before the disease becomes marked, and the most general term of their appearance seems to be two or three days before hydrophobia supervenes. In one case which we attended, and which we have also described, the patient died on the seventh day after the pain commenced in the part bitten, and fifty-six hours after the hydrophobia had distinctly commenced. The recrudescent symptoms, therefore, occupied more than four days. With regard to this point, however, and to the relative frequency with which the symptoms of the second stage are present or absent, no very precise information can be obtained. They are rarely mentioned in the more ancient cases, and occur so frequently in those of modern date, that the difference can only be attributed to the older writers having considered the state of the cicatrix with little attention. By Aurelianus, however, and consequently by the authors whose collective views he represents, this symptom was beheld in a most important light: Præpatitur enim ea pars, quæ morsu fuerit vexata; unde initium denique passionem (s. c. hydrophobicam) sumere, nemo negat." This, however, is not the only medical observation that seems for a time to have suffered a certain degree of oblivion. In point of fact, it has been proved by Dr. Hamilton that by far the greater number of hydrophobic cases commence between the thirtieth and fifty-ninth day after the bite, and consequently at a time when the wound produced at first by the animal, and afterwards enlarged by the surgeon, is in many cases scarcely healed up, and almost always retains that high degree of sensibility proper to recent wounds, and which generally gives rise to considerable pain upon any great change taking place in the system; often, indeed, from mere vicissitudes of the weather. In several instances the pain has been percieved immediately after a debauch, and in one remarkable example it darted into the part the moment the patient was told that another person bitten by the same dog had died of hydrophobia. Though there can be no doubt, therefore, of the actual occurrence of this recrudescence in examples taking place long after all the superinduced sensibility of the part had disappeared, or where re-opening, discharge, or eruption had taken place around it; yet it is not easy to come to a conclusion in cases where the circumstances have been different. A late distinguished nosologist, Dr. Good, has received this phenomenon of recrudescence, which without doubt is very general, into his definition of hydrophobia; and we have judged it necessary therefore to explain, as far as was attainable, the modification to which this character is frequently subjected.

Third stage, or hydrophobic phenomena.This assemblage of symptoms, from its fatal event, the pity, consternation, and horror excited in beholders, and its obvious diversity from all other maladies afflicting the human race, whilst the latent and recrudescent periods which succeed the application of the exciting cause differ little from any other morbid states of the system, has very generally been consi

dered as constituting the whole generic disease of hydrophobia. In strict accuracy, however, this whole group is to be considered merely as a symptom which may be resolved into separate parts, but yet simply indicates a single stage, such as is well known to occur symptomatic of many states of disease or irritation in the system; nor is there any better reason that the patient's health is entire and the disease quiescent, during the two first periods, than in that period of calm composure, facility of drinking and swallowing, absence of pain and mental suffering, which appear so generally for some time before the sudden death of the patient, and which sometimes, as in Dr. Johnston's case, interposes itself in the midst of the disease under the form of remission. We are in no hurry to anticipate the different views that have been taken of the mode or train of action by which the bite of a rabid animal produces this horrible disease; being different, they cannot all be true, and could therefore render us little service here. But, however unknown, they exert an operation on the day in which they render the disease cognizable to the senses, which they could not put forth before, and have therefore been undergoing a series of changes themselves, or operating a series of changes in the constitution from which has resulted this increase of power. From the moment of the bite, then, a morbid action is in progress and accumulation, and he who would deny this may equally deny that the death of the patient, in many instances so visibly disjoined from the paroxysmal state, is owing to the same cause; he must deny, also, that it produces the return of this state after the remission. Yet this series of paroxysmal symptoms is that to which the attention of the practitioner is chiefly directed, and he is, therefore, very easily led to consider it as the essential part of the disease. For some days previous to that on which the disease presents itself, the countenance of the patient indicates anxiety, and he is himself conscious of a restless, rather depressed state of mind. The eyebrows are contracted, the face tumid, and there is headach with tremors. In a certain number of cases a sense of general chilness, like that preceding fever, is perceived, before any more marked symptoms appear. He is sometimes drowsy through the day, and in other instances has his sleep broken and disturbed in the night. The disagreeable feelings originating from the cicatrix go on to increase; occasional sighing, unaccountable flushes and rigors of momentary duration, and in a few cases slight febrile symptoms succeed. A sudden loathing of food has been repeatedly observed at this period, the patient being sometimes surprised at finding his usual appetite converted into aversion on sitting down to table; and in other instances he becomes suddenly affected with nausea or vomiting. In some persons the peculiar pain, usually referred to the scrobiculus cordis and diaphragm, has been first perceived at this instant, and in one or two cases appeared to originate in the violent efforts made to vomit; but the symptom gene

