, leprosy 29, goitre 152 
 Edinburgh, puerperal fever 452, 455 
 Egypt, leprosy 2, 11, syphilis 78, tape- 
 worm 281, distoma 296, anchylo- 
 stoma 315, filaria 32S, guinea-toornt 
 340, ringworm 374, hospital gan- 
 grene 486, chlorosis 501, scurry 529, 
 scrofula 620 
 Elephantiasis associated with filaria 
 
 328 
 Endemic Colic, see Lead Colic
 
 INDEX. 
 
 671 
 
 Endemic Hematuria, see Distoma 
 Endemic, spots of leprosy, 32, 41, 
 syphilis Q2i, verruga 117, goitre 162> 
 iSi., pellagra 227, 231, "trembles" 
 256, distoma 295, gui}iea-worm 347, 
 sand-fiea 366, ringioorm 376, pinta 
 382, erysipelas 394, "poms" 563, 
 beriberi 581, 594, scrofula 627 
 England, leprosy 6, syphilis 64, goitre 
 142, ergotism 206 (table), Zeac? coZ^'c 
 266, trichinosis 303, 308, erysipelas 
 395, puerperal fever 423 (table), 
 450, «c«ri'j/ 518, 520 (note), 531, 
 547, 550, scrofula 615, diabetes 645, 
 ^omZ 655 
 Epidemics of syphilis 63, 92, 98, 
 verruga 114, 117, 120, goitre 156, 
 161, ergotism 204, pellagra 237, 
 acrodynia 249, milk-sickness 260, 
 Ze«(Z oo?/f 265, trichinosis 306, 
 guinea-ivorm 346, iffA 360, er^- 
 sipelas 394, seq., puerperal fever 
 421, seq., hospital gangrene 4:1*7, seq., 
 beriberi 577 
 Eegotism, historical references to, 
 under the name of " ignis sacer " 
 203 ; the gangrenous and the con- 
 vulsive form 204 ; chronological 
 table of epidemics of both forms 
 204 ; the countries most affected by 
 each kind of ergotism 210; mostly 
 confined to France, Germany, Russia 
 and Sweden 212 ; outbreaks else- 
 where 213 ; wet season favorable to 
 214 ; specially affects the children 
 of the rural poor 215 ; question why 
 sometimes gangrenous and some- 
 times convulsive 216 
 Erysipelas, history of the word 389 ; 
 its connotation still doubtful 391 ; 
 definition of 392 ; commonest in the 
 temperate zone 392 ; instances of, in 
 warm and tropical countries 393; 
 endemics of, in hospitals 394 ; epi- 
 demics of, in hospitals 395 ; other 
 epidemics 395 ; epidemics with 
 throat complication {erysipelas ma- 
 lignum) 396 ; the great epidemics in 
 the United States, their clinical 
 characters 398, and morbid anatomy 
 400 ; chronological table of ditto 
 401; summary of ditto 404; favoured 
 by higher latitude 406 ; favoured by 
 cold season 406, and by variable 
 weather 407 ; alleged effect of wet 
 soil on 407; all races alike liable 
 409; appearance of, on a dark skin 
 409 ; causes of, in hospitals 410 ; 
 exceptional outbreaks in ditto 411 ; 
 epidemics in country towns and vil- 
 
 lages 412; the virus a micrococcus 
 413; question of communicability 
 413 ; history of the doctrine (note) 
 413 ; laws of pi-opagation unknown 
 414; question whether there is al- 
 ways a breach of surface 414 ; no 
 real distinction between simple and 
 malignant 415 
 
 Europe, leprosy 4, tapeworm 284, 
 puerperal fever 419, diabetes 644, 
 gout 652 
 
 Europeans may contract leprosy 
 abroad 56; escape yaivs 109, but 
 are peculiarly liable to verruga 120 ; 
 very rarely take beriberi 584 
 
 Experiments to communicate leprosy 
 45, yaios 108, goitre 195, pellagra 
 239, " milk-sickness " 261, erysipelas 
 414, hospital gangrene 489, scurvy 
 560, scrofula 640 (note) 
 
 P 
 
 Falmouth, Ky., milk-sickness 260 
 
 Faluh, goitre 144 
 
 Faroe Islands, leprosy 9 (immunity 
 from) syphilis '71, itch 360, erysipelas 
 392, chlorosis 495, scrofula rare 616 
 
 Favus, common among Jews and Mo- 
 hammedans in Eastern Europe and 
 the Levant 372; unequal distribution 
 372 
 
 Fiji, yatvs 105, ringworm 377 
 
 FiLARIA MEDINENSIS, SCC GUINEA- 
 WORM 
 
 FiLARiA SANGTTiNis HOMiNis, SO named 
 by Lewis 326; inquiries of Wucherer 
 in Brazil, and of Lewis at Calcutta 
 327 ; evidence that haemato-chyluria 
 and elephantiasis are caused by it 
 328 ; observations of Manson in China 
 328 ; discovery of the mature worm 
 by Bancroft and others 329; the 
 mosquito the intermediate host — 
 conjectured by Bancroft, discovered 
 by Manson 330; observations on the 
 nocturnal and diurnal periodicity of 
 the larvK 331 ; Mackenzie's case 332; 
 the probable habitat of the parasite 
 in the body 332 ; not all cases, of 
 chyluria due to filaria 333 ; its geo- 
 graphical distribution, chiefly in 
 Brazil 333, China 335, and India 
 335 ; list of writers on 335 
 
 Finland, tapetvorm 289 
 
 Fish diet as cause of leprosy 36, of 
 bothriocephalus 291, of beriberi 589 
 
 FlTJORlNE as cause oi goitre 195 
 
 Feamb(esia synon, for yaws 101
 
 672 
 
 INDEX. 
 
 France, leprosy, 7, 9, syphilis 64, goitre 
 127, 156, ergotism 204, 212, pellagra 
 225, acrodynia 248, ieaci coZ/c 265, 
 scrofula 612 
 
