This disease has, of late years, attracted considerable attention from the circumstance of its having occurred as an epidemic in different parts of Europe and the United States. Its first recorded epidemic visitation in America was in 1806, when it occurred in Massachusetts. Hence it gradually spread through the New England States, Canada, New York, and Pennsylvania, from 1807 to 1812. It was epidemic in a number of the States between 1840 and 1850; and again in 1852 and 1858. But in 1862 and 1863, during the war, it was much more widely prevalent, being first, at that time, clearly described by Dr. Gerhard of Philadelphia. Since then it has never altogether disappeared from the country. In New York and Brooklyn, at the beginning of the present year (1872) a considerable number of fatal cases have been reported; mostly in children.

The symptoms by which the disease commences are, in general, of a very formidable character, and its accession is often sudden and quite unexpected; in a large number of cases the patient is in his ordinary health and spirits up to the very moment of the seizure, and experiencing no premonitory symptoms to warn him of his danger. In four of the cases at the South Dublin union, the boys had eaten a hearty dinner, and retired to bed in apparent health, when the disease, all at once, declared itself.

Very generally, however, the attack is preceded by more or less pain of the head, especially of the forehead, temples or back of the head. The pain is usually constant, but sometimes remittent, or even intermittent.. Pain is, also, sometimes experienced in the back of the neck, and along the course of the spine, with a sense of soreness in the limbs and joints. In a few cases the attack is preceded by a sense of giddiness, with or without dimness of sight.

Occasionally, the attack commences with a feeling of chilliness, succeeded by a slight increase of the heat of the surface, and pain, extending from between the shoulders to the back of the head, with stiffness of the muscles at the back of the neck. In other cases, the patient may be attacked by chilliness, pale countenance, coldness of the extremities, low moaning, or muttering delirium, quickly succeeded by restlessness, flushing of the face, a frequent pulse, a wild expression of the eyes, and a hot and dry skin. In other cases, again, the disease may be ushered in by a sense of lassitude and uneasiness, considerable prostration, and a dull, heavy pain in the head, with giddiness, especially when an attempt is made to stand up; the eyes are languid and half-closed; the speech laborious and indistinct. Occasionally the patient is attacked with drowsiness, attended by a sense of extreme debility, giddiness, dimness of sight, or double vision. Or, finally, the attack may commence with severe pain in the abdomen, immediately succeeded by nausea and perhaps vomiting. In violent attacks of this character, the extremities become, at the same time, cold, and of a bluish colour, and the pulse is reduced to a mere thread. After a few hours, reaction, more or less complete, generally ensues.

Whatever may be the character of the symptoms at the commencement, they are replaced, sooner or later, by a state of violent agitation, or by a state of stupor, more or less decided, with a slow, occasionally full pulse, and the pupils of the eyes dilated and immovable. When in this condition, touching any portion of the patient's body will sometimes cause him to cry out; at other times the patient utters, from time to time, acute cries, and carries his hand frequently to his head. When spoken to, he will, in general. exhibit a degree of consciousness by a motion of the head, by an attempt to speak, or by opening his eyes for a moment.

Pain, more or less intense, of the, and along the spine is present in the early stage of nearly all cases. Pressure applied to the upper portion of the spine will often produce pain in the head, darting to the forehead, eyes, and temples, as well as pain in the chest, while pressure lower down on the spine will produce pain lower down in the chest, or about the navel. The pain is frequently severe, and continuous for some time after the pressure is removed.

Delirium is commonly present from an early period of the attack; and in the majority of cases there is more or less intolerance of light and sound: in some, to such an extent, that the slightest ray of light, or the least unusual sound, is apt to excite convulsive movements.

In some cases there is partial or complete deafness; in others a constant ringing in the ears is complained of from an early period of the attack.

There is generally great tenderness over the whole surface of the body, and the patient shrinks on the slightest touch, even of the bed-clothing.

In very violent cases, petechia occur upon the extremities and over the eyelids, within a few hours after the attack.