rally comes on considerably later. A sense of stiffness, gradually becoming painful, is now felt in the back part of the neck, and extending forwards along the basis of the jaw towards the root of the tongue and the pomum Adami of the larynx. Sighing is more frequent; the respiration is easily hurried; and there is often some headach complained of at this period. If the patient attempt to swallow any thing, he finds himself unable to perform that office; the matters introduced are rejected with violence from the mouth, and the muscles of the mouth and pharynx are seen by the bystanders to be thrown into violent convulsions, in which not unfrequently the muscles of the face participate. This is the pharyngeal or hydrophobic spasm, which, by creating a dread of swallowing fluids, has given name to the disease; for although patients are generally able to swallow food and other solid substances with tolerable facility, yet any attempt at drinking, be the fluid what it may, is almost sure to be followed by the spasm and sense of suffocation. Though in most cases the painful spasm is the only cause of the dread of swallowing fluids, and eventually of the fluids swallowed; yet this fear may, in its turn, become the cause of the spasm, the patient, by endeavouring to avoid its recurrence, often originating the very motions which produce it. The same error of function is frequently observed to take place in these parts in persons who find a natural difficulty in swallowing pills, in painful cynanche, and in eating and drinking while the mind is much engaged upon something else. The parts are scarcely quite voluntary, as is proved by its being impossible to make them perform their office when they are altogether dry; and accordingly our knowledge of the position of objects within them derived from their mere sensation is always obscure, and the efforts made in consequence sometimes prove misdirected or fallacious. In drinking it is not necessary that greater efforts should be made than in eating; but from the facility with which fluids glide along, they often present a larger mass, which requires a greater effort to be propelled at once into the pharynx by the organs of deglutition; and as they easily slide into the smallest cranny, they render the closest approximation of the two lips of the glottis, and of the epiglottis upon these again, indispensably necessary; and as the movement of drinking is generally of the continuous kind, the oppression of the respiratory processes which it produces is always considerable, even in health, as is demonstrated by the strong inspirations rendered necessary after a large draught. They must eventually, however, be much greater in hydrophobia, where difficult respiration and irritability of the larynx and fauces are already at their maximum. Besides, in the movement of swallowing, the larynx is drawn upwards and forwards, and the root of the tongue thrown backwards over the larynx, a circumstance which must greatly increase the tendency to suffocation resulting as described; hence the very great augmentation of this spasm while