 Frauconia, ^0(Yre 177 
 
 G 
 
 Gaboon, sand-flea 364, scrofula 621 
 Galle, ^o/ire 147 
 
 Gabbisons, syphilis 70, epidemic goitre 
 156, acrodynia 252, trichinosis 306, 
 scurvy 540, beriberi 581, 588 
 Gascony, pellagra 225 
 Germany, leprosy 9, syphilis 64, goitre 
 135, ergotism 212, trichinosis 306, 
 312, hospital gangrene 480, scurvy 
 513, scrofula G14!,gout 655 
 Gilbei't Islands, ringivorm 375 
 Gironde, pellagra 225 
 GoiTBE, ancient references to 121 ; first 
 good account of (for Salzburg), by 
 Paracelsus 122 ; later authorities 
 122 ; Malacarne's observations in the 
 Aosta valley 123 ; present distribu- 
 tion — Italy (table of conscripts ex- 
 empted owing to) 124, France (similar 
 table) 127, Spanish centres (Pyre- 
 nees, &c.) 130, Switzerland 132, 
 Tyrol 132, Styria, Carinthia and 
 other Austrian provinces 132, South 
 Germany 135, North Germany 140, 
 other European centres 142, Siberia 
 144, Himalaya 145,Terai 146, Central 
 Provinces of India 146, East Indies 
 147, Abyssinia 148, Niger basin 148, 
 Hudson's Bay Territory 149, United 
 States 149, Mexico 150, Guatemala, 
 &c. 150, New Granada 151, Vene- 
 zuela 151, Ecuador, Peru, Bolivia, 
 Chili, Argentine Ilepublic, Brazil 
 152; recent decrease in Piedmont, 
 Switzerland, &c. 153; increase in 
 Siberia and in New Granada 155; 
 epidemic outbreaks in garrisons, 
 schools, &c., chiefly French 156, but 
 also in Silesia, at Stuttgart, at 
 Kokaun, and in Brazil 159; found 
 in the most various climates 160; 
 so-called "goitre estiv.il" 161; nar- 
 row limits of goitrous spots 162; 
 animals affected by the endemic in- 
 fluence 163 ; new arrivals become 
 goitrous 163 ; elevations at which it 
 occjirslG4; doctrine of narrow valleys 
 165, 180; gcolosy and mineralogy 
 of goitrous soils 166, table 168; 
 occurs both on wet soil and on dry 
 171; drainage of the ground has 
 
 good effect 173; special connexion 
 with magnesian limestone 174 — 
 McClelland's observations in India 
 175, Billiet's in Savoy 175, Grange's 
 in the Alps, Pyrenees, &c. 176, Vir- 
 chow's in Franconia 177 ; exceptions 
 to the magnesian-limestone rule 177 ; 
 liability of different races 178 ; miser- 
 able living only predisposes or helps 
 180; theory of vascular pressure in 
 the neck-region 182, illustrations of 
 183 ; women most liable to 185 ; evi- 
 dence in favour of a drinking-water 
 causation 186, "goitre- wells" 186; 
 evidence against ditto 188; objec- 
 tions to ditto answered 189 ; theory 
 of glacier-water 189; theory of ex- 
 cess of lime and magnesia 190; ex- 
 ceptions to the rule as regards lime 
 190, and as regards magnesia 192; 
 theory of deficiency of chlorides 194; 
 theory of excess of metals (iron and 
 copper) 194 ; theory of fluorine 195 ; 
 theory of deficiency of iodine in air 
 and water 196; due to a morbid 
 poison 197; relation to cretinism 
 199, 200, 201 (tables) 
 Gout, references to, in the Hippocratic 
 writings 648; enormously prevalent 
 nnder the Empire 649 ; increase of, 
 due to increasing luxury of the 
 Empire 649; Lucian's comedy on 
 650 ; references to, by Galen 650 ; 
 afterwards merged with arthritis 
 651; extension of the meaning of, 
 subsequent to Sydenham 652 ; de- 
 crease of, in recent times 653; pre- 
 sent distribution of, in Europe 654; 
 rare in tropical and subtropical 
 countries 656 ; found in northern 
 Hindostan and in the East Indies 
 656 : the heredity of 658 ; con- 
 nexion of, with luxurious living 660; 
 cases of, not due to luxury 661 ; in- 
 stances of luxurious living unat- 
 tended by 662 ; Dundas on the 
 remarkable immunity from, in 
 Brazil 662 ; a specific factor in 662 ; 
 spring and autumn the proper 
 seasons of 663 ; the immunity of 
 the tropics from 663 ; differences of 
 liability according to race 664 ; 
 alleged contagiousness of 664 (note) 
 
 Greece, leprosy 22, syphilis 9'7,"ponos," 
 or children's scurvy 563 
 
 Greenland, free from syphilis 88; ery- 
 sipelas 392, scurvy 529; free from 
 sciofula 621 
 
 Grenada, giiinea-wnrm 349 
 
 Guatemala, ^'ofY re 150, sand-flea 365
 
 INDEX. 
 
 673 
 
 Gniana, leprost/ 10, 29, 46, yaws 106, 
 lead colic 269, anchulostoma 314, 
 jilaria 334, guinea-tvorm 343, nand- 
 flea 365, spoiled skin 387, beriberi 
 577 
 
 Guinea Coast, leprosy 12, syphilis 79, 
 guinea-worm 339, scrofula 621 
 
 Guinea-worm, references to, in anti- 
 quity 337; its distribution — West 
 Coast of Africa 339, North Africa, 
 Nubia, &c. 340, India 341, Cura9ao 
 343, Bahia 344; its proper season 
 344; influence of rainfall 345 ; epi- 
 demics of 346; prefers certain soils 
 346, but no soil precludes it 347; no 
 racial, social, or other immunity 
 from 348; the larval forms of 349; 
 question of how it enters the body 
 351 ; its favourite seats in the body 
 351 ; theory that it enters through 
 the skin 351 ; allesed frequency in 
 water-carriers in India 353 ; evidence 
 that it enters with the drinking- 
 water 353 ; localised outbreaks 354; 
 Fedschenko's discovery that the Cy- 
 clops is its intermediate host 355 ; 
 has followed the African negro 356 ; 
 question of original habitat 356; list 
 of writers on 357 
 
 Gujerat, guinea-worm 342 
 
 H 
 
 Hj^matochtluria, associated with 
 filaria 326, seq. 
 
 HEMATURIA, endemic, of Egypt and 
 the Cape, due to Distoma hcema- 
 tobium 295 
 
 Halifax, puerperal fever, 460 
 
 Halle, puerperal fever 456 
 
 Harz Mountains, ^0i7;'e 141 
 
 Hawaiian Islands, leprosy 19, 46, 
 syphilis 74, itch 362, scrofula 619 
 
 Heat favorable to pellagra 218, to 
 lead colic 278, to ascaris 320, to 
 guinea-ivorm 344, to beriberi 579 
 
 Heredity in leprosy 51, in yaivs 109, 
 in goitre 202, in pellagra 244, in 
 ancemia intertropica 502 ; (erroneous 
 doctrine of) in scurvy 517; in scro- 
 fula 635, in gout 658 
 
 Herpes tonsurans, see Ringworm 
 
 Hesse, goitre 139, 140 
 
 HiNCHAZON, Cuban name for beriberi 
 568 (note) 
 
 Holland, lead colic 206. scrofula 614 
 
 Honduras, sand-flea 365 
 
 Hospital Gangrene, references to, by 
 ancient writers 476 ; accounts of, by 
 
 VOL. II. 
 
