till midday, when he complained of an aching and numbness in his left arm and also of some numbness about his lower extremities. In the evening he first complained of his throat, and said he could not swallow properly, and that his breathing was difficult. He was able, however, to drink some tea and take a little bread and butter. He passed a very restless night with scarcely any sleep, and at times he was somewhat excited, pacing up aud down the room, and exclaiming that he could not breathe. I saw him at 10 a.m. He was dressed and down stairs, his manner was dull and uneasy, but all questions put to him were answered readily and intelligently. He had no breakfast, assigning as a reason his inability to swallow. I then tried him with a little fluid in a tea-spoon, aud after urging him to take it, he swallowed it with a gulp. Told me his throat NOTES ON THE RABIC VIRUS. was sore, and on examining it, I found the fauces By Vincent Richards, F.R.C.S. and pharynx were looking inflamed, due, perIt is but a short time since all snake-poisons haps, to the irritation caused by the frequent He were as their noxious regarded owing proper- spitting which commenced in the night. ties to one specific agency, but it has now been put his hand to his throat two or three times as Said his left arm pretty well conclusively shown by the re- if feeling uneasy there. ached in its whole length, but neither now nor searches of Weir-Mitchell and Reichart and Wolfenden, that not only is there a distinct differ- subsequently did he complain of any special ence in the chemical composition of the venoms pain at the situation of the bite, and there was Once of the various snakes, but that the virulence of no redness or peculiarity of any kind. each venom depends not on a single factor, but or twice afterwards he complained of pain in on the combination of two or more poisonous elethe elbow, and once he said his middle finger ments of a proteid nature. Each of these elewas very painful ; tongue furred ; no vesicles ments possesses a distinctive physiological provisible. I looked for these soon after the bite, perty, that is to say, the injection of either but never discovered auy then or afterwards ; into an organism is followed bj characteristic bowels acted freely four or five times yesterphysiological phenomena. Our knowledge of day. Pulse 84 ; temperature 99?. Ordered this particular animal poison is much in advance half a dram of solution of hydrochlorate of morof our knowledge of any other ; and it is certain- phia every 4 hours. 2 p. M., temperature 99*8?; ly not a little singular that a virus so insidious pulse 88. Fancies he can swallow better, and in its action, and terrible in its effects as that of lias taken corn-flour, and drank a little currentrabies, should have received so little, of what I water. 8-30 P.M., temperature 100?; pulse. 100; breathing more "catchy." Says he has may call, manipulative investigation. In the absence of any chemical analysis of rabic virus, knobs in his throat ; has eaten a biscuit, but is it possible to form any reasonable opinion as swallows with more difficulty, and has more freI think it is, but I would wish it quent paroxysms of the sensation of choking, to its nature ? to be understood that my remarks 011 this subcausing him great distress ; his manner is more and excited and lie is slightly delirious ; he is conare the merely ject are purely speculative, Before constantly spitting up white, viscid sputa, which he outcome of reasoning by analogy. sidering the chemical composition of ordinary hawks up with violent efforts ; is very thirsty ; saliva, I will invite attention to the peculiar tongue has a creamy fur on it ; pupils dilated ; manifestations, of the disease which we term eyes wild and staring. 11 P.M., temperature " 100'6? ?, pulse 80. For the first time he has I will desHydrophobia." For my purpose to take his medicine, and I was refused of the disease??one distinct cribe two very types obliged to press him before he would. Asks to have"all the psychical manifestations preiu which dominate ; and the other, in which disturbance draughts of air kept from him, as they bring on the paroxysms, ami the mere act of lifting his of the functions of the medulla oblongata are bed clothes to cover him up, brought on a sharp the chief characteristics of the attack. Several times he tried to blow his nose, attack. Case No. 1.?" C. J. was bitten by a dog, and could not, for each time the handkerchief in July 1877, in the left thumb and ball of the touched the nose he went off in a violent pathumb?wounds were cauterised. Premonitory symptoms, September 11 th.?He roxysm, appearing for many seconds as if he went to work yesterday as usual, and worked | would be strangled. O
NOTES ON THE RABIC VIRUS.
July, 1886.]