the larynx is being drawn up. As the disease proceeds, this symptom becomes more severe, and calls in a more extensive train of concomitant evils; of which number are laborious respiration, sighing, vomiting, flatulent eructations, a sense of a ball or pressure on the throat, urgent thirst, a burning pain along the course of the spine, neck, and vertebral column. The increase of saliva at this period seems to arise partly from the vehement irritation of the salivary glands which is produced by these movements, as a similar state occurs in many healthy persons, when induced from anger or loquacity to move the muscular parts in the basis of the jaw with great activity. In other cases, however, the saliva is said to precede the spasm, particularly in animals; and in all such instances it must be referred to the specific effect of the poison upon the salivary organs, a series of glands which, of all others in the body, most readily yield their secretion to a new stimulus. The best authors are agreed that it is the experience of the painful sensations thus produced which in general gives rise to this fear of drinking, which is afterwards, by a too natural process of association, extended to liquids themselves, and finally to polished bodies, to light, to cold, to fresh air, to names or sounds, or indeed to any thing that serves to suggest to the mind of the patient the horrible idea of his sufferings while attempting to swallow fluids. In this opinion we feel ourselves obliged to coincide, as well from the result of our own experience as from the consideration of a number of recently well attested cases, in which the patients not only denied every antecedent dread of fluids, but made many spirited and occasionally successful efforts to overcome that spasmodic resistance which alone prevented their transmission to the stomach. If we add to this the fact of the dread of water disappearing during the intermissions which have occurred in some cases, and in that final remission which occasionally takes place before death, we shall see that the spasm is the chief cause of the dread of water; and that if the latter had depended, as some think, upon a peculiar modification of the mind produced by the bite, it would not be so frequently absent. The disease is now fairly constituted; the patient is tormented with thirst, every attempt to allay which by drinking only serves to bring a new and more severe paroxysm, the convulsions of which often extend themselves to every muscle of the body, whether of head, trunk, or extremities. There are vomiting of a greenish or dark-coloured matter, eructations, inflation of the stomach and bowels, great pain in the region of the diaphragm, restlessness, heat of skin, and sometimes considerable frequency of pulse. The latter has counted as high as one hundred and fifty beats in a minute. In addition to the headach and singular cast of countenance already mentioned, a peculiar brightness, a wild and sparkling expression' of the eye, compared by authors to that observed in incipient ebriety, and a retraction of the angles of the mouth approaching to the sardonic grin, and referred to the well known sympathy sub

sisting between the diaphragm and zygomatic muscles, are symptoms confined to the head and face. The latter is sometimes suffused, sometimes pale, or varied with large, irregular, ruddy spots. A great plurality of testimonies has satisfactorily established that a certain change or alienation of mind takes place during this disease; but in what that alienation consists, how it is to be described, or where it has its origin, are questions which have all been violently disputed. The most general form under which it appears is a certain promptitude of action and loquacity while engaged in conversation, which is chiefly evinced by the patient rendering longer answers and more circumstantial explanations than he might naturally be expected to do at another time; yet his ideas are said to be perfectly coherent, his reasoning just and consecutive. But the susceptibility of the mind also, as well as of the body, becomes greatly increased, and in this point the analogy with incipient ebriety fails, with the exception perhaps of a very few instances. This morbid susceptibility is manifested by a tendency to take alarm at inadequate causes, and to form suspicions without any probable grounds; and, in fact, the dread of water itself and of every thing suggesting the idea of water, may in certain subjects be merely another of its indications. High delirium is seldom present except during the extreme violence of a paroxysm, and then but rarely; and as to the states of mental alienation, vulgarly designated by the terms mania and melancholia, they can scarcely ever be said to be present in this disease, however universally the former opinion may once have been diffused. It is fair, however, to remark that the reasoning faculties cannot be altogether entire in a patient who indulges undue suspicion, and who, contrary to previous habit, launches into verbose harangues upon every trifling occasion; for it seems to be the very essence of sanity to perceive justly the relation of its possessor to present external circumstances, which relation is by such persons evidently neglected. We dare not, however, go to the length of proposing for this peculiar susceptibility of mind the term of lyssomania, so many patients having expired of this disease without having exhibited the least symptom of suspicion or loquacity. There is still ground for apprehending that their fears are in some instances owing to the vulgar apprehensions of the rough treatment under which the last scene of hydrophobia was till very lately generally believed to terminate. Thus, taking one of many instances, the patient Groves, whose case is related by Dr. H. Maclean of Sudbury, in 1792, had imbibed the idea that " he was to be smothered between beds, and in the most earnest manner entreated us not to shorten his sufferings in this manner." Indeed, only twenty years before, an attempt had been made by the attendants in the Leicester Infirmary to destroy a hydrophobic boy, Nourse, in a similar manner, and they were only prevented from effecting their horrid purpose by the timely intervention of Dr. Vaughan. Groves was a

powerful man, in the prime of life; and when we consider the characteristic timidity of hydrophobic patients, we may well conceive that a very great number must have suffered under this apprehension, without daring to give it utterance. So late as 1814, Dr. Albers of Bremen was sent for by a hydrophobic patient in order to bleed her to death, and thereby release her from her sufferings; and she seems to have considered this as quite within the line of the doctor's ordinary practice. The loquacity, though in most instances the result of the peculiar nervous excitement present, may in others arise from the new and terrific circumstances under which the patient is placed, something like what is often observed in persons led forth to execution; and it is no doubt greatly promoted by the accelerated circulation and intensity of sensation which accompany the hydrophobic spasm. Both are symptoms, however, very generally present, and it is under that view they are brought into notice here.