 Paracelsus and by Pare 477 ; modern 
 history of, in military hospitals 478, 
 ship-epidemics in the tropics 479, in 
 civil liospitals 480 ; worst in the 
 tropics ; includes " foul sloughing 
 ulcers" and " phagedenisme tro- 
 pical ;" why most common in the 
 tropics 482 ; not always primarily 
 a disease of hospitals 483 ; has often 
 occurred in clean hospitals 484, but 
 mostly associated with unwholesome 
 wards, &c. 485, dirty ships 487, and 
 bad transport 488 ; a specific disease 
 having a virus 489; communicable 
 489 ; relation to other traumatic 
 diseases 490 ; alleged identity with 
 diphtheria 491 
 
 Hospitals, erysipelas in 394, 410 ; 
 puerperal fever 422, seq. ; hospital 
 gangrene 478, 483 
 
 Hudson's Bay Territory, goitre 149 
 
 Hungary, goitre 134 
 
 Hydatids, commonest in Iceland 292, 
 and in Victoria (Australia) 293 ; 
 instances of in other countries 293 ; 
 relation to the tapeworm of the dog 
 {Taenia echinococcus) 294 
 
 Hydra, endemic of "ponos" or chil- 
 dren's scurvy 561 
 
 Iceland, leprosy 26; immnnity from 
 syphilis 71, 88; hydatids 292, 294, 
 itch 360, chlorosis 495, scurvy 527, 
 scrofula 616 
 
 Immunity from syphilis of Malagasys 
 76, 89, negroes in Central Africa 77, 
 89, Greenlanders 80, 89, Icelanders 
 88, Miquelonnais 88 ; from second 
 attack of yaivs 109 ; of the goitrous 
 regions of South America from cre- 
 tinism 150 — 153; of Hindus, Malays, 
 &c., from Tcenia mediocanellata ; 
 of Iceland, Greenland, &c., from 
 tapeivorms generally ; of women 
 from distoma ; of the tropics 
 (relative) from erysipelas 392 ; of 
 uncivilised countries ivnm jjuerperal 
 fever 419 ; (relative) of women and 
 children, Europeans, and new ar- 
 rivals, from beriberi 583 ; of Brazil 
 from gout 658, 662 
 
 Importation, alleged of, leprosy (by- 
 negroes) to America 10, 46, to the 
 Hawaiian Islands 19 ; to New Bruns- 
 wick 27 ; of syphilis to the Western 
 Hemisphere 67, 81, to the Pacific 74 ; 
 (alleged) of yaios to America by 
 
 43
 
 674 
 
 INDEX. 
 
 African negroes 106; (alleged) of 
 Trichina spiralis by Chinese swine 
 312, or by the brown rat 312; of 
 anguillula from Cochin China to 
 Toulon 323, to Brest 325 ; of 
 guinea-worm to the Western Hemi- 
 sphere by African negroes 343, 356 ; 
 of sand-Jlea from Brazil to the West 
 Coast of Africa 364, and in single 
 instances into Europe 365 ; of ri7iff- 
 toorm to islands in the Pacific 376 
 
 Increase of goitre 155, of pellagra 
 224, of chlorosis in Sweden 496, 
 (alleged) of scrofula 609 
 
 India, leprosy 4, 15, 33, 39, syphilis 
 66, 72, goitre 145, tapeiuorm 283, 
 287, Jilaria 335, guinea-worm 341, 
 larvCB in nose 369, ringioorm 374, 
 puerperal fever 421, 443, hospital 
 gangrene 482, scurvy 528, 537, 548, 
 beriberi 575, scrofula 618, diabetes 
 643, 646, 647, gout 656 
 
 Indiana, trembles 255, 257 
 
 Indians, Ameeican, syphilis 81, creti- 
 nism 150, scrofula 622, 634 
 
 Infectiveness, see Virus. 
 
 Iodine, deficiency of, as cause of goitre 
 196 
 
 Ionian Islands, leprosy 23, pellagra 
 226, 236 
 
 Ireland, leprosy 6, button-scurvy 112, 
 scurvy 527, 547, scrofula 615 
 
 Irkutsk, goitre 144 
 
 Iron in the water as cause of goitre 
 194 
 
 Italy, leprosy 8, 21, syphilis 64, 71, 
 goitre 124, ergotis'^i 213, pellagra 
 221, seq., anchylostoma 316, 321, 
 scrofula 611 
 
 Itch, general facts of its distribution 
 360 ; colloquial names 362 ; special 
 varieties (" Malabar itch," &c.) 363 
 
 Jamaica, leprosy (among Jews) 56, 
 
 malignant erysipelas 405 
 Japan, leprosy 18, syphilis 66, itch 361, 
 
 scurvy 528, beriberi (" Kak-ke ") 
 ' 573, 587, 591, scrofula 619 
 Java, leprosy 17, syphilis 74, yaws 
 
 105, ^oiire 147, beriberi 575, scro- 
 
 /wZa 619 
 Jutland, syphilis 94 
 
 K 
 
 Kabylia, leprosy 12, syphilis 78, ^for^re 
 148, i^cA 362, scrofula 621 (note) 
 
 Kak-ke, Japanese name of beriberi 
 
 569, 572 
 Kamscbatka, leprosy 19, syphilis 73, 
 
 i^cA 361, scurvy 526 
 Kenton, Ohio, »2j7^ sickness 260 
 Kioto, beriberi 573, 583 
 Kirghiz Steppe, leprosy 24, syphilis 
 
 70, guinea-worm 341, scrofula rare 
 
 or unknown 617, 635 
 Kokaun, epidem. goitre 159 
 Kremnitz, anchylostoma 317 
 Kumaon, leprosy 15, goitre 145, 175, 
 
 scrofula 618 
 
 Labuan, beriberi 574 
 
 Ladak, goitre 145 
 
 Ladoga (Lake), goitre 144 
 
 Landes, pellagra 225 
 
 Laos, syphilis 72, 73 
 
 Lapland, scurvy 527 
 
 LAEViE OF FLIES in the nose 368 ; 
 mostly occur in the tropics 369; 
 alleged connexion with ozaena 369 
 
 Lead Colic, early references to 265 ; 
 first cases due to lead in the wine in 
 Burgundy, &c. 265 ; in Holland 266, 
 Devonshire 266, Madrid 266, United 
 States 267 ; Benjamin Franklin on 
 267 ; same as the " dry belly-ache " 
 of the West Indies 268, Guiana 269, 
 Senegambia, &c. 270; no endemic 
 colic other than lead colic 271 ; 
 prevalence on board steamships 272, 
 especially French men-of-war 273 ; 
 explanation of their liability 275; 
 oftenest in tropical waters 276 ; 
 Lef evre's explanation of the peculiar 
 liability to, on board French men-of- 
 war 277 ; why commonest in the 
 tropics 278 
 
 Lena, goitre 144, 155 
 
 Lepeost, old generic use of the name 
 1; ancient references to, in the 
 East 2 ; first appearance in Europe 
 5 ; general outbreak in Europe 6 ; 
 alleged importation by crusaders 7 ; 
 confusion with syphilis 8 ; extinction 
 of the European endemic 8 ; first 
 appearance in America 10 ; present 
 distribution — Egypt 11, East Africa 
 and islands 11, Algiers 12, Western 
 Islands 12, West Africa 12, Persia, 
 Syria, &c. 14, India 15, East Indies 
 17, China and Japan 18, Hawaiian 
 Islands 19, Spain and Portugal 20, 
 Comacchio 21, Riviera 21, Provence 
 21, Sicily 22, Greece and islands 22,
 
 INDEX. 
 