8 a.m.?Temperature 103? ; all .night, which at delirium 96. High pulse the time of my visit was of a religious turn. Intense thirst ; can swallow no better, and the paroxysms continue just the same 2-30 P.M.? 11 a.m.?Temperature 102-5? Spitting frequently and in all directions, and sometimes on those about him; foaming at the mouth, and holding his tongue out like a tired dog. He is more violent, and struggled furiously with two men and a woman who are required to hold him. Conjunctivae slightly congested. Pupils widely dilated. Gave an enema of half an ounce of syrup of chloral and three ounces of beef-tea. Has been sick several times, vomiting up bile and other liquids. 4 p.m.?Muchquieter ; got quieter half an hour after the enema of chloral and beef-tea. 7-30 p.m.?Temperature 103?; weak, and I could not count it; still pulse very has the " busy " delirium without the violence Saw him again at 8-30 P.M., when he seemed weaker and quieter, and at 10 P.M., he died from exhaustion. Remarks.?(c No fear of water or any liquid, Swallowing produced the violent qua liquids. There paroxysm whether of liquids or solids. was a strong apprehension from the first, both on his part and that of his friends, that he would suffer from hydrophobia. Attempted to give chloroform, which was resisted. Rigor mortis in an hour ; urine was rather high on came coloured, otherwise normal." (Case related by Dr. Adams. Lancet, Vol. II, 1877, p.
September \2th,
.
.
.
567.)
Case No. 2.?"On the afternoon of
Thursday, April 30th, 1876, a butler, aged forty-two years,
residing in Loudon, was bitten in the left hand by a young dog, about six months old,knowu to be unwell, but supposed to be suffering from distemper. There does not appear to have been
any provocation, and the dog was not known to have bitten any other person or animal. It was immediately carried from the room by his Avife, but the dog did not bite her, and it was The wound destroyed later the same day. was considerably lacerated, and the man applied to a neighbouring druggist, who recommended it to be kept constantly moist with rags soaked in cold water; no caustic or other application was used, and the wound healed favourably. On the Monday following, the man appearing unwell, his wife applied to a neighbouring surgeon, to whom the history of the case was given. 1 he wound being then nearly healed, but the nervous system being depressed, tonics were administered, and his wife cautioned not to refer to the injury before the patient. This caution was rigidly observed, and the man himIt was also self never alluded to the injury. recommended that his mind should be as much as possible amused. The nervous system, however, continuing depressed without any apparent
205
cause, he lias ordered into the country, and left town for Canterbury on Saturday, June 3rd.
From his wife's account he seemed to be much benefited by the change and the country air. On the Tuesday following, namely, June 6th, he spent witli his wife the greater part of the day at Whitstable, and bathed in the sea, soon after which he felt chilled, and could not recover his natural warmth for several hours. He returned to Canterbury in the evening, and slept comfortably through the night without any unpleasant symptoms, and was much better on the next day, Wednesday. On Thursday, lie spent the day at Dover, but did not bathe, and returned to Canterbury in the evening, apparently in better health and spirits tluiu at any time since the injury. On Friday morning, about 4 o'clock, seven weeks and a few hours after the injury, he awoke with a suffocating feeling, for which a mustard poultice was applied to his chest with some benefit ; but as there was still an uncomfortable feeling about his chest at midday, I was requested to see him. The history of the case was explained to me. At this time there was slight difficulty, but not inability, to swallow. Iiis friends were again recommended to avoid any reference to the injury before the patient. As his bowels were evidently torpid, he was ordered five grains of calomel and one grain of opium, to be taken every four hours until relief was procured; the powders being taken in honey, which he swallowed satisfactorily. He was seen again in the evening, when the symptoms were the same. On Saturday morning, after a restless night, there was total iuability to swallow, but there was no flow of saliva. There had been no *>leep or alvine evacuation, but a very plentiful discharge of urine, which presented a healthy appearance. Later in the day an enema was given, but not producing the effect, it was repeated in the evening, which produced a copious alvine evacuation, after which he slept tranquilly for between two and three hours, and really appeared much better on Sunday morning. He could then take a little liquid, but not without sotne difficulty, and he was not in any pain. In this state he continued till about 2 o'clock in the afternoon, when, upon some dinner being put before him, unmistakable symptoms of the dread disease witli great severity manifested themselves, great difficulty of breathing, total iuability to swallow, and a constant copious discharge from the fauces which lie could not without much difficulty remove from his mouth. He was soon after seen by Dr. Lochee, who recommended a hypodermic injection of a quarter of a grain of morphia, to be repeated, it necessary. He had within an hour without any two injections benefit ; but the skin at this time being very sensitive, he would not submit to a third injection. At 5 P.M., half an ounce of laudanum
THE INDIAN MEDICAL GAZETTE.