The whole of the symptoms above expressed may establish themselves in a few hours after their commencement, though in general they can scarcely be said to become so fully developed before the second day; and death most usually happens on this and the third, according to Hamilton's table, although in a considerable number it has taken place after twenty, twentyfour, or thirty-six hours; and in others it does not happen before the fifth day, and in some few instances not before the eighth or ninth day. Hence there is seldom much time afforded for contemplation of the more exasperated form into which they subsequently pass, but yet they have been observed and described by medical writers with great exactness, and have gradually become separated from the fictions with which they were combined by ancient authors. The sense of thirst, and sometimes also of hunger, become much more urgent; there is frequent vomiting of a green or bilious matter, which does not relieve the pain of stomach or the tension of the præcordia. Besides these greenish and black fluids, which are probably different forms of bile, authors have described the matter vomited as sometimes glairy, sometimes cineritious, and sometimes resembling coagulated blood. The patient is tormented with a burning heat and dryness in the fauces; and the saliva, no longer receiving its due admixture of watery fluid, becomes thick, viscid, and adhesive, and frequently accumulating about the glottis of the patient, and thereby threatening immediate strangulation, causes the unhappy sufferer to make every effort to blow it forward out of the mouth. It is the sound made by this effort which produces that faint resemblance to the barking of a dog, and that appearance of froth adhering to the lips of the patient, which have been so absurdly described as characteristic of the disease. Surgeons, who know that suffocation is produced in good health by a little blood from the tonsils being allowed to accumulate about the glottis, will be at no loss to comprehend how this acrid saliva must irritate the sensitive and frequently inflamed fauces of hydrophobic patients, and

make them anxiously endeavour to remove it. Besides, they are often at this period seen to labour under such extreme difficulty of breathing that bronchotomy has been practised for their relief; and it is probably to this cause also we are to attribute the anomalous movement of the cheeks and lips described in some patients, and the occasional presence of black blood in the left side of the heart after death. The restlessness, the tremors, the guttural and general convulsions, return now with much more frequency, and are elicited by the slightest causes; the mind becomes much agitated, and in several cases seems quite unsettled during the paroxysms; impatience of the slightest contact with the skin, of light, and of sound, is frequently present to a remarkable degree; and when the pulse and heat of skin are considerable, a person who saw hydrophobia in this stage for the first time might easily mistake it for phrenitis; but the skin is generally cool, the urine natural, the blood yields no buffy coat, the pain of head is inconsiderable, and the delirium transient. The pulse varies extremely in velocity, but is generally quick, and has been counted as high as 150; it is seldom, though sometimes, strong and hard; and the feeling it impresses on the finger as to fulness, creeping, &c., is by no means uniform. Meantime, the powers of nature are gradually suffering exhaustion, under these repeated paroxysms of action, in which muscle and nerve seem alike to participate. The patient, who usually complains of debility from the commencement, whatever force he may be found to exert during the paroxysm, appears to become rapidly weaker, until at length, after one or more desperate exacerbations, life is extinguished. In a few cases he unexpectedly becomes tranquil, and most of his sufferings subside or vanish; he can eat, nay, drink, or converse with facility; and former objects, associated with the excruciating torture of attempting to swallow liquids, no longer disturb his feelings. From this calm he sinks into repose, and suddenly waking from his sleep, expires. Sometimes, on attempting any new movement, he dies suddenly; but in many cases he is carried off from this deceitful calm by a sudden and violent convulsion. In the great majority there is no calm or intermission, but the paroxysms, becoming more and more violent, at length carry off the patient. The muscles remain rigid long after death, and the eyes in some instances retain their peculiar brightness, and the iris its contractility, till the following day (Gorcy); nay, in one case the pupil, which had remained, constantly dilated during the disease, returned to its natural dimensions after death.