 675 
 
 Crete 23, Southern Russia 23, Sweden 
 24, Norway 25, Iceland 26, Tracadie 
 (New Brunswick) 27, Mexico and 
 Central America 28, West Indies 28, 
 Ecuador 29, Guiana 29, Brazil and 
 Argentine Republic 30; inadequate 
 hypotheses of its cause 31 ; prevalent 
 in very various climates 32 ; asso- 
 ciation with sea coasts or rivers not 
 invariable 34; malarious influences 
 excluded 36 ; hypothesis of a staple 
 diet of putrid fish 36 ; evidence 
 against ditto 37 ; influence of other 
 food (rice, maize, pork) 40 ; mostly 
 a disease of the poor 40, but not 
 unknown among the well-to-do both 
 now and formerly 41 ; due to a 
 specific cause 42; the "bacilli of 
 leprosy " 43 ; not now contagious 
 44 ; alleged importation to America 
 by the negro 46, and by Chinese to 
 the Hawaiian Islands 46 ; summary 
 of evidence against contagiousness 
 ^ 47 ; predisposition to it inherited 51 ; 
 Norwegian leprous families in the 
 United States 54; special liabilitj' 
 of negroes 55, and of Jews in the 
 West Indies 56; often acquired by 
 Europeans resident in leprous cen- 
 ti'es 56; anaesthetic form commonest 
 58 
 
 Lignria, pellagra 222 
 
 Lithuania, syphilis 95 
 
 Lombardy, pellagra 221, anchylostoma 
 316 
 
 London, erysipelas 394, 411, puerperal 
 fever, 422 (table), 454, hospital 
 gangrene 483, 484 
 
 Louisiana, leprosy 2/J 
 
 Lymph-sceotum associated with^^ZariO! 
 328 
 
 Lyons, hospital gangrene 478, 486, 
 gout 654, 661 
 
 M 
 
 Macassar, yaws 105 
 
 Madagascar, leprosy 11, syphilis 76, 89, 
 yaws 105, goitre 148, Jilaria 334, 
 gout 657 
 
 Madeira, leprosy 12 
 
 Madras Pres., guinea-worm 357, beri- 
 beri 575, 580, 581, 592 
 
 Madrid, lead colic 266 
 
 Magnesian water as cause of goitre 
 178, 186 
 
 Maize, diet of damaged, cause of pel- 
 lagra 230, seq. ; ergot-parasite on, 
 cause of pelade 253 
 
 Malabar Coast, guinea-worm 342, itch 
 363, beriberi (rare) 575 
 
 Malacca, leprosy 17, ringworm 377 
 
 Malta, milk sickness 262 
 
 Manchester, puerperal fever 451 
 
 Maobis, leprosy among 19, syphilis 75, 
 scrofula 620 
 
 Maraquita, goitre 151, pelade 253 
 
 Martinique, anguillula 325 
 
 Matucana, verruga 118 
 
 Mauritius, leprosy 11, syphilis 76, 
 round-worm 300,Jllaria 334, beriberi 
 576 
 
 Mesopotamia, leprosy 10 
 
 Metal Mountains, goitre 141 
 
 Mewar, guinea-worm 345, 355 
 
 Mexico, leprosy 28, 40, syphilis 81, 
 goitre 150, sand-flea 364, 366, pinta 
 381, chlorosis 497, mountain sickness 
 504, scrofula 622 
 
 Miasma, doctrine of, in verruga 119, 
 in the trembles 258, in puerperal 
 fever 438, in scurvy 541, 558, in beri- 
 beri 596, 600 
 
 "Milk-sickness" occurs where "the 
 trembles" of cattle is prevalent 259 ; 
 symptoms of 259; morbid anatomy 
 of 259 ; epidemics of 260 ; evidence 
 that it is due to poisonous milk or 
 meat 260; Graff's inquiries 261; 
 occurs oftenest in adults ; selects its 
 victims 262; a similar outbreak at 
 Malta traced to toxic milk 262 
 
 Miquelon, free from syphilis 88 ; much 
 chlorosis in 495 ; scrofula 621 
 
 MoiSTUEE, see Rainfall 
 
 Moluccas, syphilis 74, yaws 105, ring- 
 worm 377, beriberi 574 
 
 Monte Video, puerperal fever 421 
 
 Morocco, leprosy 12, syphilis 78, goitre 
 148 
 
 Mountain Sickness, local names of 
 (tiote) 503; symptoms and clinical 
 history 503 ; affects beasts of burden 
 504 ; occurs only at great elevations 
 — Cordillera, High Alps, Himalaya, 
 &c. 504; various theories of 505; 
 observations and conclusion of Paul 
 Bert 505 ; acclimatisation to 506 ; 
 idiosyncrasy for 506 
 
 Mozambique, leprosy 11, yatvs 105, 
 itch 362 
 
 Myiasis, South American name for 
 hava; in the nose 369 
 
 N 
 
 Natal, distoma 296 
 
 Neguoes peculiarly liable to leprosy
 
 676 
 
 INDEX. 
 
 55 ; protected from syphilis in Mada- 
 gascar. &c., and in interior of Africa 
 77, 89 ; in East Indies protected 
 from yaws 106, but elsewhere very 
 liable 109 : "cachexie aqueuse" of, iu 
 West Indies 313; imported ^wiwea- 
 worm to Egypt 340, and to America 
 313, 356 ; not exempt from erysi- 
 pelas 109 ; liable to beriberi iu the 
 West Indies 569 {note), 576 
 
 Nepaul, goitre 145 
 
 Nertcliinsk, goitre 145 
 
 Nervous phenomena in leprosy 58, 
 in ergotism 210, in pellagra 218-220, 
 in acrodynia 248, in trembles 254, 
 in milk-sickness 259, in beriberi 570 
 
 Nbw Brunswick, leprosy 27, 47 
 
 New Caledonia, yaws 105 
 
 New Granada, goitre 151, 155, 160, 
 sand-fiea 365, bots Z10, jrinta 382 
 
 New Guinea, beriberi 575 
 
 New Hampshire, goitre 149 
 
 New York, ergotism 211, puerperal 
 fever 434 
 
 New Zealand, leprosy 19, syphilis 75, 
 scrofula 620 
 
 Nicaragua, goitre 150 
 
 Niger basin, goitre 148 
 
 Nile basin, leprosy 11, syphilis 78, 
 worms 280, guineaivorm 340, scurvy 
 529 
 
 North- West Provinces of India, le-prosy 
 16, goitre 145, guinea-worm 341 
 
 Norway, leprosy 25, 38, syphilis 93, 
 Ao/* 371, chlorosis 495, scurvy 527 
 
 Nossi-Be, ringworm 374, beriberi 576 
 
 Nubia, syphilis 78 
 
 
 