20G
injected into the no good. Later
rectum and retained, but iu the evening I prepared to place him under the influence of chloroform, but as soon as the odour became perceptible to him he became frantic, stating that, although he knew he had not long to live, he would not submit to be put to death. It was impossible after this for me to approach him?he dreaded so much the chloroform?and nothing could convince him but that we were prepared to kill him. He remained in this state till early on Monday morning, when he sank into a state of perfect exhaustion, and died at 9 a.m., nineteeu hours after the more severe symptoms, three days and five hours after the first symptoms of suffocation, and seven weeks and three days after the injury to his hand. It should be stated that throughout his illness, until within two hours of his death, his mind was perfectly collected. He was particularly affectionate to his wife, who was constantly in attendance upon him, and for whose welfare he was very solicitous, he being quite aware that he had not many hours to live, and he gave full directions He at no about the distribution of his effects. time attempted to injure any one, although after the attempt to administer chloroform, he did not like that I should approach him. His pulse throughout his illness was excited and tremulous, and his pupils were unaffected." (Case related by Mr. Rigden. Lancet, Vol. II, was
it did
1877, p. 423.)
What a very material difference iu the manifestations of the disease is here apparent. In the one case, there was marked mental furor, and comparatively little disturbance of the functions of respiration and deglutition ; while in the other, the dysphagia, dyspnoea, and respiratory spasm were pathognomonic of the disease, the mental disturbance being almost, if not quite, absent. It has been argued that the mental anxiety incidental to the bite by a rabid animal accounts for the mental phenomena, but mental anxiety would cause mental depression and not the characteristic furor above described. Moreover, in the dog, which certainly cannot be subject to mental anxiety account of a bite, veterinary surgeons on types of the disease?? recognise two different " call which one of they barking," and the other, "dumb" rabies. Now, let us enquire into Saliva some of the characteristics of saliva. is, as we know, of a mixed character?that is, it is a combination of secretions from the parotid, submaxillary, sublingual, and buccal glands. These secretions differ in their degree of viscidity, and in their chemical composition, and as the flow of saliva from the different glands? especially the parotid and submaxillary?is considerably influenced by circumstances, the mixed saliva must vary from time to time in the proportion of its several constituents.
It
[July,
contains, amongst
other
substances,
1886. two
and serumalbumin, aud it so happens that these are two of the toxic elements in snake venom; the globulin attacking certain centres of the medulla oblongata, and the albumin producing motor paralysis. Now, bearing in mind this fact and the circumstauce that two distinct types of the disease result from the inoculation of rabicvirus, is it not possible, nay, very probable, that the distinctive character of the phenomena in each case depends upon, or results from the inoculation of two or more noxious principles differing in proportion one to another, and to the fluid in which they are found? It may possibly be found that virulence of the saliva results merely from an enormous increase in the proportion of these two elements. I do not say that these, what I will call rabic-proteids, have an identical physiological action with those of snake-venom proteids. Indeed, in some particulars, they would seem to exercise some unknown antagonistic action on the same nerveFor the purposes of this paper, I centres. suppose that we have at least two toxic elements of a proteid character in the rabic slaver, and I further assume that one is? having an action upon cerRabic-globulin tain centres of the medulla oblongata, especially the respiratory centre with its neighbouring convulsive centre, the cardio inhibitory centre, the centre for reflex excitation of the secretion of the saliva, and the centres for deglutition and vomiting, aud destroying the coagulability of the blood. And the other
proteid bodies,
?
viz.,
globulin
-
?
-
?
Rabic-albumin?having a special action, more particularly on certain centres of the anterior, temporal, and posterior lobes of the cerebrum. Assuming that these toxic elements may be
present in the saliva of the rabid animal in
one and sometimes the other preponderating?the peculiarities of the disease?hydrophobia?are accounted for. Though it is true that my contention is mainly hypothetical, still it has the merit of affording the best solution of an otherwise perplexing and insoluble problem, as to how the inoculation of the rabic-virus can be the cause of two distiuct series of physiological phenoWhether it is as true as it is plausible mena. remains to be proved. In the meantime, I commend my views to the consideration of those experts in physiological chemistry who may have the necessary opportunity of submitting thein to experimental test.
varying proportions?sometimes
18tli
June,
1886.
NOTES ON THE RABIC VIRUS.
July, 1886.]