The breathing is sometimes irregular and laboured, a difficulty seems to be experienced sometimes in expanding the lungs, with respiration chiefly through the nostrils. There is often great thirst with irritability of the stomach, and tenderness on pressure; and the bowels are generally confined. The tongue is generally coated with a pale ash, white, or yellowish fur. In bad cases of the disease it has been observed to be broad and flabby, and sometimes so enlarged as to impede articulation, and indented around its edge from pressing upon the teeth.

The pulse, during the period of excitement, is usually full and frequent, from 120 to 140 in a minute; often, however, it is very slow, sinking sometimes to 48 or 50 in a minute.

The most striking characteristic of this disease is the state of the muscular system. The muscles of the neck, in particular, become rigidly contracted, drawing back the head upon the spine sand firmly fixing it in that position, so that the patient is unable to move it forwards; neither can this be done by the attendants by the employment of any justifiable degree of force. The countenance, at the same time, assumes very much the tetanic expression. The patient also loses the power of moving his limbs, and of assuming an erect posture. In some cases there is a difficulty in using the hands; it being with great difficulty that the patient can take and drink water from any vessel without assistance. In some cases involuntary twitchings of the muscles are produced whenever the patient attempts to move or seize anything, as if he were under the influence of strychnia. In others, violent convulsions are produced the moment the inferior extremities are raised up, or merely touched. There is great irregularity as to the period when the tetanic symptoms occur. They may set in as early as the first day of the attack, or not until several days after.

This disease, although it is generally marked by pain in the head, more or less intense, pain in the back, heat of the scalp, redness of the eyes, some degree of intolerance of light and noise, great sensibility of the skin generally, tendency to insensibility, and a tetanic affection of the muscles of the neck and perhaps extremities, may, nevertheless, in some instances present no symptoms of so decided a character as to lead us to suspect the existence of serious disease of the brain and spinal marrow, until the laboured pulse, the dilated pupil, the profound insensibility, or the severe spasmodic or convulsive attacks indicate but too plainly the near approach of death. In other cases, again, and those by no means of rare occurrence, symptoms of a most formidable character may present themselves at the very outset of the disease. Thus the patient may be attacked at once with violent paroxysms of general convulsions, requiring manual restraint to protect him from injury; or he may suddenly, without any striking premonitory symptoms, sink into a state of insensibility almost apoplectic in its character, or, into a half-unconscious condition, with constant moaning or plaintive cries, and grinding of the teeth.

The duration of the disease is very uncertain. Death may occur within a few hours from the commencement of the attack. The generality of cases terminate about the fourth day, some, however, last to fourteen days or longer. Convalescence is usually slow and lingering. Even after an apparently perfect recovery, secondary diseases are apt to occur, and sooner or later destroy the patient.

This disease mostly attacks young persons, and most frequently those of the male sex. In Ireland, boys under twelve years of age were those almost exclusively attacked. In Gibraltar, in the great majority of cases, it occurred in males between two and fifteen years of age. In Tennessee its principal victims were children, between the ages of six and fifteen years. In Missouri between ten and fifteen years. In St. Augustine, Texas, the patients were generally under fifteen years; in but two or three instances did the disease attack those over eighteen years of age, and not in a single instance a female. In Alabama, however, the majority of those attacked, over fifty per cent., were beyond twenty years of age. Fifty-four per cent. were males. In Texas, there was not an instance of the disease occuring among the negroes. In France the disease occurred, for the most part, among the young conscripts who had lately joined their regiments.

Treatment

The treatment of these cases is stated to be "unsatisfactory." More than half of the cases are fatal; often within twelve or twenty-four hours. The treatment must be guided by the symptoms present, which vary a great deal in different cases. Opium, a grain every two or three hours, is said to have been beneficial in some cases. In Germany, leeches behind the ears are said to have proved useful. Hot baths, mustard poultices to the feet and legs, friction with red pepper and whiskey, may also be tried. Spanish Fly, (20 to 40 drops of the tincture every hour, until an improvement takes place). Camphor, Chloroform, Sulphite of Soda, Bromide of Potassium, and Hydrate of Chloral have all been given, and with asserted benefit in some cases. Few diseases, however, have, so far, more obstinately baffled treatment.