 Oceania, leprosy 19, syphilis 74, r««^- 
 
 worwj 375 
 Organisms, minute parasitic, in leprosy 
 
 43, syphilis 84, ^roi^re 199, erysipelas 
 
 412, puerperal fever 465 
 OupiiANAOES, beriberi 583, scrofula 
 
 633, 638 
 Ottawa, syphilis 81, scurvy 529 
 OxYUEis VEKMiCTJLAEis, general facts 
 
 of its distribution 302 
 
 Paraguay, /e;;ro5j/ 10, 30, ^o/^ce 152, 
 
 sand-Jlea 365, beriberi 577 
 Pakalytic symptoms in pellagra 218, 
 
 in beriberi 570 
 Pakanqi, name of yaws in Ceylon 101 
 
 Parasitic Fungi in skin diseases 372 
 
 Parasitism, restricted application of 
 the terra iu this volume 279; doc- 
 trine of, in specific infections 279; 
 mostly prevalent in the tropics 280; 
 doctrine of, in leprosy 43, in beriberi 
 598, in scrofula 640 
 
 Paris, acrodynia 249, puerperal fever 
 447, hospital gangrene 478, 485 
 
 Pelade, a toxic disease found in Co- 
 lombia 253 ; hair coming out is the 
 chief symptom 253; due to ergot 
 pai'asite on maize 253 ; effects of 
 ergot of maize on cows with calf 253 
 
 Pellagra, clinical history of 217 ; 
 morbid anatomy of 219 ; distribution 
 in Spain 220, in Italy 221 ; table for 
 the various Italian provinces 223; in 
 France (Gascouy) 225 ; alleged oc- 
 currence in Hungary, Egypt, Algiers 
 225 {note); in lloumauia 226, in 
 Corfu 226 ; a modern disease of the 
 peasantry in a few localities 227; 
 miserable living in general does not 
 account for it 229 ; evidence that it 
 is due to living on damaged maize 
 230 ; occurs most where maize- 
 polenta is the staple food 231 ; un- 
 known in Europe until maize intro- 
 duced 232 ; symptoms may abate 
 when maize-food stopped 233 ; not 
 owing to low nutritive value of maize 
 234; due to maize grown on unsuit- 
 able soil, gathered unripe, and badly 
 stored 235 ; Wallacks in Transyl- 
 vania free from it, but iu Roumania 
 liable to it, differences in their hus- 
 bandry of maize 236; the circum- 
 stances in Corfu 236 ; epidemics of, 
 follow bad seasons 237; goes with 
 poor soil 238; inquiries of Balar- 
 dini on the virus, 238 ; of Lombroso 
 on ditto 239; objections to Lom- 
 broso's conclusion 240 ; resemblance 
 to ergotism 242; why no pellagra 
 in other maize-eating countries 242; 
 sporadic pellagra 242; not a con- 
 tagious disease 244; evidence of 
 heredity 244; literature of 245 
 
 Persia, leprosy 10, 14, itch 361 
 
 Peru, syphilis 83, verrvga 114, goitre 
 152, anchylostoma 314, itch 362, 
 sand-flea 365, mountain sickness 504, 
 scrofula 623, gout 658 
 
 PiAN, synon. for yaws 101 
 
 Piedmont, ^o«7re Ib'd, pellagra 222, 238 
 
 Pig, liable to trichinosis 311, host of 
 fcenia solium 287 
 
 PiNTOS, MAL DE LOS, list of Writers on 
 {note) 379; clinical characters and
 
 INDEX. 
 
 677 
 
 varieties of 380; its iiistory in 
 Mexico uncertain 381 ; present dis- 
 tribution — Mexico 382, Venezuela 
 and New Granada 382 ; waruitli and 
 moisture favour it 383; miserable 
 living predisposes to it 383 ; earlier 
 views of its pathology 384; discovery 
 of a fungus in, by (iastambiile 385 ; 
 question of the cause of various tints 
 385 ; its communicability 386 ; other 
 tropical discolorations of skin allied 
 to it 386 
 Pityriasis versicolor 372 
 Plymouth, puerperal fever 455 
 Pondicherry, yrtw* 105 
 ■"PoNOS," a malady of young children 
 in two Greek islands, allied to scurvy 
 561; clinical history 562; morbid 
 anatomy 563 ; confined to Spezza 
 and Hydra 563 ; present frequency 
 564 ; factors in the etiology 564 ; a 
 congenital constitutional malady 564 
 Portugal, leprosy 20, 32, scrofula 610 
 Poverty as a factor in leprosy 40, in 
 yatos 108, in verruga 118, in goitre 
 180, in ergoilsm 215, in pellagra 
 229, in anchylostoma 320, in nial de 
 lospintos 383, in beriberi 589 
 Prague, hospital gangrene 484 
 Prisons, hospital gangrene 484, acro- 
 dynia 251, 252, scurvy 527, 536, 540, 
 550, beriheri 588, scrofula 634 
 Puerperal Fever, modern doctrine 
 of, originated by Semmelweiss 416 ; 
 references t", in ancient and medi- 
 aeval writings 418; lirst understood 
 by Willis 418; commonest in civilised 
 countries 419 ; table of deaths from 
 419 ; survey of its present distribu- 
 tion 420 ; chronological table of epi- 
 demics of 422 ; epidemics commonest 
 in cold and wet weather 432 ; tables 
 showing this for St. Petersburg and 
 Vienna and Bergen 433, and for 
 New York 434 ; cold acts indirectly 
 by discouraging free ventilation 435 ; 
 specially a disease of lying-in hos- 
 pitals 436 ; comparison of death-rate 
 after delivery in hospitals and in 
 private houses 437 ; why a hospital 
 disease 438 ; influence of overcrowd- 
 ing 439, at Stockholm 440, Dublin 
 440, Halle, &c. 441 ; in India 443 ; 
 exceptional outbreaks 444 ; the mias- 
 matic-contagious hypothesis 445 ; 
 objections to ditto 446 ; tables of 
 the cases in various hospitals of 
 Paris, St. Petersburg, and Vienna 
 417 ; no pandemic influence 449 ; 
 cases showing how the virus 
 
 originated and was transmitted 
 450 — 462 ; remarkable experiences 
 at Vienna in connexion with the 
 teac^hing of morbid anatomy 462 ; 
 reforms of Semmelweiss 464 ; media 
 of carrying the virus 465 ; micro- 
 organisms 465 ; may coincide with 
 erysipelas in a place (instances) 467 
 may originate from erysipelas 468 
 may be the source of erysipelas 469 
 is itself sometimes erysipelatous 470 
 list of writers on 471 
 
 Punta Arenas, yaws 106 
 
 Pyrenees, _9'0(Yre 129, 130, pellagra 225, 
 scrofula 628 
 
 Q 
 
 Q,y\ec\\s\A\v\, filar ia 329 
 Quito, mountain sickness 503 
 
 R 
 
 Radesyge, endemic syphilis of Nor- 
 way and Sweden 93 
 
 Rainfall, influence of, in guinea-ioorm 
 344, in beriberi 580 
 
 Rajpootana, guinea-toorni 342, scuroy 
 549 
 
 Rat, host of trichina parasite, 311 
 
 Reichenbach, puerperal fever 469 
 
 Reunion, leprosy 11, si/philis 76, spotted 
 skin 388, beriberi 576 
 
 Rice diet as cause of leprosy 40, of 
 beriberi 589 
 
 Ringworm, general facts of its dis- 
 tribution 374 ; mostly in warm coun- 
 tries 374, and among the dark-skinned 
 races 375; special forms in the 
 Pacific — "gune " 375, Tokelau ring- 
 worm 376, Cascadoe 377; relation 
 of these varieties to herpes tonsurans 
 378 
 