8 a.m.?Temperature 103? ; all .night, which at delirium 96. High pulse the time of my visit was of a religious turn. Intense thirst ; can swallow no better, and the paroxysms continue just the same 2-30 P.M.? 11 a.m.?Temperature 102-5? Spitting frequently and in all directions, and sometimes on those about him; foaming at the mouth, and holding his tongue out like a tired dog. He is more violent, and struggled furiously with two men and a woman who are required to hold him. Conjunctivae slightly congested. Pupils widely dilated. Gave an enema of half an ounce of syrup of chloral and three ounces of beef-tea. Has been sick several times, vomiting up bile and other liquids. 4 p.m.?Muchquieter ; got quieter half an hour after the enema of chloral and beef-tea. 7-30 p.m.?Temperature 103?; weak, and I could not count it; still pulse very has the " busy " delirium without the violence Saw him again at 8-30 P.M., when he seemed weaker and quieter, and at 10 P.M., he died from exhaustion. Remarks.?(c No fear of water or any liquid, Swallowing produced the violent qua liquids. There paroxysm whether of liquids or solids. was a strong apprehension from the first, both on his part and that of his friends, that he would suffer from hydrophobia. Attempted to give chloroform, which was resisted. Rigor mortis in an hour ; urine was rather high on came coloured, otherwise normal." (Case related by Dr. Adams. Lancet, Vol. II, 1877, p.
September \2th,
.
.
.
567.)
Case No. 2.?"On the afternoon of
Thursday, April 30th, 1876, a butler, aged forty-two years,
residing in Loudon, was bitten in the left hand by a young dog, about six months old,knowu to be unwell, but supposed to be suffering from distemper. There does not appear to have been
any provocation, and the dog was not known to have bitten any other person or animal. It was immediately carried from the room by his Avife, but the dog did not bite her, and it was The wound destroyed later the same day. was considerably lacerated, and the man applied to a neighbouring druggist, who recommended it to be kept constantly moist with rags soaked in cold water; no caustic or other application was used, and the wound healed favourably. On the Monday following, the man appearing unwell, his wife applied to a neighbouring surgeon, to whom the history of the case was given. 1 he wound being then nearly healed, but the nervous system being depressed, tonics were administered, and his wife cautioned not to refer to the injury before the patient. This caution was rigidly observed, and the man himIt was also self never alluded to the injury. recommended that his mind should be as much as possible amused. The nervous system, however, continuing depressed without any apparent
205
cause, he lias ordered into the country, and left town for Canterbury on Saturday, June 3rd.
From his wife's account he seemed to be much benefited by the change and the country air. On the Tuesday following, namely, June 6th, he spent witli his wife the greater part of the day at Whitstable, and bathed in the sea, soon after which he felt chilled, and could not recover his natural warmth for several hours. He returned to Canterbury in the evening, and slept comfortably through the night without any unpleasant symptoms, and was much better on the next day, Wednesday. On Thursday, lie spent the day at Dover, but did not bathe, and returned to Canterbury in the evening, apparently in better health and spirits tluiu at any time since the injury. On Friday morning, about 4 o'clock, seven weeks and a few hours after the injury, he awoke with a suffocating feeling, for which a mustard poultice was applied to his chest with some benefit ; but as there was still an uncomfortable feeling about his chest at midday, I was requested to see him. The history of the case was explained to me. At this time there was slight difficulty, but not inability, to swallow. Iiis friends were again recommended to avoid any reference to the injury before the patient. As his bowels were evidently torpid, he was ordered five grains of calomel and one grain of opium, to be taken every four hours until relief was procured; the powders being taken in honey, which he swallowed satisfactorily. He was seen again in the evening, when the symptoms were the same. On Saturday morning, after a restless night, there was total iuability to swallow, but there was no flow of saliva. There had been no *>leep or alvine evacuation, but a very plentiful discharge of urine, which presented a healthy appearance. Later in the day an enema was given, but not producing the effect, it was repeated in the evening, which produced a copious alvine evacuation, after which he slept tranquilly for between two and three hours, and really appeared much better on Sunday morning. He could then take a little liquid, but not without sotne difficulty, and he was not in any pain. In this state he continued till about 2 o'clock in the afternoon, when, upon some dinner being put before him, unmistakable symptoms of the dread disease witli great severity manifested themselves, great difficulty of breathing, total iuability to swallow, and a constant copious discharge from the fauces which lie could not without much difficulty remove from his mouth. He was soon after seen by Dr. Lochee, who recommended a hypodermic injection of a quarter of a grain of morphia, to be repeated, it necessary. He had within an hour without any two injections benefit ; but the skin at this time being very sensitive, he would not submit to a third injection. At 5 P.M., half an ounce of laudanum
THE INDIAN MEDICAL GAZETTE.