Such is the most general progress of the disease, but there are many varieties observed to occur in different individuals, a circumstance which has given rise to many controversies. At times hydrophobia intermits, and at others remits. From the histories on record, it would appear that these interruptions tend somewhat to prolong the duration of the disease, but have no distinct effect in rendering it less fatal. This conclusion, however, is not universal, and the

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circumstances which lead to these temporary suspensions of hydrophobia are not entirely unknown. The alvine secretion, perspiration, and urine, seem generally to continue in a natural state throughout the disease; but the skin frequently becomes intensely sensible, causing the patient to start or scream with horror on the slightest touch. The settling of a fly upon the surface of the body, the contact of cold air, or of heated air moving in a current, produce the same insufferable sensations and the same tremors. Perhaps the dread expressed of mirrors and smooth objects is rather to be attributed to the patient's associating with them the effects of cold upon this irritability of the skin, than with the torture experienced in the act of drinking. We may probably refer to the same source, the observation of Eudemus (A. C. 23), that the trickling of a tear down the cheek will sometimes excite the paroxysm. In a few instances, however, the skin is hot and dry; in others, it is harsh to the feel, but without heat; and in one or two cases it is described as appearing livid; sometimes it is described as covered with a profuse perspiration. In Dr. Johnston's case, the bowels were confined throughout the whole disease, and so closely constricted was the extremity of the rectum by spasm, that every attempt of the medical man to introduce the clyster-pipe proved fruitless, although made with abundant firmness. nearly all the cases that have come to our knowledge, the urine was natural, a most remarkable circumstance considering the waste constantly going on from the blood by the saliva, and by the pulmonary and cutaneous exhalations, and the impossibility of introducing a fresh supply of moisture. In a few instances, however, it has been remarked to be scanty, in others of a greenish, and in others of a pale lemon colour. Generally speaking, the organs which excrete this fluid have scarcely been known to be affected with spasm in hydrophobia, although this is a common symptom in hysteria and hypochondriasis, diseases which it resembles in many particulars. In one of Mead's cases, however, (the first,) there was difficulty of passing urine: the patient had "strangury to a great degree, exciting cries on attempting to pass urine; the urine was as well coloured as ordinary." In short, the glandular organs appear to be but slightly affected, and perhaps never primarily in hydrophobia, with the exception of the salivary and lachrymal apparatus. Some persons experience an extreme soreness in the scalp on its being touched, and others, as we have seen, have a similar aversion to contact on any part of their surface, declaring that it hurts them; others experience more or less of pain in the region of the larynx or trachea, during the whole or part of the disease; and some have suffered pain and enlargement of the thyroid gland, generally on one side only. During the latter stages of some forms of hydrophobia, the lymphatic glands around the basis of the jaw became sensibly enlarged. Cases are related, in which the first indication of spasmodic action about the neck does not occur in the

muscles attached to the basis of the skull, but in the root of the tongue, in the muscles originating from the os hyoides, and it is described as commencing by a sense of rigidity and stiffness merely in that position: on looking into the throat, for the most part nothing is to be seen; but in other instances turgescence and the general signs of inflammation are distinctly visible upon simple inspection. Externally, in some rare instances, the larynx, or the thyroid gland, or the submaxillary gland, have appeared to the medical attendants to be somewhat enlarged.