 Riviera, leprosy 21 
 
 Roumania, syphilis ^Q, pellagra 226, 
 236 
 
 Round-worm, see Ascaris 
 
 Russia, leprosy 23, syphilis 70, goitre 
 144, ergotism 212, tapeworm 286, 
 trichinosis 309, scurvy 526, scrofula 
 616, gout 655 
 
 S 
 
 Saigon, syphilis 73, anguillula 324 
 Salzburg, goitre 122, 199 
 Sauiarang, beriberi 575, 583 
 Samoa, yaws 105, 107, ringworm 376 
 Sand-flea, confined to certain parts of 
 Central and South America and th„
 
 678 
 
 INDEX. 
 
 West Coast of Africa 364 ; cases of 
 importation to Europe 365; fre- 
 quents filthy huts and piggeries 366; 
 enters houses in the rainy season 
 367; natives on their guard against 
 it 367 ; mostly found about the toes 
 368 
 
 San Domingo, yaios 104 
 
 San Francisco, beriberi 577 
 
 Sau llcmo, leprosy 21 
 
 San Salvador, goitre 150, sand-Jlea 
 365 
 
 Saskatchewan, goitre 149 
 
 ^A\oy, goitre 129, 169, 175 
 
 Schmalkalden, goitre 140 
 
 SCHOOIS, beriberi in 583 ; scrofula in 
 632, 638 
 
 Scotland, leprosy 6, 9 ; syphilis 64, 92 
 {sibbens) ; goitre 143 ; fajus 373 ; 
 scurvy 547 
 
 Scrofula, etymology of name 604 
 (note) ; clear references to, in ancient 
 writers 605 ; development of the 
 doctrine of scrof ulosis 606 ; applied 
 indiscriminately to children's diseases 
 in 18th cent. 607 ; present doctrine 
 based on morbid anatomy and clini- 
 cal history 608; historical estimate 
 of amount of scrofuli difficult owing 
 to vagueness of term 608; no evi- 
 dence of increase since vaccination 
 609; present area — Europe 610, 
 table for Italy 611, France 612, Swit- 
 zerland, Belgium, Holland, Germany 
 614, Britain 615, Scandinavia 616, 
 Russia 616, other parts of Eastern 
 Europe 617, India 618, East Indies, 
 China, &c. 619, Hawaiian Islands 
 619, Tahiti, New Zealand, &c. 620, 
 Cape Colony 620, Abyssinia, Egypt, 
 &c. 620, Alaska 621,'Miquelon 621, 
 (rare in) Greenland621, United States 
 621, West Indies 622, Brazil, &c. 
 623, Chili, &c. 623; common both 
 in tropical and temperate latitudes 
 624; young persons coming from 
 the tropics to Europe peculiarly 
 liable to it 625 ; not limited to low 
 and damp soils 626 ; recent increase 
 in parts of Belgium 627 ; occurs at 
 high and low points in the Pyrenees 
 628 ; affects the children of the rich 
 and poor alike 629; a malady of 
 nutrition 630 ; effects of close con- 
 finement 630, in children put early 
 to work 631, in orphanages and 
 workhouses, &c. 632, in factories 
 633, in Millbank Prison 634; alleged 
 immunity of nomadic peoples 635; 
 may be inherited or congenital 635, 
 
 or acquired 636; the doctrine of a 
 scrofulous virus 637 ; no evidence of 
 commuuicability 638 ; alleged con- 
 veyance by vaccination 639 ; para- 
 sitic doctrine of 640 
 SCUEVY, Lind's services to historical 
 study of 507 ; the " lienes magni " 
 of ancient writers not scorbutic but 
 malarial 508; doubtful if " stoma- 
 kake " and " skelotyrbe " were scor- 
 butic 509; genuine Hippocratic 
 reference to 511; mediaeval refer- 
 ences 511 ; historical outbreaks at 
 sea 512 ; early accounts of land 
 scurvy 513 ; rise of the doctrine of 
 a scorbutic constitution 514; his- 
 torical sketch of ditto 515 ; the dog- 
 matism of Eugaleuus 516; reason- 
 able views of Sydenham, Hoffmann, 
 Mead and Kramer 519 ; not especi- 
 ally common in former times 520 ; 
 table of epidemics 521; countries 
 most liable to land scurvy — Russia, 
 526, Iceland, &c. 527, Arabia, Japan, 
 Australia 528, Soudan, West Coast 
 of Africa 529, Greenland, Alaska, 
 Ottawa 529; services of Blane for 
 the navy 531;- modern instances in 
 English navy 531 ; in mercantile 
 marine 531 ; in other navies 532 ; in 
 French ships of war 533 ; in arctic 
 ships 533 ; spring and winter its 
 proper seasons 535; cold and wet 
 only predispose to 535 ; outbreaks in 
 warm and dry weather 536 ; not 
 dependent on cold and wet at sea 
 537 ; damp soil only predisposes 539 ; 
 no "scorbutic miasma" 540; over- 
 crowding and impure air have a 
 determining influence 540; remarks 
 of Armstrong on ditto 542 ; not 
 caused by absolute want of food 543, 
 or by want of fresh meat 544, but 
 by want of fresh vegetables 545; 
 instances in proof of this — European 
 wars 546, Irish famine 547, India 
 548, United States 548, Australian 
 exploration 549, prisons 550, ou 
 board ship 551 ; causes of recent 
 decrease 553 ; Garrod's table of 
 amount of carbonate of potash in 
 articles of diet 554; outbreaks in 
 spite of lime-juice 554 ; predisposi- 
 tion caused by previous hardships 
 556 ; anomalous outbreaks 557 ; the 
 miasmatic and infective doctrine — 
 Krugkula 558, Villemin 559, Kiihu 
 559 ; experiments to infect animals 
 with 560 ; summary of the etiology 
 561 J list of writers on 565
 
 INDEX. 
 