20G
injected into the no good. Later
rectum and retained, but iu the evening I prepared to place him under the influence of chloroform, but as soon as the odour became perceptible to him he became frantic, stating that, although he knew he had not long to live, he would not submit to be put to death. It was impossible after this for me to approach him?he dreaded so much the chloroform?and nothing could convince him but that we were prepared to kill him. He remained in this state till early on Monday morning, when he sank into a state of perfect exhaustion, and died at 9 a.m., nineteeu hours after the more severe symptoms, three days and five hours after the first symptoms of suffocation, and seven weeks and three days after the injury to his hand. It should be stated that throughout his illness, until within two hours of his death, his mind was perfectly collected. He was particularly affectionate to his wife, who was constantly in attendance upon him, and for whose welfare he was very solicitous, he being quite aware that he had not many hours to live, and he gave full directions He at no about the distribution of his effects. time attempted to injure any one, although after the attempt to administer chloroform, he did not like that I should approach him. His pulse throughout his illness was excited and tremulous, and his pupils were unaffected." (Case related by Mr. Rigden. Lancet, Vol. II, was
it did
1877, p. 423.)
What a very material difference iu the manifestations of the disease is here apparent. In the one case, there was marked mental furor, and comparatively little disturbance of the functions of respiration and deglutition ; while in the other, the dysphagia, dyspnoea, and respiratory spasm were pathognomonic of the disease, the mental disturbance being almost, if not quite, absent. It has been argued that the mental anxiety incidental to the bite by a rabid animal accounts for the mental phenomena, but mental anxiety would cause mental depression and not the characteristic furor above described. Moreover, in the dog, which certainly cannot be subject to mental anxiety account of a bite, veterinary surgeons on types of the disease?? recognise two different " call which one of they barking," and the other, "dumb" rabies. Now, let us enquire into Saliva some of the characteristics of saliva. is, as we know, of a mixed character?that is, it is a combination of secretions from the parotid, submaxillary, sublingual, and buccal glands. These secretions differ in their degree of viscidity, and in their chemical composition, and as the flow of saliva from the different glands? especially the parotid and submaxillary?is considerably influenced by circumstances, the mixed saliva must vary from time to time in the proportion of its several constituents.
It
[July,
contains, amongst
other
substances,
1886. two
and serumalbumin, aud it so happens that these are two of the toxic elements in snake venom; the globulin attacking certain centres of the medulla oblongata, and the albumin producing motor paralysis. Now, bearing in mind this fact and the circumstauce that two distinct types of the disease result from the inoculation of rabicvirus, is it not possible, nay, very probable, that the distinctive character of the phenomena in each case depends upon, or results from the inoculation of two or more noxious principles differing in proportion one to another, and to the fluid in which they are found? It may possibly be found that virulence of the saliva results merely from an enormous increase in the proportion of these two elements. I do not say that these, what I will call rabic-proteids, have an identical physiological action with those of snake-venom proteids. Indeed, in some particulars, they would seem to exercise some unknown antagonistic action on the same nerveFor the purposes of this paper, I centres. suppose that we have at least two toxic elements of a proteid character in the rabic slaver, and I further assume that one is? having an action upon cerRabic-globulin tain centres of the medulla oblongata, especially the respiratory centre with its neighbouring convulsive centre, the cardio inhibitory centre, the centre for reflex excitation of the secretion of the saliva, and the centres for deglutition and vomiting, aud destroying the coagulability of the blood. And the other
proteid bodies,
?
viz.,
globulin
-
?
-
?
Rabic-albumin?having a special action, more particularly on certain centres of the anterior, temporal, and posterior lobes of the cerebrum. Assuming that these toxic elements may be
present in the saliva of the rabid animal in
one and sometimes the other preponderating?the peculiarities of the disease?hydrophobia?are accounted for. Though it is true that my contention is mainly hypothetical, still it has the merit of affording the best solution of an otherwise perplexing and insoluble problem, as to how the inoculation of the rabic-virus can be the cause of two distiuct series of physiological phenoWhether it is as true as it is plausible mena. remains to be proved. In the meantime, I commend my views to the consideration of those experts in physiological chemistry who may have the necessary opportunity of submitting thein to experimental test.
varying proportions?sometimes
18tli
June,
1886.