It has already been observed that those bitten by cats have seldom the dread of water, or the difficulty of drinking it to any great degree; so that to many of them the fable of Tantalus, if ever it alluded to hydrophobia, becomes an allegory misapplied. Such is the notion of Dr. Good, who probably omitted the fear of water from his definition on this account; but the proposition is not rigorously true. In Dr. Vaughan's case of a boy bitten by a cat, he "sobbed deeply at the sight of water, turning away with perturbation." Mr. Bellamy also, and the patient described by Dr. White, (Hamilton, pp. 340, 430,) were both distinctly affected with the hydrophobic spasm; and perhaps the only reason for this supposed peculiarity in the bite of the cat, and which has induced this learned nosologist to create two new species, 1, the rabies felina, with little spasm, and, 2, the rabies canina, with much spasm, has been the simple fact that the cases on record of hydrophobia from cats are too few to afford a firm basis for any inference. In other cases there is no nervous agitation, in others no vomiting, in others no tracheal irritation, in others no fever; many have the respiration nearly free to the last; some await their end with considerable tranquillity, their mind being little disturbed during the whole scene: while, besides those affected in the manner we have described, there are others who become delirious from the middle period of the disease. Finally, it is not the modification of one individual symptom that is to fix the attention of the medical observers in hydrophobia, but the changes in one or other of those great original groups to which we have said each individual must belong; the chills and flushes, the tremors, the excessive cutaneous tenderness, the intolerance of light, of sound, of pungent smells, the preternatural activity and force of action, the tendency to certain motions, as leaping upwards, running backwards, climbing; the facial, guttural, and thoracic spasms; the great increase of muscular force, the general convulsions, and at length paralysis of the limbs; the amaurosis, and mental aberration, are symptoms many in number and various in aspect, but all flowing distinctly from one source, a nervous system irritated and finally exhausted by the action of the poison: the priapism, spasmodic contraction of the cremaster muscles, and involuntary emissions, which occasionally occur, have the same origin. That satyriasis ever attended these last symptoms in the hydrophobic patients of Britain, we have not been able to learn. There

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are good reasons for thinking it never did, as being familiarly mentioned by the ancients, it was not likely to be passed over in the great exactness of modern description. French writers, however, assert that it frequently occurs so combined in that country; and the respectable Portal bears witness to his having seen several instances of furor uterinus occurring in hydrophobic women. This is probably another example of variety resulting from the diversity of national education. Many irritations of the nervous centre are known to produce these symptoms, and if they are sometimes occasioned in hydrophobia by spasmodic contraction of the perineal muscles, the origin of that spasm is the same. Neither must it be forgotten that the reasoning powers, the present conversation, and the previous knowledge of a patient, as well as his physical power of enduring pain, will considerably modify all the mental phenomena; and when the fever is vehement, there will be a further change of these phenomena from that cause. The respiratory phenomena must likewise vary according to these leading symptoms; the sighing will have more relation to the fever; the sobbing more to the nerves. The theory of sighing is well known; but that of sobbing is evidently of the nervous class, and has been traced by Sir Charles Bell to the sole action of the respiratory system of nerves. It is exactly the movement produced by throwing cold water suddenly upon the naked shoulders, and was long since described as such by practical authors. (Hamilton, App.) This affection of the respiratory class of nerves lent some countenance to the peculiar hostility of the rabid virus to the eighth pair, to which we have elsewhere alluded.

The changes which take place in the functions of the organs of sense are abundantly curious. At first there is a distinct increase of their power, the exercise of which seems far from disagreeable to the patient himself; and hence the wandering aspect and rapid movements of his eve: he listens to sounds, and detects smells, which no one else can observe. Sometimes he speaks of a disagreeable smell exhaling from the wound, and possibly with correctness, it being no great argument to the contrary that the bystanders cannot perceive it. M. Majendie attended a hydrophobic patient, who, though born deaf and dumb, heard very distinctly during the paroxyms. Neither is the sense of touch at first disagreeable; and one patient whom we attended compared it to tickling. But in a short time they all become affected with pain, and finally with anesthesia or paralysis; the patient hears indifferently, has numbness in certain parts, the pupil becomes dilated, the sight indistinct, and at length lost. This progress from an agreeable excitement to pain and collapse seems to mark the progress of some mischief accumulating upon the nervous system. The supervention of partial paralysis, paraplegia, and even hemiplegia, tends much to confirm the same opinion; nay, in the case just alluded to there was an universal paralysis, or, in other words, an apoplexy; and

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