 679 
 
 Sea-coast, leprosy 34, scurvy 559, 
 beriberi 581 
 
 Season of ergotism 214, of pellagra 
 217, 237, of lead colic 276, of dis- 
 toma 299, of guinea-worm 345, of 
 sand-flea 367, of ringworm 374, of 
 pinta 383, of erysipelas 406, of ^wer- 
 peral fever 432, 434, 443, of hospital 
 gangrene 482, of scurvy 535, of Jen- 
 ieri 579, of ^om< 663 
 
 Segu-Sicorro, goitre 148 
 
 Senaar, goitre 148 
 
 Senegambia, leprosy 12, syphilis 79, 
 tapeworm 282, larvcB in nose 369 
 
 Servia, endemic syphilis 96 
 
 Sex, female, most liable to goitre 185 ; 
 male, most liable to distoma 298, 
 to beriberi 583 
 
 Shetland Islands, leprosy 9, 6o^s 371, 
 scrofula 615 
 
 Ships, erysipelas in, 395, hospital gan- 
 grene in 479, 487, scurvy in 530, 
 551, beriberi in 577 
 
 Siam, leprosy 17 
 
 Siberia, syphilis 73, goitre 144, i^cA 361 
 
 SiBBENS, endemic syphilis in Scotland 
 92 
 
 Sicily, leprosy 22, 34 
 
 Singapore, leprosy 17, beriberi 574, 
 597 
 
 Skelotyebe, a disease of antiquity 
 supposed by some to have been 
 scurvy 509 
 
 Skeeljevo, endemic syphilis of Dal- 
 matia 95 
 
 Skin, Discoloeation of, in the tropics 
 386, in Brazil 387, in Guiana and 
 West Indies 387 ; doubtful instances 
 in Africa, &c. 388 
 
 Soil as a factor in goitre 166, 171, 174, 
 in pellagra 238, in the trembles 257, 
 in anchylostoma 320, in guinea-worm 
 346, in erysipelas 407, in beriberi 
 581, in scrofula 626 
 
 Soudan, Eastern, scurvy 529, see also 
 Nile basin 
 
 Soudan, Greater, yaws 105, goitre 148, 
 tapeworm 282 
 
 Spain, leprosy 20, syphilis 63, goitre 
 130, pellagra 220, scrofula 610 
 
 Spezza, endemic of "ponos" or chil- 
 dren's scurvy, 561 
 
 Spoeadic cases of leprosy 23, 30, 67, 
 of pellagra 234, 242 
 
 St. Domingo, yatos 104 
 
 St. Etienne, anchylostoma 317, 319 
 
 St. Helena, leprosy 11 
 
 St. Marie, leprosy 11, syphilis 77, 89 
 
 St. Petersburg, puerperal fever 433, 
 448, scwruy 536, ^o«^ 655 
 
 Stockholm, puerperal fever 440, 458 
 
 Stomakake, a disease of antiquity 
 supposed by some to have been 
 scurvy 509 
 
 Steuma, old name for scrofula 605 
 {note) 
 
 Styria, goitre 133 
 
 Suceeeies, maladie des. West Indian 
 name for beriberi 569 (note) 
 
 Sudetic Mountains, goitre 141 
 
 Sumatra, ^atos 105, goitre 147, beri- 
 beri 574 
 
 Surinam, leprosy 10, see also Guiana 
 
 Sweden, leprosy 24, 37, syphilis 93, 
 tapetoorm 289, chlorosis 496, 500, 
 scurvy 527, scrofula 616 
 
 Switzerland, cretinism 130, goitre 132, 
 ergotism 213, bothriocephalus 289, 
 291, scrofula 614 
 
 Syphilis, inclusive sense in which the 
 term is used 69 {note) ; summary of 
 evidence that both the constitutional 
 and the local forms existed in anti- 
 quity 59 ; used to be kept secret from 
 the profession 60 ; afterwards mixed 
 up with leprosy 62; a case at Valencia 
 63; the great European epidemic, 
 beginning 1488 64 ; virulence of 
 type of ditto 65 ; ancient evidence 
 of the constitiitional forms in the 
 East 66 ; brought to the New World 
 by Europeans 67; present distribu- 
 tion — Europe 69, European armies 
 (table) 70, Asia 71, India 72, Saigon 
 73, Kamschatka 73, China and 
 Mongolia 73, East Indies 74, Ha- 
 waiian Islands and Tahiti 74 ; enor- 
 mous prevalence of, in Zanzibar, Mo- 
 zambique, Madagascar, &c. 76, in the 
 last confined to the Hovas, exempt- 
 ing the Malagasys 77 ; Livingstone 
 on immunity from, in interior cf 
 Africa 77 ; enormous prevalence of, in 
 Abyssinia, Nubia and Egypt 78, 
 Tunis and Algiers 78, Senegambia 
 79, Guinea Coast 79 ; immunity of 
 Greenland and Miquelon (N. P.) 80 ; 
 prevalence in Alaska, Vancouver's 
 Island and British Columbia 80, 
 Canada 81, California 81 ; Mexico 
 its primary focus in the New World 
 82 ; enormous prevalence of, in Brazil 
 and Argentine Republic 83 ; admis- 
 sions into hospital at Valparaiso 83; 
 original habitats uncertain 84; search 
 for the virus in the form of a fungus 
 84 ; type may be as virulent in 
 tropical as in temperate latitudes 
 86; said to be intensified by alti- 
 tude 87; remarkable instances of im-
 
 G80 
 
 INDEX. 
 
 immity — Icelanders, Miquelonnais, 
 Greenianders, Central Africans, Ma- 
 lagasys 88 ; said to be worse when 
 got from persons of another race 90 ; 
 good effects of police surveillance 90 ; 
 bad etlVcts of war and movements of 
 troops 91 ; remarkable endemics — 
 the sihbens of Scotland 92, the rade- 
 .tfige of Norway and Sweden 93, the 
 Jutland syphiloid 94-, the Dithmar- 
 sian disease 94, the syphiloids of 
 Lithuania and Courland 95, the falca- 
 dina of Belluno 95, the skerljevo of 
 Dalmatia 95, the frenga of Servia, 
 loala of Roumauia and Bulgaria, 
 and spirokolon of Greece 96, the 
 endemic of Chavanne (Haute-Saone) 
 97, of Bidschow (Bohemia) 97, and 
 of Capistrello (Abruzzi) 97 ; the 
 great fifteenth century epidemic 
 illustrated by these modern in- 
 stances, both iu its rise and decline 
 98 
 Syria, leprosy 10, 14, tapeivorni 282, 
 trichina 310, guinea-worm 341 
 
 T 
 
 T^NIA ECHINOCOCCUS 294 
 
 T.i;nia MEDiocANELLATA chiefly met 
 with iu Abyssinia 281 ; also in other 
 African countries 282 ; and iu India 
 283, China, Japan &c. 284; in- 
 stances of, in Europe, in South 
 America 285 ; due to eating un- 
 cooked beef 281—284, 288 
 
 T^NiA SOLIUM, etymology of name 285 
 {note) ; mostly European in its dis- 
 tribution 286, but met with also in 
 Newfoundland and Mexico 286 j 
 goes with eating pork 286, 287 
 
 Tahiti, leprosy 19, si/philis 75, goitre 
 147, lead colic 271, scrofula 620 
 
 Tartary, goitre 147 
 
 Terai, goitre 146 
 
 Ternate, leprosy 54 
 
 Thibet, goitre 146 
 
 Thuringia, goitre 140 
 
 Tirabuctoo, yaws 105 
 
 Tinea imbeicata, form of ringworm 
 in the East Indies 377 
 
 Tokelau IsXunds, ringioorm 376 
 
 Tokio, beriberi 580, 583, 586 
 
 Toulon, anguillula 323, sand-flea 366, 
 hospital gangrene 486 
 
 Toxic effects of the food in leprosu 
 36, m ergotism 214, in pellagra 230 
 in acrodynia 251, in the trembles 25'l' 
 and in milk-siclcness 259; of the 
 
 food or drink in lead colic 265, seq. ; 
 of the food in beriberi 589 
 
 Tracadie, leprosy 27 
 
 Tkanspoets, hospital gangrene 487, 
 488, scurry 531, 533, 541, 552, beri- 
 beri 577, 588 
 
 Transylvania, _^o«7re ISi, ergotism 213 
 
 Teembles, a disease of cattle in Prairie 
 States of America 254 ; symptoms of 
 254; distribution in the United States 
 of America 255 ; early notices of 
 255; associated with the i)asturage 
 of certain spots 256 ; mostly on poor 
 or fallow land 257 ; due to a toxic 
 substance in the pasture 257 ; not 
 niahu'ial, nor owing to a mineral 
 poison iu tiie water 258; milk of 
 animals suffering from, causes a 
 peculiar disease in man 259 
 
 Trichina spiralis, T first discovery of 
 
 Trichinosis, J tlie parasite 303 ; 
 
 first case observed during life 305; 
 Zenker's case 305 ; earlier cases and 
 outbreaks not diagnosed at the time 
 305 ; cases and outbreaks since 
 Zenker's 307 ; mostly in North 
 Germany 308; instances in other 
 couutries 308 ; in the United States 
 310 ; question of the intermediate 
 host of the parasite — pig or rat 311 ; 
 unequal distribution of 312 
 
 Trichocephalus dispar, general facts 
 of its distribution 302 
 
 Troops, syphilis 70, 72, 91; verruga 
 114; epidemic goitre lo6; acrodynia 
 215 ; guinea-icorm 345, 348, 355 ; 
 «7eA 360 (note) ; sand flea 366; mat 
 de los pintos 382 ; liospital gangrene 
 477, seq., 483, 487; scurvy 511, 521 
 (table), 536, 546, seq., 556; beriberi 
 574, 580-1, 590 
 
 Tropics, leprosy 32, syphilis 87," ya7vs 
 107, verruga il8, lead colic 268, 276, 
 parasites 280, ascaris 299, filaria 
 sanguinis 333, guinea-worm 339, inal 
 de los pintos 382, 386, hospital gan- 
 grene 479, 481, beriberi 579, anamia 
 502, immunity from gout 663 
 
 Tunis, syphilis'78, spotted skin. 388, 
 scrofula 621 
 
 Turkestan, leprosy 14, guinea-ivorm 
 341 
 
 Turkey, leprosy 22, erysipelas 393 
 
 Tuscany, pellagra 222 
 
 Tyrol, syphilis 95, goitre 132 
 
 U 
 
 Union Islands, ringworm 376 
 
 United States, leprosy (among Norwe-
 
 INDEX. 
 
 681 
 
 gians) 54, goitre 149, trembles 254, 
 lead colic 267, trichinosis 310, 
 anchylostoma 315, epidemic ery- 
 sipelas 398, hospital gangrene 487, 
 acrofula 621, ^om/ 657 
 
 Uiuguay, leprosy 10 
 
 Uta, the Peruviau name of a disease 
 caused by larvse of flies deposited 
 uuder the skin 370 
 
 V 
 
 Vaccination, alleged influence of, in 
 producing scrofula, 609, 638 
 
 Vallais, cretinism 131 
 
 Valleys, narrow, always the seats of 
 verruga 117, often the seats oi goitre 
 165 
 
 Valparaiso, syphilis 83 
 
 Vancouver's Island, syphilis 80 
 
 Venetia, pellagra 221 
 
 Venezuela, goitre 151, 170, pinta 382 
 
 Vermont, goitre 149 
 
 VebkUGA Peeuviana, disastrous out- 
 break of, in Pizarro's army in six- 
 teenth century 114; found in 1842 
 to be endemic in a small area of 
 Peru 114 J clinical characters — 
 bleeding warts of skin and mucous 
 membranes 115 ; course of the dis- 
 ease 116; histology of the wart 116; 
 localities where tound 117 ; natural 
 features of ditto 117 ; a specific 
 disease easily caught by new comers 
 118; the drinking-water suspected 
 119; doubtfully contagious 119; 
 fatality among Englishmen making 
 the Trans-Andean Railway 120 ; 
 rate of mortality 120 
 
 Victoria, hydatids 293 
 
 Vienna, puerperal fever 416, 433, 448, 
 462 
 
 ViBCS, doctrine of specific, in leprosy 
 42, in yaws 108, in verruga 118, in 
 goitre and cretinism 197, in pellagra 
 238, in erysipelas 413 ; questioned 
 for puerperal fever 466 ; in hospital 
 gangrene 489 ; denied for scurvy 558 ; 
 in beriberi 595, in scrofula 637 
 Vosges, goitre 138 
 
 \V 
 
 Waldeck, goitre 141 
 
 Wak3 followed by endemics of syphilis 
 91, 92, seq., 99 ; by hospital gan- 
 grene 478, see also Tkoops 
 
 Waet (Peruvian), see VeekUQA 
 
 Water (drinking) as cause of goitre 
 186, of verruga 119 ; as medium of 
 distoma 297, of anchylostoma 320, 
 of filaria sanguinis 331, of guinea' 
 icorm 350; as cause of scurvy 545, 
 ofponos" 564 
 
 West Indies, leprosy 10, 28, syphilis 
 67, 82, yaws 106, lead colic 268, 
 anchylostoma 314, filaria 334, 
 guinea-iuorm 343, sand-flea 365, 
 beriberi 576, scrofula 622 
 
 Wurtemberg, goitre 135, 170, 190 
 
 Yaws, synonyms of 101 (and note) ; 
 clinical history of 101 ; morbid ana- 
 tomy of 103 ; a specific infective 
 disease quite distinct from syphilis 
 103; historical references to in St. 
 Domingo, Brazil, East and West 
 Indies 104 ; present ai'ea — West 
 Coast of Africa its chief seat 105, 
 found in Madagascar,&c. 105, common 
 in East Indies, found in Ceylon, New 
 Caledonia, Fiji and Samoa 105, com- 
 mon ia West Indies 106 ; doctrine of 
 importation by the African negro 
 106 ; endemic in Samoa 107 ; a dis- 
 tinctly tropical disease 107 ; helped, 
 but not directly caused by poor 
 living 108 ; highly contagious 108 ; 
 negroes almost exclusively liable 
 109 ; mostly attacks young children 
 109; one attack gives a degree of 
 immunity 110; literature 110 
 
 Zanzibar, leprosy 11, syphilis 76, a«« 
 chylostoma dlb, filaria 334 
 
 PRINTED BY J. E. ADLARD, BARTHOLOMEW CLOSE. 
 
 VOL. II. 
 
 44
 
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